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Fasd CIP Module 1
- 45. The Many Faces of Fetal Alcohol Syndrome (Streissguth, 1994)
- 49. 2. Growth Problems Chart Source: http://www.cdc.gov/growthcharts/clinical_charts.htm Photo Source: http://pubs.niaaa.nih.gov/publications/social/Module10KFetaExposure/Module10K.html
Hinweis der Redaktion
- Materials: none Procedures: A Visualization Exercise. Ask students to envision the scene as you read aloud the scenario below. “ You are walking down a street in the business section of your community. You are alone, and it is about 9:00 p.m. An individual is walking toward you on your side of the sidewalk. There are tall trees lining the street and attractive shrubs at the curb. You feel comfortable and unafraid. Suddenly you see someone walking toward you. Looking closely at the individual, you notice a lack of coordination which, as the individual approaches, becomes a stumbling gait. Feeling less comfortable, you keep your eye on the approaching individual, noticing that the odor of alcohol and vomit hangs in the air. The individual is muttering quietly with slurred speech. Looking into the person’s face, it is easy to see the glazed eyes and puffy skin. This individual is obviously drunk.” (Doctor, 2005) The most important thing is that when you describe the imagery, do not use a personal pronoun (exclude he or she). Engage the students in discussion by asking the following questions: As you were listening to the scenario, what was the gender of the person you envisioned? Would your reaction to the alcohol-impaired person change if it were a woman? What would your reaction be if the alcohol-impaired person was pregnant? Source: Doctor, S. (2005). Women and Addiction Online Course. University of Nevada, Reno
- Data obtained from the 2008 National Survey on Drug Use and Health: National Findings http://www.oas.samhsa.gov/NSDUH/2k8NSDUH/2k8results.cfm#Ch3
- Data obtained from the 2008 National Survey on Drug Use and Health: National Findings http://www.oas.samhsa.gov/NSDUH/2k8NSDUH/2k8results.cfm#Ch3
- Data obtained from the 2008 National Survey on Drug Use and Health: National Findings http://www.oas.samhsa.gov/NSDUH/2k8NSDUH/2k8results.cfm#Ch3
- Data obtained from the 2008 National Survey on Drug Use and Health: National Findings http://www.oas.samhsa.gov/NSDUH/2k8NSDUH/2k8results.cfm#Ch3
- Because SAMHSA only collects aggregate admission data, this number represents ALL substance abuse treatment admissions and includes first-time admissions and subsequent readmissions.
- American Cancer Society Breast Cancer Facts & Figures 2007-2008 http://www.cancer.org/acs/groups/content/@nho/documents/document/bcfffinalpdf.pdf
- Women absorb and metabolize alcohol differently from men. They have higher blood alcohol levels (BACs) after consuming the same amount of alcohol as men and are more susceptible to alcoholic liver disease, heart muscle damage (1), and brain damage (2). The difference in BAC's between women and men has been attributed to women's smaller amount of body water (3). An additional factor contributing to the difference in BAC's may be that women have lower activity of the alcohol metabolizing enzyme alcohol dehydrogenase (ADH) in the stomach, causing a larger proportion of the ingested alcohol to reach the blood. The combination of these factors may render women more vulnerable than men to alcohol-induced liver and heart damage (4-9).
- (because of genetics, or developmental or environmental factors)
- With Abstinence, the brain can begin to recover, however, it is not known whether complete recovery will occur even with long term abstinence. This slide shows a PET scan of the brain of a normal non-addicted individual (top row). The yellow stain is specific for dopamine receptors which are known to be effected by chronic cocaine addiction. Compare the brain of the normal non-addicted individual to that of a chronically cocaine addicted individual abstinent for 10 days (second row) and 100 days (third row) respectively. It appears that there is some increase or recovery of dopamine receptors after 100 days abstinence relative to only 10 days of abstinence. However the distribution and number of dopamine receptors even after 100 days’ abstinence are clearly less that that of the normal non-addicted individual. Although some continued level of recovery is likely with even longer periods of abstinence, it is not known whether complete recovery or normalization of dopamine receptors will occur with sustained long term abstinence. There is also some evidence that individuals who are vulnerable to developing addiction may have pre-existing (prior to the onset of drug use) reduced dopamine receptor density compared to individuals with low addiction vulnerability Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang C-I, Fowler IS, Wolf AP, Dewey SL. Long-term frontal brain metabolic changes in cocaine abusers. Synapse 11:184-190, 1992; Volkow ND, Fowler JS, Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey 5, Wolf AP. Decreased dopamine D2 receptor availability is associated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.
- Alcohol is not a benign substance despite its widespread use. As a result, women of childbearing age often are unaware of the risks posed by drinking alcohol before and during pregnancy.
- Materials: None Procedures: This is an introduction to the FASD curriculum. In September, 2008 the Center for the Application of Substance Abuse Technologies (CASAT) at the University of Nevada, Reno was awarded a cooperative agreement from the Centers for Disease Control and Prevention (CDC) to develop the Frontier Regional FASD Training Center (Frontier RTC). The Frontier RTC includes seven frontier-designated states. (Colorado, Idaho, Montana, Nevada, North Dakota, Utah, and Wyoming). The purpose of the teaching modules is to increase practitioner: awareness and knowledge of FASDs, and skills in conducting screening and brief intervention for a women at risk of an alcohol-exposed pregnancy as well as referral of individuals who might have an FASD.
- Materials: none Procedures: Explain to students that the next two slides will list our Learning Goals and Outcomes, based on the Core Competencies identified by the CDC within the Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice ( 2009). The following CDC Core Competencies serve as the basis for the content in Module I: Competency I: Foundation Competency IV: Biological Effects of Alcohol on Fetus Competency VI: Treatment Across the Life Span for Persons with Fetal Alcohol Spectrum Disorders Competency V: Screening, Diagnosis, and Assessment of FAS
- Materials: None Procedures: Continue from previous slide: These are the specific learning outcomes for Module I [Instructor Note: The learning outcomes were developed using Bloom’s Taxonomy of Learning Domains.] Source: Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice . Atlanta, GA: Centers for Disease Control and Prevention
- Materials: None Procedures: Engage students in discussion by asking why they think they might need to know about FASDs? Explain : The term Fetal Alcohol Spectrum Disorders (FASDs) refers to all of the disorders resulting from prenatal alcohol exposure. There is No cure for FASDs and it is a disability that will last a lifetime. However, ALL FASDs are 100% preventable. Providers should encourage all clients of child bearing years to discuss their drinking history and be able to provide clients with resources to reduce and/or quit drinking. Patient and Health Care Challenges that clients often face can include: Sparsely located populations Geographic isolation Low rates of health insurance coverage Too few health care and substance abuse treatment providers and facilities Distances make awareness and access to FASD services somewhat difficult
- Materials: None Procedures: As a comparison between the prevalence of FASDs and other developmental disabilities. 1. The CDC (2002) reports the prevalence of Autism Spectrum Disorders in the U.S. as 6.6 per 1000 8yr olds, or 1 in 150 children. (Found at: http://www.cdc.gov/ncbddd/autism/faq_prevalence.htm). 2. The CDC (2009) reports that 13 of every 10,000 babies born in the United States each year are born with Down syndrome Source: Grab and go: FASD faqs. (2009). SAMHSA FASD Center of Excellence. Retrieved on August 10, 2009, from http://www.fasdcenter.samhsa.gov/grabGo/fasdfaqs.cfm/ . Autism information center. (2009) Department of Health and Human Services: Center for Disease Control. Retrieved on August 10, 2009, from http://www.cdc.gov/ncbddd/autism/index.html.. Down syndrome. (2009). ) Department of Health and Human Services: Center for Disease Control. Retrieved on August 10, 2009, from http://cdc.gov/NCBDDD/birthdefects/DownSyndrome.htm .
- Materials: HANDOUT #1: Surgeon General’s Advisory on Alcohol Use in Pregnancy Procedures : Go over historical timeline of awareness of FAS within the United States: 1968 : Paul Lemoine described the effect of prenatal alcohol exposure in medical literature 1973 : Researchers recognize FAS in U.S. 1981 : Surgeon General releases public health advisory warning on alcohol use during pregnancy 1990s - Present : Impact of FASD hits mainstream media * (see note below) 1996 : Institute of Medicine Report on FAS and he release of the FAS guidelines for Referral and Diagnosis (2004) 2001 : SAMHSA FASD Center for Excellence 2002 : CDC funds round one of the FASD Regional Training Centers grant 2003 : 1 st Online academic FASD Class developed and offered by the Center for the Application of Substance Abuse Technologies at the University of Nevada, Reno 2004 : Definition of FASD established 2005 : Surgeon General re-issues public health advisory warning on alcohol use during pregnancy 2006 : CDC funds round two of the FASD Regional Training Centers grant
- **Note: Not all value statements listed below need to be discussed. Select the items that would resonate the most with your particular audience. Procedures Instructors can adapt this exercise to make appropriate for the number of students they have in class. Participants are asked to react to the following statements (read by the instructor) either affirmatively (by standing up or “thumbs up”), negatively (by remaining seated or “thumbs down”), or somewhere between the two (by raising a hand or “so-so”). They are asked not to talk to one another as they respond to the statements. They are instructed to “act as if” the issues in the statements are possible: Addiction is a moral weakness. Anyone can stop drinking if s/he uses. Women who drink when pregnant should be incarcerated. A woman who drinks when pregnant should have her children removed from her until she is sober for at least 6 months. A practicing alcoholic should not be permitted to have children. Taxpayers should bear the expense for services to the alcohol-exposed infant. Taxpayers should bear the expense for services for the uninsured mother. Taxpayers should bear the expense for services for the uninsured father if he is involved with the family. Alcohol/drug treatment should be provided free of cost to all pregnant women needing help to stop drinking. The fetus of an alcoholic is an innocent victim. All women and their babies should be screened for alcohol and drugs at delivery. Pregnant women who fear a punitive response to their addictive behavior will not seek prenatal care and other services necessary to a healthy delivery. Each of the statements above is deliberately constructed to be provocative and to create personal insight regarding values/beliefs relating to the issues representing the complexity of FASD. Following the completion of the exercise, participants will be told that because personal values and beliefs lead to personal/professional behavioral responses, introspection provided by participation in this exercise can be valuable. After a brief discussion regarding individual feelings, insights, etc. experienced while participating in the exercise is recommended.
- Materials: Video Clip Procedures: This is a short 2 minute video segment created by the SAMHSA FASD Center for Excellence is a segway to the rest of the material provided within this module of the curriculum. The Recovering Hope video is an hour in length and presents eight women telling their own stories about how alcohol use in pregnancy affected their children. To order a copy of the Recovering Hope video for you personal video library please visit the Frontier FASD Regional Training Center website at: frontierfasdr.tc and click on the ‘Free Printed Materials’ tab under Resources. This will send you directly to our online ordering system where you can order FAS/FASD related materials free of charge.
- Materials: None Procedure: Alcohol is damaging to fetal development because it is a potent solvent (i.e., teratogen) that can dissolve into cellular material and cause malformation to the developing fetus. Alcohol can go anywhere water can go inside the human body. It (alcohol) freely crosses into cells and dissolves inside most body cells, which are 98% water. This is unlike chemicals like methamphetamine or opioids that interact with specific receptors on the outside of specific cells. This quality of alcohol, the nearly complete distribution into most body cells, helps us understand why the effects on the fetus are so widespread. Since alcohol is dissolving into the cells that make up the central nervous system, the fetal brain is affected. Since it freely dissolves into the cells that make up body structures, facial abnormalities can occur. The cells of fetal liver, kidney and heart are likewise exposed to alcohol which passes freely through the placental from the mother's circulation to the fetal bloodstream.
- Competency IV, p. 3 describes how: Alcohol is not a benign substance despite its widespread use. Rather, alcohol is a potent solvent (i.e., teratogen) that can interfere with normal fetal development. As a result, women of childbearing age often are unaware of the risks posed by drinking alcohol before and during pregnancy. Alcohol is so harmful because it is water soluble and therefore can go anywhere water can go inside the human body. Since cells in the body are 98% water, alcohol freely crosses into cells and moves rapidly through the water compartments in the body, such as blood plasma and other cellular fluids. Alcohol’s rapid solubility in water is unlike chemicals like methamphetamine or opioids that interact with specific receptors on the outside of specific cells. Normally there is no mixing of maternal and fetal blood, except for the small capillaries that facilitate the exchange of oxygen and nutrients from the mother to the fetus, and carbon dioxide and wastes from the fetus to the mother. Although the placenta acts as a barrier for many toxins that might harm the fetus, the physical properties of alcohol and its widespread distribution into most body cells affects the placenta’s ability to detect / screen out alcohol from the maternal blood. Consequently, the alcohol is easily passed from the mother to the fetus, absorbed into the fetal circulation, and distributed throughout the tissues and cells of the fetus. Because the liver and enzymes responsible for ethanol metabolism are not fully developed, the fetus’s ability to metabolize the alcohol is limited and results in alcohol levels in the fetal tissues similar to those found in the mother. As a result, alcohol is freely distributed throughout the developing organs and dissolving into the cells that make up the fetus’s central nervous system (affecting the brain, spinal cord, and peripheral nerves), and body structures (causing facial abnormalities). Thus, alcohol’s water-soluble quality, ability to cross the placental barrier, and the fetus’s inability to metabolize alcohol helps us understand why the effects on the fetus are so widespread. Source: Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice . Atlanta, GA: Centers for Disease Control and Prevention
- Materials: None Procedures: Fetal Alcohol Spectrum Disorders (FASDs) defined: The term FASDs is not intended for use as a clinical diagnosis. The term fetal alcohol spectrum disorders (FASDs) has emerged to address the need to describe the spectrum of disorders related to fetal alcohol exposure. It is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects can include physical, mental, behavioral, learning disabilities, or a combination of these, with possible lifelong implications. Although FAS is one of the diagnoses included under the umbrella term FASDs, those with other prentatal alcohol-related diagnoses sometimes do not present the identifying physical characteristics of FAS. As a result, they often are undiagnosed. Available from the CDC at: http://www.cdc.gov/ncbddd/fasd/facts.html
- Materials: Continue with Handout #3 – Terms Related to Prenatal Alcohol Exposure Procedures Participants are directed to read the first paragraph on their handout and discuss in their small groups. The instructor will then emphasize the important information included. The important thing to remember is that Fetal Alcohol Spectrum Disorders (FASDs) is not intended for use as a clinical diagnosis. The term FASDs has emerged to address the need to describe the spectrum of disorders related to fetal alcohol exposure, and thus is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects can include physical, mental, behavioral, learning disabilities, or a combination of these, with possible lifelong implications. Unlike people with FAS, those with other prenatal alcohol-related conditions under the umbrella of FASDs do not show the identifying physical characteristics of FAS and, as a result, they often go undiagnosed. Source: FASD Regional Training Centers Curriculum Development Team. (2009). Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice . Atlanta, GA: Centers for Disease Control and Prevention.
- Materials: None Procedures: Different terms are used to describe FASDs, depending on the types of symptoms. Pictured here is a set of acronyms representative of the range of effects included in Fetal Alcohol Spectrum Disorders (FASDs). For many, these acronyms can be confusing. Terms Related to Prenatal Alcohol Exposure: From the DHHS/CDC, FASD Competency-Based Curriculum Development Guide for Medical and Allied Education and Practice Fetal alcohol spectrum disorders (FASDs). This umbrella term describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASDs is not intended for use as a clinical diagnosis. Fetal alcohol syndrome (FAS). A disability resulting from maternal prenatal use of alcohol. It is characterized by abnormalities in three domains—growth retardation, neurobehavioral abnormalities, and specific facial characteristics. Confirmed maternal use of alcohol might or might not be documented. Fetal alcohol effects (FAE). T he term Fetal Alcohol Effects (FAE) was formerly used to describe intellectual disabilities and problems with behavior and learning in a person whose mother drank alcohol during pregnancy. In 1996, the Institute of Medicine (IOM) replaced FAE with the terms alcohol-related birth defects (ARBD) and alcohol-related neurodevelopmental disorder (ARND). Alcohol-related birth defects (ARBD). This diagnosis describes the physical defects linked to prenatal alcohol exposure, including heart, skeletal, kidney, ear, and eye malformations (this is not a complete list). Alcohol-related neurodevelopmental disorder (ARND). This term describes functional or cognitive impairments linked to prenatal alcohol exposure. These include learning difficulties, poor school performance, poor impulse control, and problems with mathematical skills, memory, attention, judgment, or a combination of these. pFAS – Partial Fetal Alcohol Syndrome. Patients with Partial FAS (pFAS) have a confirmed history of prenatal alcohol exposure and present with most, but not all, of the growth deficiency and/pr facial features of Fas and central nervous system damage (structural, neurological, and/or functional impairment). Source: FASD Regional Training Centers Curriculum Development Team. (2009). Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (Appendix A-2 – A-3). Atlanta, GA: Centers for Disease Control and Prevention.
- Materials: None Procedure: The next discussion focuses on the critical periods in fetal development
- Procedures: Orient students to the slide: The top shows weeks of development. After week 8, the timeline is condensed. Interpret the fetal development chart as follows: The blue portion of the bars represents the most sensitive periods of development. During these periods, the effects of alcohol consumption would be the most harmful and result in major structural abnormalities in the fetus. The gray portion of the bars represents periods of development during which physiological defects and minor structural abnormalities could occur. For the purpose of this curriculum, when we talk about the Central Nervous System (CNS), we are referring specifically to the “Brain” The instructor, asks participants to look on their handout while the following points are discussed: During the first two weeks of gestation (the period of the ovum), the embryo is not susceptible to the possible effects of in utero alcohol exposure (i.e., the period of time during which the fertilized egg makes the trip to the uterus). --Many women do not know they are pregnant until 4-6 weeks gestation and 50% of pregnancies are unplanned…therefore, the fact that they are ‘safe’ at 1-2 weeks becomes essentially irrelevant since they still won’t know at 3 or 4 weeks either. The issue of being “safe” really only applies to the woman who finds out she is pregnant and realizes she was drunk at conception (which yes, we do get those inquiries). But what are the chances she was only drunk at conception and didn’t drink again this whole time until recognizing she is pregnant? Once the fertilized egg has attached to the wall of the uterus, the fetus is vulnerable to the effects of alcohol exposure due to the presence of alcohol that can pass from the mother’s bloodstream to the bloodstream of the fetus. Alcohol metabolites are present in the fetal bloodstream 1 to 1.5 times longer than the maternal bloodstream. The instructor asks participants to respond to the following: During what week does the risk for alcohol-related damage to the fetus begin? [It is crucial to understand this and a major concern because most women don’t know they are pregnant at week #3] The eyes develop from the middle of the 4 th week of gestation through the third trimester. What else is developing during this period of time and could also be impaired by in utero exposure to alcohol? Which organ system is vulnerable throughout gestation (with the exception of the first 2 weeks) and could be impaired by in utero exposure to alcohol? When is it safe to drink during pregnancy? [Never…no safe time, known amount, or kind.] This clearly points out that there is NO safe time for a mother to drink alcohol when pregnant, and NO known safe amount and NO safe kind of alcohol that can be consumed during pregnancy. Conversely, it is NEVER too late to discontinue drinking alcohol when pregnant. -------------------------- Take home message : There is No Safe Time to drink alcohol during pregnancy and it is never too late to discontinue drinking when pregnant and/or if you are contemplating getting pregnant. Source: National Organization on Fetal Alcohol Syndrome (NOFAS). (2004; adapted from Moore, 1993). In Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (IV-7). Atlanta, GA: Centers for Disease Control and Prevention
- Materials: None Procedures: Most women do not know exactly when they conceive. Therefore, there is NO safe type, NO known safe amount, and NO safe time to consume alcohol for women of childbearing age who are: Trying to get pregnant Sexually active and not using effective contraception Already pregnant For women of childbearing age who are using effective contraception, the current guidelines for alcohol consumption should be followed: No more than 7 drinks per week No more than 3 drinks on any one occasion Source: O’Connor, M. J., Floyd, L., & Guiton, G. (2009). IV. Brief interventions. Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (II-22). Atlanta, GA: Centers for Disease Control and Prevention
- Purpose: In the next few slides we will examine the CDC diagnostic criteria for FAS
- Materials: HANDOUT #5 - Diagnostic Criteria for Fetal Alcohol Syndrome. This handout provides in-depth diagnostic criteria. However, the lecture for this section will only highlight the basics of diagnosis. Procedures Inform students that diagnosing FAS can be difficult because there is no medical test, like blood test for it. And other disorders such as ADHD (attention-deficit/hyperactivity disorder) and Williams syndrome, have symptoms like that of FAS (CDC, 2009). Note: Confirmation of prenatal alcohol exposure is not needed to obtain an FAS diagnosis. Prenatal alcohol exposure can be confirmed or not confirmed (see FAS guidelines for more information on this). For the diagnosis of FAS, the following criteria is taken into consideration: Abnormal facial features (facial dysmorphia): smooth philtrum (e.g. smooth ridge between nose and upper lip) thin upper lip (vermillion border) , and Short distance between the inner and outer corners of the eyes, giving eyes a wide space appearance (small palpebral fissures (at or below 10th percentile)). Lower than average height, weight or both (growth problems): Confirmed prenatal or postnatal height or weight, or both, at or below the 10th percentile. Central nervous system problems: Documented structural, neurological, or functional problems in areas associated with prenatal alcohol exposure (e.g., small head size, problems with attention and hyperactivity, math, poor executive functioning and coordination). Review the previous definition for FAS: “ FAS represents the severe end of the FASD spectrum. Fetal death is the most extreme outcome from drinking alcohol during pregnancy. People with FAS might have abnormal facial features, growth problems, and central nervous system (CNS) problems. People with FAS can have problems with learning, memory, attention span, communication, vision, or hearing. They might have a mix of these problems. People with FAS often have a hard time in school and trouble getting along with others.” Available from the CDC at: http://www.cdc.gov/ncbddd/fasd/facts.html FAS: Fetal Alcohol Syndrome is one of the most severe effects of drinking during pregnancy. Source: Brimacombe, M., Fry-Johnson, Y., Bertrand, J., Fuller, T., Levine, R., & Venable, C. L. (2009). II. Clinical issues. Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (I-9). Atlanta, GA: Centers for Disease Control and Prevention
- Materials: none Procedures: The handout provides much more technical detail than can be covered in this module. However, the take home point is that alcohol interacts with the developing central nervous system through multiple actions, including (NIAAA, 2000): Interfering with the normal proliferation of nerve cells Altering brain cells ability to produce or regulate cell growth, division, and survival Altering the expression of certain genes Altering the pathways of biochemical or electrical signals within the cells. [this is not a comprehensive list]
- Materials : None Procedures: This is an animated slide, once you get to this slide, you must click on the mouse or slide advancer to move the row of pictures forward. Each series of pictures shows the age progression of 3 individuals with FAS. Click the mouse once to start the animation for each series of photos. Striessguth, A.P. (1994). A long-term perspective of FAS. Alcohol Health & Research World, 18 (1), 74-81.
- Materials : None Procedures : Using the handout and the photo, point out evidence of facial dysmorphia. Abnormal Facial Features/Facial dysmorphia: Smooth ridge between nose and upper lip (i.e. Smooth philtrum: smoothness of the philtrum) Thin upper lip (i.e. thin vermillion border) Short distance between the inner and outer corners of the eyes, giving eyes a wide-spaced appearance (i.e. Small palpebral fissures) This slide demonstrates the work of a solvent. Source: Adapted from Bertrand, J., Floyd, R. L., Weber, M. K., O’Connor, M., Riley, E. P., Johnson, K. A., Cohen, D. E., & National Task Force on FAS/FAE. (2004). Fetal alcohol syndrome: Guidelines for referral and diagnosis. In Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (Competency V-6 – V-6). Atlanta, GA: Centers for Disease Control and Prevention. (FASD curriculum guide, Competency V, p. 6)
- Materials: None Procedures: This is a comparison of a non-FAS child and one diagnosed with FAS. Ask students to point out the differences they see. Students should note the thin upper lip (thin vermillion border) and smooth ridge between nose and upper lip (smooth philtrum). Source: Astley, S. J., & Clarren, S. K. (2001). Measuring the facial phenotype of individuals with prenatal alcohol exposure: Correlations with brain dysfunction. Alcohol & Alcoholism, 36 (2), 147-159.
- There is No Safe Time and No Known Safe Amount! Materials : None We’ve been showing slides of the brain and facial features. This slide reminds students of the organs that can be impaired due to exposure to alcohol. Source: National Organization on Fetal Alcohol Syndrome (NOFAS). (2004; adapted from Moore, 1993). In Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice (IV-7). Atlanta, GA: Centers for Disease Control and Prevention
- Materials: None Procedures: Another FASD diagnostic criteria is deficiencies in infant/child growth. Specifically: Height, weight, or both are at or below the 10th percentile documented at any one point in time (adjusted for age, sex, gestational age, and race or ethnicity.) (CDC, 2004) This is a typical growth chart used to track infants’ growth (i.e., height and weight) for the first 36 months of life, and a photo of an African American baby born with FAS. FAS characteristics present in this child include facial dysmorphia and growth problems (small for his age at the 5 th percentile in height and weight). Chart Source: Clinical Growth Charts. Centers for Disease Control and Prevention. Retrieved August 9, 2010, from http://www.cdc.gov/growthcharts/clinical_charts.htmv Photo Source: Module 10K: Fetal alcohol exposure. (n.d.). National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health: Social work education for the prevention and treatment of alcohol use disorders. Retrieved on August 10, 2009, from http://pubs.niaaa.nih.gov/publications/Social/Module10KFetaExposure/Module10K.html .
- The central nervous system (CNS) is made up of the brain and spinal cord. It controls all the workings of the body. When something goes wrong with a part of the nervous system, a person can have trouble moving, speaking, or learning. He or she can also have problems with memory, senses, or social skills. There are three categories of central nervous system problems: 1. Structural FAS can cause differences in the structure of the brain. Signs of structural differences are: Smaller-than-normal head size for the person’s overall height and weight (at or below the 10th percentile). Significant changes in the structure of the brain as seen on brain scans such as MRIs or CT scans. 2. Neurologic There are problems with the nervous system that cannot be linked to another cause. Examples include poor coordination, poor muscle control, and problems with sucking as a baby. 3. Functional The person’s ability to function is well below what’s expected for his or her age, schooling, or circumstances. To be diagnosed with FAS, a person must have: Cognitive deficits (e.g., low IQ), or significant developmental delay in children who are too young for an IQ assessment. Problems in at least three of the following areas: Cognitive deficits (e.g., low IQ) or developmental delays Executive functioning deficits Motor functioning delays Attention problems or hyperactivity Problems with social skills Source: http://www.cdc.gov/ncbddd/fasd/diagnosis.html
- Materials: none Procedures: This slide shows photos of brains from two 6 week old infants. Left photo: Normal brain [this baby died of a respiratory disease] Right photo: extreme case of FAS brain [this baby was not able to breathe on its own after being born] Source: Streissguth A.P., & Little, R.E. (1994). "Unit 5: Alcohol, Pregnancy, and the Fetal Alcohol Syndrome: Second Edition" of the Project Cork Institute Medical School Curriculum ("slide lecture series") on Biomedical Education: Alcohol Use and Its Medical Consequences, produced by Dartmouth Medical School (79 slides with 62 pages of text). (A slide/teaching unit available from Milner-Fenwick, Inc., 2125 Greenspring Drive, Timonium, MD 21093. Phone: 1(800)432-8433.
- Corpus Callosum: The corpus callosum connects the two hemispheres of the brain, allowing the left and right sides to communicate with each other. Prenatal alcohol exposure can cause thinning or complete absence of the corpus callosum. These abnormalities have been linked to deficits in attention, intellectual function, reading, learning, verbal memory, and executive and psychosocial functioning. Magnetic resonance imaging showing the side view of a 14-year-old control subject with a normal corpus callosum; 12-year-old with FAS and a thin corpus callosum; 14-year-old with FAS and agenesis (absence due to abnormal development) of the corpus callosum.
- These two images are of the brain of a 9-year-old girl with FAS. She has agenesis of the corpus callosum (ACC), and the large dark area in the back of her brain above the cerebellum is essentially empty space. Agenesis of corpus callosum (ACC) is a rare disorder that is present at birth (congenital). It is characterized by a partial or complete absence (agenesis) of an area of the brain that connects the two cerebral hemispheres. This part of the brain is normally composed of transverse fibers. The cause of agenesis of corpus callosum is usually not known, but it can be inherited as either an autosomal recessive trait or an X-linked dominant trait. It can also be caused by an infection or injury during the twelfth to the twenty-second week of pregnancy (intrauterine) leading to developmental disturbance of the fetal brain. Intrauterine exposure to alcohol (Fetal alcohol syndrome) can also result in ACC. In some cases mental retardation may result, but intelligence may be only mildly impaired and subtle psychosocial symptoms may be present. ACC is frequently diagnosed during the first two years of life. An epileptic seizure can be the first symptom indicating that a child should be tested for a brain dysfunction. The disorder can also be without apparent symptoms in the mildest cases for many years. Source: Agenesis of corpus callosum. WebMD. Retrieved on August 10, 2011 from http://children.webmd.com/agenesis-of-corpus-callosum
- Research has demonstrated that there can be long-term consequences among the children of women who continue to drink during pregnancy. Fetal Alcohol Exposure Effects on behavior and cognition Materials : Handout #7 - Fetal Alcohol Exposure Effects on Behavior and Cognition Procedures: The instructor reviews the information regarding both the Secondary disabilities and the consequent Protective factors with participants. Prenatal alcohol exposure is associated with a variety of potential structural and functional alterations to the developing nervous system. Any single alteration affects the ability of the cell to function appropriately and correctly communicate or process information essential to the nervous system. Reduced function or efficiency of nerve cells will result in alterations that might be expressed as changes in functions related to thinking, learning, and movement. No matter how severe or subtle they might be, the effects of alcohol might contribute to intellectual disability or movement disorders. Also associated with organic brain dysfunction are various maladaptive behaviors. Behavioral deficits might include: (The following slides go into greater detail on the following) Cognitive or developmental deficits or discrepancies Executive functioning deficits Motor functioning delays Attention deficit or hyperactivity Poor social skills Other Source: Fetal alcohol spectrum disorders competency-based curriculum development guide for medical and allied health education and practice . Atlanta, GA: Centers for Disease Control and Prevention Competency V.
- Cognitive or developmental deficits such as specific learning disabilities (especially math and/or visual-spatial deficits) Cognitive deficits (e.g., low IQ) or developmental delays Examples include (this is not a complete list): specific learning disabilities (especially math), poor grades in school, performance differences between verbal and nonverbal skills, and slowed movements or reactions.
- Executive functioning deficits These deficits involve the thinking processes that help a person manage life tasks. Such deficits include but are not limited to: poor organization and planning, concrete thinking lack of inhibition, difficulty grasping cause and effect, difficulty following multistep directions, difficulty doing things in a new way or thinking of things in a new way, poor judgment, and inability to apply knowledge to new situations.
- Motor functioning delays These delays affect how a person controls his or her muscles. Examples include but are not limited to: delayed motor milestones delay in walking (gross motor skills), difficulty writing or drawing (fine motor skills), clumsiness, balance problems, tremors, difficulty coordinating hands and fingers (dexterity), and poor sucking in babies.
- Attention problems [Attention Deficit Disorder (ADD)] or hyperactivity [Attention Deficit Hyperactivity Disorder (ADHD)] A child with these problems might be described as (this is not a complete list): “ busy,” overly active, inattentive, easily distracted, or having difficulty calming down, completing tasks, or moving from one activity to the next. Parents might report that their child’s attention changes from day to day (e.g., “on” and “off” days).
- Poor social skills include but are not limited to: Lack of stranger fear; often the scapegoat; naiveté and gullibility; easily taken advantage of; inappropriate choice of friends; preference for younger friends; adaptive skills significantly below cognitive potential
- Other problems can include: sensitivity to taste or touch, difficulty reading facial expression, difficulty responding appropriately to common parenting practices (e.g., not understanding cause-and-effect discipline), Pragmatic language, and Memory deficits.
- Procedure: Ask students to unscramble the letters to come up with two words comprised of the following letters. Allow 2 minutes for this activity. When unscrambled, the letters say: TWO WORDS
- Procedure: You have 1 minute to complete the 4 items on this slide, each with a value of 15 points. Each letter represents a word. All items are commonly known. Your score will be included toward your semester grade (or weight this depending on the population to which you are presenting the material). After a minute, the instructor should tell the participants to put down their pencils and shows the slide with the answers. The participants are instructed to grade themselves and pass in their papers. After the instructor collects the papers, s/he tells the participants to relax, this is not going to count toward their semester grade. Then s/he asks what they believe the point of the exercise to be . The sought for answer is that they were given a tiny opportunity to understand the pressure of being evaluated unfairly, and assigned something that can’t possibly be completed in the time allotted . (These directions are also found in the Notes for the next slide.)
- Procedure: The sought for answer is that students/class participants were given a tiny opportunity to understand the pressure of being evaluated unfairly, and assigned something that can’t possibly be completed in the time allotted . The conclusion that the instructor needs to guide participants towards is experiencing an evaluative situation of something that is nearly impossible to accomplish in the time permitted. Once you get participants to that conclusion ask them: what does this have to do with the materials being taught?
- Materials: Handout #8 – Adverse Life Outcomes Associated with FASDs Handout #9 - Protective Factors Associated with the Secondary Disabilities Handout #10 - Streissguth, A.P., Bookstein, F.L., Barr, H.M., Sampson, P.D., O’Malley, K., Young, J.K. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Developmental and Behavioral Pediatrics, 5 , 228-238. Procedures: The instructor reviews the information regarding both the Adverse Life Outcomes and the consequent Protective factors with participants. Data cited in the next 5 slides are from a descriptive study conducted by Anne Streissguth at the University of Washington, Seattle. The results were first released in 1996, then republished in 2004 ( see Handout #10 ). Sample Demographics : 415 individuals with a diagnosis of either FAS ( n = 155) or FAE ( n = 260). Age Range Median age Overall ( n = 415) 6 - 51 years 14 years Children ( n = 162) 6.0 – 11.9 years 8.8 years Adolescents ( n = 163) 12.0 – 20.9 years 16.0 years Adults ( n = 90) 21.0 – 51.0 years 28.4 years Victim of physical or sexual abuse, or domestic violence: 67% Median percent of time living in a stable/nurturing home: 75% of their life Adverse life outcomes: Begin early in life Adverse life outcomes are not problems that a person is born with, but rather difficulties that may be acquired as a result of having an FASD. The adverse life outcomes can possibly be ameliorated through better understanding of the disability and appropriate interventions. (See Protective Factors, slide 43.)
- Inappropriate sexual behavior (ISB) on repeated occasions (Mean age of onset: 9.6 years) The most frequent adverse life outcome across the lifespan, increasing slightly with each age category Little difference in overall prevalence for males compared to females Trouble with the law for ISB was twice as frequent among males (19%) as females (8%)
- Disrupted school experience (reported for 14% school children and 61% adolescents & adults) defined as having been suspended or expelled from school or having dropped out of school. If truancy, referrals to the vice-principal in charge of discipline, school bus write-ups, etc. had been included, this percentage would probably be a lot higher than it appears here.
- Trouble with the law (reported for 14% school children and 61% adolescents & adults) (Mean age of onset: 12.8 years) defined as ever having been in trouble with authorities, charged, or convicted of a crime. Actually charged, arrested, and/or convicted increases with age: Children (13%); Adolescents (67%); Adults (87%)
- Confinement includes in-patient treatment for mental health problems or alcohol/drug problems or ever having been incarcerated for a crime.
- Alcohol and drug problems (Mean age of onset: 13.4 years) Alcohol abuse began on average 2 years before street drug use Drinking while Pregnant: Of the 30 with FAS/an FASD who had given birth, 57% no longer had their child in their care, 40% drank when pregnant, 17% had children diagnosed with FAS or another FASD, and an additional 13% had children suspected of having an FASD.
- Factors that Protect Against the Secondary Disabilities Common to FAS/FASDs Eight protective factors emerged from the Univ. of WA’s study addressing the occurrence of secondary disabilities associated with FAS and FASDs. The study also indicates factors that protect against the secondary disabilities. The protective factors are presented in the order of their strength as “universal” protective factors. (Streissguth et al., 1996, p. 35) Living in a stable & nurturing home for over 72% of life Being diagnosed before the age of 6 years Never having been a victim of violence Staying in each living situation for an average of 2.8 years Living in a good quality home from age 8 to 12 years Having been found eligible for DDD (Division of Developmental Disability) services Having a diagnosis of FAS (rather than the other FASDs) Having basic needs met for at least 13% of life This slide represents a revision of Streissguth et al.’s work, as noted in the CDC curriculum The instructor concludes this exercise by asking the following questions and waiting for volunteer responses to each question before moving to the next question: Of these protective factors which represents : the greatest challenge? the easiest to address? See also: Streissguth, A. P., Barr, H. M., Kogan, J., & Bookstein, F. L. (1996). Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Final report to the Centers for Disease Control and Prevention on Grant No. R05/CCR008515 (Tech Report No. 96-06). Seattle: University of Washington, Fetal Alcohol and Drug Unit.
- Framework for FAS Diagnosis and Services This slide brings it all together showing the flowchart of treating a person with FAS or an FASD. Materials Handout #11 - “Framework for FAS Diagnosis and Services” Procedures: Have the students to look at this chart and assess it from the standpoint of their [nursing] [social work] training. Lead a discussion based on the following questions: Where is the job for [nurses] [social workers] [counselors] within this framework? What specifically might you do? After 3-4 minutes, ask for feedback (i.e., “popcorn responses”) Source: Bertrand, J., Floyd, R.L., Weber, M.K., O’Connor, M., Riley, E.P., Johnson, K.A., Cohen, D.E. National Task Force on FAS/FAE. Fetal alcohol syndrome: Guidelines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention; 2004, p 8.
- Materials: None Procedures: If ample time is left in the session, use this question to generate classroom discussion. Include in the discussion the feasibility of eliminating alcohol use among pregnant women, the role of the professional, and the expectations of adherence of pregnant women. (Compare with STDs, Type II Diabetes)
- Procedures: The following slides highlight the summary/take home messages for Module 1. As you go through the slides, ask students to share what they remember about each point.
- Materials: None Procedures This slide references that FASD is a term that covers multiple diagnoses associated with prenatal exposure to alcohol. [As a reminder] Fetal alcohol spectrum disorders (FASDs). This umbrella term describes the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. The term FASDs is not intended for use as a clinical diagnosis. The term fetal alcohol spectrum disorders (FASDs) has emerged to address the need to describe the spectrum of disorders related to fetal alcohol exposure. It is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects can include physical, mental, behavioral, learning disabilities, or a combination of these, with possible lifelong implications. Unlike people with FAS, those with other prenatal alcohol-related conditions under the umbrella of FASDs do not show the identifying physical characteristics of FAS and, as a result, they often go undiagnosed.
- Alcohol is damaging to fetal development because it is a potent solvent (i.e., teratogen) that can dissolve into cellular material and cause malformation to the developing fetus.
- Need to be aware of how our personal values compare to our professional values How might your personal values influence how interact with clients?
- Materials: None Procedures This slide references both the prevalence and high cost of FASDs. FAS 0.2 – 1.5 cases per 1,000 live births Translates to about 800 to 6,000 alcohol-affected births per year Estimated lifetime cost per individual of $2 million (Lupton, et. al) FASD 9 - 10 cases per 1,000 live births Translates to about 40,000 alcohol-affected births per year Estimated lifetime cost per individual of $1.4 – 1.5 million
- Materials: None Procedures This slide covers the section on the critical periods in fetal development and how alcohol affects this development. Alcohol metabolites are present in the fetal bloodstream for 1 to 1.5 times longer than the maternal bloodstream. The only time the fetus is vulnerable to the effects of alcohol exposure is when alcohol metabolites are present in the fetal bloodstream. FAS may cause : Facial dysmorphia: smooth philtrum, thin vermillion border, and small palpebral fissures (at or below 10th percentile). Growth problems: Confirmed prenatal or postnatal height or weight, or both, at or below the 10th percentile. Central nervous system abnormalities: Documented structural, neurological, or functional problems in areas associated with prenatal alcohol exposure (e.g., attention, math, executive functioning). In particular, alcohol affects development of the Central Nervous System: Alcohol interferes with the normal proliferation of nerve cells Alcohol alters brain cell’s ability to produce or regulate cell growth, division, and survival Alcohol alters the expression of certain genes Alcohol alters the pathways of biochemical or electrical signals within the cells
- Materials: None Procedures It is important to note that we are not saying a woman of childbearing age can never drink. But for questions regarding the critical periods of development and the question about when it is safe for a woman of childbearing age or pregnant to consume alcohol: While fetal development is not impacted at 1-2 weeks, it is important to note that women do not usually know they are pregnant until approximately 4-6 weeks gestation, and 50% of pregnancies are unplanned. Most women do not know when they conceive so all women of childbearing age should be cognizant of their alcohol intake and aware of the problems associated with alcohol consumption. For women who are pregnant, there is NO safe time for them to drink alcohol, NO safe type of alcohol, and NO known safe amount of alcohol that can be consumed during pregnancy. Conversely, it is NEVER too late to discontinue drinking alcohol when pregnant.
- This is the end of Module I. Module II will provide information on screening and brief intervention for women of childbearing age.