Dr. Mary Mather Consultant Paediatrician (retired)
Dear Mum and Dad I am having a great time at the youth detention Centre . They cannot help me here because they know nothing about me. I HATE YOU. I am NEVER coming home. It is raining and I have lost my shoes> YOU are NOT my real parents. I hope you rot in hell! Please write back soon. Your loving son
Managing a child or adult with chronic behaviour problems is a very challenging task Behaviour is a symptom not a diagnosis Permanent untreatable brain damage causing bizarre behaviour may be sustained before birth
Time to challenge some assumptions: ▪ Behaviour problems usually secondary to trauma and poor attachment ▪ Addressing parenting seen as crucial to modifying behaviour although birth parents may be equally damaged and substitute parents excellent ▪ Child has a normal structural and functional brain ▪ Somewhere/someone has effective treatment ▪ A child who looks normal and is very verbal does not need special services
Parents always play down extent of the problem Professionals do not know how to ask “ hard” to raise the issue with middle class mothers” We fail to get a good alcohol history By the time the child has problems, ▪ Lawyers say we need permission to access health information about parents ▪ Adopters are told to “live with uncertainty” ▪ Other wrong diagnoses are made ADHD, autism etc
Deeply entrenched cultural attitudes The only way of having a good time is to get completely intoxicated A “great night out” is one “no one can remember” From Chaucer to Shakespeare to reality TV, drunkenness is seen as funny by the British (unlike drug use or smoking) Essential for office parties, stag and hen nights, weddings, christenings, funerals, Christmas, family meals, most weekends and even Thursdays! Consumption in UK increased 50% since 1970
Sweet German Rieslings (9.5%) Small glasses Tea with family meals No supermarkets
Stronger drinks ▪ White wine 12-14% ▪ Red win 12-15% ▪ Beer 4-8.5% Bigger glasses ▪ 175-250ml Wine with meals Supermarkets open 24/7
Alcohol Consumption in the UK 10 Litres of alcohol consumed per head of 8 6 population 4 2 0 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
Synthetic estimate % adult population 5.37 to 8.36 4.71 to 5.37 4.33 to 4.71 3.94 to 4.33 0.00 to 3.94
Synthetic estimate % adult population 21.052 to 28.933 17.256 to 21.052 15.645 to 17.256 14.718 to 15.645 00.000 to 14.718
██ > 10 litres ██ 5 - 9.9 litres ██ 2 - 4.9 litres ██ 1 - 1.9 litres ██ < 1 litres
Percentage of all deaths attributable to alcohol ██ 8% to 20% ██ 6% to 8% ██ 4% to 6% ██ 1% to 4% ██ 0.35% to 1%
Emergency Admissions for alcohol related liver disease 30 and above 25 - 30 20 - 25 15 - 20 < 15
80 Age Standardised Mortality rate per 70 60 50 100,000 40 30 20 10 0 1950 1960 1970 1980 1990 2000 Other European Countries England & Wales Scotland
Women drinking more than the recommended guideline on at least one day in a week 45 40 35 30 25 % 1998 20 2003 15 2011 10 5 0 16-24 25-34 35-44 45-54 55-64 Age
5 countries with highest prevalence in the world ▪ Ireland 60.4% ▪ Belarus 46.6% ▪ Denmark 45.8% ▪ UK 41.3% ▪ Russia 36.5% Study excluded indigenous populations, adolescents, women with a low socio-economic status or an alcohol use disorder Worldwide estimates 119,000 affected children born every year Popova et al Lancet 2017
Percentage women drinking in pregnancy ▪ 79% first trimester ▪ 63% second trimester ▪ 49% third trimester 53% drinking during first trimester were drinking more than recommended guidelines (mean 15.1 units per week)
Women drinking were more likely to be ▪ aged 35 or older ▪ to have a university degree ▪ have a professional or managerial background ▪ to be of white ethic origin ▪ less likely to live in a deprived area Even women adhering to the guidelines were at significant risk of preterm labour and having babies with lower birth weight Impact of alcohol strongest in first trimester
Generally accepted worldwide that 1% of all births are affected by alcohol (1 in 100) In the UK: this means 7000 affected babies per year More than the combined total of infants born with Downs Syndrome, cerebral palsy, Sudden Infant Death Syndrome (SIDS), cystic fibrosis, and spina bifida Most experts think UK figure will be much higher 3-5%
Peterborough community audit 40 months from 2010-2013 In 2010: only 2 children with FAS on the child health system Identified 72 Children with FAS/D ▪ Complex behaviors clinic ▪ Statutory medicals for LAC ▪ Adoption medicals Dr Geraldine Gregory Journal Adoption and Fostering Oct 2015
43 (60%) were looked after by LA 15 living with extended family 8 were adopted 6 pre-placement adoption medicals 3% of all referrals to community child health services but 27% referrals for LAC 34% of LAC having statutory medicals had been exposed to drugs or alcohol or not neonatal withdrawal
Alcohol No of No of glasses needed to have a Glass Volume Content Units binge (6 units in a sitting) 1.1 5.5 A 125ml 9% 3.8 B 125ml 13% 1.6 C 250ml 9% 2.25 2.7 3.25 1.8 D 250ml 13%
A unit of 13.5% wine is But this not this…
Very difficult to find 3.5% beer Most are 4% ▪ 1 pint = 2.3 units Tetley’s and John Smiths 3.8% Bottled beers range from 3.8% to 9.0% Low alcohol beer is 2% ▪ 1 pint = 1.1 units
Cheap cider, contains no apples, pocket money prices ▪ 7.5% ▪ 3 litres £2.99 ▪ 22 units/ 3 litre bottle Extra-strength beers ▪ 9% ▪ 4 cans about £4 ▪ 440ml can = 4.5 units ▪ 4 cans = 18 units
By day 23, baby has 125,000 neurones At birth, over 100 billion 250,000 per minute for 9 months Cowan, 1979
Neurones migrate to appropriate parts of brain Differentiate into specialised types Form appropriate connections with others Myelination of axons to ensure the rapid transfer of impulses Selective cell death eliminates unwanted tracts
80 billion neurons connected by 176,000 14 weeks 22 weeks 28 weeks 10 weeks kilometres of myelinated axonal cables 100,000 billion synaptic connections 32 weeks 40 weeks
Pre-School School Years High Numbers Peer social Symbol skills Vision Language Emotional Habitual ways control of responding Hearing Low 0 1 2 3 4 5 6 7 Age Years
Sufficient nutrition to grow ▪ Protein ▪ Energy from fats and carbohydrates ▪ Micronutrients: vitamins A,B, C & D, calcium, folate, iron, selenium, iodine and zinc Freedom from toxins ▪ Alcohol ▪ Drugs (legal and illegal) ▪ Cigarettes Brain most vulnerable between 24 and 42 weeks because of rapid increase in complexity
Age 22 Age 29 Age 31 Age 33 The fetus shares this environment for 9 months Critical information usually absent or missing Confidentiality and the GMC do not help
45 mothers prescribed methadone in pregnancy ▪ 91% babies exposed to other substances ▪ 73% opiates ▪ 70% benzodiazepines ▪ 59%cannabinoids ▪ 14% cocaine ▪ 7% amphetamines 47% exposed to excess alcohol (9x) greater than number identified on maternal history 23% socially matched controls excess alcohol All mothers denied excess alcohol use
Meth- Nicotine Alcohol Cannabis Opiates Cocaine amphetamine Short term effects / birth outcomes Fetal Growth Effect Strong Effect No Effect Effect Effect Effect Abnormalities No Agreement Strong Effect No Effect No Effect No Effect No Effect Withdrawal No Effect No Effect No Effect Strong Effect No Effect * Behaviour Effect Strong Effect Effect Effect Effect Effect Long term effects Growth No Agreement Strong Effect No Effect No Effect No Agreement * Behaviour Effect Strong Effect Effect Effect Effect * Cognition Effect Strong Effect Effect No Agreement Effect * Language Effect Effect No Effect * Effect * Achievement Effect Strong Effect Effect * No Agreement *
Alcohol/drugs/poor diets & lifestyles in pregnancy cause Permanent changes in both the structure & function of the foetal brain Alcohol is the most important cause of damage and the most often ignored These babies are damaged before birth Often present years later with a combination of learning difficulties and bizarre behaviour
Dose Pattern: Binge v Chronic Developmental stage of foetus Susceptibility Maternal characteristics: health, diet Synergistic reaction with other drugs Ethnicity
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