Cognition and Behavior

Notes from Presentation by Ann Streissguth. Ph.D

Elements of Success: Helping Individuals with FASD and Co-occurring Disorders

Dumas Bay Retreat Center – FAS*FRI Conference

September 25, 2007

*****Need to read Seattle Prospective Study on psychiatric disorders with FASD over 25 years (Am J Psychiatry)

“The brain is the most vulnerable organ affected by prenatal alcohol exposure.”

Riley and Driscoll’s study in 1990 showed that the behaviors that we see in children with a history of prenatal exposure to alcohol are the same as those seen in animals exposed to prenatal alcohol, so we know these effects are caused by alcohol independent of environmental factors. There are reports that show evidence of alcohol effects in monkeys and fruit flies. Someone stated that a study with spiders exposed to different substances, where alcohol had the most adverse effects of all.

“FASDs are birth defects of the brain.” We set up diagnostic clinics, but we are getting the children too late, they are missing out on the early intervention services that can make a big difference in outcome later. Countries like Sweden that have health care for all do not have a big problem with FASD because it is dealt with in prenatal care. In the U.S. we have more problems with FASD and we have a very high death rate for babies.

Testing: WISC, WAIS, WRAT may not show the severity of deficits in FASD. When doing the VABS on individuals with FASD, the score is 2 standard deviations below the person’s own IQ, and even more so when compared to general population. IE, IQ of person with FAS might be 80, and the Vineland score would be 60.

The Fetal Alcohol Behavior Scales (FABS) designed by Streissguth is based on behaviors observed in those with a diagnosis.

Behavioral Phenotypes:

Poor Habituation (difficulty modulating incoming stimuli)
Becomes over stimulated in social situations
Over-reacts to situations with strong emotional response
Has mood swings set off by small things
Has poor attention span
Has trouble completing tasks

Poor cause and effect reasoning in social situations
Unaware of consequences of own behavior
Poor judgment about whom to trust
Interrupts with poor timing
Cannot take a hint
Wants to be the center of attention

In persons who have a diagnosis of an FASD but have a normal IQ, scores are below normal in certain attention tests: COWAT (shifting sets), RUFF (perseveration), CVLT (free recall intrusions, adds to stories). In some attention tests, they do well while there are no distractions, but when distractions were added, they scored 1-2 standard deviations below normal.

FASD does not fit the MR model, but it fits better with the model for Traumatic Brain Injury.

In persons with FASD, problems with Executive Functions are much worse than those with similar IQ.

Clinical Implications for Adolescents and Adults with FASD

Difficulties they haveWhat this means for them:

Poor judgmentEasily victimized (and then becomes victimizer)

Attention deficitsEasily distracted

Poor math skillsCannot manage money

Memory deficitsDifficulty learning from experience

Difficulty abstractingCannot figure out the consequences

Disoriented in time and spaceMisses social cues

Frustration toleranceQuick to become angry

Longitudinal Study of Individuals with Prenatal Exposure to Alcohol:

Infancy outcomes show poor suck, latency in beginning to such (delayed response to nipple), poor reflexes. Leading indicator is poor habituation to light, which is related to later learning disorders.

Bayley scales on babies at 18 months did not detect effects. This is NOT the time to test.

At 4 years of age, we can detect difficulties in areas of attention, arithmetic, processing time, latency to correct errors, poor balance, perseverance, verbal interruptions, hypertonic (some can be hypotonic).

From age 4 to 14, behavioral differences are seen in laboratory (blind tests) in these areas: distractible, uncooperative, rigid, seeks reassurance, disorganized, impulsive (14).

Teacher rating shows problems with cooperation, impulsivity, memory, attention, unpredictable behavior. The same results were observed at 21 years of age.

We have failed in identification of FASD in time for early intervention to prevent secondary disabilities. We have failed in getting relevant help when they are in the institutions and facilities when they are most vulnerable (schools, mental health, criminal justice system). And we have failed to provide adequate services and supports for the families caring for then.

Recommendations:

Funding for Public Health Model to initiate Neonatal Health Study to look at the corpus callosum of newborn through fontanel ultrasound ($150, nonintrusive, mother can observe and be informed immediately to access early intervention services). Pilot study shows ability to accurately detect FASD in half of newborns prenatally exposed to alcohol.

States need to initiate the following:

Residential program and transitional resources for affected individuals
Training in Behavioral Health System
Screening programs to identify FASD in persons getting mental health services and measure outcomes
Screen newborns with fontanel ultrasound (described above)
Provide services and supports to families caring for children and adults with FASD