Creating a Family: Talk about Adoption & Foster Care

Prenatal Exposure: Diagnosing and Treatment

November 23, 2022 Creating a Family Season 16 Episode 47
Creating a Family: Talk about Adoption & Foster Care
Prenatal Exposure: Diagnosing and Treatment
Show Notes Transcript

Do you wonder if your child was prenatally exposed to alcohol or drugs? There may be nothing in the files, but something feels not right? We talk about diagnosing and treating these kids with Dr. Larry Burd, a professor of pediatrics at the University of North Dakota School of Medicine and the Director of the North Dakota Fetal Alcohol Syndrome Center.

In this episode, we cover:

  • Most of our audience is foster, adoptive, and kinship parents and professionals. Often they don’t know for sure if a child has been exposed. The US government estimates that about 10% of all children in the US have been prenatally exposed to alcohol or drugs. Do you have a feel for the percentage of children in foster care or who have been involved with the child welfare system? International adoption? Domestic infant adoption?
  • Does prenatal exposure increase the likelihood of a disruption to a foster or adoptive placement? 
  • How is prenatal exposure to alcohol detected or diagnosed?
  • What type of training do pediatricians receive during their education or residency on prenatal exposure and on how to diagnose?
  • Can you tell at birth or in infancy if a baby has been exposed to alcohol in utero?
  • How is prenatal exposure to drugs detected or diagnosed?
  • How does birth order change the likelihood that a child who is at risk has been exposed during pregnancy?
  • What are the long-term impacts of alcohol exposure? What are the symptoms that are most noticeable to parents, teachers, and other professionals working with these children?
  • Alcohol exposure affects multiple systems in the body.
  • Does it matter what type of alcohol was consumed?
  • Who can diagnose a child with Fetal Alcohol Spectrum Disorder?
  • What are the long-term impacts of the following drugs?
    • Opioids
    • Heroin and Fentanyl
    • Depressants (benzodiazepines, such as Valium, Xanax)-Prescribed and unprescribed
    • Stimulants-Prescribed and unprescribed
    • Methamphetamines
    • Marijuana
    • Tobacco/Nicotine
  • Do pediatricians have a body of resources to offer parents regarding raising a child with prenatal exposure?
  • Tips for parents

Additional Resources Mentioned in Interview:

Still Face Experiment

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Please pardon any errors, this transcript is automated
Welcome, everyone to Creating a Family talk about adoption and foster care. I am Dawn Davenport and I'm the host of this show, as well as the director of the nonprofit creating a Today, we're going to be talking about prenatal exposure. How do you know if your child has been exposed and then what to do about it? We will be talking with Dr. Larry Burd. He is a Professor of Pediatrics at the University of North Dakota School of Medicine, and the director of the North Dakota Fetal Alcohol Syndrome Center. Well, prenatal exposure, let me just start by saying can be to alcohol or drugs and the drugs can be both legal and illegal. And quite frankly, often children are exposed to both. In this discussion, we're going to be trying as much as possible to be inclusive of all prenatal exposures, unless we specify otherwise. All right, so let me just jump in. So most of our audience is foster adoptive and kinship parents as well as professionals. And often they don't know for sure if the child has been exposed. So the US government estimates at about 10% of all kids in the US children born in the US have been prenatally exposed to alcohol and drugs. Do you have a feel for the percentage of children in foster care who had been involved with the child welfare system?

Well, certainly in foster care, prenatal exposure is very high. And I think we conceptualize that by thinking of the circumstances around this. If we had two doors, one door, where children enter foster care whose parents have no substance use disorders that would be infrequently used. So the overwhelming majority of children enter foster care, because their parents have substance use disorders. And I always like to refer to foster care. And I think this is appropriate as a substance use treatment program. Because the overwhelming majority of parents whose children are in foster care, are struggling with substance use disorders. So in answer to your question, it would be very high, be very high thank and foster care, probably very high for many adoptions, and least in my experience, kinship care, as a lot like foster care, somebody else is raising these children because the parents have substance use disorders.

Yeah, the vast majority of kinship parents have stepped in because of at least tangentially substance abuse disorder, mental illness as well. But But oftentimes, that's has its there are substances involved as as well. Do you have a feel for international adoption? Of course, that depends a lot on the country. But from what you see, what would be the percentages? Or how high would it be prenatal exposure in international adoptions?

I think, again, it depends part on where the children are from. But surely, if your child is from Eastern Europe or in that general area, then the rate of prenatal alcohol exposure is very high, might well exceed 40 60%. Of course, it's very difficult to document that because the children are separate, separate from the records are separated from their, the historians, people who could tell us about this, but it's very high.

And I will throw out that South Korea, we see acknowledgement of alcohol use, not infrequently in the referrals that come from South Korea. What about domestic infant adoption, where families are not working through a public agency that the birth parents or birth mother has made a placement on her own for domestic infant?

You know, that's more complicated, and I probably don't have a good feel for that, except to say that where there's difficulty with children, substance use is very prominent. And so for moms, who, for whatever reason, have decided that adoption is the best course of action for them and their child. I think that these poly substance exposures would be quite common.

Going back to foster or adoptive placements. Do you think that prenatal exposure increases the likelihood of a disruption of a placement of either a foster or adoptive placement?

Yes. So in our clinical setting, in fact, yesterday, I saw one of these very children. If you look at the children who have the highest number of adverse childhood experiences, who have the highest number of placement, It's the majority of those children pretty substantial majority have a fetal alcohol spectrum disorder. Now often they were exposed to other substances. But the predominant clinical finding is that of Fetal Alcohol Spectrum Disorders. Not to belabor this point, but so yesterday I saw a child with 23, foster care placements, who was nine, the record at our center is 31. And the reason for these placements is that children exhibit a pattern of difficulties over and over and over again, that make it difficult for them to stay in these homes. Two really prominent problems are asleep disturbance sleep a couple hours get up. And very few adults can take that kind of schedule. So after a while the foster parents just no longer can function in a new placement. While the foster care system is so overwhelmed so overstressed right now, across the United States, that they don't have a way to pick an optimal placement, they just pick the available placement. And the cycle just keeps repeating itself. In rural settings, North Dakota, for example, sometimes you'll locate children who have very complicated problems, geographically very far from services, because that's where the foster homes are available. And that, of course, is an additional complicating factor.

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Well, I think there's two versions of this. There's one in theory, you had interviewed the birth mother, she'd be completely forthcoming and factual. And you'd get a very detailed explanation of prenatal alcohol exposure. Then there's a reality based version of this, where many of the mothers aren't close to the children, they're incarcerated. They're struggling with their addiction, the children have been removed from their care, termination of parental rights. So it's very seldom. And I emphasize very seldom, they get interviewed the birth mother. So then you're stuck with looking through the medical records, a very poor source of information about alcohol use, you can go through the foster care records, another very poor source of information about alcohol, much better about drugs, but very poor for alcohol. And then you're stuck with trying to find somebody who can give you some information. I saw her drinking, I'm her brother, she lived a mile from me. You know, that kind of thing. My last comment on this. Sometimes we get upset about these moms. And we say I don't understand how she could do that. How could she continue to drink? Well, one metric that might be very helpful, is if people understand that, if you have a child diagnosed with a fetal alcohol spectrum disorder, the birth mother is 44 times more likely to die prematurely than the mother of a child who does not have FASD. And since we're talking about young women, we're really talking about a marker for mortality, early death that exceeds any other markers we have available for women that age. And I think that tells us how severe the disease is. As among these women,

I think there's a misperception that, that we can just run a test on a newborn, and determined if the newborn has been exposed to alcohol. But does that exist?

So we have tests, they're very infrequently used. There's lots of problems with interpretation. I think a good example that's in Toronto over the last year and a half or so, where there's been very serious problems using these tests up there. So we have a Mykonian test the baby's first stool, we can send that in and have that analyzed for alcohol exposure. That will tell us about the last 20 weeks of pregnancy.

Oh, pick up even going as far back as 20 weeks. Yeah,

well, this works best, you know, for the last trimester, but meconium starts being formed around 20 weeks. There's a hair sample. There's tissue and blood methods. But the point is, these are very infrequently used. Hospitals might routinely test for drugs, but they rarely test for alcohol exposure.

That's what we have seen, too. So what type of trainings do pediatricians receive during their education or residency on prenatal exposure in general and how to diagnose it?

I think it's inadequate. It's inadequate on interviewing the mother about exposure. It's inadequate in diagnosing fetal alcohol spectrum disorders. And it's extremely inadequate when it comes to management of these children. And, clearly, we have to do a much better job across professions, social workers, pediatricians, Family Medicine, doctors, obstetricians, neonatologist, etc. So I think we're maybe beginning to make some progress there. That slow?

Yeah, I, I would, from my experience, it is slow. We hear from pediatricians that even when they suspect it, they don't want to raise it with the parents after the child is already born. Because at that point, they feel like it will interfere with their working relationship, because when you raise it as an issue, there is a shame associated it is something that is caused by behaviors of the birth mom of the mom. So they don't want to raise it, because they feel like at that point that it will do more harm than good.

Yeah, I find that to be an odd consideration. That they think not diagnosing a problem which lasts a lifetime, which is highly likely to result in foster care placement, extremely likely to result in the child having mental health problems, school failure, development of substance use, contact with a mental health system, and a high rate of mortality is not something they want to do. And I think it's among that particular group of doctors, where you can see the lack of training, because often they'll tell us, well, we're already doing everything we could for this child, what would we do different if they're diagnosed? And I think when that comes up, it's time to give serious thought to getting a new doctor.

So how is now moving to drugs? How is prenatal exposure to drugs detected or diagnosed in infants, newborns or infancy,

so many, many methodologies for doing that, particularly for drugs like opioids, where, in some settings where opioid use is prevalent, pretty much all newborns get screened, amphetamines, marijuana, all these have very robust biomarkers that you can elicit from conium. And often other tissues, hair, etc. So a lot of places, they do a pretty good job of screening for those things, but they don't screen for alcohol and those very same places.

Yeah, and you know, when you described the what it would take, because as you point out, very few mothers are forthcoming. We've done a good job of educating, I think we could certainly do a better job, but most people know they shouldn't be drinking during pregnancy, and therefore there's a shame associated with it. And there's also a fear because they're fearful that the child could be removed. So for all of those reasons, as you point out, it is rare for a mom to be forthcoming about the full extent of her alcohol use or drug use, although as you point out with drugs, or they're routinely drug tested, and then going in finding extended family members to give you history and stuff, just I mean, very few pediatricians or obstetricians have that time in order to, you know, go and interview people who are not in their care. So it just doesn't, it just doesn't happen doesn't happen frequently. And one of the frustrating things is that often, even screening for drugs is done. They have to it has to be done at some hospitals, they don't do everyone they do, if we have reason to believe, which means that that it is not universal, for sure. And it also means that probably a disproportionate of moms of color are being tested in and white moms or not. So we see all of those things that that also can happen. It's just not universal, although some hospitals do universally do it. All right, if you are a seminar audience will be, as I said before foster adoptive and kin parents. So one piece of information they will have, they will know where this child that they are either considering fostering or adopting, is has falls in the birth order. Is there a correlation between birth order and the likelihood that a child would be exposed? If indeed the mom is struggling with substance abuse?

Quite a crucial question, quite quite quite a crucial concept. So broadly put, people ask well, why screen for alcohol use during pregnancy? For a newborn infant? Well, one of the primary reasons is to identify a mother who needs treatment, to identify an infant who's been exposed, and extremely importantly, to prevent exposure and subsequent pregnancies. And these three reasons are so compelling, it just shocks me. So if we think about this, and we look at a sub ship of several children, the younger children in the sub ship, tend to have a higher prevalence of being diagnosed with fetal alcohol spectrum disorder, they tend to have more severe symptoms, and I think their mortality risk is higher. So it's it's important that we share with people that identifying prenatal alcohol exposure is worthwhile. It gives you an opportunity at its lowest level to prevent exposure and future pregnancies.

Is is the reason that subsequent children subsequent born children are more likely is that is that just the nature of substance abuse disorder, that it tends to increase in severity as as stress as time goes on and stress goes on? Is that the reason?

I think that's potentially a good reason, the generalized health of the mother decreases over time. It's possible that other things are operating here. But yeah, I think it's likely that this just has a generalized effect on the well being of the mother.

So what are some of the long term impacts of alcohol exposure in utero?

So a good way to think about this is if we take a large group of women who are drinking, the majority of them are going to drink during the first part of pregnancy, because they're going to be pregnant quite some time before it becomes clear to them they are pregnant. So exposure during the first six 810 weeks of pregnancy is very high. If we follow that group of women to the end of pregnancy, and we look and see how many of them, we can demonstrate drank during pregnancy, one out of 12, a very high number, one out of 12 women in the United States, I think are drinking during pregnancy. So prenatal alcohol exposure. If we think of it like this, when a mom drinks, whatever Her blood alcohol concentration is, it's the same for the fetus. Alcohol primarily impacts the brain. So every episode of drinking is an episode of brain damage during pregnancy. So when these babies are born, they have many neuro developmental problems, low muscle tone, difficulty relating Well, some of them have health problems. prematurity is very common, increase risk for lung eighth term stillbirth, then as they get older, of course, we see increasing numbers of difficulties as they go along. Delayed milestones, needing early intervention, increased rates of vision and hearing problems, high rates of Attention Deficit Hyperactivity Disorder. Many of them are going to need preschool programs, rates of school difficulties are very high. And when you go forward from there, then you see huge impacts on the mental health system. Lots of these children are going to develop substance use disorders.

Why is that? Why are they more at risk for substance abuse disorder themselves, if they were prenatally exposed to substances?

I think they have the magic duo. They have a genetic predisposition to this often from both parents, often it's multigenerational in these families. And for many of them, they've had a difficult early life, lots of adverse childhood experiences, which increase the risk for substance use later in life. So identifying these children is important. So parents can orient themselves to thinking about these upcoming problems, implementing strategies to decrease risk for these problems. And the idea that any diagnosis or do, we're already doing everything that could be done is really ridiculous. When you look at the developmental course for these

disorders. Did you know that most people find out about podcast by word of mouth, they talk with their friends, they've talked with somebody they meet at the park and they see that they're listening to something they ask. I certainly know I am a client. I am a podcast addict. I love to listen to podcasts. And I certainly know for myself that that's where I find out about most of the podcast I listen to. So you could do us a HUGE favor. If you would please tell your friends, your family, whatever, about the creating a podcast. Our mission is to inspire and strengthen the adopted Foster and kinship community and you are a valuable partner in our doing that. Does it matter? We certainly hear people say, Well, I only drink beer or a healthy drink wine I didn't do heart didn't drink hard liquor. Does it matter the type of alcohol that was consumed by the Mon Sol two

comments on that one? No. It doesn't matter all alcohol is the same. Forget your alcohol from beer wine, bourbon, you're drinking some product that has alcohol in it is not designed for consumption, it's all the same. It's the amount of alcohol, how often you use it, when you use it to make a difference. I think a second point is that for many people, their pattern of use is problematic before they become pregnant. They go out on Friday and Saturday nights with the intent of consuming multiple drinks. When you do that, and you have unprotected sex, then it's likely that if you become pregnant, you're going to be drinking through the first part of pregnancy. Before you learn, you're pregnant. And you can decide if you're going to quit or not. So all alcohol is the same. It's the amount of it and the duration of usage. That makes it different.

That makes sense. What type of doctor can diagnose a child or a baby with fetal alcohol spectrum disorder?

Well, certainly, we have to tool up a pediatrician. So this becomes a routine diagnosis in their office. Right now, in quite a few centers in the United States. There's this multidisciplinary diagnostic team. Well, those are incapable of seeing even a tiny fraction of the actual number of kids with FASD fetal alcohol spectrum disorder in the United States, or even evaluating children with other drug use. So this is a job for, I think, primarily three groups of doctors, initially pediatricians, neonatologists and obstetricians. All three of those groups need to Take their chunk out of this need. The obstetricians need do a much better job about screening for and putting in the medical record issues about substance use, especially alcohol. Because as we know, it's the most concerning substance of all, none of the rest of these things are nearly as harmful as alcohol. The neonatologist need to be involved in this, because many of the most complicated children end up going to the NICU, staying for weeks being treated for all kinds of complicated problems, but maybe not getting in the chart, or reflecting that the most complicated problem is prenatal alcohol exposure. All children need to be screened more than once at a well child visit. Or the doctor routinely sets down. When was your last drink? Very effective screening question not complicated. And when they asked about depression, domestic violence, running water, all this kind of stuff, they asked about these questions, a question like that as well?

Well, you've certainly described an ideal situation, what we see now is exactly what you say that most places, it is hard to get a diagnosis because pediatricians don't feel competent. You can go to a developmental pediatrician, or clinical geneticists, but as you point out, that limits the the number of people who are actually going to be seen. And we know it is more common than that.

Yeah, I just have a couple of thoughts on geneticists I think are helpful for a very small number of these children. And that's the children where there might be another disorder present. But by and large, geneticists are not particular don't have particular expertise in brain function for children. And the outcomes from drinking during pregnancy are primarily damage to the developing brain. So pediatricians, psychologists, neurologists, school psychologists, psychiatrists all need to develop additional expertise, because that's who these children see in very large numbers.

That makes sense. You've already mentioned that of all the substances that children can be exposed to prenatally alcohol has the greatest impact. It's the greatest stratagem. But let's talk about some of the other commonly abused drugs. We've got opioids, heroin, increasingly fentanyl, to presents, you know, benzodiazepines both prescribed and unprescribed, stimulants, methamphetamine, things such as that cocaine crack. What do we know about the long term impacts of these drugs?

I think broadly, we know some useful things. Substance use is associated with a late start for prenatal care, and few prenatal visits to important clues for concerns about this. As an aside, we've done a two studies now looking at women who go to the emergency room. And bizarrely we have found that if you are pregnant, you are screened very infrequently for drug and alcohol use, compared to non pregnant women. So there is an incorrect assumption there, that pregnancy is somehow protective, and simply not true. So, substance use late start for prenatal care, fewer prenatal visits. When we tried to look at these, one of the most confounding and complex problems, is that people tend to use multiple substances at once. And I'll give you an example of how important this is. So when you drink during pregnancy, you produce a certain amount of risk. Separately when you smoke during pregnancy, you produce a certain amount of risk, cream maturity. But when you drink and smoke together, those two exposures multiply the risk factors. So they're not additive as you would expect, there are multiplicative, so you have this huge increase in risk for adverse outcomes for moms who both drink and smoke I hear a lot of people say, well, in our setting, it's mostly drugs. That's a problem here. And of course, that's not true. If you look at the alcohol sales for communities, I just gave a talk in North Carolina. I think alcohol sales, in two years I looked at had increased 13%. A huge amount of this alcohol is being consumed by women. We've just got to get our thinking clear on this. So it's not mostly drug use. It's mostly poly substance use, and heroin, opioids and now fentanyl used to be associated with fairly high mortality rates, because of the neonatal withdrawal syndrome. Now, as complicated as that is, it is a routine problem in neonatal nurseries. They identify this with regularity. They worked out complex treatment protocols for it. They know what they need to use for treatment, how long treatment needs to go on. So the mortality for children exposed to opioids has gone down substantially. The long term outcome improved. Some drugs are so problematic, that there are many adverse outcomes. Methamphetamine, really, really addictive substance takes a huge toll on the mother's health when she is pregnant, often folks with meth addiction, or meth, probably addictions, not the right term. But methamphetamine dependency, live in really difficult circumstances. They're not eating well, they're not getting prenatal care, their vitamin intake is very low. They use a huge range of substances in addition to methamphetamine. So broadly, we could say, the opioids nowadays, in almost all settings, well identified, well treated, the children are well managed. When they leave the hospital, they go into a follow up system, they're doing much, much better. And feta means are lag behind that. And amphetamines, I would say there's a lot we don't know about the effects of amphetamine use on child development. Methamphetamines a fairly new drug, there's a couple of versions of methamphetamine, the most recent version, I think, is going to turn out to be much more detrimental than the previous versions of this. And so that's going to be complicated. I am particularly worried about the effects of marijuana use on development,

I was gonna raise that as an issue because I, I know, I have heard of pregnant women saying, Well, I'm going to smoke pot, because I don't want to drink and thinking that that there is an enforces becoming legal. And so that is leading to the idea that perhaps it's not that that harmful. What do we know about the impact of cannabis on fetuses?

So I think in general cannabis use decreases birth weight, because it's a version of smoking. Many of these children have a period of habituation. So they weren't getting regular exposure to cannabis during pregnancy, they're delivered or they're not getting it. Now, that requires some adjustment in their thinking. And as they studies come forward, cannabis users, one of the things we have to think about is the potency the amount of the active material, THC. And this is increasing dramatically. It's many fold greater than it used to be 15 or 20 years ago. So the potency of the cannabis, and the likelihood of an adverse effect, I think is going up a lot. So you watch these children, and of course, many of them are going to end up with modest learning and development problems that ideal families, early intervention would make a difference for. But many of them don't live in a setting where If that's going to be provided, so I think quite a number of them are going to struggle.

What about CBD?

I have no knowledge of that. All right.

I'm just curious because that's even more. I think that the number of people who are taking benzo dyads I mean, they the Valium, Xanax, things like that. I don't know if it's increasing. I believe it is. But I think that it is certainly both the prescribed and they and they unprescribed use of benzos is high. What do we know? And being a depressant, you would think that it would have a significant impact on the fetus. What do we know about fetal exposure to Valium, Xanax and others.

So little bit of background might be helpful. Prior to COVID rates of anxiety were increasing. One measure of the prevalence of anxiety is that if you go to a university campus, and you go to Student Health, and you say, What's the most common problems people come to see you for? Almost always, three of the top five will be different anxiety disorders. So it's extremely common among young people. When COVID came, the rates of anxiety have been increasing dramatically in adults and children of all ages, since. So the amount of time we spend on anxiety disorder in the clinic I'm in is going up very rapidly. Tragically, now, we're seeing young children who have significant anxiety. So when you're studying this, you have to untangle two problems. One is the mother's use of this particular class of substance, benzodiazepines, etc. Second, is the effect of the mask. And there's a very nice little video available. If you type still face into the search bar, you will get to see an experiment showing what happens when moms don't react to babies overtures. We'll include a link to that. And the baby in just seconds becomes aware of this and start ramping up their behavior demanding some kind of response. But I think people have forgotten is we're now dealing with a couple of years of babies who were born and cared for by people who spent a long time wearing a face mask. And we have no idea if using a face mask around infants is safe or not.

You're not talking about the me I think I was going a different direction. You're not talking about the effect of moms who are taking depressants, Valium, and Xanax and others for anxiety, that it it mutes their responses in their emotions. It sounds like you're talking literally about these all parents regardless of whether they're taking benzodiazepines or other depressants. So you're talking both or you're talking just exclusively about the effect of facemasks in general. So I'm

talking about the ultimate in lack of responsiveness, you hang something over your face, so the baby cannot see your facial expressions. This promotes an anxious, agitated state and babies, huge amounts of their care during COVID have been provided by people wearing face masks. In that group, our moms who use different types of benzodiazepines and likely cannabis use fits into this category, who are less responsive to their babies than they would otherwise be. So many of these infants are getting a kind of a double dose of problems designed to make them more agitated, anxious, I have more difficulty controlling their behavior than they otherwise would. And surely we are seeing that now. huge increases in anxiety.

Well, and also many of these children would likely also have been exposed if their moms were taking these drugs during pregnancy. They also have the added insult of having been exposed prenatally.

Yes, lots of moms use these medicines during pregnancy.

And it's one thing if their obstetrician is aware of it and and they're controlling dosage and It may be actually better it may it's if they're needing the drug that's maybe subject control anxiety, it may be something that is useful, but they're the dosage is being controlled. It's being overseen by a doctor. It's another thing when they're self medicating with these medications.

Yeah, nothing. None of my comments should be designed to have women change advice from their doctor.

Right? There's actually some interesting studies that exist as far as in taking antidepressants. In pregnancy versus experiencing depression. Both are harmful, or potentially harmful, I should say. We have a new partner I'm excited to tell you about. It is fostering families Today magazine. They help kinship adoptive and resource parents provide the best possible care for the children in their homes. It is a print and digital magazine and has educating and informing caregivers for over two decades. There are articles, there's free online events and virtual community through social media, you can sign up for a one year subscription today and save 10% Just go to the fostering families and enter family 10 at checkout. So that's fostering families And the code you enter is family 10. And you enter that when you're checking out. So do pediatricians or neonatologist or family practitioners and obstetricians? Do they have resources commonly available or readily available resources to offer parents regarding raising a child with prenatal exposure? I think we know that they have resources to say that using alcohol or drugs during pregnancy is is ill advised. But what about for raising children who may have been exposed?

So if we just look at prevalence studies, and we say, well, fetal alcohol spectrum disorder, is twice as common as autism. So there's two times many kids with FASD. At any age level as there are with autism, right. FASD is much more common than Down syndrome, probably, you know, 234, other common childhood conditions. And pediatricians have quite a bit of expertise in those areas. The American Academy of Pediatrics does have some materials. They are updating these once in a while on fetal alcohol spectrum disorder. But I think when you look at what the Academy does, when you look at the publications in their journals, information about fetal alcohol spectrum disorder is dwarfed by information about autism, rare genetic conditions, where there's so much more of

I know, why is that you're spot on. But why is that?

Well, I think it gets back to this idea that they're fearful there, they will have a problematic relationship with the mother if they bring this up. Or that they might upset the grandmother, if they bring this up. Or that the foster parents don't want to hear this news. I've never found this to be the case. It could be I just see a different population. I think people often are secretly worried about this problem. They'd have great relief, if their doctor brought it up. They could talk about it in a forthright manner. And the doctor actually knew had an action plan for so you know, we see these kids have been evaluated six, seven times for different problems. But fetal alcohol spectrum disorder is never really brought up. The foster parents, the adoptive parents, the grandmothers, figure this out, make an appointment, bring these kids out. I think we just need better from our health care providers.

I would agree. I spoke with a clinical geneticists that part a great part of this practice is diagnosing FASD. And he said that in his years of practice, and he had been practicing for over 30 years, he could count on one hand a number of birth parents who brought their kids in for a diagnosis, suspected prenatal exposure to this his case it was alcohol and he was talking and I said well, who's bringing them in? It goes almost always it's adoptive foster or grandparents in

you know, I think we could make some changes in the way we talk to people. One of the things I teach medical students and train quite a few of them is when this issue comes up, step out of your office and go get two cups of coffee or two Diet Cokes or two sprites, come in, give the mom one, you sat down with one. So you can talk about this. This sets a condition for discussion. That's important. Many moms are just desperate for information about whether or not their drug use their alcohol use caused problems for their baby. And by avoiding that, we increase the stigma around it. Instead of treating this like we do every other problem. We ratchet up stigma, because it becomes an unmentionable thing from the doctor to you. And are you going to bring that up with a doctor? No. So we make it worse by doing this.

I mean, I understand it. If you're bringing up autism, there is no reason to believe that anything you as a parent did caused your child have autism. But when we're bringing up fetal alcohol spectrum or issues associated with drug use during pregnancy, there is something that the parent did that caused the problem so you can understand it. But as you say, there, it's not that there aren't things that we can do early wreck, we know that some of the best protective factors for these children and indicating a better outcome for these kids is early recognition, early diagnosis, early recognition and getting the supportive services.

Yeah, what's one of our goals, one of our goals, if you didn't strap your child in to a car seat, when you're driving to the store, you get in a car accident and they're injured, we're going to take care of both you and the child. If you used drugs during pregnancy, we're going to take care of both you and the child. If used alcohol during pregnancy, we need to take care of both you and the child. And this idea that somehow this is some separate path we have to travel simply not true. We don't know what causes autism. So we can't say it was nothing parents did. We can't say that it was because we have no evidence of that. We do know that moms who have substance use disorders increase the risk for adverse outcomes for their baby. Most of them already know this. They're looking for care. They're looking for compassion, understanding.

And what can I do now? Yeah, yeah. Okay. So if you were going to leave parents with a couple of tips, if we're talking to parents who are now raising kids who have been prenatally exposed? What tips would you have for those parents?

First, if your child was in foster care, if your child is adopted, your child's in kinship care, the risk for prenatal exposure to alcohol and other substances was high. Earlier identification of this problem is going to provide you with more information. On upcoming problems, you can minimize or successfully avoid fetal alcohol spectrum disorder itself, a very long term problem. It's unlikely you're going to be successful managing this by treating these children for something else. We need to identify this so that we utilize treatment interventions designed for children with prenatal alcohol exposure, poly substance exposure. And for those that have fetal alcohol spectrum disorder, it's all about anticipating what's coming up. I'll kind of conclude the way I started the record in our places as child with 31, foster care placements.

That's heartbreaking.

This is a preventable problem. By not recognizing this, we've done damage to this child it's hard to calculate. So we can do better by thinking about this and acting on it.

Thank you so much, Dr. Larry Bird for being with us today to talk about prenatal exposure is you can tell this is a topic that I feel really passionate about and that creating a family is spending a lot of resources on it. Creating a lot of resources to try to help families and I truly appreciate your expertise and you're sharing it with our audience today

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