The Impact of Child Trauma & Prenatal Alcohol Exposure on Neurobiological Development & Function :The Impact of Child Trauma & Prenatal Alcohol Exposure on Neurobiological Development & Function Western Michigan University College of Health & Human Services HSV 6350-105 Special Topics Course: Child Trauma Module 2, Part 2 Mark A. Sloane, DO Center for Behavioral Pediatrics WMU Children’s Trauma Assessment Center Kalamazoo, MI With Audio


Neurodevelopmental Function: FASD & Traumatic Stress :Neurodevelopmental Function: FASD & Traumatic Stress Including research data: WMU CTAC (2000-2006)


Essential Neurodevelopmental Functions :Essential Neurodevelopmental Functions Attention Language Memory Neuromotor Visual-Spatial Processing Tempero-sequential processing Higher-level cognitive processing Social ability


Attention :Attention


Attentional Function :Attentional Function “Attention is at the center of human performance” William James (1890) Much more than ? ADHD…yes or no Profoundly affected by many neuropsychiatric conditions Profoundly affected by FASD Profoundly affected by traumatic stress exposure


Attentional Function :Attentional Function Exceedingly complex CNS function involving: Alertness / arousal (keeping the brain awake & alert) Attentional processing (focus & concentration) Production (impulse) control (weighing / editing behavioral responses)


Norepinephrine role in attentional function :Norepinephrine role in attentional function Dampens noise Executive operations Facilitates inhibition Solanto. Stimulant Drugs and ADHD. Oxford; 2001. Norepinephrine


Dopamine role in attentional function :Dopamine role in attentional function Enhances signal Improves attention Focus On-task behavior On-task cognition Solanto. Stimulant Drugs and ADHD. Oxford; 2001. Nigrostriatal Pathway Mesolimbic Pathway Substantia nigra Ventral tegmental area Mesocortical Pathway Dopamine


Slide 9:NEURODEVELOPMENTAL FUNCTION Attention N=103 N=155 Percentile


Language :Language


Language :Language Critical medium for receiving information Major vehicle for transmitting ideas, feelings (including frustration), & information to others Essential element for social communication and interaction Essential catalyst for memory function


Language :Language Valuable code for reasoning, problem solving, and creativity Facilitates metacognition (thinking about thinking) Serves as a means of introspection Tool for learning new motor skills


Language :Language The Language of Language Phonology (sound-symbol awareness) Morphology (morphemes ? words / phrases) Semantics (specific words / meanings) Syntax (words ? sentences via grammar) Discourse (passages & paragraphs) Pragmatics (social language) Metalinguistics (thinking about language)


Language :Language Language Processing Receptive language (understanding others) Language Production Expressive language (Finding words in our memory and then putting words together in phrases, sentences and passages) Speech articulation (How we form the sounds and words we speak)


Language :Language Linguistic ability CRITICAL for optimal academic functioning (especially in secondary school) Attention & Language overlap: Diagnostic issues Importance often overlooked during clinical assessment for school dysfunction 88% of CTAC clients had moderate to major language problems Traditional training for SLPs does not include any information re FASD and/or traumatic stress


Slide 16:NEURODEVELOPMENTAL FUNCTION Receptive Language N=103 N=156 Percentile Clinically Significant


Slide 17:NEURODEVELOPMENTAL FUNCTION Expressive Language N=102 N=157 Percentile


Memory :Memory


Memory :Memory Learning without memory is inconceivable Major memory impact: FASD /trauma Closely collaborates w/ other ND functions Memory capacity ?? w/ age, but… Memory demands also ?? and reach apex in childhood / adolescence (esp. c/w adults) Memory NOT a simple or unitary concept


Memory :Memory Registration Auditory Visual Short-term memory Working Memory Sequential memory Long-term memory Retrieval


Slide 21:NEURODEVELOPMENTAL FUNCTION Memory N=101 N=156 Percentile


Neuromotor Function :Neuromotor Function


Neuromotor Function :Neuromotor Function Fine Motor Graphomotor Gross Motor Neuromaturational Associated movements Synkinesia


Neuromotor Function :Neuromotor Function Intricately linked to other ND functions “Double jeopardy” when children w/ learning problems also have motor problems Motor proficiency can be valuable asset in LD / ADHD kids Gross motor problems have ? impact as age ? Sensory processing impact: FASD / trauma Developmental Output Failure (DOF)


Neuromotor Function :Neuromotor Function DOF as “final common pathway” Multiple inter-related ND pathways involved: Graphomotor disability Memory deficiency Attentional dysfunction Expressive language problems Organizational problems


Neuromotor Function :Neuromotor Function Impact of DOF DOF problems “peak” in middle school Can profoundly impact self-esteem Often leads to frustration & mood problems (including explosiveness) Ubiquitous in FASD & traumatized kids


Slide 27:NEURODEVELOPMENTAL FUNCTION Fine Motor Function N=103 N=157 Percentile


Slide 28:NEURODEVELOPMENTAL FUNCTION Graphomotor Function N=103 N=157 Percentile Clinically Significant


Slide 29:NEURODEVELOPMENTAL FUNCTION Gross Motor Function N=102 N=156 Percentile


Visual Processing :Visual Processing “3-D” thinking Spatial relationships Non-verbal problem solving Often a relative strength in these kids Can contribute to frustration /explosiveness when kids have strong visual skills and poor language ability


Slide 31:NEURODEVELOPMENTAL FUNCTION Visual Processing N=100 N=155 Percentile


Temporal-sequential Processing :Temporal-sequential Processing Sequential analysis and serial order Time as major medium for TSP Sequential detail is processed: Visually Auditorily Kinesthetically Critical for effective / efficient production


Temporal-sequential Processing :Temporal-sequential Processing TSO Dysfunction Confusion w/ time concepts (before, after, until) Delayed mastery: days of week, months of yr Trouble w/ multi-step directions / explanations Difficulties w/ complex sequential motor tasks Difficulty w/ narrative organization (summarization, writing, oral re-telling) Poor use of time, chronic “lateness”, problems “staging” projects


Slide 34:NEURODEVELOPMENTAL FUNCTION Sequencing N=99 N=155 Percentile Clinically Significant


Higher-level Thinking Skills :Higher-level Thinking Skills Concept formation / acquisition Problem-solving skill Integration abilities Rule development & utilization Divergent / creative thinking Metacognition “Thinking about thinking” Represents ultimate level of human intellectual activity Often becomes problematic in MS / HS / college


The school age child’s battle cry: :The school age child’s battle cry: AVOID HUMILIATION AT ALL COSTS !!!


Social Ability :Social Ability Social success is of paramount importance Children are preoccupied with: Evading embarrassment Face saving Looking good Social maneuvering may take precedence over academics, drains attention / energy, & requires keen skill Many interrelationships w/ other ND functions Often overlooked during assessment process


Social Ability :Social Ability ND dysfunction & impact on social ability Attention / intention Impulsive, poorly planned acts / aggressive behavior Trouble sharing / lack of attention to social detail Difficulty with social prediction Memory (problems learning from experience) Language (? pragmatics [social communication] ? expressive language) Higher-order cognition (? social metacognition)


Important neurodevelopmental functions are impaired in FASD and traumatized children & adolescents :Important neurodevelopmental functions are impaired in FASD and traumatized children & adolescents


Slide 40:Kaufman Brief Intelligence Test (K-BIT) N=141 N=193 Average Below Average


Treatment Overview in FASD & Child Traumatic Stress :Treatment Overview in FASD & Child Traumatic Stress


Multimodal Management :Multimodal Management Comprehensive assessment is critical (and is the first step in treatment!) Individual psychotherapy (especially when the child is also traumatized) Family therapy Cognitive Behavior Therapy (some limitations) Play Therapy Social skills training (limited evidence-base)


Multimodal Management :Multimodal Management Parent / caregiver training Behavioral Coaching / Strategies Collaborative Problem Solving Advocacy / effective classroom strategies in the schools Language therapy (including social skills training using pragmatic vehicle) Expressive therapies (Dance, Art, Music)


Multimodal Management :Multimodal Management Demystification / psychoeducation (for all parties) Occupational Therapy (especially Sensory Processing Treatment) Psychotropic medication(s)


Role of Medication in Neurodevelopmental Pediatrics & FASD / Traumatic Stress :Role of Medication in Neurodevelopmental Pediatrics & FASD / Traumatic Stress


Changing Landscape of Psychotropic Medication :Changing Landscape of Psychotropic Medication Since 2000, many new medications have been introduced It is difficult for primary care physicians to keep pace with new meds Especially tough for professionals / caregivers to get useful information on medication New choices = new treatment opportunities These are exciting times!!


Psychopharmacologic Treatment :Psychopharmacologic Treatment Important points in using medications: Target Symptoms vs DSM-IV Diagnoses “Deconstructing the DSM” Impairment of Function required : Starting medications Changing medication doses Changing type of medication


Psychopharmacologic Treatment :Psychopharmacologic Treatment Important points in using medications: Emphasize to parents that the GOAL of medication treatment is to restore brain function as much as possible The goal is NOT to cover up behavioral symptoms !!!!!!!!


Psychopharmacologic Treatment :Psychopharmacologic Treatment Essential to explain the how and why of medication to the kids!!! Use simple / concrete analogies: Computer (“Your software / operating system needs upgrading”) Car (“Your engine / brain is fine…but you need high-octane fuel” (meds) “Glasses for your mind”


Important take-home point! :Important take-home point! Medication should never be thought of as another intervention that reinforces to the child that he/she is bad


Educators / other health professionals & medication :Educators / other health professionals & medication Professional’s input here is simply invaluable!! PCPs can not treat these kids optimally without professional’s input! Professional should NOT stress about having too much responsibility here “I am not a physician…” Just observe carefully and report your observations!!!


Remember, its all about… :Remember, its all about… Leveling the playing field!!!!


Medication Treatment Issues in FASD & Traumatic Stress :Medication Treatment Issues in FASD & Traumatic Stress Controversial area Accurate diagnosis of comorbidity is major key to effective medication treatment Presence or absence of traumatic stress is also important Significant limitations of DSM-IV as treatment paradigm


Medication Treatment Issues in FASD & Traumatic Stress :Medication Treatment Issues in FASD & Traumatic Stress “Deconstructing the DSM” Target symptoms appear to be more appropriate re treatment Anger / explosiveness is common in FASD +/- traumatic stress Anxiety issues MAY be more problematic in traumatic stress (+/- FASD)


Medication Treatment Issues in FASD & Traumatic Stress :Medication Treatment Issues in FASD & Traumatic Stress Very limited medication treatment literature available NO double-blind placebo controlled data Treatment of dysregulated affect is often key to successful medication management Polypharmacy is the rule not the exception


Medication Treatment Issues in FASD & Traumatic Stress :Medication Treatment Issues in FASD & Traumatic Stress CTAC has evaluated > 1500 clients since 2000 ~40% of CTAC clients have had FASD MAS has done >400 medication consultations MAS currently following ~100 FASD patients Retrospective chart review recently completed FASD pilot study being planned NIMH prospective study currently being planned


Practical Medication Considerations in FASD :Practical Medication Considerations in FASD Cannot simply consider FASD alone when making medication decisions No specific medication for FASD per se Must factor in genetics (family history of neuropsychiatric illness) Must factor in traumatic stress issues No existing database in the current med literature: Anecdotal information (e.g., my retrospective study) and clinical experience become paramount Evidence-based prescribing ? Prescribing-based evidence


Practical Medication Considerations in FASD :Practical Medication Considerations in FASD FASD without trauma seems to be less “intense” re medication complexity / difficulty Stimulants are MUCH more difficult to use in FASD with comorbid mood disorders (including traumatic stress) Mood generally should be addressed first, especially if stimulants are being considered


Final Thoughts - I :Final Thoughts - I Medication often “levels the playing field” for traumatized / FASD children! This then allows other essential treatment modalities to be more effective: Trauma-focused CBT / EMDR Occupational Therapy (Sensory Integration) Play Therapy Psychoeducation of families, schools, MH professionals, physicians, etc.


Final Thoughts - II :Final Thoughts - II Useful websites: www.nctsnet.org www.nofas.org www.fasalaska.com www.come-over.to/fas/ www.depts.washington.edu /fadu


References :References Fast DK, Conry JL, Loock CA. Identifying Fetal Alcohol Syndrome Among Youth in the Criminal Justice System, Journal of Developmental & Behavioral Pediatrics 20:370-372 (1999) Malbin D. FAS/FAE: Strategies for Professionals (1993) Moore TE, Green M. FASD: A Need for Closer Examination by the Criminal Justice System Criminal Reports 19:99-108 (2004) National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, FAS: Guidelines for Referral & Diagnosis (2004) Streissguth A. Fetal Alcohol Syndrome: A Guide for Families & Communities (1997) Streissguth A. The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities (1997) Streissguth A, Bookstein FL, Barr HM, et al, Risk Factors for Adverse Life Outcomes in FAS/FAE. Journal of Developmental & Behavioral Pediatrics 25:228-239 (2004) Wiig J, Widom CS, Tuell JA, Understanding Child Maltreatment & Juvenile Delinquency: From Research to Effective Program, Practice and Systemic Solutions. CWLA Press (2003)


Please Post Questions On-line :Please Post Questions On-line


Slide 65:Thank you all for coming!