FASD: Co morbid psychiatric conditions and psychopharmacology Dr. Terri Erwin Assistant Professor of Psychiatry Division of Child and Adolescent Psychiatry Associate’s in Pediatrics Weisskopf Child Evaluation Center University of Louisville Louisville, KY

Central Nervous System Abnormalities 1. Structural Cerebral cortex: microcephaly, hypo plastic gyri and sulci Cerebellum, cerebellar cortex, and hippocampus: malformations Corpus Callosum: alterations in structure 2. Neurotrophic effects, Effects on Neurotransmitter receptors, and Effect on Signal Transduction

Central Nervous System Abnormalities/Functional Global Cognitive or intellectual deficits representing multiple domains,(2 SD from mean), Or Functional deficits: (1 SD from mean in 3 areas) Cognitive or developmental deficits Executive Function deficits Motor functioning delays Problems with attention or hyperactivity Poor Social Skills Sensory or Pragmatic language problems, memory deficits

Fetal Alcohol Exposure Effects on Neurobehavior Cognitive: FAS IQ’s often borderline range Psychiatric/Behavioral Memory and learning impairments are common features in FAS and FASD Verbal Learning: variety of problems with language and memory Visual-Spatial Learning: perform poorly on tasks involving learning spatial relationships among objects

Psychiatric/Behavioral Attention: (hallmark of prenatal alcohol exposure), Able to focus and maintain attention, but difficulty shifting attention from one task to another Reaction time: slower less efficient information processing Executive Function: easily distracted and impulsive; difficulty abandoning ineffective strategies when approaching problem solving tasks; respond poorly when asked to switch back and forth from identifying objects

Secondary Disabilities These behaviors may be expressed through secondary disabilities, 6 have been recognized and assessed: mental health issues- more than 90% mental health issues- more than 90% disrupted school experiences - > 60% trouble with the law, (juvenile justice)-60% trouble with the law, (juvenile justice)-60% confinement or incarceration-40% inappropriate sexual behavior Streissguth,A. (1997), Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Brookes Publishing. ISBN

Psychopharmacological Considerations 1. Stimulants 2. Alpha-2 adrenergic agonists 3. Antidepressants 4. Neuroleptics 5. Anti-anxiety drugs

Psychopharm - reviews “Research based interventions for children and youth with FASD.” Child: Care, health, and development. July 2007 Literature review with 2 reviewers assessing eligibility and quality of studies, resulting in 10 studies and unable to obtain 3 studies. Unable to use meta-analysis since studies examined different interventions and outcomes. Studies included stimulants (Methylphenidate, Dextroamphetamine, and Pemoline) and Cognitive Control Therapy. Studies had small samples and/or weak design and no conclusive findings.

Psychopharm “Survey med responses in children and adolescents with FAS.” Mental Health Aspects Developmental Disability. October – December FAS, PFAS, ARND ages 3.5 to 17 years with confirmed in utero exposure. Chart review in child development unit over prior 7 years. 22 patients with 66 med trials Groups of meds: 1. Stimulants 63% responded well 2. Mood stabilizers 88% 3. SSRI’s 82% 4. Antipsychotics 83%

Psychopharm: ADHD and FASD Psychopharm in Neuropsychiatric Diagnosis and Treatment ADHD dx 94% individuals with heavy prenatal alcohol exposure. Some evidence ADHD in FASD is clinical subtype Weak evidence Dextroamphetamine may be more effective than Methylphenidate. Limited scientific evidence on effective interventions for children with FASD and ADHD.

Psychopharm: ADHD and FASD Canadian Journal of Psychiatry. May 2002 Animal and human research FASD + ADHD: Earlier onset of ADHD Inattentive sub-type Co morbid psychiatric, medical, and developmental May be differential response to stimulants.

Psychopharm: FAS and ADHD Streissguth 1997 Univ. of Washington 6 – 16 yr old with FAS + ADHD Predicted Stimulants would improve ADHD symtoms Mixed results

Psychopharm: Executive Function Journal of Canadian Academy of Child and Adolescent psychiatry. Review of EF deficits and pharmacological management in Children and adolesents. Executive System uses Dopamine as main neurotransmitter Dopamine agonists (stimulants) and antagonists (neuroleptics) commonly used to tx EF SSRI’s not very helpful