FASD: Attachment, Comorbidities and Neurodevelopment...Attachment and Autism / De Schippers 2006:...
Transcript of FASD: Attachment, Comorbidities and Neurodevelopment...Attachment and Autism / De Schippers 2006:...
FASD: Attachment, Comorbidities and
Neurodevelopment
Dr Raja Mukherjee
Consultant Psychiatrist /
Lead Clinician FASD Behavioural Clinic
Surrey and Borders Partnership NHS trust
Honorary Reader University of Salford
Countries where FASD has been assessed in literature:
And shows a similar profile
BRIEF Scores from UK and Canada (Mohamed et al 2018)
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85
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Inhib
it
Shift
Em
otio
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Co
ntro
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Beha
vio
ura
lR
egula
tion
Index (B
RI)
Initia
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Work
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Me
mo
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Pla
n/O
rgan
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Org
an
izatio
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ate
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Mo
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Me
tacog
nitio
n In
de
x (M
I)
Glo
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Exe
cu
tive
Co
mpo
nen
t(G
EC
)
UK National FASD Clinic Rai et al. (2016)
Screening prevalence of ]
Fetal alcohol spectrum disorders (FASD) in a region of the
United Kingdom:
a population-based birth-cohort study
Dr Cheryl McQuire et al Population medicine 2018
Results – Clinical Characteristics
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10
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30
40
50
60
70
80
90
100
Growthdeficiency
Fullfacialphenotype
Partialfacialphenotype
CNSimpairment PAE
Proportionw
ithcharacteristic(%
)
NotFASD FASD
Method Total FASD prevalence
Single imputation 6.0%
Complete case 7.2%
Multiple imputation (MAIN
ESTIMATE)
17.0%
(sensitivity analyses 12.7% –
12.8%)
Results – FASD Screening Prevalence
Environment vs Biology
Parts involved
Environmental issues e.g. Attachment
Biological insults e.g. Genetic + prenatal /
postnatal causes
Observed Symptoms
Parts involved
Environmental issues e.g. Attachment
Biological insults e.g. Genetic + prenatal /
postnatal causes
Observed Symptoms
Parts involved
Environmental issues e.g. Attachment
Biological insults e.g. Genetic + prenatal /
postnatal causes
Observed Symptoms
Psychiatric onion! To coin a phrase!
Environmental Influences
Vulnerability from function
Neurodevelopmental
problems
Development of attachment (Schaffer and Emerson)
0 -6 weeks: Asocial; in both social and non social situations will make
responses
6 weeks – 7 months: Indiscriminate attachment; Begin to seek
social contact but from anyone. By 3 months a preference towards main carer is being
established
7-9 months: Specific attachment; preference for one person
established
10 months +: Multiple attachments: Babies begin to develop
attachments and can transfer security
Secure
Avoidant
Ambivalent
Disorganised
Reactive
Adjustment
Disorder
• Inhibited
• Disinhibited
Attachment styles
http://www.practicenotes.org/v19n3/identifying.htm
Attachment and PAE/ FASD , Wray, Palod, Mukherjee
7 Studies (2 FASD)
2 FASD ones showed no effect
Others with Prenatal alcohol exposure showed mixed findings on
attachment with most showing more insecure attachment
(disorganised type) irrespective of initial parenting
Some improvement with good consistent parenting
All had methodological issues
None stratified by intellectual level or level of exposure
Needs more research
Attachment and Autism /
ID research De Schippers 2006: Dutch Study of attachment behaviours
• Some attachment behaviour established
• Variations in the attachment behaviour seen
Schuengel 2007 attachment to parents with Child ID
• Attachment behaviour less clear
• Percentage children secure attachment lower
De Schippers 2008: Observation study Dutch Schools
• Secure attachment behaviour less characteristic.
• Higher the developmental age the more attachment behaviour
seen
Rutgers (2007) Attachment and parenting comparing ASD,
LD and normal controls,
• Parenting not found to be cause of attachment problems in ASD
group
Impact of Neglect and ACE Alcohol 2018
Mukherjee, Price, Norgate, Cook
Effects of neglect
Romanian study. Being adopted after 6 months
shows developmental delays. Even if some catch
up seen not as good as those adopted before 6
months. (Rutter et al 1998, Sonuga Barke2017)
Neglect associated with difficulties with behaviour
issues, emotional issues, cognitive problems,
medical sequelae which remain later in life. (Kauffmann
2009)
Overview Bellis 2005
• Romanian study showed significant neglect
• Tizzard and Hodges 74 and 77with lesser levels of neglect
showed improvement with no significant cognitive deficits
• PTSD common
• Effects on myelination and corpus collsum found but never
controlled alcohol.
Systematic review of Childhood Trauma and PAE (Price et al 2017)
5 Studies identified
Diverse studies with
heterogeneous methods
Where both, more likely to
present with more complex
communicatory, cognitive and
behavioural issues.
Limited by diverse and
sometime flawed methodology
More systematic evaluation
needed
Exploring the impact of Neglect and FASD
PAE Neglect Both
Outcomes
Exploring the impact of Neglect and FASD
PAE Neglect Both
Outcomes
Neurodevelopmental outcomes seen
( no significant difference between groups)
Neurodevelopmental outcome No neglect Some neglect
(up to 6
months)
Prolonged
neglect
Total
Autism spectrum disorder (ASD) or
social communication disorder (SCD)
No ASD/SCD 10 (34.5%) 5 (35.5%) 14 (26.6%) 29 (31.9%)
ASD/SCD 19 (65.5%) 8 (61.5%) 35 (71.4%) 62 (68.1%)
Total 29 13 49 91
Attention deficit hyperactivity disorder
(ADHD)
No ADHD 9 (28.1%) 3 (23.1%) 13 (25.0%) 25 (25.8%)
ADHD 23 (71.9%) 10 (76.9%) 39 (75.0%) 72 (74.2%)
Total 32 13 52 97
Findings Summary
Our findings suggest 2 broad
conclusions
• That Neurodevelopmental disorders
are seen independent of neglect
• Neglect does not appear to make
the neurodevelopmental
presentation any worse
Limitations
• Numbers not huge but does allow
analysis
• Does not have a group of neglect
alone
• Does not measure the psychological
impact and overlap
Exploring the impact of Neglect and FASD
PAE Neglect Both
Outcomes
Henry et al 2007
Specialist MDT assessment of
children
• PAE + Neglect
• Neglect alone
Both had been studied but not
together
Retrospective study 274
children 6-16 Michigan area
Comparing PAEwith Neglect to
neglect alone
• severe neurodevelopmental deficits
in language, memory, visual
processing, motor skills, and
attention greater oppositional/defiant
behaviour,
• inattention, hyperactivity, impulsivity
• social problem
Alan Price PhD ACE and FASD
Behavioural Emotional Social
Online survey advertised via social media
Completed by parents/cares of 253 children aged 4-16 with FASD
from 8 countries, but mostly from UK, USA and Canada
Adverse Childhood Experiences (ACE) questionnaire
• Abuse, neglect, witnessed domestic violence, lived with parent that
was an addict, mentally ill or imprisoned, experienced divorce
Griffith Empathy Measure
• Cognitive and affective empathy
Strengths and Difficulties Questionnaire
• Peer problems, conduct problems, hyperactivity, emotional problems,
prosocial behaviour
Adverse Childhood Experiences
• Sample of children with FASD scored significantly higher than population data on all ACE’s except for physical and sexual abuse.
• Physical abuse score was similar to population data and sexual abuse score was lower.
• However, these Figures probably underestimate the true scores.
• Survey was completed by (mostly adoptive) parents on behalf of their children and many reported being unsure of neglect or abuse.
Strengths and difficulties Questionnaire
• SDQ is standardised and gives a score of average, raised, high or very high
• Most children in general population will score average on every scale.
• Majority of FASD sample of children were very high on every scale. Prosocial is reverse scored so a high score indicates a lack of prosocial behaviour
• Overall, 82% of FASD children were in very high for overall behavioural difficulties.
• On empathy, FASD children in every age range had significantly lower empathy scores than normative data, with high effect sizes.
Relationship between ACEs
and behavioural/emotional/social functioning
No difference in empathy
or behavioural difficulties
related to maltreatment
No correlation between
ACE score and empathy
No, or weak impact of
trauma on
behavioural/social/emotion
al functioning in children
with FASD
Summary and conclusions
Children in this population with FASD had high levels of ACEs including
maltreatment
Low empathy, high levels of behavioural/emotional/social difficulties
Neurological and cognitive functioning was in normal range
Little or no impact of trauma on cognitive and behavioural
functioning identified in children with FASD
Impact on carers
Experiences of caregivers
12 interview with families of 17 of the FASD children
aged 8-14 from neurocognitive study
About half of those children had a history of
maltreatment
Questions on cognitive, daily living, behavioural, social
difficulties of children, and how these affected parents
and other family members
Thematic analysis identified 9 themes, which formed 2
overarching domains
The Child
The system
Experiences of caregivers - trauma
Parents of children with a history of maltreatment
described those events
Parents of children with and without maltreatment
contributed to all themes
Children with history of maltreatment qualified for
services designed for trauma/attachment
Children without maltreatment were also offered these
services
Nothing designed specifically for FASD
Themes found Carers Study ( Mukherjee et al 2015)
Different from other Children
Lack of information given
Lack of knowledge
• in professionals
• How to manage children
Have to fight for things
Misunderstood and blamed
Family stress and benefits of 1:1
Concerns future
Attachment Summary
Limited studies with FASD
Where have been done
• More likely to be disorganised
• Irrespective of parenting
Limitations by level of disability
Damaged underlying brain means
typical attachment not always seen
Biology appears to be influenced
prenatally and leads to vulnerability
that is impacted by experience
Not always the parents fault
How do I diagnose it And how do I make sure I don’t miss
it : Clinical pathways.
How it presents Mukherjee et al JRSM 2006
Gray and Mukherjee JMHLD 2007
Reasons for referral
Growth problems
Behavioural issues
Learning issues
Physical problems
Comorbidity of FASD Svetlana Popova PhD*1,2,3,4, Shannon Lange MPH1,4, Kevin
Shield MHSc1,4, Alanna Mihic MSc2, Albert E. Chudley MD 5,
Raja A. S. Mukherjee, PhD6, Dennis Bekmuradov BA7, and
Jürgen Rehm PhD1,2,4,8
The Lancet Jan 5 2016
Main findings
5068 studies identified of which
127 met criteria for inclusion
428 comorbid conditions linked
to FASD
From 18/22 chapters of ICD10
Important consideration clinically
and research
Co morbidity pooled estimates 1
Conduct disorder
Language disorders
Intellectual impairments
Other mental health disorders
Co morbidity pooled estimates 1
Visual impairments
Hearing issues
Surgical issues e.g. hernia
Other congenital abnormalties
Developmental Divergence by age
2 4 6 8 10 12 14 16 18
FASD
Non FASD
Neurodevelopmental findings Mukherjee, Mohamed, Carlisle 2018
Brain Structure
Alcohol and Myelin
• Clinically delayed myelination it has been observed
• Riikonen et al., 1999
• alcohol-induced delayed myelination are due to the delayed expression of myelin basic protein (MBP) and transferrin
• Ozer et al., 2000
• Effect is decreased speed of neural processing
2. Migration
Note that differentiation
is going on as neurons
migrate.
Courtesy of Diana S. Woodruff-Pak, Ph.D
Alcohol effects migration of cortical
neurons
Control Alcohol
Courtesy of MW Miller
CIFASD DTI studies
fMRI Controls ARND Dys PAE
(FAS)
Controls ARND Dys PAE
(FAS)
Left hand
response to
Same side
stimulation
(LS)
Right hand
response to
Same side
stimulation
(RS)
Slide courtesy of CIFASD and E Riley
Results: ‘Opposite’ Condition Controls ARND Dys PAE (FAS)
Controls ARND Dys PAE (FAS)
Left hand
response to
Opposite side
stimulation (LO)
Right hand
response to
Opposite side
stimulation (RO)
Significant difference between FAS and Control groups in
primary motor (arrows) and premotor areas
Significant difference between FAS and Control groups in premotor area
Slide courtesy
of CIFASD and
E Riley
FASD CONTROL FASD CONTROL
Response to CS at 250ms Response to US at 100ms
FASD fail to fully engage frontal and parietal cortex in the processing of CS+.
Enhanced activation to US reflects lack of prediction of the CS+/US relationship.
CS+
Paired
CS+
unpaired
CS-
never
paired
MEG Activation Patterns
The greater the demand the more the challenge
Cognitive flexibility is an issue
When combined with wider
executive deficits leads to
problems, e.g. holding and
manipulating information
Also affected by wider ability
Outcomes seen
Cause or Effect?
Top down or bottom up ?
Bottom Up: Aetiology
Top Down: Phemomenology
Cluster of Symptoms
Inattention
Hyperactivity
Poor social understanding
Impulsivity
obsessionality
Tics
Poor Planning
Cognitive flexibility problems
Working Memory deficits
Receptive language deficits
Expressive language deficits
Poor imagination
Cluster of Symptoms: ADHD
Poor social understanding
obsessionality
Tics Poor Planning
Cognitive flexibility problems
Working Memory deficits
Receptive language deficits
Expressive language deficits
Poor imagination
Inattention
Hyperactivity
Impulsivity
Cluster of Symptoms: ASD
Inattention
Hyperactivity
Poor social understanding
Impulsivity
obsessionality
Tics
Poor Planning
Cognitive flexibility problems
Working Memory deficits
Receptive language deficits
Expressive language deficits
Poor imagination
Cluster of Symptoms: ASD / ADHD
Inattention Hyperactivity
Poor social understanding
Impulsivity
obsessionality
Tics
Poor Planning
Cognitive flexibility problems
Working Memory deficits
Receptive language deficits
Expressive language deficits
Poor imagination
Cluster of Symptoms: FASD
Inattention Hyperactivity Poor social understanding
Impulsivity
obsessionality
Tics
Poor Planning
Cognitive flexibility problems
Working Memory deficits
Receptive language deficits
Expressive language deficits
Poor imagination
Relationship between disorders
(Chapter 13 FASD Inter professional perspectives Raja Mukherjee)
ASD Diagnoses by FASD category
FAS pFAS ARND Total
(%)
ASD
f84.0 6 19 63 88
(76.5)
Soc
Comm
f80.99
0 0 5 5
(4.3)
No
ASD 1 6 15 22
(19.1)
Total 7 25 83 115
(100)
88
5
22
115
76.5
4.3
19.1
100
0
20
40
60
80
100
120
140
ASD Soc Comm No ASD Total
Chart Title
Number Percent
SCQ scores as a screen for ASD
58.8% are above the internal
threshold for ASD
65.1% Score 13 or more
73.6% score 11 or more
Systematic review suggested
that based on pooled
prevalence (Lange et al 2017)
• ASD 2.6%
• ADHD 52.9%
28
9 7
41
21
106
26.4
8.5 6.6
38.7
19.8
100
26.4 34.9
41.5
80.2
100 100
0
20
40
60
80
100
120
0 to 10 11 + 12 13 + 14 15-21 22+ Total
Numbers Percentage Cumulative percentage
An example of complexity that needs to be
understood
S
o
c
i
a
b
i
l
i
t
y
High
Low
Angelmans
Runbenstein Taybi
Fragile X
Different types of social functioning
In people on the Autistic Spectrum
Oliver et al 2012 Cornelia de Lange
FASD
ADHD outcomes by FASD diagnosis
FAS pFAS ARND Total
(%)
ADHD
Combined 7 7 25 39 (30)
ADHD
Inattentive 2 14 42 58
(44.6)
ADHD
Hyperacti
ve/
Impulsive
1 1 1 3 (2.3)
No ADHD 0 7 23 30 (23.1)
Total 10 29 91 130
(100)
39
58
3
30
130
30
44.6
2.3
23.1
100
0
20
40
60
80
100
120
140
ADHD Diagnoses Percentage
76.9% will meet diagnostic criteria for
One forms of ADHD
Single item analysis of ADHD diagnostic criteria: inattentive symptoms
Percentage of Group meeting
Criteria (%) Total in group (130)
Not pay attention 77 (59.2)
Fail to stick at task 37 (28.5) Can stick to self directed
activity
Not listen when spoken to 77 (59.2)
Fail to Finish an instruction 100 (76.9)
Difficulties planning 113 (86.9)
Avoid areas find difficult 114 (87.7)
Loose things needed for task 101 (77.7)
Easily distracted 119 (91.5)
Forgetful 104 (80.0)
Single item analysis of ADHD diagnostic criteria: Hyperactive impulsive
criteria
Percentage of Group meeting
Criteria (%) Total in group (130)
Sits fidgeting 84 (64.6)
Gets up when should sit down 50 (38.5)
Not stay still / squirm 48 (36.9)
Cannot be quiet 57 (43.8)
Driven by a motor 38 (29.2)
Talk excessively 59 (45.4)
Blurt out answers 89 (68.5)
Difficulties waiting turn 82 (63.1)
Interrupts others 107 (82.3)
Comparison Between Cohort and Steinhaussen 2002
FAS Current
(n=21)
FAS *
(n= 38)
PWS *
(n=42)
FRAX *
(n=49)
Mean age (range) 9.9 (6.10- 16) 6.3 (4-12) 7.8 (3-16) 8.6(5.7-16.10)
Disruptive Subscale
Abusive 51.7(12) 57.9 (22) 25.6(10) 53.1(26)
Overexcited 85.7 (18) 65.8 (25) 46.2 (18) 71.4 (35)
Impulsive 100(21) 68.4(26) 46.2 (18) 79.6(39)
Irritable 80.9 (17) 57.9 (22) 25.6 (10) 59.2(29)
Jealous 85.7 (18) 63.2 (24) 30.8 (12) 55.1 (27)
Kicks hits others 71.4 (17) 73.7 (28) 25.6(10) 53.1 (26)
Mood changes rapidly 76.2 (16) 68.4 (26) 35.9 (29) 59.2(29)
Noisy or boisterous 90.4 (19) 78.9(30) 12.8(5) 57.1 (28)
Overly attention seeking 80.9(17) 78.9 (30) 38.5(15) 77.6(38)
Throws or breaks objects 66.7(14) 65.8(25) 12.8 (5) 49(24)
Manipulates or provokes others 66.7 (14) 63.2(24) 25.6(10) 40.8(20)
What happens if I miss it ?
It is everything getting on top on the person that leads to them kicking off!
Person with FASD
over aroused
Trauma
Auditory filtering
Executive deficits
Communication Sensation seeking
Social communication
difficulties
Cognitive flexibility problems
Vineland adaptive behaviour schedule: adaptive age scores
(n=51)
Domain Minimum Maximum Average
Age 6.10 16.00 9.93 (95%CI)
Receptive language 1.1 8.6 3.3 (2.8-3.6)
Expressive
language
2.9 13.0 5.4(4.9-5.9)
Written Language 4.5 14 8.1(7.4-8.8)
Personal Daily living
Skills
2.9 11.3 5.4(4.8-6.0)
Domestic Daily
living skills
1.0 20 6.2(5.3-7.1)
Community skills 2.5 16.3 6.9(6.2-7.6)
Interpersonal skills
0.9 13.6 4.3 (3.7-5.0)
Play/ leisure
socialisation
1.1 13.6 4.7(3.9-5.5)
Coping 1.1 12.6 4.4(3.8-5.1)
Behavioural Checklist (Sakano, Mukherjee, Turk 2018)
0
10
20
30
40
50
60
70
80
90
100
Disruptive Self Absorbed Communication Anxiety Social relating Total
Behaviour Checklist Percentile Ranks n=99
Parent Report Teacher Report
Secondary Disabilities
Disability %
Psychiatric problem 90
Disrupted School
experience
60
Trouble with the law 60
Confinement 50
Inappropriate sexual
behaviour
50
Alcohol /Drug
problems
30
Streissguth et al 1996, 2000
Ok So what difference does it make?
New publication on management Young et al 2016
Available on my research gate site
Intervention areas
Intervention areas
Red Flags
Rarely present as FASD but knowing FASD modifies
treatment response
• Complex NDD
• Non typical response to medication
• Hx of LAC / adoption and fostering
• Inattentive/ impulsive subtype with higher level of social
communication issues and sensory problems than typical ADHD
Treatment pathway
Principles
Try non pharmacological strategies first
Then if well try stimulant
• Principle of when needed and dose release
• Methylphenidate / dexamphetamine choice
If not working then re think and look if other things
affecting situation
Then change/ add
Additions if more complex presentation
FASD Clinic