COSIG CONFERENCE BROCHURE.pdf - Drexel University College ...

Fetal alcohol spectrum disorders for mental health professionals Lockhart 467
respect to their psychiatric presentation, attention
disorders, depression, suicide threats/attempts, panic
attacks and hallucinations, were the most common
mental health problems in a group of 415 individuals
in the `secondary disabilities' study of Streissguth et al.
[38]. In that study, exposed individuals also had more
problems with conduct disorder, sexual problems and
substance use disorders than the general population.
Attention disorders, a common and pervasive problem
for alcohol-exposed individuals, continues to be poorly
understood. In an important study by Coles et al. [39], a
group of children with attention de®cit hyperactivity
disorder (ADHD) was compared to children with
prenatal alcohol exposure on various measures of
attention, as de®ned by Mirsky et al. [40] (e.g. focus,
shift, encode and sustain). Her team found that the two
groups were different on these four attention measures.
Children with prenatal alcohol exposure had more
dif®culties with encoding and shifting attention,
whereas the children diagnosed with ADHD had more
dif®culties with focus and sustaining attention. Streissguth
et al. [4 .. ] found that 60% of subjects aged 6±21
years with both FAS and fetal alcohol exposure reported
attention de®cit problems. Attention problems appear to
be a common disability in this population, but studies
are still underway to understand its underlying neurobiology
and relationship with the clinical diagnosis of
ADHD.
Oesterheld et al. [41] found a prevalence rate of ADHD
symptoms in 54.5% of 22 subjects with FAS at their
Birth Defects Clinic (followed from 1984 to 1997),
utilizing the Connors parent rating scales and the
Connors teaching rating scales. Oesterheld et al. [42]
also carried out a pilot study on the effectiveness of
methylphenidate in four native American children with
FAS living in a residential center. She found that
methylphenidate was effective in all four children on
scores of hyperactivity but not on daydreaming attention
scores.
A self-report questionnaire for maternal and child
depression was administered by O'Connor and Kasari
[43 .. ], to study the relationship between prenatal alcohol
exposure and depressive symptoms. They found that
prenatal alcohol exposure, maternal depression, and the
child's gender seemed to be highly correlated with
childhood depressive symptoms. The authors suspect
from their ®ndings however that mood disorder symptoms
elicited in this study may be more the organic
effect of alcohol related neurotoxicity than environmental
or genetic factors; although they clearly must be
considered as possible factors [44]. They concluded that
prenatal alcohol exposure is a risk factor for early onset
depression.
There is a huge body of data accumulating about the
neurobiological underpinnings of DSM IV disorders
especially ADHD. Treatments for these disorders
continue to be based on research performed on
individuals without the markedly disturbed CNS that
is characteristic of many of those with prenatal alcohol
exposure. As a result, attempts at psychopharmacological
and psychotherapeutic approaches to behavior and
emotional disorders using generic treatments for these
individuals continue to be even more complicated and
challenging than in the treatment of non-alcohol
exposed populations.
Treatment implications
For mental health providers, one of the most challenging
issues is the ability to identify a patient (especially an
older patient) who may have psychiatric and cognitive
disability as a consequence of prenatal alcohol exposure.
In the identi®cation, there is an acknowledgement that
the patient has an organically based disability, and is not
necessarily exhibiting dif®cult behaviour out of wilful
disobedience or other motivation. These individuals
have, in addition to the major psychiatric symptoms
present, executive functioning abnormalities and social
skills disability that may not improve greatly with an
amelioration of mood, ADHD, psychotic or anxiety
symptoms. The neuropsychiatric symptoms when superimposed
on cognitive disability can produce even more
severe psychosocial disability not treatable with medication
alone. And as described previously, because of the
delirious effects of alcohol on the developing brain,
these individuals may not respond fully to standard
pharmacological protocols. These standard treatments
however can be helpful and often reduce the sometimes
extreme nature of behavioral and emotional dif®culties.
Alcohol exposed individuals with even average or higher
intelligence often are described by their parents and
teachers as having social and moral de®cits, as well as
problems in adaptive living skills. These organically
based de®cits appear to lead them into everyday
problems of understanding cause and effect, exercising
good judgment, avoiding victimization, being appropriately
guarded with strangers, and not acting on impulses.
These individuals are also susceptible to committing
`innocent crimes', in which they can be arrested or
incarcerated for offences they did not understand they
were committing. These are problems that continue to be
dif®cult to solve even with appropriate psychiatric care,
emphasizing the importance of multilevel treatment [44].
Important areas to cover in the affected alcohol exposed
patient include psychopharmacological treatment, behavior
therapy, proper educational placement, speech and
language services, occupational therapy, direct advocacy
(with a personal 1 on 1 aide), parent education and
support, social services, and vocational services.