Unlike Whiskey and Water, Some Things Just Don’t Mix: The Neurocognitive Effects of Maternal Prenatal Alcohol Consumption on the

Fetus and Postnatal Developing Child

Presented by Paulette D. Pitt, Ph.D.

February 10th, 2016

Unlike Whiskey and Water, Some Things Just Don’t Mix: The Neurocognitive Effects of Maternal Prenatal Alcohol Consumption on the

Fetus and Postnatal Developing Child

Presented by Paulette D. Pitt, Ph.D.

February 10th, 2016

Thomas Durham, PhD

Director of Training

NAADAC, the Association for Addiction Professionals

www.naadac.org

tdurham@naadac.org

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To obtain a CE Certificate for the time you spent

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1. Watch this entire webinar.

2. Pass the online CE quiz, which is posted at

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4. A CE certificate will be emailed to you within 21

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Using GoToWebinar – (Live Participants Only)

Control Panel

Asking Questions

Audio (phone preferred)

Polling Questions

Paulette D. Pitt, Ph.D.

Clinical Assistant Professor

Section of Adolescent Medicine

Department of Pediatrics

Paulette-Pitt@ouhsc.edu

Today’s Presenter

University of Oklahoma

Health Sciences Center

Webinar Learning Objectives

Participants will be able to educate clients and

families on the cognitive and functional

outcomes associated with alcohol consumption

during pregnancy.

• Prenatal cognitive effects of maternal

alcohol consumption

• Residual cognitive effects of maternal

alcohol consumption

1 3

Webinar Learning Objectives

Learners will identify major neurocognitive

changes associated with prenatal alcohol

consumption and name neurocognitive and

functional assessment measures that

accurately evaluate residual neurocognitive

and functional deficits.

• Various localization implications

• Functional Deficits

• Assessment Measures

• Developmental implications

2

Webinar Learning Objectives

Attendees will be able to recognize appropriate

interventions to implement both at home and in

other environments based upon residual

neurocognitive and functional difficulties for

those prenatally exposed to alcohol.

• Interventions relevant to strengthening

deficit functioning

• Interventions utilized for skill

replacement

3

• Lower Socioeconomic Status

• Fewer educational accomplishments

• Less spiritual involvement

• Surrounded by others who drink heavily

• Number of previous pregnancies

• Tobacco use

• Advanced maternal age

• Poor education regarding use during pregnancy

Maternal Risk Factors for Use

Amount utilized by mother

At what time in the pregnancy the mother drinks

Earlier exposure is more likely to cause major morphological

abnormalities

Later exposure is likely to affect growth

Central Nervous System damage is likely to be observed with use at

any point throughout the pregnancy

Pattern of alcohol use during pregnancy

Relationship between duration of exposure and impairment

Postnatal environment may mediate outcomes for individuals exposed to prenatal

alcohol consumption

Biological predisposition versus placental health

Risk Factors to Child

Fetal Alcohol Facts

• “Almost all drugs are known to cross the placenta and have

some effect on the fetus”. (Behnke, M., Smith, V.C., 2013)

• The effects of alcohol have been studied for approximately 45

years. Fetal Alcohol Syndrome was first described in 1973 by the

American Academy of Pediatrics

• Alcohol related diagnoses on the Fetal Alcohol Spectrum

Disorders (FASDs) include Fetal Alcohol Syndrome, partial Fetal

Alcohol Syndrome, Alcohol-Related Birth Defects, Alcohol-

Related Neurobehavioral Disorder (ARND) (Davis, 2011)

• Prenatal alcohol exposure is the most common, preventable cause of non-genetic intellectual disability

• According to The National Survey on Drug Use and Health, alcohol use among pregnant women was approximately 10.8% (Behnke, M., Smith, V.C., 2013).

• Incident rates approximately .5 – 7.0 per 1,000 live births (Davis, 2011; CDC, 2009)

• Physicians lack confidence in diagnosing FASDs

Fetal Alcohol Facts Continued

Understood there is a dose dependent relationship between alcohol exposure and alcohol

effects though poorly understood

There is no “safe” level of prenatal alcohol exposure

Substances have serious teratogenic effects early in gestation

More subtle effects occur during the fetal period

Abnormal growth/maturation

Alterations in neurotransmitters/receptors

Alterations in brain organization

Congenital anomalies

Methods of indirect effects include altered nutritional status including placental insufficiency

Poor nutrition

Decreased access/compliance with health care

Effects of Alcohol Use

Effects of Alcohol Use Continued– Increased exposure to violence

– Increased risk of mental illness

– infection

• Ethanol crosses the placenta into the fetus with identification in amniotic fluid and fetal blood

• Effects of alcohol

– Embryonic stage

– Fetal stage

– Effects on placenta

– Altered prostaglandin and protein synthesis

– Hormonal alterations

– Nutritional effects

– Altered Neurotransmitter levels in brain

– Altered brain morphology and neuronal development

– Hypoxia (decreased placental blood flow/decreased vascular tone)

Polling Question #1

Prenatal alcohol consumption results in a spectrum of developmental

disabilities. True or False?

• Includes the various presentations attributed to alcohol exposure

• Characterized by the following:

• Wide range of deficiencies

• Cognitive and learning difficulties

• Behavior problems

• Attention-Deficit/Hyperactivity Disorder

Fetal Alcohol Spectrum Disorders (FASD)

FASD Continued

Reduced intelligence quotient

Fetal Alcohol Syndrome

• Diagnostic criteria– Confirmed history of maternal alcohol consumption– Characteristic pattern of minor facial abnormalities– Prenatal/postnatal growth retardation– Deficient brain growth/abnormal morphogenesis– For every child with FAS, three children are born

without the physical manifestations

• Applies to children prenatally exposed to alcohol

• Exhibit facial dysmorphology

• Display neurodevelopmental deficits

• BUT have normal growth (height, weight)

Partial Fetal Alcohol Syndrome (pFAS)

• Children having confirmed prenatal alcohol exposure

• Exhibit neurodevelopmental deficits

• BUT do not meet physical criteria for FAS or pFAS

Alcohol-Related Neurobehavioral Disorder

(ARND)

Alcohol Effects on Fetal Growth

• Growth restriction

• Required to make diagnosis of Fetal Alcohol

Syndrome

• Can be associated with even moderate alcohol

consumption amounts

• Physical outcomes

• Low birth weight

• Small head circumference

• Shorter stature

• Volumetric reductions

– Global

– Lobes

• Gray matter versus white matter

• Cortical thickness

Neurocognitive Effects

Gray vs. White Matter

Frontal Lobe

Attention, working memory, executive functions

Increased cortical thickness

Overall volume reduction

Parietal Lobe

Visuospatial functioning, attention

Increased cortical thickness

Overall volume reduction

Temporal Lobe

Memory, auditory processing, language comprehension

Increased cortical thickness

Overall volume reduction

Neurocognitive Effects Continued

Neuroanatomical Implications• Subcortical structures

– Basal Ganglia

• Motor control, learning

• Decreased volume

– Caudate Nucleus

• Learning, mental flexibility, behavioral inhibition

• Decreased volume

– Thalamus and hypothalamus

– Reduced volume

• Corpus Callosum

– Midline brain abnormality

– Absence

– Reduced volume

• Cerebellum

– Attention, executive functions, complex tasks, movement

– Reduced volume

– Displacement of vermis

– Functional deficits

Polling Question #2

Prenatal alcohol consumption has various effects upon the

developing brain including which of the following:

a. Overall volume reductions

b. Decreased presence of white matter

c. Cortical thinness

d. Only A and B

• Cognitive Functioning Difficulties

– Executive functioning deficits

• Deficient planning skills

• Poor problem solving

• Poor conceptual set shifting

• Processing speed

• Response inhibition

• Working memory

Cognitive Effects

– Attention

• Sustained Attention impairments

– Visual more impaired than auditory

• Impairments found in those with low to moderate exposures as well as heavily exposed individuals

– Memory and Learning

• Difficulty learning new information

• Unclear as to exact nature of memory deficits regarding verbal versus nonverbal information

• Verbal memory intact but verbal learning problematic

Cognitive Effects Continued

Cognitive Effects Continued

– Language functioning

• Interferes with language development and use of language

– Deficits in both expressive and receptive abilities

– Mild speech errors to problems with intelligibility

– Deficits relative to I.Q.

– Deficits in phonological processing

– Visual Spatial Difficulties

• Possible deficits in detailed visual spatial processing as opposed to global processing

– Motor Functioning

• Deficits in fine and gross motor functions

• Difficulties with postural stability

• Poorer academic performance as related to intellectual ability, sometimes exceeding intellectual deficits

– Mathematics deficits

– Reading problems

Academic Problems

Polling Question #3

Academic problems experienced by children with prenatal

alcohol exposure are limited to reading difficulties only. True

or False?

• Linked to significant behavior problems

• Linked to problematic adaptive behaviors spanning from early childhood to adulthood

– Communication

– Daily living skills

– socialization

• Poor social interactions

• Aggressive behaviors

• Inappropriate sexual behaviors

Associated Behavior Problems

Associated Behavior Problems Continued

• Negative affect

• Disrupted school experiences

• Delinquent behavior

• Criminal behavior

• Substance abuse – increased risk of alcohol abuse later in life

• Increased psychiatric disorders/comorbid diagnoses

• Major Depressive Disorder

• Attention-Deficit/Hyperactivity Disorder

• Oppositional Defiant Disorder

• Conduct Disorder

• Identification is key

• Psychological/neuropsychological assessment is necessary

• Home interventions

– Parental psychoeducation regarding abilities and expectations

– Stability of home environment

– Home-based behavioral programming to manage behavioral difficulties

Interventions

• School interventions

– Child may be eligible for Special Education placement with an Individual Education Plan or may be eligible for Section 504 accommodations

– Academic supports geared toward specific deficits

– Behavioral supports addressing problematic behaviors

– Coordination between home and school regarding academics and behavior

– Adaptive skills training

Interventions Continued

Interventions Continued

• Other interventions

– Language and socialization deficits may require interventions by a Speech Language Pathologists

– Motor deficits may be remediated by an Occupational Therapist or Physical Therapist

– Social deficits may improve with direct teaching involved in social skills groups

– Individual psychotherapy to address emotional control and provide alternative coping strategies for stressful emotions.

Summary

• Prenatal alcohol consumption creates a spectrum of

developmental difficulties impacting neurological

development resulting in problematic expressed

cognitive abilities and functioning.

• Specific effects upon the brain and cognitive

functioning are known.

• Impacts upon academic functioning and adaptive

abilities are becoming increasingly clear.

• Behavioral and mental health outcomes are poorer for

individuals exposed to alcohol prenatally.

• Interventions addressing various deficits should be

utilized to maximize outcomes.

Alvik, A. Aalen, O.O., Lindemann, R. (2013). Early fetal binge alcohol exposure predicts

high behavioral symptom scores in 5.5-year-old children. Alcoholism: Clinical and

Experimental Research. Vol 37(11). P. 1954-1962.

Behnke, M., Smith, V.C., (2013). Prenatal Substance Abuse: Short-and Long-term Effects

on the Exposed Fetus. American Academy of Pediatrics 131, number 3, 1009-1024.

Blair, P., O’Connor, M.J. (2011). Behavioral Interventions for Children and Adolescents

with fetal alcohol spectrum disorders. Alcohol Research Health. 34(1) p. 64-75.

Centers for Disease Control and Prevention Alcohol use among pregnant and non-

pregnant women of childbearing age: United States, 1991 – 2005. MMWR: Morbidity and

Mortality Weekly Report. 1009a;58(19):529 – 532. [PubMed]

Chasnoff, I.J., Wells, A.M., Telford, E., Schmidt, C., Messer, G. (2010).

Neurodevelopmental functioning in children with FAS, pFAS, and ARND. Journal of

Developmental Pediatrics 31. p. 192-201.

References

Davis, A. (Eds.) (2011). Handbook of Pediatric Neuropsychology. (1st ed.). New York, NY:

Springer Publishing Company, LLC.

Doney, R., Lucas, B.R., Jones, T., Howat, P., Sauer, K., Elliott, E.J. (2014). Fine motor

skills in children with prenatal alcohol exposure or fetal alcohol spectrum disorder.

Journal of Developmental & Behavioral Pediatrics. Vol 35(9). P. 598-609.

Graham, D.M., Crocker, N., Dewesse, B.N., Roesch, S.C., Coles, C.D., Kable, J.A., May,

P.A., Philip, A., Kalberg, W.O., Sowell, E.R., Jones, K.L., Riley, E.P., Mattson, S.N.

(2012). Prenatal alcohol exposure, attention-deficit/hyperactivity disorder, and sluggish

cognitive tempo. Alcoholism: Clinical and Experimental Research Vol 37(1). P. E338-

E346.

Hepper, P.G., Dorman, J.C., Lynch, C (2012). Fetal brain function in response to maternal

alcohol consumption: Early evidence of damage. Alcoholism: Clinical and Experimental

Research. Vol 36(12). P. 2168.2175.

References

Koren, G., Zelner, Ir., Nash, K., Koren, G (2014). Foetal Alcohol spectrum disorder:

identifying the neurobehavioral phenotype and effective interventions.

Neurodevelopmental and Neurocognitive Disorders. Vol 27(2). P. 98-104.

Lewis, C.E., Thomas, K.E., Dodge, N.C., Molteno, C.D., Meintjes, E.M., Jacobson, J.L.,

Jacobson, S.W. (2015). Verbal learning and memory impairment in children with fetal

alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research. Vol 39(4).

P. 724-732.

Marquardt, K., Sigdel, R., Caldwek, K., Brigman, J.L. (2014). Prenatal ethanol exposure

impairs executive function in mice into adulthood. Alcoholism: Clinical and Experimental

Research. Vol 38(12). p 2962-2968.

References

Nunez, S.C., Florence, R., and Sowell, E.R. (2011). Focus on: Structural and Functional

Brain Abnormalities in Fetal Alcohol Spectrum Disorders. Alcohol Research Health. Vol

34(1). P. 121-132.

Rojmahamongitkol, P., Cheema-Hasan, A., Weltzman, C. (2015). Do Pediatricians

recognize fetal alcohol spectrum disorders in children with developmental and behavioral

problems? Journal of Developmental & Behavioral Pediatrics Vol 36(3). P. 197-202.

Ware, A.L, Glass, L., Cocker, N., Deweese, B.N., Coles, C.D., Kable, J.A., May, P.A.,

Kalberg, W.O., Sowell, E.R., Jones, K.L., Riley, E.P., Mattson, S.N. (2014). Effects of

prenatal alcohol exposure and attention-deficit/hyperactivity disorder on adaptive

functioning. Alcoholism: Clinical and Experimental Research. Vol 38(5). p. 1439-1447.

References

Paulette D. Pitt, Ph.D.

Clinical Assistant Professor

Section of Adolescent Medicine

Department of Pediatrics

Paulette-Pitt@ouhsc.edu

Thank You!

University of Oklahoma

Health Sciences Center

www.naadac.org/prenatalalcoholconsumption

Cost to Watch:

Free

CE Hours

Available:

1.5 CEs

CE Certificate for

NAADAC

Members:

Free

CE Certificate for

Non-members:

$20

To obtain a CE Certificate for the time you spent

watching this webinar:

1. Watch this entire webinar.

2. Pass the online CE quiz, which is posted at

www.naadac.org/prenatalalcoholconsumption

3. If applicable, submit payment for CE certificate

or join NAADAC.

4. A CE certificate will be emailed to you within 21

days of submitting the quiz.

CE Certificate

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