FASD: Co morbid psychiatric conditions and psychopharmacology

Dr. Terri Erwin Assistant Professor of Psychiatry

Division of Child and Adolescent PsychiatryAssociate’s in Pediatrics

Weisskopf Child Evaluation CenterUniversity of Louisville

Louisville , KY

Central Nervous System Abnormalities

1. StructuralCerebral 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/BehavioralMemory 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%

disrupted school experiences - > 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 1-55766-283-5

Psychopharmacological Considerations1. 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 2001.

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. 2010.

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 ADHDInattentive 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 FunctionJournal 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