Fetal Alcohol Syndrome Diagnosis, Epidemiology, Prevention, and Treatment (1996) / Chapter Skim
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8 The Affected Individual: Clinical Presentation, Intervention, and Treatment
8 The Affected Individual: Clinical Presentation, Intervention, and Treatment
Pages 154-193
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From page 154... ...
As a result, many affected individuals do not receive correct diagnosis or treatment for their alcohol-related disabilities. For obvious reasons, the focus of prevention efforts has been on the prevention of maternal alcohol use in pregnancy or on the prevention of pregnancy itself.
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From page 155... ...
It is also well known that most medical and other professionals are not comfortable dealing with substance abuse or with addicts (Chappel, 1973; Robinson and Podnos, 1966~. In addition, however, there has been an attitude that "the damage is done" and that, given the biological nature of the insult to the nervous system, there is little to be done to help affected children.
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From page 156... ...
However, a number of physical problems have been reported to be related to alcohol exposure and should be considered specifically. These include cardiac defects, urogenital problems, skeletal abnormalities (Streissguth et al., 1985)
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From page 157... ...
Deceleration in the rate of head growth, with or without deceleration in other growth parameters, is very unusual in fetal alcohol syndrome and warrants consideration of brain imaging studies. Finally, it is important to mention that alcohol exposure can occur in gestations already complicated by chromosomal anomalies or other birth defect syndromes.
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From page 158... ...
retrospective and clinical studies of clinically referred children with FAS and fetal alcohol effects, and (2) prospective research studies of children exposed to alcohol in utero due to maternal drinking.
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The level of prenatal alcohol exposure tends to be less than that found in retrospective studies of identified FAS individuals. This can lead to problems in interpretation of the findings.
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From page 160... ...
that trained observers can identify both the facial features and the behavioral signs associated with prenatal alcohol exposure during this period. Behavioral patterns characteristic of alcohol-exposed neonates are often those associated with withdrawal from a CNS depressant (Coles et al., 1984, 1985; Nugent et al., 1990; Robe et al., 1981~.
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From page 161... ...
Language Development. The possibility that there are deficits in language development as a result of prenatal alcohol exposure has been examined, particularly in young children.
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found that in comparing the experimental and the clinical literature on FAS and alcohol effects, a pattern of communication dysfunction could be identified. This is described as "social but dysfunctional communicative interaction" (p.
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From page 163... ...
Despite the importance of this period of children's academic and intellectual development and socialization, there are few empirical studies of the effects of prenatal alcohol exposure during this time. Those controlled research studies that do exist have focused on cognitive performance, academic achievement, and attention or hyperactivity.
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From page 164... ...
(1986) found that greater fetal alcohol exposure was associated with poorer test performance on a vigilance task, particularly greater distractibility and more impulsivity.
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From page 165... ...
Therefore, the impact of prenatal alcohol exposure on school-age children remains to be clarified. Adolescence In clinical populations, adolescents with FAS are considered to have significant deficits in intelligence, learning, academic achievement, andmore particularly in social behavior (LaDue et al., 1989; Spohr et al., 1993~.
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From page 166... ...
, there was a significant relationship between academic problems (e.g., "word attack skills" and mathematics problems) and prenatal alcohol exposure in what the authors described as a "dose-dependent" manner.
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Although there are hundreds of experimental studies (particularly animal models', the information available from well-conducted clinical studies and prospective studies is very limited. The research paradigms that are required to investigate the effects of prenatal exposure are very difficult to carry out.
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From page 168... ...
cumulative effects of the interaction of the biological insult and nonoptimal environments; and (4) the type of neurological damage associated with prenatal alcohol exposure.
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From page 169... ...
Although it is logical to assume that outcomes result from interaction between the child's biological status and the caregiving environment, such a statement is too general to provide meaningful guidelines for intervention and treatment. Neurobiological Markers of Prenatal Alcohol Exposure Animal studies as well as clinical reports support the belief that prenatal exposure to alcohol affects both the structure and the function of the brain.
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From page 170... ...
Even the mother who is attached to the child and well motivated may have inadequate personal resources and social support to enable her to deal with the special needs of the alcohol-affected child (Wilson et al., 1984~. This problem occurs, at least in part, because many alcohol abusing or dependent women were themselves reared in dysfunctional families and were themselves the victims of abuse, neglect, and perhaps, prenatal alcohol exposure (Briere and Zaidi, 1989; Cohen and Densen-Gerber, 1982~.
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From page 171... ...
"Neglect" and "caregiver absence or incapacity" were the primary reasons for the removal of young children from their families in these states (68 percent in 19911. Examination of a random sample of case files at one major location in each state found that 78 percent of young foster children had a least one parent who abused alcohol or other drugs, and prenatal alcohol exposure was explicitly cited in 7.1 percent of these cases.
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172 ._ en 5 ._ V: ._ .> Cal V so ._ V C)
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However, despite these differences, it is evident that children affected by prenatal alcohol exposure are at high risk for caregiving instability and loss of family. In understanding the development and behavior of alcohol-affected children, it is necessary to take these environmental factors into account.
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From page 174... ...
Speech therapy mproved developmental outcome Emergency room Physical therapy Protective services Occupational therapy Emotional, social Foster care placement versus biological parents Preschool (3-6 yr) Health care clinics Medical services Improved health Pediatricians Education interventions Improved parenting Head Start Intervention with parents, parenting classes School Age (6-12 yr)
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From page 175... ...
It is assumed that many children with FAS or other alcohol effects are receiving medical and therapeutic services of many kinds through private and public programs (e.g., Medicaid and Supplementary Security Income) and educational services through federally mandated Early Intervention Services, Head Start, or Special Education Services when they reach school age.
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From page 176... ...
Medical and Therapeutic Intervention Children affected by maternal alcohol exposure have intervention needs in numerous areas. They need a primary care physician and may need specialty consultation in neurology, endocrinology, ophthalmology, otolaryngology, and developmental medicine.
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, alcohol-affected children qualify for existing early intervention and special education services. Those who meet the criteria set forth in Public Law 94-142 and Public Law 99-457, which provide for the education of handicapped individuals under 21 years of age, can receive such services.
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From page 178... ...
Is the method effective ? Before recommending that a particular strategy or program be used, it first must be tested to see if it improves performance for children in general; for children with FAS or other alcohol effects; and for alcohol-affected children with different characteristics (i.e., age, cognitive status, family structure, clinical history)
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From page 179... ...
A survey conducted in Washington State in 1994 (James Bowman Associates, 1994) suggested that both the identification of affected individuals and the provision of services could be improved by better training of providers, many of whom, in both public health and social service roles, expressed discomfort in dealing with substance abusers.
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From page 180... ...
As a result, much emphasis is currently being placed on family involvement in the process of therapy and intervention. Although there are excellent reasons, both historical and practical, for this emphasis, it may result in difficulties in treating the children of substance abusers if appropriate care is not directed at dealing with such families.
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From page 181... ...
Because of the high incidence of abuse and neglect, alcohol-affected children often come into the foster care system or are placed for adoption (e.g., Egeland et al., submitted for publication)
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From page 182... ...
Because the research literature (see above) is inconsistent in its findings about the attentional effects of alcohol exposure and because, in the population of abused and neglected children usually referred for assessment, such behaviors may have various etiologies (Zeanah et al., 1993)
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From page 183... ...
These patterns do not result solely from deficits in the validity of test instruments or from poor reliability, but from the nature of the developmental process itself and, probably, from the impact of negative social environments and the particular kinds of brain damage caused by fetal alcohol exposure (see above)
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From page 184... ...
SUMMARY: INTERVENTION AND TREATMENT Although the most desirable way of dealing with fetal alcohol syndrome, ARBD, and ARND is through prevention of the birth of an affected child, provisions must be made for affected children when such efforts fail. Efforts to prevent secondary disabilities will involve coordination of several levels of identification, intervention, and treatment in order to maximize the child's postnatal development.
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From page 185... ...
that interventions, including placement in foster care or adoption, do not change the prognosis for children affected by prenatal alcohol exposure. Such negative ideas have affected the way in which children with FAS, ARBD, or ARND are treated by caregivers, health care providers, educators, and social service agencies (ConnBlowers, 1991; Streissguth, 1992~.
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From page 186... ...
The committee, thus, views further research as essential to providing adequate treatment of children affected by FAS, ARND, and ARBD. The committee recommends additional research in the following areas: · research to distinguish the role of the postnatal environment in modifying the effects of fetal alcohol exposure, including research on adopted versus nonadopted children with these disorders; · research on the social and emotional status of school age children affected by FAS, ARND, or ARBD and research on the existence of specific impairments associated with these syndromes, particularly impairments in attention, language, sensory integration, and other behavioral problems; · further basic research using animal models to examine the underlying neurobiological mechanisms of behavioral and environmental interventions over the life span; and · evaluation of the effectiveness of educational interventions on children with FAS, ARND, or ARBD, possibly beginning with the examination of educational interventions that look promising in case studies or in studies of children exposed to illicit drugs in utero.
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Erickson S et al. Effects of prenatal alcohol exposure at school age.
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Effects of prenatal alcohol exposure at 6 years: I Physical and cognitive development.
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Prenatal alcohol exposure and language development. Alcoholism: Clinical and Experimental Research 1990; 14:937-945.
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Ragozin AS. Behavioral correlates of prenatal alcohol exposure: A four-year follow-up study.
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Multilevel intervention for prevention of fetal alcohol syndrome and effects of prenatal alcohol exposure. Recent Developments in Alcoholism, Vol.
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Moderate prenatal alcohol exposure: Effects on child IQ and learning problems at age 7.5 years. Alcoholism: Clinical and Experimental Research 1990; 14:662-669.
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Fantastic Antone Succeeds: Experiences in Educating Children with Fetal Alcohol Syndrome.
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