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3 WHAT HAPPENS IN THE WOMB INTERUTERINE EXPOSURE TO SUBSTANCES In the last book you read about the effects of trauma attachment and relationships on brain development Adverse changes to brain development can begin Inbefore the child isread about the effects of trauma attachment and relationships on the last book you born starting in utero This book explores the risks of tobacco development Adverse changes the fetus You will can stories of families brain alcohol and illicit drug use onto brain development hearbegin before the child is raising children utero This book explores the risks ofthey encounter and illicit born starting in exposed in utero and the obstacles tobacco alcohol drug use on the fetus You will hear stories of families raising children exposed in utero and the obstacles they encounter
IN THIS BOOK YOU WILL LEARN ABOUT The impacts of maternal stress on the fetus The developmental impairments associated with alcohol use during pregnancy How Fetal Alcohol Spectrum Disorders affect a child s daily life Strategies developed by parents to help their children cope Alcohol and tobacco use in developing countries The short and long term effects of illicit drug use exposure in utero The developmental consequences of prescription drug use during pregnancy Page 2
MATERNAL STRESS IN UTERO Page 3
The choice of adoption is always an agonizing decision for the birthparent(s), and usually involves a back and forth debate about raising their child or making an adoption plan. Ultimately, the decision to go with adoption is made for various reasons including inability to provide, poverty, unsupportive partner or family relationship, harmful lifestyle choices, and gender discrimination. It should be expected that the decision-making process places significant stress on the gestational parent, and consequently the fetus.
In Book 2 you read about how complex trauma activates an over-reactive stress response system altering normal brain development. Stress hormones also impact neurodevelopment in gestation through the gestational parent's stress response system.1 If the gestational parent experiences chronic stress, the child receives less oxygen, their heart rate increases, and alterations to neuronal circuitry in the brain occur.
Recall that the brainstem (primitive area) begins developing in utero, and impacts all higher-level areas of the brain (feeling and thinking).
When the brainstem becomes disorganized this can result in delayed learning and motor function, difficult temperament,2 and there is evidence of increased risk of mental illnesses such as depression, ADHD, and substance abuse.3 What we see at birth are babies who have problems regulating behaviour; they are hyper-vigilant, colicky, difficult to soothe, and have sleep difficulties..4
Even if an infant goes home with you after birth, early programming of the brain has already occurred, which can make an infant more difficult to care for. For the little ones who have nurturing adoptive or foster parents from the beginning, these impacts are alleviated by loving relationships that form into a secure attachment. Those placed in state care or in an orphanage without a buffering relationship are not so lucky.
TOXIC EXPOSURE ALCOHOL USE
ALCOHOL USE FETAL ALCOHOL SPECTRUM DISORDERS FASD Page 5
Prospective adoptive parents often worry about the gestational parent's illicit drug use during pregnancy, when in fact alcohol use can cause the most significant damage to the brain, impacting the child throughout their life.
Many adoptive births are unplanned; so if a gestational parent drinks any alcohol, you should suspect that they consumed alcohol before knowing they were pregnant. Although dose, frequency, and duration of exposure impact the severity of the developmental deficits, there is no proven safe amount of consumption during pregnancy.5 Even small amounts of alcohol can result in miscarriages, still births, and infant death syndrome.6
When the gestational parent drinks so does the fetus. Alcohol passes freely through the placenta into the fetus’s blood stream. The blood alcohol level of the fetus is greater than the gestational parent's because the fetus’s liver is only able to metabolize so much of the substance at a time.7 In the process, alcohol affects the development of the brain, heart, eyes, ears, central nervous system, and immune system. On the other hand some gestational parents can metabolize an amount of alchol without damages to the fetus. These babies are indeed far and few between.
Not all children are affected in the same way; therefore, several diagnoses of FASD exist.8
FASD is an umbrella term incorporating three diagnoses:
Fetal Alcohol SyndromePartial Fetal Alcohol SyndromeAlcohol Related Neurodevelopmental DisorderThese diagnoses are marked by adverse changes to the central nervous system, growth deficiencies, and specific facial characteristics. The effects range from mild to severe, and impact all children differently. The only consistent factor in FASD is irreversible brain damage.
The brain damage is variable and affects one child’s ability to learn, regulate behaviour, and socially interact with others differently than another’s.9
ALCOHOL USE FASD DIAGNOSIS 10 11 DIAGNOSIS Fetal Alcohol Syndrome CHARACTERISTICS Growth deficiencies below the 10th percentile Minor facial abnormalities small eyes thin lip flattened philtrum Central nervous system damage structural neurological and functional impairment Partial Fetal Alcohol Syndrome No growth deficiencies or impairments before or after birth 2 out of 3 facial abnormalities Central Nervous System damage Alcohol Related Neurodevelopmental Disorder No growth deficiencies or impairments before or after birth No facial abnormalities Central Nervous System damage Page 6
ALCOHOL USE STRUCTURAL WHAT WE SEE IN CHILDREN WITH FASD NEUROLOGICAL WHAT WE SEE IN CHILDREN WITH FASD FUNCTIONAL WHAT WE SEE IN CHILDREN WITH FASD COGNITIVE DEFICITS EXECUTIVE FUNCTIONING DEFICITS skills required for daily life functioning Page 7
FASD is sometimes described as the “hidden disability" because physical differences are not always present, and the child’s basic language and vocabulary skills are intact.12 However, the structural, neurological, and functional aspects of the central nervous system (the brain and spinal cord), which controls the workings of the body, may be affected. Let’s explore each of these functions in more detail:
Poor coordination, tremors, problems with suckling, motor function delays including balancing problems, difficulty writing, delays in walking and coordinating hands and fingers.
There are physical differences in the structure of the brain.13
Poor organization and planning, poor judgment, difficulty following instructions, difficulty changing patterns and applying knowledge to new situations.
ADAPTIVE SKILLS:
Table manners, budgeting and handling money, personal hygiene, and keeping track of time.
Learning disabilities, poorer school performance, slower reaction time, memory (forgetting how to complete tasks performed frequently).
Higher level thinking, including cognition, executive functioning, and social skills.
How the central nervous system sends, receives, and interprets information to coordinate the movements of the body. 14,15
ALCOHOL USE FUNCTIONAL CHARACTERISTICS CONT BEHAVIOURAL DEFICITS N O R M A L Non Compliance Actually Non Competence F A S D Frustration Flip Out Overwhelmed Reasoning Problems Memory Deficits Adaptive Problems Language Processing Difficulties Affective Disorder Social Skills Deficit Sensory Integration Problems Disorganized Behaviour Jan Lutke 2011 Page 8
SOCIAL SKILLS:
Difficulty empathizing with others, lack fear in approaching strangers, immature,
struggle with sharing and resolving conflict, difficulty making and keeping friends.
ATTENTION PROBLEMS AND HYPERACTIVITY:
Difficulty calming down and completing one task before moving onto the next,
easily distracted and impulsive.16,17
If you are interested in watching the entire FASD: Finding Hope documentary, it should be available for loan from your local library.
It is always helpful to get different perspectives of the challenges, developmental outcomes and energy you need to invest in a child with FASD by listening to the life stories of other families.
Before moving on to the next section, please watch both videos
Fetal Alcohol Spectrum Disorder & Whitecrow VillagePage 9
ALCOHOL USE MOLDING YOUR ENVIRONMENT STRATEGIES FOR COPING WITH FASD Page 10
You saw in the videos that each child has their own unique strengths and challenges. Children with FASD learn, and develop when provided with resources, support, and attention from their family and community. However, these children have a disability that prevents areas of “normal” functioning. It is hard for many of us to understand where certain behaviour might come from, why they can’t grasp a concept, or why they cannot remember to wash their hands after using the washroom. In a society where we think, “if you put your mind to it, you can do it”, it is difficult to accept that children with FASD actually can’t do, remember, organize and integrate certain information, and complete tasks the way children with normal functioning can.
The scientific community is only recently beginning to explore whether psychological treatments can rewire the brain to repair the effects of FASD.18 Although promising, we are not there yet. So, rather than trying to change your child, you need to mold your environment to accommodate their neurological and functional abilities.
In the documentary the Saunder's family did this by:
Getting Jayden the out of school support he neededHaving a reward system when he accomplished a taskRecognizing that flexibility and compromise were key factors in ensuring behavioural regulation.FASD organizations, governmental ministries, and medical professionals have written reports on changing the environment to help children learn, regulate behaviours, and enhance motor development.
“Let’s Talk FASD” a guide by the Public Health Agency of Canada and Victorian Order of Nurses is an informative and practical resource. It is a compilation of parent driven strategies on caring for children with FASD. The guide also outlines how parents need to think about taking care of themselves in the process, by talking to people who share similar experiences, and taking a break from time to time.
To familiarize yourself with the guide please read pages 2 to 14 and 16 to 19. Click here to access the guide.
ALCOHOL USE RAISING AN ADULT WITH FASD Page 11
We do not expect our infants and young children to problem solve on their own, remember everything they need to do in a day, manage money, or follow through with instructions, but we do expect this from teens and adults. We expect them to take responsibility and transition into the real world. But for many teens and adults with FASD this is a challenge; remembering to pay the rent, pick up groceries, go to an appointment, and hold down a job.
Adults with FASD can go on to live very successful lives. You saw this from the mentors working at Whitecrow. However, Whitecrow is conducive to shaping work and life around FASD needs. If only the rest of our society was like this!
Adoptive parents also need to be prepared for the secondary disabilities associated with FASD. Secondary disabilities are those that are not presented at birth, but rather are caused by how the primary disability, FASD, affects social integration, relationships, behaviour, and how one’s environment can compensate for these additional disabilities. Secondary disabilities may include: legal problems, alcohol and drug addiction, school disruption, and inappropriate sexual behaviours.
The reality is people misunderstand this
disability, so as parents you might need to guide and advocate for your child into their adult years.
ALCOHOL USE FASD IN ADOPTED CHILDREN Country Pure Alcohol Consumptions Per Capital of Females 15 2005 23 Pure Alcohol Consumptions Per Capital of Females 15 2010 24 Cambodia N A 5 7L India 5 9L 7 6L China 10 36L 10 6L South Korea N A 3 5L Philippines N A N A Vietnam 11 6L 0 9L Thailand 6 2L 5 2L Haiti N A 6 7L Bulgaria 8 7L 9 7L Kenya 19 00L 9 6L Zambia 21 36L 9 6L Page 12
You are probably wondering, “We have talked about FASD so broadly, is it really a concern in adopted children?” And the answer is YES! In Canada, FASD is the number one leading cause of preventable disability;19 and in a recent study by the Institute of Health Economic Alberta, FASD diagnosis for children in state care is between 30.5% and 52%.20
The rates of FASD in intercountry adoptions are unknown. However, the folks at Sunny Hill Health Centre found between 1 to 2
children adopted by BC families are diagnosed with FASD monthly.21 The rate of alcohol consumption among women in developing and industrialized countries is on the rise. Among the adoption countries Sunrise partners with, pure alcohol consumption per capita in women of reproductive age has increased in India, Bulgaria, and China, and according to a 2014 World Health Organization report, the pure alcohol consumption in women 15+ in Kenya and Zambia is higher than in Canada.22
ALCOHOL USE KEEP LEARNING Page 13
If you are considering adopting a child whom you know is or was exposed to heavy drinking (5 or more drinks on at least one occasion) be ready to learn as much as you can about FASD. Read books, watch videos, search the Internet for others’ stories, and try to connect with someone parenting a child with this disability.
You will not be ready until you’re in the parenting role, but by educating yourself you can separate the “I just want to be a parent” and start evaluating “Can and should I parent a child with FASD”.
Ask yourself"
Am I willing to take considerable time off work? How will this affect my other children? Can I handle stares and comments made by strangers in public? Does my family have the financial means? Am I prepared to support my child into adulthood?SMOKED TOBACCO USE Page 14
Similar to alcohol use, there is no safe level of tobacco use during pregnancy. A gestational parent exposes the fetus to more than 7000 chemicals when they smoke including tar, carbon monoxide, and nicotine.25
Nicotine causes hypoxia: constriction of the blood vessels in the umbilical cord. This deprives the fetus of adequate oxygen and nutrient supply as both are received from the gestational parent’s blood.26 This places the gestational parent at risk for premature birth and miscarriage, and the unborn child at risk for low birth weight, and behavioural problems.
Nicotine also causes structural changes in the brain by rewiring neuronal connections, affecting developmental processes.27 In a study by Marroun and colleagues they used Magnetic Resonance Imagining to test if prenatal exposure to smoking results in brain morphology and impacts on behaviour and emotional regulation.
113 children between the ages of 6 and 8 were matched on age, ethnicity, maternal education, alcohol use during pregnancy, and birth weight.
The only variable between the subjects was gestational parent tobacco smoking during pregnancy. The researchers found that children of gestational parents who smoked had smaller total brain volume, and smaller cortical gray matter (gray matter makes up most of the neuronal cell bodies, including areas of the brain responsible for emotion, speech, decision making and self control). Gestational parents who smoked for the duration of their pregnancy had children with affective problems (impulsivity, aggression, irritability, depression, hyperactivity), as well as anxiety. Surprisingly there was no dose response relationship. If a gestational parent stopped smoking when they found out they were pregnant there was no effect on brain morphology, and the fetus’ brain development was comparable to children of non-smoking gestational parents.28
A body of research also links tobacco smoking during pregnancy to cognitive delays. Studies demonstrate a relationship between tobacco exposure in utero and lower academic achievement and IQ. At the same time research shows that a highly stimulating home environment can mitigate the negative effects of in-utero exposure on cognitive development.29
SMOKED TOBACCO USE DOMESTIC INTERNATIONAL SMOKING RATES Page 15
Smoking has decreased in developed countries, yet the rate of smoking during pregnancy is reported at 10.5-21% in Canada.30 Smoking rates are also increasing in low and middle-income countries, which now account for more than 80% of smokers worldwide.31 In the last two decades tobacco companies have targeted advertising towards youth and women.32,33
Furthermore, with the weakening of social, cultural and political constraints, more women are entering the workforce feeling empowered to be more like their male counterparts. It is estimated that 17%-22% of women in Europe and the Americas smoke, and in South Koreas there was at 11.4% (1.6% to 13%) increase in female smokers in a decade.34,35
Although the percentage of women smoking in developing countries is less than in Canada, women in developing countries are likely to be impacted by alcohol or tobacco regardless of whether they use the substances. If their partner uses funds to purchase tobacco or alcohol, money may be directed away from prenatal care, and maternal nutrition.
TOXIC SUBSTANCES ILLEGAL SUBSTANCE USE
ILLEGAL SUBSTANCE USE COCAINE Page 17
Whether it is illegal or legal substances the gestational parent consumes during pregnancy there is an effect on the developing fetus. There are four primary illegal substances, and one legal substance explored in this section: methamphetamines, opiates, cocaine, cannabis (marijuana), and prescription medication, specifically Selective Serotonin Uptake Inhibitors (SSRIs). Keep in mind early childhood development is dependent on many underlying factors, such as one’s home environment, socio-economic status, and dosage consumed.36 You will notice that a nurturing, stimulating environment mitigates many developmental impacts from exposure in utero. These substances are typically consumed concurrently with alcohol and tobacco, so it can be difficult to isolate the effects of any one illicit substance.
In the early to mid 1980’s the medical community feared fetuses exposed to crack cocaine would be the most state-dependent citizens due to cognitive and physical disabilities. The medical and political community flooded media outlets with unsubstantiated evidence about the health outcomes of what were known as “crack babies.”
Take a look at these accounts by watching this short video clip “Crack Babies: A Tale from the Drug Wars” by the “New York Times.” Click here to watch it.
Over the past three decades research has debunked many developmental concerns reported during the crack era.
Infants born to gestational parents using cocaine are typically smaller in weight and height compared to non-exposed infants. This is because cocaine constricts the blood vessels of the uterus and placenta resulting in reduced nutritional intake.37 However, the effects of poor fetal growth are typically absent by school age.38
Some experts are also convinced that cocaine exposure results in tremors, poor feeding, sleep irregularities, irritability and high-pitched cry among infants; however, other research discredits cocaine use as a cause of these symptoms.39
Developmental trends in children exposed to cocaine in utero are quite normal. In a “Review of the effects of prenatal cocaine exposure among school aged children” ages 6-12, only 1 out of 32 articles reported significantly lower IQ scores. There was a very small difference in language functioning after the authors took into consideration parental sensitivity, and the environment. Interestingly, the authors found, when compared with children who were not exposed to cocaine in utero but grew up in similar environments, levels of academic performance were similar.40
In older children, up to 13 years of age,
researchers have found behavioural problems. Some children exhibited Oppositional Defiance
Disorder, and Attention Deficit Hyperactivity Disorder (ADHD).41
ILLEGAL SUBSTANCE USE HEROIN SYMPTOMS OF OPIOID USE IN INFANTS 42 43 CENTRAL NERVOUS SYSTEM GASTROINTESTINAL SYSTEM RESPIRATORY SYSTEM Page 18
Heroin falls under a class of drugs known as opioids, often used to treat pain, and recreationally used to induce euphoria.
The primary medical concerns for infants exposed to heroin are withdrawal, low birth weight and prematurity. Heroin passes freely through the placenta, which makes the child dependent on the substance. Withdrawal, a passive dependency on the substance, in infants is known as Neonatal Abstinence Syndrome. Heroin affects the central nervous system, gastrointestinal and respiratory systems.
Trouble breathing
Nasal stuffiness
Blue color of the lips and finger tips
High pitched cry
Irritability
Uncoordinated sucking and swallowing mechanism
Tremors and/or seizures
Muscle stiffness
Regurgitation
Loose stool
Vomiting
ILLEGAL SUBSTANCE USE HEROIN CONT DEVELOPMENT COGNITIVE DEVELOPMENT BEHAVIOURAL FUNCTIONING Page 19
Medical conditions of premature babies exposed to heroin in utero are respiratory failure, nutritional deprivation, blood borne infections and jaundice.44 Many of these little ones require hospitalization and treatment with medication to relieve the withdrawal symptoms. Infants are assessed on their signs of withdrawal and treated with short acting opioids such as morphine or methadone and slowly weaned off them.45 Approximately 50-75% of infants exposed to heroin or other types of opioids require treatment.46
There is some evidence suggesting that children exhibit behavioural problems such as depression, greater anxiety, and ADHD; however, these findings are conflicting, and children who are adopted also exhibit lower rates of externalizing behaviour.48
Studies show that children who remained with their gestational parent who used opioids during pregnancy are at risk for motor, attention functioning impairments, intellectual learning disability and poor reading and math skills. However, infants who were adopted had normal intellectual and learning abilities, and had minimal reductions in IQ.47
ILLEGAL SUBSTANCE USE HEROIN CONT METHADONE EXPOSURE DEVELOPMENT Page 20
Gestational parents treated for opioid addiction are often prescribed methadone maintenance treatment. Methadone is a medication used to reduce the withdrawal symptoms typically associated with heroin use. Methadone treatment is considered highly beneficial for opioid-dependent gestational parentss because it creates a more stable intrauterine environment for the fetus, reducing the risk of oxygen deprivation, and reduced complications during delivery and labour. Pregnant individuals on methadone also have an opportunity to stabilize their lives. The comprehensive services offered at methadone clinics get her on track for improved prenatal care, and nutrition.49
Infants born to individuals undergoing methadone treatment have higher birth weights, and a decreased risk for premature birth. Neonates are hospitalized for an average of 10 days less compared to pregnant individuals using heroin (17 days verses 27 days). The stay is shorter because neonates born to individuals with a history of heroin abuse typically require more care and supervision for complications related to premature birth.50
Methadone exposed babies are treated for Neonatal Abstinence Syndrome similar to heroin exposed babies.51
When socioeconomic status, biological, and health factors are taken into consideration the developmental outcomes for children exposed to methadone in utero do not differ from non-exposed infants.52
ILLEGAL SUBSTANCE USE MARIJUANA METHAMPETAMINES Centre for Adoption Medicine RESOURCES EXPLORING ONLINE Page 21
The Centre for Adoption Medicine is a website operated by three physicians specializing in adoption medicine. The website provides adoptive parents with quick, easy to read information based on scientific evidence.
To access the website please click here.
In this exercise of “Exploring Online Resources” please:
Read: “Prenatal Marijuana Exposure” article by clicking here.Read: “Prenatal Methamphetamine Exposure” article by clicking here.Gestational parents who use marijuana and/or methamphetamines increase the child’s risk of health complications at birth. Marijuana reduces fetal growth, and increases the risk of premature birth. Neonates are also likely to have tremors, and a startled response to touch.53
Methamphetamine use increases the risk of perinatal mortality rates. Neonates are 3.5 times more likely to be small for gestational age, have a smaller birth weight, length and head circumference. The risk of congenital malformations (physical defects presented at birth to different parts of the body) is also increased.54
Similar to cocaine and heroin use, studies vary on the effects on development later in life. To learn more about exposure to marijuana and methamphetamine, please read the instructions below.
PRESCRIPTION DRUG USE
PRESCRIPTION DRUG USE SELECTIVE SEROTONIN REUPTAKE INHIBITORS SSRI S Page 23
You have information on the effects of alcohol, tobacco, and illicit drug use on fetal development, but what about prescription drugs, specifically antidepressants prescribed to gestational parents before or during pregnancy?
Research out of John Hopkins Bloomberg School of Public Health, and The Norwegian Institute of Public Health link SSRI’s, such as Prozac, Celexa, Paxil and Zoloft to birth defects, autism, and developmental delays
SSRI’s block reabsorption of the neurotransmitter serotonin in the brain. This alters the chemical balance in the brain and body of a person experiencing feelings of agitation, anxiety, sadness, and suicidal ideation. During pregnancy the antidepressant freely passes through the placenta, increasing levels of the "happy" hormone in the fetus. Because serotonin is a cell-signaling molecule it tells the other neurons in the body how to develop; therefore, it plays a critical role in fetal development.55
In the Norwegian Mother and Child Cohort Study that included more than 40,0000 women, 373 women reported using SSRI’s during pregnancy.
After controlling for confounding variable such as maternal depression, and anxiety during and after pregnancy, and duration of symptoms, long term exposure to SSRI’s during gestation was associated with language delays in children at three years of age.56
At John Hopkins, the research study including 966 mother and child pairs (ages 2 to 5) and found boys were at greater risk for Autism Spectrum Disorder when exposed to SSRI’s during the first trimester. They also found developmental delays in young boys exposed to SSRI’s during the third trimester. Rates of autism are higher among boys; however, the study had a disproportionally higher rate of participation among males – 82.5%; hence, further research with a similar sex ratio is warranted.57
The use of SSRI’s during the third trimester is associated with birth complications such as prolonged hospitalization, seizures, inconsolable crying, and breathing difficulties, likely caused by withdrawal from the drug.58 There remains an increased risk of heart defects including holes and malformations in the atria of the heart; however, the risk is low at 0.5%.59 Some little ones have Persistent Pulmonary Hypertension, a lung condition that can be life threatening.60
PRESCRIPTION DRUG USE Page 24
What we know about the effects of SSRI’s on the developing fetus is worrisome, yet antidepressants are the number one most frequently prescribed class of drugs in Canada for individuals of reproductive age (25-39).61
Clinicians rarely offer other therapeutic options for individuals experiencing a difficult time. The attitude remains among some that depression during pregnancy is more harmful for the pregnant person, so individuals are often advised to remain on the drug in fear of reoccurring symptoms.
If you consider the various factors contributing to depression in pregnancy, it is not surprising some pregnant individuals are feeling anxious, low energy, and sad. Lack of social support, community violence, social isolation, and not to mention the apprehension of grief are all reasons why a birth parent may experience these symptoms.
When a counsellor speaks to a prospective birth parent who is taking SSRIs, they will encourage them to discuss the issue of SSRI use in pregnancy with their medical providers.63
PRESCRIPTION DRUG USE OTHER PRESCRIPTION DRUGS THAT CAN CAUSE PROBLEMS DURING PREGNANCY The chart below lists the effects of other prescription drugs on fetal development please review it This chart is taken from The Merck Manual a text of medical references for medical students and health care professionals 64 TYPES Antianxiety drug Antibiotics EXAMPLES Diazepam Fluoroquinolones such as ciprofloxacin ofloxacin levofloxacin and norfloxacin Nitrofurantoin Streptomycin PROBLEMS When the drug is taken late in pregnancy depression irritability shaking and exaggerated reflexes in the newborn Possibility of bone and joint abnormalities seen only in animals In women or fetuses with G6PD deficiency the breakdown of red blood cells Damage to the fetus s ear resulting in deafness When the drugs are given late in pregnancy jaundice Sulfonamides such as and possibly brain damage in the newborn sulfasalazine With sulfasalazine much less risk of problems and trimethoprim sulfameIn women or fetuses with G6PD deficiency the thoxazole breakdown of red blood cells Tetracycline Slowed bone growth and permanent yellowing of the teeth Occasionally liver failure in the pregnant woman Trimethoprim Anticoagulants Defects of the brain and spinal cord neural tube defects such as spina bifida Heparin Thrombocytopenia a decrease in the number of platelets which help blood clot in the pregnant woman possibly resulting in excessive bleeding
PRESCRIPTION DRUG USE TYPES Birth defects Bleeding problems in the fetus and the pregnant woman Some risk of birth defects including neural tube defects such as spinal bifida Bleeding problems in the newborn hemorrhagic disease of the newborn which can be prevented if pregnant women take vitamin K by mouth every day for a month before delivery or if the newborn is given an injection of vitamin K soon after birth Warfarin Anticonvulsants Carbamazepine Same as those for carbamazepine Phenobarbital Same as those for carbamazepine Phenytoin Some 1 risk of birth defects including a cleft palate neural tube defects such as a meningomyelocele and defects of the heart face skull spine and limbs Valproate Antihypertensives PROBLEMS EXAMPLES Angiotensin converting enzyme ACE inhibitors When the drugs are taken late in pregnancy kidney damage in the fetus a reduction in the amount of fluid around the developing fetus amniotic fluid and defects of the face limbs and lungs When some beta blockers are taken during pregnancy a slowed heart rate a low blood sugar level and possibly slowed growth in the fetus Low blood pressure in the mother Beta blockers Calcium channel blockers Inadequate growth before birth growth restriction Possibility of birth defects seen only in animals Chemotherapy drugs Actinomycin Page 26
PRESCRIPTION DRUG USE TYPES EXAMPLES Busulfan Chlorambucil Cyclophosphamide Doxorubicin Mercaptopurine Methotrexate Vinblastine Vincristine Mood stabilizing drug Nonsteroidal anti inflammatory drugs NSAIDs Lithium Aspirin and other salicylates Ibuprofen Naproxen PROBLEMS Birth defects such as underdevelopment of the lower jaw cleft palate abnormal development of the skull bones spinal defects ear defects and clubfoot Slowed growth Same as those for busulfan Same as those for busulfan Heart problems depending on the dose taken Possibly birth defects seen only in animals Same as those for busulfan Same as those for busulfan Possibility of birth defects seen only in animals Possibility of birth defects seen only in animals Possibly birth defects mainly of the heart Lethargy reduced muscle tone poor feeding under activity of the thyroid gland and nephrogenic diabetes insipidus in the newborn When the drugs are taken in large doses possibly miscarriages during the 1st trimester a delay in the start of labour premature closing of the connection between the aorta and artery to the lungs ductus arteriosus jaundice necrotizing enterocolitis damage to the lining of the intestine and occasionally brain damage in the fetus and bleeding problems in the woman during and after delivery and or in the newborn When the drugs are taken late in pregnancy a reduction in the amount of fluid around the developing fetus
PRESCRIPTION DRUG USE TYPES EXAMPLES A very low blood sugar level in the newborn Inadequate control of diabetes in the pregnant woman When the drug is taken early in pregnancy by a woman with type 2 diabetes possibility of increased risk of miscarriage Chlorpropamide Glyburide Oral antihyperglycemic Metformin drugs Tolbutamide Sex hormones When this drug is taken very early in pregnancy masculinization of a female fetus s genitals sometimes requiring surgery for correction Danazol Diethylstilbestrol DES Synthetic progestins but not the low doses used in oral contraceptives Skin treatments Etretinate Isotretinoin Thyroid drugs Methimazole Propylthiouracil Radioactive iodine PROBLEMS Abnormalities of the uterus menstrual problems and an increased risk of vaginal cancer and complications during pregnancy in daughters Abnormalities of the penis in sons Same as those for danazol Birth defects such as heart defects small ears and hydrocephalus sometimes called water on the brain Same as those for etretinate Intellectual disability Risk of miscarriage An enlarged or underactive thyroid gland in the fetus Scalp defects in the newborn An enlarged or underactive thyroid gland in the fetus Destruction of the thyroid gland in the fetus When the drug is given near the end of the 1st trimester a very overactive and enlarged thyroid gland in the fetus Page 28
PRESCRIPTION DRUG USE TYPES EXAMPLES An overactive and enlarged thyroid gland in the fetus Triiodothyronine Vaccines live virus Other PROBLEMS Vaccine for German measles rubella and chickenpox varicella Potential infection of the placenta and developing fetus Drowsiness in the newborn shortly after birth Buprenorphine and metha Irritability and shaking symptoms of drug withdrawdone which are opioids al in the newborn because at birth passage of the opioid from the mother is stopped Corticosteroids Pseudoephedrine a decongestant Vitamin K Possibly a cleft lip when these drugs are taken during the 1st trimester Narrowing of the blood vessels in the placenta possibly reducing the amount of oxygen and nutrients the fetus receives and thus resulting in inadequate growth before birth Possible risk of a defect in the wall of the abdomen that allows the intestines to protrude outside the body called gastroschisis In women or fetuses with G6PD deficiency destruction of red blood cells hemolysis Unless medically necessary drugs should not be used during pregnancy However drugs can be essential to maintain the health of the pregnant woman and the fetus In such cases a woman should talk with her health care practitioner about the risks and benefits of the prescription drugs she is taking before she stops taking them She should not stop taking them on her own Page 29
A WORD ON IMMUNIZATIONS SCIENTIFIC EVIDENCE Page 30
In recent years a decline in vaccination rates has caused the resurfacing of preventable and what were thought to be eradicated illnesses. Although inoculations are the best way to protect your children against serious and sometimes fatal viruses, some parents are making a conscious decision not to vaccinate their children for personal reasons, religious beliefs, misconceptions about safety, adverse reactions, and the belief their child is protected by herd immunity.
As prospective adoptive parents your primary responsibility is the wellbeing of your child. You are also responsible for ensuring your child does not cause unnecessary harm to others. Choosing to delay vaccinating or rejecting immunizations all together, does not only affect your family, but also your community, and the most vulnerable members of society.
Too often the herd immunity card is played as an excuse not to vaccinate. Herd immunity is not intended to protect children whose parents simply decided not to immunize. It is meant to protect the elderly, newborns and those who are immunosuppressed and cannot receive vaccinations for health reasons. As vaccination rates continue to plummet the effectiveness of herd immunity begins to crumble, and the risk of outbreak rises.
It is important that you make decisions about vaccinating your child based on scientific evidence from reputable organizations and accredited health professionals. Vaccinating your child in Canada is very safe. On average it takes 10 years of research, development and monitoring before a vaccine is administered to the public. Following approval, the National Advisory Committee on Immunizations advises on the secure use of the vaccine, and the Public Health Agency of Canada monitors any adverse events from immunizations and vaccine failures.65
Dangerous ingredients, developmental outcomes, and overwhelming the immune system are typical concerns for parents. Since the controversial and discredited 1998 paper published in the Lancet, linking the Measles, Mumps and Rubella vaccine to Autism, it has been challenging to shake off the fear that vaccines are developmentally harmful. For more than a decade now researchers have studied this risk in different population groups, and across countries, and have not found any causation between vaccination and Autism.66
A WORD ON IMMUNIZATIONS Page 31
Parents also worry about Thiomersal, a compound containing forms of mercury. Thiomersal is not present in most vaccines, and the barely traceable amounts found in the Influenza or Hepatitis B vaccine are not associated with any risks to neurodevelopment.67
Lastly, vaccines do not overwhelm a child’s immune system. A vaccine trains the child’s body to fight off the virus, strengthening, not weakening immunity.68 Your child is exposed to germs from food, floors they crawl on, and playgrounds they play on everyday. The body is able to recognize and respond to millions of organism, including small amount of vaccine antigens.
Even though vaccines are considered the greatest medical advancement in the past 160 years, and have saved hundreds of millions of lives, apprehension about vaccinating one’s child continues. It is important we continue engaging in a dialogue so we have the answers to our concerns. If you are unsure about vaccinating your prospective adopted child make sure to speak to your family doctor, or visit a nurse at a community health center.
If you would like more information on vaccinations in Canada please read “A Parent’s Guide to Vaccinations” by The Public Health Agency of Canada by clicking here.
WRAP UP HEAR IT FROM AN EXPERT PRENATAL ALCOHOL DRUG EXPOSURE Page 32
If you prefer to listen to the podcast online please Click Here
This poscast is 1 hour and 2 minutes in length
To conclude this section, please listen to the interview with Dr. Ira Chasnoff as he recaps some of the information covered in this section, including the realties of adopting a child prenatally exposed. Make sure to listen to the entire podcast, as Dr. Chasnoff speaks to the importance of screening and also provides prospective adoptive parents with encouraging words. This podcast also touches on some information learned in the attachment and trauma section.
1. Why is alcohol use during pregnancy more harmful than illicit drug use?
2. What are the cited behavioural problems in children exposed to marijuana in utero?
3. What are the developmental concerns if a gestational parent uses SSRI’s during pregnancy?
Clients must complete the questions at the end of each book. The purpose of these questions is to get you thinking about the material you learned, what you need clarification on (check out the “Resources for Extra Learning” section), and also as an accountability measure to ensure you read the material, watched the videos, listened to the podcasts, and went through the “Exploring Online Learning Activities.”
Please copy and paste the questions into a word document, and answer them to the best of your ability. We do not require overly lengthy answers; we simply want to know you understand the material presented to you, and you are aware of the risks and challenges in adoption.
Your social worker will read over your answers, and clarify any answers either in written form or during your homestudy visits.
RESOURCES FOR EXTRA LEARNING
EXTRA READINGS Baby Steps Caring for Babies with Parental Substance Exposure What Early Childhood Educators Need to Know About Fetal Alcohol Spectrum Disorders A Parent s Guide to Vaccinations by the Public Health Agency of Canada How Much Alcohol is Safe by Ira J Chasnoff MD Page 35
Please Click Here to read it.
A study published in the Journal of Epidemiology and Community Health in 2010 stirred media attention nationally and internationally when the study claimed that drinking alcohol during pregnancy was safe. Read the article to find out the methodological flaws in the study that debunk the safe consumption of alcohol during pregnancy.
Although the guide is targeted towards educators, it is applicable to adoptive parents considering adopting a child with FASD. The guide clearly outlines the developmental deficits, and provides strategies parents can exercise.
This booklet is a resource for parents and caregivers of babies who have been exposed to alcohol and other drugs. The report includes information from professionals, published books, and parents.
Please Click Here to read it.
Please Click Here to read it.
Please Click Here to read it.
PODCASTS DOCUMENTARIES WEBINARS PODCASTS Creating a Family Podcasts DOCUMENTARY Jabbed Love Fear Vaccinations WEBINAR Effective Intervention for Children and Adolescents with FASD Page 36
- Long Term Effects of Prenatal Alcohol an Drug Exposure with Ira Chasnoff.
- Practical Guide to Raising Kids with FASD, or Drug Exposure - Panel of Adoptive Mothers.
- Parenting a Child with Fetal Alcohol Syndrome or Drug Exposure with Julian Davis.
A webinar hosted by Julian Davis on Fetal Alcohol Syndrome, and strategies for parents to help their children cope.
This documentary reveals how vaccinations are key to public health, the facts, and how we need to start a new conversation about vaccinations to reach a more thoughtful and informed decision
WEBSITES FASD Finding Hope National Organization on Fetal Alcohol Syndrome Fetal Alcohol Spectrum Disorder Centre for Excellence ILLICIT DRUG USE National Institute on Drug Abuse OTHER Mother Risk Through Sick Kids Page 37
Click Here
Click Here
If you want to learn more about specific prescription drugs which cause birth defects, cognitive or behavioural impairments, as well as more information on nicotine, alcohol, and substance use please visit the following webpage.
Click Here
Click Here
Click Here
SERVICES Pacific Community Resources Centre The Asante Centre ImmunizeCA App Page 38
Responds to inquiries across the province regarding resources or services pertinent to different aspects of FASD, and other complex developmental needs.
Provides support to families with youth affected by Fetal Alcohol Spectrum Disorder (FASD) and other complex needs. Social workers provide information, support, parenting strategies, service coordination, partnership, and advocacy to enable families to provide enhanced care for their youth.
This Application from Immunize Canada helps you easily record and store vaccination information, access vaccine schedules, and receive alerts about diseases outbreaks in the areas.
Click Here
Click Here
ENDNOTES 1 Buss C Entringer S Swason J et al The Role of Stress on Brain Development Cerebrum 2012 pg 1 16 2 Ibid pg 6 7 3 Kolb B Robbin G Brain Plasticity and Behavior in the Developing Brain Journal of Canadian Academy of Child and Adolescent Psychiatry 20 no 4 2011 pg 265 276 4 Mina TH Reynolds RM Mechanism Linking in Utero Stress to Altered Offspring Behavior Curr Top Behav Neursci 18 2014 pg 97 98 5 Canadian Centre on Substance Abuse Canada s Low Risk Alcohol Drinking Guidelines National Alcohol Strategy Committee 2013 6 American Academy of Pediatrics Fetal Alcohol Spectrum Disorder Program Frequently Asked Questions 2014 7 Clarenn S Cook J Dose response effects of alcohol consumption during pregnancy and prenatal alcohol exposure A brief review Government of Alberta 2013 8 American Academy of Pediatrics Fetal Alcohol Spectrum Disorder Program Frequently Asked Questions 2014 9 Public Healthy Agency of Canada Fetal Alcohol Spectrum Disorder 2014 10 Ibid 11 Rowe T Senikas V Pothier M et al Alcohol Use and Pregnancy Consensus Clinical Guidelines Journal of Obstetrics and Gynecology Canada 32 no 8 2010 pg S31 12 American Academy of Pediatrics Fetal Alcohol Spectrum Disorder Program Frequently Asked Questions 2014 13 Centre for Disease Control and Prevention Fetal Alcohol Spectrum Disorders FASDs 2014 14 Ibid 15 Auch A Cox Millar M Hanion Dearman A et al What Early Childhood Educators Need to Know About FASD Healthy Child Manitoba 2010 pg 18 26 16 Centre for Disease Control and Prevention Fetal Alcohol Spectrum Disorders FASDs 2014 17 Auch A Cox Millar M Hanion Dearman A et al What Early Childhood Educators Need to Know About FASD Healthy Child Manitoba 2010 26 39 18 Mcilroy A Rewiring the brains of children with fetal alcohol syndrome Globe and Mail 2011 19 Public Health Agency of Canada Fetal Alcohol Spectrum Disorder 2014 20 Ospina M Dennett L Systematic Review on the Prevalence of Fetal Alcohol Spectrum Disorders Institute of Health Economics 2013 21 Harrington M Radford J Lutke J et al Effect and intercountry adoptions Know the risks Adoptive Families Association of BC 2014 22 World Health Organization Global Status report on alcohol and health 2014 Individual Country profiles 2014 23 Ibid 24 Ibid 25 Black M Nair P Spanier A Dose and timing of parental tobacco exposure threats to early childhood development Lancet 2 no 9 2014 pg 677 26 Ibid pg 677 679 27 Behnke M Smith V Parental Substance Abuse Short and Long Term Effects on the Exposed Fetus Pediatrics 2013 pg 1012 28 Marroun H Schmidt M Franken I et al Parental Tobacco Exposure and Brain Morphology A Prospective Study of Young Children Neuropscychopharmachology 39 2014 pg 792 800 29 Clifford A Land L Chen R Effects of maternal cigarette smoking during pregnancy on cognitive parameters of children and young adults Neurotoxicology and Teratology 34 no 6 2012 pg 560 570 Page 39
ENDNOTES 30 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 9 31 World Health Organization WHO Report on the Global Epidemic 2013 Enforcing bans on tobacco advertising promotion and sponsorship 2014 pg 24 32 Samet J Soon Young Y Gender Women and the Tobacco Epidemic World Health Organization 2010 pg 2 33 Swahn M Palmier J Benegas Segarra A et al Alcohol marketing and drunkenness among students in the Philippines findings from the national representative Global School based student Health Survey BMC Public Health 13 2013 34 World Health Organization WHO Report on the Global Epidemic 2013 Enforcing bans on tobacco advertising promotion and sponsorship 2014 pg 24 35 Samet J Soon Young Y Gender Women and the Tobacco Epidemic World Health Organization 2010 pg 2 36 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 5 37 Ibid pg 36 38 Ackerman J Riggins T Black M et al A Review of the Effects of Prenatal Cocaine Exposure Among School Aged Children Pediatrics 2010 pg 554 593 39 Nelson C Bhagat R Browing K et al Baby Steps Caring for babies with parental substance exposure Ministry of Children and Family Development Coast Fraser Region 2011 pg 9 40 Ackerman J Riggins T Black M et al A Review of the Effects of Prenatal Cocaine Exposure Among School Aged Children Pediatrics 2010 pg 554 593 41 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 96 42 Nelson C Bhagat R Browing K et al Baby Steps Caring for babies with parental substance exposure Ministry of Children and Family Development Coast Fraser Region 2011 pg 4 43 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 44 44 Ibid pg 34 45 Johnston A Metayer J Robinson E Management of Neonatal Opioid Withdrawal pg 1 14 http www pqcnc org documents nas nasresources VCHIP_5NEONATAL_GUIDELINES pdf 46 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 36 47 Ibid pg 98 48 Ibid pg 98 49 Ibid pg 73 50 Ibid pg 36 51 Johnston A Metayer J Robinson E Management of Neonatal Opioid Withdrawal pg 2 http www pqcnc org documents nas nasresources VCHIP_5NEONATAL_GUIDELINES pdf 52 Kinijnenberg C Melinder A Parental exposure to methadone and buprenorphine A review of the potential affects on cognitive development Child Neuropsychological A Journal on the Normal and Abnormal development in Childhood and Adolescents 17 no 5 2011 pg 497 500 53 Finnegan L Licit and Illicit Drug Use During Pregnancy Maternal Neonatal and Early Childhood Consequences Canadian Centre on Substance Abuse 2013 pg 39 54 Ibid pg 37 Page 40
ENDNOTES 55 Sadler TW Selective serotonin reuptake inhibitors SSRIs and heart defects potential mechanisms for the observed association Reproductive Toxicology 23 no 4 2011 pg 484 9 56 Skurtveir S Selmer R Roth C et al Parental exposure to antidepressants and language competence at age three results form a large populations based pregnancy cohort in Norway Royal College of Obstetricians and Gynecologists 10 2104 pg 1625 1629 57 Harrington R et al Parental SSRI Use and Offspring with Autism Spectrum Disorder or developmental delays John Hopkins Bloomberg School of Public Health 2014 58 Currie J SSRI Antidepressants During Pregnancy Considerations and Risks Canadians Women s Health Network 2010 pg 6 59 Pederson LH Henriksen TB Vestergaard M et al Selective serotonin reuptake inhibitors in pregnancy and congenital malformation population based cohort study BMJ 23 no 339 2009 60 Currie J SSRI Antidepressants During Pregnancy Considerations and Risks Canadians Women s Health Network 2010 pg 6 61 Ibid pg 1 62 Rabin R Are Antidepressants safe during pregnancy New York Times 2014 63 Currie J SSRI Antidepressants During Pregnancy Considerations and Risks Canadians Women s Health Network 2010 pg 3 7 64 Gunatilake R Avinash G Drug Use During Pregancy The Merck Manual Home Edition 2013 65 Public Health Agency of Canada Canadian Immunization Guide Government of Canada 2013 http www phac aspc gc ca publicat cig gci p02 01 eng php evaluation 66 Taylor et al Vaccines are not associated with autism an evidence based meta analysis of case control and cohort studies BMJ 32 no 29 2014 3623 9 67 World Health Organizations Thiomersal in vaccines Global Vaccine Safety 2012 68 CBC Frequently Asked Questions About Multiple Vaccines and the Immune System NCEZID 2011 Page 41
Sunrise Family Services Society 2015