These letters create quite an alphabet soup for many parents. First of all you are tired from a lack of sleep and the constant managing of behaviors. Then you keep hearing these letters from well intentioned loved ones and professionals. Family and friends keep talking about ADHD. But the meds and treatment haven't been working. You wonder about fetal alcohol and drug exposure, but don't know a lot about the mother's use, especially in the first trimester.
Earlier this month I had the opportunity to attend a full day workshop with Dr Ira Chasnoff, MD. Ira J. Chasnoff, M.D., an award-winning author, researcher and lecturer, is president of NTI Upstream and a Professor of Clinical Pediatrics at the University of Illinois College of Medicine in Chicago. He is one of the nation's leading researchers in the field of child development and the effects of maternal alcohol and drug use on the newborn infant and child. Since 2002, Dr. Chasnoff has been leading cutting edge research into innovative treatment for children with Fetal Alcohol Syndrome and thought I'd share some of the information I learned with you.
For those of us in foster or adoptive families we often don't have a lot of information about the mother's alcohol & drug use during pregnancy, so unless we see some obvious facial features or have a positive drug test in a newborn we don't think about long term effects of any possible use. But what I learned is a couple of interesting findings...
If the biological father is high at the time of conception there is some early research that this could impact the functioning of the child later in life
If the biological mother has a binge drinking experience during days 16-22 of gestation this could permanently impact the dopamine levels of the child. (Note: Dopamine is a neurotransmitter that helps control the brain's reward and pleasure centers. Dopamine also helps regulate movement and emotional responses, and it enables us not only to see rewards, but to take action to move toward them. Dopamine deficiency results in an increased rate of addiction due to the individual looking to feel pleasure.)
A pregnant mom shares oxytocin levels with fetus. When she feels positive towards the baby and her partner, she feels happy and then the oxytocin levels in her brain go up. Because they share these levels as her oxytocin goes up do the baby's. Drugs decrease natural oxytocin levels. If a pregnant mother doesn’t feel warm for the fetus and is using drugs to help feel better. This leads to an infant with supressed oxytocin levels resulting in attachment disorders as those with low oxytocin levels struggle to create emotional bonds.
If drugs are used in the first 20 days of pregnancy dopamine levels are permanently damaged. True ADHD is the result of genetic low levels of dopamine. Medications like Ritalin & Concerta release dopamine and help individuals improve their pre frontal cortex functioning. However, if the low levels of dopamine are due to substance use in pregnancy these medications may have the opposite effect and result in increased activation and even aggression in some children. In these situations medications like Guanfacine are actually more helpful.
80% of substance abusing women also abuse alcohol. The same is true for pregnant women. Polysubstance abuse is creating much more problematic brain development issues. So if you have information that the biological mother used substances during pregnancy, you can assume there is a good chance she also used alcohol.
Alcohol exposure limits the ability to transfer information from short term to long term memory. So they may have good short term, but it won’t last. However, early intervention before age 6 can make significant permanent improvements in this area.
There have been cases of fraternal twins where one displays features of FASD and the other does not have any symptoms. So in some families it appears that despite consistent substance use by the mother, does not always result in a diagnosis for each child. However, it appears that the younger children have more symptoms that the other. One hypothesis of this is that the liver is having more trouble with the alcohol and more of the toxins are going to the fetus than in earlier pregnancies.
Some regions of the world, like South Korea, have significantly higher rates of FAS and it appears due to a later exposure to alcohol (so poorer tolerance) as opposed to western european nations whose citizens have been drinking alcohol for centuries.
So what is Fetal Alcohol Spectrum Disorder (FASD)?
The diagnostic criteria includes the following three details:
I. Confirmed prenatal alcohol exposure
II. Growth impairment (shorter than average height, low birth weight)
III. Facial dysmorphology (folds on the eyes, flat bridge on the nose, upturned nose, flat skin under the nose, thin upper lip, lower set ears)
But if you don't have a confirmed prenatal alcohol exposure report and they are average height without facial symptoms, do you just go back to ODD and ADHD? Not necessarily! There are a lot of functioning issues that have resulted in a new diagnosis of Alcohol-Related Neurodevelopmental Disorder (ARND).
Cognitive & Behavioural Problems with With FASD and Alcohol-Related Neurodevelopmental Disorder ARND
1. Neurocognitive functioning: Most substance exposed kids will have IQ in the mid 80’s. So we are looking for an IQ generally 70 or above, but have issues with executive functioning, learning disabilities and memory issues. Does your child struggle with the following?
Poor ability to work with abstract thought?
Problems with memory?
Black and white thinking comes easy, but grey issues are challenging?
Difficulty delaying gratification
Impaired judgment & struggles with cause and effect thinking
Risk-taking behavior & sensation seeking
Might not be able to differentiate between safe and unsafe behavior
Problems with time, budgeting, deadlines
If you bring your child in for a neuropsychological evaluation ask for them to complete a "BRIEF" test. This is the Behavioral Rating Inventory of Executive Functioning which will help evaluate their Neurocognitive Functioning.
2. Self Regulation: Does your child struggle with self regulation? ADHD appears similar as both disorders result in challenges with attention and impulsivity. But substance exposed children and teens will also demonstrate issues with mood swings. These kiddos are always hyper-aroused, so it’s like a pot on the stove and then when a trigger happens they are ready to boil over. This issue with regulation can impact sleep and sensory processing as well. Look for...
Difficulties with social interactions
3. Adaptive Functioning: This refers to the ability to take what you know and apply it to daily living. Is your child able to communicate, socialize and get around in the world?
Does your child have issues with communication or social skills? Do they have age appropriate close friends?
Abstract reasoning and concept formation? In most school systems around age 8 or 9 is when instruction moves from concrete to abstract reasoning. So for a lot of children that struggle with adaptive functioning they will begin to have behavioral / academic problems around this time as the work will become more difficult for them.
If you bring your child in for a neuropsychological evaluation ask for them to complete a "Vineland" or "Adaptive Behavior Adaptive System" ABAS. These tests help differentiate from ADHD or exposure problems.
If the above bullet points are making you wonder. It may be worth while to request an evaluation. If you live in the Chicago area, Dr Chasnoff's clinic The Children's Research Triangle specializes in these evaluations and treatment and has contracts with DCFS.
What do to with an exposed infant?
If you take home a baby who you know was exposed to alcohol or drugs in utero begin using attachment soothing strategies immediately. These include:
Skin to skin whenever possible at feeding. Even if you are fostering, even if you are bottle feeding. This helps the child develop the ability to bond and attach and even if they only live with you a short time it will improve their brain chemistry and allow them to bond with their parents in the future.
Baby wearing as much as possible.
When you can see the baby getting emotionally overloaded: Swaddle in a flexed position (knees up & arms in) and give them a pacifier - this will increase their natural opiate levels which will help them calm down.
If you have a crying baby who is going through withdrawals (which can last up to 8 months) and you feel that you are becoming tense yourself, put the baby down on their back and step away and take some deep breaths so you can relax. The baby matches your heart rate and stress level so it is no good to continue to hold them when you are upset. Once you have taken a moment, pick up the baby and hold him out at arms length face up. When you are able to be calm starting talking in a soft voice (watch the sucking motion on the pacifier to notice opiate levels raising). The LAST thing you do is show the baby your face. For many of these children looking at a face up close is too stimulating and upsetting
Vertical rocking (tipping over forward) instead of side to side or up and down. They will find this much more soothing.
Eliminate mobiles, bright lights and colours as these can be over stimulating
No bouncy stuff… just floor time. All you need is a blanket.
No babysitters for first 6 months of adoption (minimum 3 months, 6 months is ideal). Let them be with the parents all the time in order to create a strong bond.
Like I said, these are some bullet points from the workshop I attended that kind of blew my mind. I would really encourage you to take some time and think about your foster & adoptive children with this lens. Check out the links below to become more educated on this topic. Do you need to advocate for more evaluations? Is it time for a different parenting strategy, therapy or medication? What does your child need from you today to have the best chance at success tomorrow?
Further Links & Resources:
NTI Upstream is Dr Chasnoff's company. Click the link to find information on his latest book, The Mystery of Risk, as well as other resources.
Psychology Today has a 29 articles written by Dr Chasnoff on various subjects including FASD, medical marijuana and pregnancy, heroin and pregnancy, how substance exposure impacts sleep, etc, that you can access by clicking the above link.
Implications of FASD for the Adoptive Family - One hour free NOFAS Webinar with Dr Chasnoff on Youtube.
The American Academy of Pediatrics FASD Toolkit.
The CDC has an informative article on FASD Basics.