So let's address some common myths and we're hoping you guys can engage with us a little bit. And, you know, it doesn't matter if you're right or wrong, but let's just see what happens. So, alcohol use during pregnancy is rare. Do you think that's true or false? False. You guys are two steps ahead of us. Yeah. So nearly 14% or 1 in 7 pregnant people reported current drinking, and about 5%, which is 1 in 20, reported binge drinking in the past 30 days. Okay, another question. Consuming alcohol is only dangerous during the first trimester. Is that true or false? False. So while some FASD outcomes are more likely at different times during the pregnancy, brain development in particular occurs throughout gestation and growth, and central nervous system problems can occur from drinking alcohol at any time. In fact, the prefrontal cortex develops or matures by the age of 25. Okay, FASD is rare, so this might be a little tricky one. What do you guys think? False? Any trues in there? Okay. Yeah, it's false. So several initial studies using active case findings indicate that 1 in 5% of children in the U.S. may have FASD, and in fact, that is a conservative number, which you'll find out soon, later on in the presentation. Most children outgrow FASD symptoms. So before I ask you to answer that, like autism spectrum disorder, you know, some people can even outgrow that. ADHD, some people can even outgrow that. So I'm just wondering, can some people outgrow FASD, true or false? I tried tricking you, but... Yep, so they last a lifetime. There's no cure for FASD, but research shows that early intervention treatment services can improve a child's development. So no cure so far, but at least there's hope, right? In making and having people have a functional life and creating opportunities for them. So I'm going to ask Dr. Nyko to come in and discuss when did we know and what did we do. Thank you. So, and I see people. I'm sorry we didn't get the slides there, but if anybody wants copies of the slides, you can give me your email and I will email them out today. So when I was researching this, I came across a really interesting paper that sort of looked at the history of how we kind of came to understand what we now call fetal alcohol spectrum disorders. And it goes way back, right? So here's some quotes that we can see from the Bible. The Old Testament, Thou shalt conceive and bear a son. Now therefore, beware, I pray thee, and drink not wine nor strong drink, nor eat any unclean thing. And there's Plato, I mean Aristotle. Foolish, drunken, or harebrained women most often bring forth children like unto themselves. Morose, language that's blaming moms, but this is a tough one. And Plato, right? It is not right that procreation should be the work of bodies dissolved by excess of wine, but rather the embryo should be compacted firmly, steadily, and quietly in the womb. So to pull out alcohol in particular, right? So I think we've seen it throughout history, right? It's a great paper. Lots of examples. Went on to more current day. In 1957, there was a woman, Jacqueline Roquette, who was the first person to notice the faces of the children who were born to alcoholics, right? And attributed it to the mom, right? Drinking during pregnancy. It was an unpublished thesis, so she didn't get any credit for it. Sounds familiar. And then in 1964, there was a French pediatrician, Paul Limone. He was credited with first acknowledging the symptoms of FASD, but he got very little credit for that as well. You can see there he saw tons of cases, like 127 cases, and nobody really paid attention until we got 1973, and they had eight cases. So this was Kenneth Jones and David Smith. They coined the phrase fetal alcohol syndrome, and the paper that they presented was eight unrelated cases, three black, three Native American, and two white. And they pointed out the similarities and were the first to say that direct ethanol toxicity was the most likely possibility for what they were seeing, and these would have been the kids who had fetal alcohol syndrome. And we're going to talk a little bit later about the differences, why fetal alcohol spectrum disorders. There's several of them, but this would have been fetal alcohol spectrum. I mean fetal alcohol disorder, right? Syndrome. Good Lord, sorry. Okay, so I was really surprised by this. So the Alcohol Beverage Labeling Act was 1988, and I always think, like, I clearly remember 1988. I was surprised to know that they did not put the health warning about drinking onto alcohol until 1988, and it wasn't until 2005 that the Surgeon General came out and said we should probably tell women not to drink any alcohol. So prior to that, they were telling women they should limit the amount of alcohol that they drink, and it wasn't until 2005. So it was a full 24 years later from when they first published the paper, which is, it was very interesting because the paper talks a lot about needing to understand what took so long for us to do this and how it's still affecting today. There was a lot of pro- and anti-abortion activism in the early 70s and then ad infinitum how autonomy, women's autonomy around their reproductive health, how all of that sort of played in and actually still plays in when we think about accurately getting a count of kids who are suffering from fetal alcohol spectrum disorders. And, okay, so we know what we have. Let's talk a little bit about how much it costs us. So they estimate that about 630,000 FASD babies are born globally each year. That's about 1,700 babies a day. And they are more prevalent than autism. And they think that, we saw that the one article that came out about the 1 to 5%, they think it might be more like almost 10%. One in 10 kids may have some form of a fetal alcohol spectrum disorder. And they figure there are several hundred new cases every day. The cost is about $23,000 per person per year, which exceeds autism, 17,000, and diabetes, which is 21,000. And this, I thought this was a great, they say it's about $5 billion is what it's costing us. I couldn't find more updated numbers. I know it says 2010, but I like the picture. But the study that's under it was more updated. So children and adolescents, FASD versus non-FASD. And things that you can, does this work? I don't know. Let me see. So here, the difference in inpatient costs, you know, three times as much. And here with adolescents, you're looking at like huge amounts of money in the difference in what we're paying for these kids and the services that they are getting. Okay, so I'm going to hand it back over. Thank you. So understanding fetal alcohol spectrum disorders. So fetal alcohol spectrum disorders is the umbrella term, and the subtypes come underneath that. There are four subtypes, which we should be aware of. Before I start that, I just want to say an umbrella term describes the range of effects that can occur in individuals exposed to alcohol in utero, and all require evidence of prenatal alcohol exposure. So the subtypes are fetal alcohol syndrome, alcohol-related birth defects, or ARBD, alcohol-related neurodevelopmental disorder, or ARND, and neurobehavioral disorder associated with prenatal alcohol exposure, or otherwise NDPAE. I will talk about each one of these in more detail. Let's first talk about fetal alcohol syndrome. And yet again, this is under the umbrella of fetal alcohol syndrome disorders. So this is the most common preventable cause of intellectual disability worldwide. Fetal alcohol syndrome requires evidence, of course, of prenatal alcohol exposure that we just discussed, central nervous system abnormalities, such as structural or functional impairments, a specific pattern of three facial abnormalities, as you can see here. Right here. Narrow eye openings, a smooth area between the lip and the nose, a thin upper lip, and growth deficits either prenatally, after birth, or both. Now let's move on to alcohol-related birth defects, or ARBD. So this includes medical conditions linked to prenatal alcohol exposure, such as heart, kidney, bone problems, malformations, difficulty seeing and hearing, and reduced immune function. Rarely seen alone, but water as secondary disorders accompanying other FASD conditions. So this is something which accompanies others, not just by itself. Now let's discuss alcohol-related neurodevelopmental disorder, or ARND. This requires, of course, prenatal alcohol exposure. And also CNS abnormalities, which may be structural or functional. Functional abnormalities, what does that mean? So complex pattern of cognitive or behavioral problems that are not consistent with developmental level, not explained by factors other than prenatal alcohol exposure, such as environment, toxicities, family background. And facial abnormalities and growth retardation don't have to be present. Now let's talk about neurobehavioral disorder associated with prenatal alcohol exposure, or NDPAE. This is a new diagnosis in the DSM-5. It requires evidence, of course, of prenatal alcohol exposure, which according to the APA means more than minimal levels of alcohol before the child's birth. So the way they say it is more than 13 alcoholic drinks per month of pregnancy, or more than two alcoholic drinks in one setting, which I don't really agree with, but which hopefully we'll learn why later on. And then we have the neurobehavioral disorder associated with prenatal alcohol exposure. More stuff I want you guys to know about it is when we say that CNS involvement is there, we mean cognition, self-regulation, adaptive functioning. So just the overall functionality of an individual is affected. So it doesn't have to be that they look a certain way or they have certain malformations which are visible. A point I want to bring up here is NDPAE and ARND are overlapping and similar, but with a major difference. NDPAE can be present with or without dysmorphic features, whereas ARND is without the presence of full cardinal dysmorphic facial features found in individuals with the full alcohol spectrum. Let's talk a little bit about the diagnosis and treatment, and let's switch gears and talk about this. The term fetal alcohol syndrome spectrum disorders is not meant for use as a clinical diagnosis. Like I said, it's an umbrella term. There are three major factors that must be addressed in the diagnosis on the FASD continuum or spectrum. Physical growth, development, structural defects, cognitive function, and neurobehavioral issues, and prenatal alcohol exposure. So if you have the rest without prenatal alcohol exposure, it cannot be FASD. Detailed information on maternal drinking and risk co-factors are often missing. Oftentimes when you ask someone, you know, do you remember? So think about this. You might see someone, a kid when they're like 10 years old, if you're a child psychiatrist, you might see an adult after, of course, age 21, and if you get in touch with their parents, they may not remember all those years back. So it's hard to get information there, right? And sometimes even when they do remember, they may be a little embarrassed to bring it up because they feel ashamed. In fact, that's one of the reasons we even talked about FASD like four years ago or something. So fetal alcohol syndrome is a major cause of birth defects in the Western world, yet it accounts for only 10% of all cases of fetal alcohol syndrome disorder. FASD children can have either a normal IQ or low IQ. So IQ doesn't have to be low. And just to summarize because I know it's a little confusing, fetal alcohol syndrome is the most well-known of the disorders because of the classic craniofacial dysmorphologies and growth to deficiency produced by early fetal alcohol exposure. Alcohol-related birth defects, or ARBD, have the physical defects of fetal alcohol syndrome without the full syndrome, namely the behavioral health component. And lastly, alcohol-related neurodevelopmental disorders, or ARND, show only the neuropsychological and behavioral dysfunction without the physical characteristics of fetal alcohol syndrome. Now I will invite Dr. Nyko to talk a little more in depth on evidence of prenatal alcohol exposure before I continue discussing diagnosis and treatment. Okay, so I want to talk for a minute about how I sort of became interested in learning more about this topic as an addiction psychiatrist. And I feel like it's important because it's really tough to talk about prenatal alcohol exposure. It is a very complicated topic. We're going to get a little bit into it here, but when I was putting these slides together, I thought we could do an entire workshop just talking about how do we talk to women about prenatal alcohol exposure, or any drug exposure, but particularly alcohol, for reasons I think we know that we don't talk nearly enough about alcohol for a period. It's been very normalized in this country. I think if COVID taught us anything, it taught us that we, as a country, do not see drinking as a problem in the way that it actually is. People reported drinking more, lots of jokes and memes, and it was like, I remember I was still working for the Substance Abuse and Mental Health Services in Delaware at that time, and when they were shutting things down in COVID, there were conversations about how we were not going to shut down places by alcohol because we couldn't have people in withdrawal showing up at the emergency rooms because we didn't know what was going to happen, right? You sort of sit back and think about those conversations, right? And how are we talking about alcohol? I had a patient that I was treating right when I was first— I started treating her when I was in fellowship, and she was a very wealthy woman, right? She had to stay very, very wealthy, and this matters, right? Because this is a woman who had three kids, and her middle son was adopted, and, you know, the kids on either side, Harvard grads, and her middle son had the best care possible. I mean, they paid for every service that you could possibly imagine, and she talked about her son a lot because it was really upsetting. He, at this point, was living across the country in some kind of residential treatment program for, I don't know what, right, kids that don't act right. And really, it was just this sort of catch-all, and he was still struggling, right? Doing things like trying to steal a plane, right? And, you know, couldn't manage his money, had to have someone with him all the time, and she brought in patients. She said, look at this and see, like, what are you thinking? I'm reading it through, and then, I don't know, what happened one day? And I said, huh, I wonder if he has, like, fetal alcohol syndrome or, you know, some kind of disorder. And she said, well, the birth mother said she didn't drink. And I said, yep, I'm sure she did, and she may have believed that, right, because the minute she found out she was pregnant, she might have stopped, right? But that doesn't mean that the damage wasn't already done, and we'll learn a little bit more about the kinds of drinking and the timing and things. It planted the seed. She wound up running with that and found a program for kids. It was a program for kids specifically who had FASD and paid the camp to give him a job because now he's like an adult, like a young adult, and he did incredibly well. Last I heard, he was doing really well. Now keep in mind, this is someone who had lots and lots of resources. Average people are not going to have those kinds of resources, right? And we don't, you know, and I sort of liken under TBI, I think about traumatic brain injuries, this is sort of there, right? What are we doing for these kids? So now throughout my career, I have patients where I'm like, everything I do doesn't seem to help, right? It doesn't matter, you know, what meds I try, what behavioral interventions, it always sits in the back of my mind, right? Like, is this an adult who has a substance use disorder, right, coming from a family of substance use disorder, is this someone who may have had prenatal alcohol exposure and is showing the consequences of that, right, behaviorally and so that's sort of where we got here, right? I see some heads nodding, so we're gonna talk some about identifying evidence of prenatal alcohol exposure. So there are some great resources out there, so, you know, if you want, like I said, if you want the slides, I put them at the very end, but the World Health Organization put out some guidelines for the identification and management of substance use disorders in pregnancy and one thing I'll point out is that if you look here, strength of the recommendations, and this was throughout, they had a lot of recommendations, were strong on the quality of the evidence, was low across the board. Can anyone here tell me when women and people of color were first required to be included in clinical trials? Anybody know? Okay, so it was 1988, but it didn't really take effect until 1993, so prior to 1993, pretty much every clinical trial you had was with white men and they required, the federal government came along and said, now you must include women, but it got really tough, right? Because nobody really wants to include women because, well, what if they get pregnant, right? And then once they're pregnant, how are you testing anything? So there's a real dearth of information just sort of in general about women across the board and particularly women in pregnancy. So keeping that in mind, they tell us that healthcare providers should ask all pregnant women about their use of alcohol and other substances past and present, because the pre-pregnancy alcohol patterns, the use patterns of anything may predict alcohol use during pregnancy and we need to think about that. The other thing was that we should provide brief interventions, and so if you know anything in the substance abuse world, right, brief interventions for treatment are incredibly effective. Right, they sort of talk about somebody comes in and they're smoking and you spend five minutes sort of talking to them about why smoking is bad and things that they might be able to do and maybe you cut back a few and that this will work. People's behavior will change. It's no different with women who are drinking alcohol during pregnancy, and the evidence would show that the younger, right, younger kids don't know at all. We're doing a really bad job, so the teenagers really don't have any information about this because we're not talking about that enough, but across the board, it's still amazing how many women don't fully know this. I could've given you, there are, it's like how much do we need to know about screening women? There are some evidence-based treatments out there specifically looking for substance use in pregnant women. Right, I have a list of them up here. There's the screening ones and then there's the things you can do to do more of an assessment after the fact. They all kind of come with pluses and minuses. There wasn't anything that was like 100% that this is what you do, but of course, across the board, you want to have a rapport with a woman and take a non-judgmental stance in talking to them about this because it's a very difficult thing to talk about, so these are just some barriers that we think about, right? Can I have that water? There's many, but if we're looking at the personal factors of guilt and shame, I'll talk some about interpersonal and then systemic and societal factors. There is significant stigma around substance use during pregnancy, significant, and obviously, I think I can write it here, but obviously, right, it's the first thing that you don't want to say anything, so I partly also got very interested in talking about fetal alcohol spectrum disorders because I was so tired of hearing about neonatal abstinence syndrome, right, and which just reminded me a lot about crack babies, right, and sort of getting really wound up about something where you don't have the data, and in fact, what did we find out? Babies are born, any baby that's substance exposed tends to have higher rates. They save like ADHD maybe, right, they're in good company, right, a lot of people have ADHD, and so, but this sort of, the crack babies didn't, I hate to call them crack babies, right? Babies that were exposed to cocaine did not wind up all being criminals, and it's not, none of that turned out to be true, and similar with neonatal abstinence syndrome, I remember talking to a nurse, and she was a labor and delivery nurse, and she was like, oh, no, these women, they come in on suboxone or methadone, I'm not judgmental at all. We had this whole conversation about how open-minded she was about these moms being on these meds and this and that, and then something came up about neonatal abstinence syndrome, and I very provocatively and kind of on purpose said, I am so tired of hearing about neonatal, like, God, these babies will be fine, and she lost her mind, right, and I got to see, really, what you think, right? These babies come out, and blah, blah, blah, and these moms are taking these meds, and I'm like, there it is, right? Like, that's what we're, that's what these women are picking up on. You can say whatever you want, but if you get to what's really happening, it's an issue, and so this stigma is really, and you have to look at yourself. What is your own bias, right? If you at least own it, if you think it, I know that in my career, I have a hard time, and I know that I have a hard time in my career, I have a hard time. I have a hard time with women who are pregnant and still using. I have to own that. It's like, oh, I just wanna, like, shake them, right? And, but there's not women who want to hurt their babies, right? Women carrying pregnancy, they are sick. They have a disorder that needs to be treated, and you sort of work through that, and you talk about it so that you are not walking into the room like that nurse was, kind of carrying her truth, right, but trying to hide it and saying the right things. It's, so now we're screening, and we have to think about the legal implications. We're gonna talk a little bit later. You're gonna see some numbers about screening, but I want you to keep this in mind. If you're screening people, it can have legal consequences for women, okay? So as of 2016, again, I couldn't find newer data. I swear COVID really screwed up a lot of things, but 43 states have policies regarding alcohol use and other substances during pregnancy. So what you see here are some of the states that have more sort of protective things, like the states there on your left have limitations against medical tests in criminal prosecutions, right? So we're saying if a mom's, of a pregnant woman who may have exposed their fetus to alcohol, you can't, we're gonna limit the tests that you can take out of the medical record. And this list on the other side of priority treatment for pregnant women is not, it's not inclusive. I think that, I know for sure that list has grown because Pennsylvania's not on it, and Delaware's not on it, and both of those states also have, consider pregnant women a priority population. I will, my asterisk with that is it's like, it's amazing that women tend to be more valuable when they are carrying a child, a fetus. It's not a child, when they're carrying a fetus, which is incredibly frustrating, but at least it's a little bit, right? We're acknowledging that people have a condition and we should get them treatment. These are the states that have legal provisions that may define alcohol use by a pregnant woman as a form of child abuse, right? And we are in, I was surprised Massachusetts, I trained in Massachusetts, I was surprised that Massachusetts was on that list. And then you can see the five, Minnesota, North Dakota, Oklahoma, South Dakota, and Wisconsin have civil commitment laws. And I know that some of this isn't updated as well because we know Tennessee, right? There was a lot of stuff that came out of Tennessee. So it'll pop up in the news every so often where you hear that a pregnant woman gets locked up and thrown into jail. I don't know if anyone as a patient has happened to in your particular community, but multiple studies say this is a bad idea, right? Because instead of bringing women into treatment, what it does is just women don't get any treatment. If you look at outcomes for babies that are born substance exposed, including alcohol, they all do better if they have prenatal care. The earlier the prenatal care, the better, right? So if people, women are afraid you're gonna take their kids, you're gonna throw them in jail, they don't come, they don't get any, they don't get substance abuse treatment, they don't get any treatment, they don't get prenatal care either, which leads to worse outcomes for the babies. So these laws are, there was a great, NIDA did a great paper, it's listed in the references that you should thank legislatures before making these laws because it's actually hurting these babies instead of doing what it is that you think it will. And I always say too, it's a slippery slope, right? If you can lock women up for drinking during pregnancy. And so you can see this is just another one that sort of says, women have been arrested, civilly committed, subjected to forced interventions or face losing custody of their children. And then another talk we could have again about the systemic racism. And we know that, for example, we overscreen certain populations. We don't screen everybody, but we overscreen black women and brown women. And we underscreen white women. And study after study shows that black women are more likely to be screened, they're also more likely to have their kids taken from them in the event that they have a baby born exposed to substances in any way. So like I said, we do a whole talk on this. There's a lot of things to think about. But keep these pieces in mind when we look later at some more statistics about screening and prevention. Okay, I'll hand it back over to Dr. Shah. Any questions or thoughts? Is this a good spot, no? Okay. Thank you. So let's continue with the diagnosis and treatment. Okay, so common physical growth, development and structural defects are often seen. These conclude many things, low body weight, poor coordination, sleep and sucking problems as a baby, vision or hearing problems, shorter than average height, small head size, abnormal facial features, which we discussed earlier, and also common cognitive function and neurobehavioral issues. And of course, there's a whole plethora of these, hyperactive behavior, inattention, poor memory, difficulty in school, speech and language delays, intellectual disability or low IQ, poor reasoning and judgment skills. There is an increased risk for cognitive disorders such as memory loss, mental illness or psychological disorders. Secondary conditions can develop. What do I mean by secondary conditions? These are conditions that may develop as a result of having FASD. These include ADHD, chronic disorder, alcohol or substance use disorder, which actually occurs in up to 85% of people with FASD and can have an earlier age of onset. What do you guys think? What age am I? Take a guess. Any numbers out there? 12 years of age. Depression and anxiety, of course. Secondary conditions will disrupt your school experience as one. Children with FASD are at a higher risk for being suspended, expelled, or dropping out of school, truancy, trouble with the law, reported overall for 14% of children and 60% of adolescents and adults with FASD. Inappropriate sexual behaviors increase slightly with age from 39% in children to 48% in adolescents and 52% in adults with FASD. So one in every two people with FASD will have inappropriate sexual behaviors as an adult. Sleep disturbance occurs in up to 85% and these include pretty much everything, like difficult falling asleep, frequent waking during the night, night terrors, early awakening, the whole spectrum. Higher risk for victimization and suicide. Given the overlap of symptoms and high rates of co-occurrence with other disorders, FASD is often misdiagnosed or underdiagnosed. Disorders with overlapping symptoms were not limited to, of course, ADHD, oppositional defiant disorder, disruptive mood dysregulation disorder, autism spectrum disorders, intellectual disability, and reactive attachment disorder. There's a wide range of overlapping symptoms across many psychiatric disorders. The disorders can vary from bipolar disorder, ADHD, ODD, to autism, trauma, and of course, FASD. The symptoms include, but not limited to, inattention, not following through on tasks, engaging in activities without considering the possible consequences, impulsivity, abnormal speech, learning disability, sleep disturbance, behaviors such as blatant lying, oppositional behavior, problems with mood and temper, difficulties with social interactions, and difficulty with transitions. So when you have these symptoms, it's sort of like, okay, so we see the symptoms, what exactly am I dealing with, right? And this is where we can talk about conditions which are often overlapping with FASD. So let's talk about FASD first, and then we can talk about autism. FASD affects one in 20 children. Effects are lifelong. Early intervention can help. Sensitive to light, touch, taste, smells, or sound. Difficulty with changing routines or transitions. Hyperactive behavior, impulsive behavior, short attention span. Of course, difficulty in school. Now let's talk about autism. Affects about one in 59 children, so more rare than FASD. Effects are also lifelong. Early intervention can help. Also sensitive to light, touch, taste, smells. One of the things people most love to talk about when they see someone with autism spectrum disorder. Difficulty with transitions. Difficulty with changing routines. Hyperactive behavior, impulsive behavior, short attention span. And of course, difficulty in school. So very similar, right? FASD, well, so here are some other things which can differentiate FASD from autism. So FASD, people are often comfortable starting conversations and joining social activities. They're discriminately friendly and have poor boundaries. Lack the interpersonal skills to move a social interaction forward in a positive way. Struggle with social cues, which is similar to autism. And tend not to understand information conveyed by speech prosody. But slightly different tinge, right? So now let's talk about autism and see what I'm talking about. So people with autism, not all, but mostly avoid social interactions. They wanna be social, but they just sort of avoid it. Appear aloof and uninterested in social interactions. And this I'm talking about someone on the lower end of the spectrum. Difficulty talking about things outside their interests. Struggle with social cues in non-literal language or non-verbal cues. Now let's talk about autism versus ADHD. So just a real quick rundown. FASD, you know, visual spatial ability impairments, verbal encoding impairment, fluency impairment, problem solving impairment. Let's do a little rundown of ADHD. Focus attention impairment, retention of verbally learned material impairment, and verbal memory impairment. So these are some things which differentiate them, right? So now let's talk about the many things which are similar. Inhibition impairments, increased impulsivity, executive functioning impairment, psychiatric comorbid illnesses, the ones we discussed earlier, like depression, anxiety, et cetera. Hyperactivity, adaptive function, verbal recall and reading. Let me just add something. So I saw a paper, right? And again, another topic that could be its own talk, right? Just sort of looking at the differences, but there's some studies out there, the one I found looking at the link between FASD and ADHD, right, that there is a lot of overlap. There was things about the genetics when it goes in that direction. And so I think we're gonna continue to find out more about why they look so similar. And, but yeah, there's a lot of good information if you see kids and wanna know about this. There's some fantastic papers out there about the overlap between the two. Yeah, and we're hoping, you know, people would become more aware of this, so when you're diagnosing someone in the clinic, you know, this is something you'll consider. Alexis, here's a short video on comparing ODD, ADHD, and FASD. Hopefully this should work here. Here we go. And here we go. So let's look at three individuals. They could be children, they could be adolescents, they could be adults. You've given them three instructions. Class, take out your math books, turn to page 43 and do problems one through 10. Or if it's a home situation, it might be, go upstairs, brush your teeth, get in your pajamas, get ready for bed. You've given them three instructions. Or you've given a parent three instructions of, I'm setting up an appointment for you to come in Tuesday at three o'clock for a school meeting, and this is what you have to bring to the school meeting. You've given them multiple instructions, and they don't follow through. So the behavior is exactly the same. There is no difference in the behavior. Well, let's look at these three individuals. One has a true oppositional defiant disorder with no co-occurring disorders. One has a true ADHD with no co-occurring disorders, and one has a true FASD with no co-occurring FASD or ODD. Sit down with the individual with oppositional defiant disorder and say, what did I tell you to do? And they can tell you what you told them to do. You told me to take out my math book, turn to page 43 and do problems one through 10, because they took the information into their brain, stored it in their brain properly, and they could recall it when they needed it. Then you say to them, well, then why didn't you do what I told you? I didn't feel like doing my math today. I don't wanna do it. You wanna do it, go ahead, do my math. I'm not doing it. It's good oppositional response. If it is a true oppositional defiant disorder, then that means that they are making a conscious decision to not do what they're told because they have the information in their brain. They know what to do. Now, you know in true ODD you don't fight everything, but if this is a battle you're gonna fight, then you set up, first of all, a positive sense of control. Control is a huge issue. When you are dealing with people with disabilities and you are dealing with adolescents, any adolescent, control is a huge issue. We control most of their life. They feel totally out of control, that other people are controlling them. And my brother who's a psychiatrist said the best way to get an adolescent to not take their medication is tell them to take it because they will do the opposite. So we wanna give them a positive sense of control. You need to do your math work. You can do it now or you can do it in three minutes. I don't wanna do it now. Okay, I'll set the timer for three minutes. When the timer goes off, you need to do your math. If you do it, here's the reward. If you don't do it here, it's a consequence because for that group, rewards and consequences work well because they know what they need to do. It's their decision not to do it. If they experience the negative consequences, they will choose at some point, hopefully, to do the right thing because this is all conscious. Sit down with the individual with ADHD and say, what did I tell you to do? And they can repeat what you told them to do. You tell me to take out my math book, turn to page 43 and do problems one through 10 because they took the information into their brain, stored it in their brain properly and could recall it when they needed it. Their problem was they reached into their desk to get their math book. There was a comic book next to it. They started to read the comic book. Another kid started talking to them. They got distracted. But if you could get them on target, they know the three things they need to do. So you need to limit stimuli and provide them with cues for the three things they need to do to get them on target. If they can't do it environmentally, they may need help with medication to help them filter out stimuli and focus. This is in true ADHD. We know, of course, ADHD is one of the most over-diagnosed and one of the most under-diagnosed disorders around. Sit down with the individual with FASD. And if it's an adolescent and you ask them the wrong question, you're going to get the wrong answer. Because if the wrong question is, why didn't you do what I told you? And an adolescent's answer almost all the time is going to be, I didn't feel like it. Remember, better to be seen as bad than to be seen as stupid. But if you ask them the right question, what did I tell you to do? They may say, read my science book, do my social studies, line up for gym. Because by the time they start, they may start looking for their math book. They can't find it. They have no idea what to do next. Even if they get their math book, they have no idea what to do next. So if it's truly FASD, because the difficulty in FASD is taking information into the brain, even if it gets stored in the brain, they can't recall it when they need it. And even if they recall it, they don't know what to do with it. And there is enough research now that's showing that actually working memory or immediate memory, we used to talk about short-term and long-term memory, we now know that there's at least a third level of memory called working memory, which is what we use when we are told to do something. But again, any time you're giving people instructions, you're relying on their working memory. If you are telling a parent what they need to do, you're relying on their working memory. If you're telling a child what they need to do, you're relying on their working memory. If their working memory is impaired, and in FASD we know across the IQ span it's impaired, they're not going to be able to follow through. It's going to look like willful, purposeful behavior. Will the approach for ODD work if it's truly an FASD? No, because you can set the limits and consequences and set the timer, and they still don't know what to do. Is just limiting stimuli and providing them with cues going to work? No, because they don't know the three things they need to do. But breaking it down to one direction at a time will work. I'm just going to say this guy is an expert in FASD, and he has a ton of great videos on YouTube to learn. He gives talks all the time, and they're really fantastic. OK, I hope it was understandable what he was talking about. So there's no cure or specific treatment for FASD, but the good news is early intervention may help reduce some of the effects and prevent secondary disabilities. Examples include having a team that includes a special education teacher, a speech therapist, physical and occupational therapist, and a psychologist. Early intervention to help with walking, talking, and social skills. Special services in school to help with learning and behavioral issues. Medications to help with some symptoms. Medical care for health problems such as visual problems or heart abnormalities. Addressing alcohol and other substance use problems if needed. Vocational and life skills training. And counseling to benefit parents and the family in dealing with the child's behavioral problems. And also providing psychoeducation to the family and, of course, to the patient. The more you understand your illness, the better you can deal with it and the better the prognosis. So I just want to finish off the treatment portion. So in a nutshell, just think of it this way. A child presents for an office visit. Some certain things trigger the suspicion of FASD in the child. After you interact with the child, it could be something like facial abnormalities or growth delay, or you just find out, hey, the mom was using alcohol well when she was pregnant. So then what you do is you do an initial evaluation. You gather specific data related to the four FAS criteria, or fetal alcohol syndrome criteria. Facial malformations, growth abnormalities, neurodevelopmental concerns, and maternal alcohol use. This is something child psychiatrists mostly do anyways in the neurodevelopmental history. Although I'm not sure if they ask about maternal alcohol use all the time. So let's say the criteria are met. Or let's assume they're not met first. What do you do? You continue to monitor the changes in the child's health over time. However, let's say you do meet these criteria. What do you do? You refer the child to a specialist for further assessment. And then comes the diagnostic part. So FAS diagnosis confirmed using dysmorphic and anthropometric assessment procedures, along with appropriate neurodevelopmental evaluation data. An intervention plan is developed using a multidisciplinary team approach. You can't do it without that, as we just talked about earlier with the team. And the services provider or some things like the intervention plan is communicated to the frontline providers, caregivers, and child with ongoing exchange with the intervention team. A case management plan is initiated at the community level based on recommendations from the intervention team. Specialty services, community, and educational resources are all included in this. Now, I will ask Dr. Nichol to come and talk about prevention of fetal alcohol spectrum disorders. I think it's important to remember that when we're talking about, like, the dysmorphic facial features, right? Most kids with even fetal alcohol syndrome do not have all of them, right? It's not as obvious as you see in the pictures. I think it's something like less than 10% can be identified just by the faces alone. And, yeah, so that's just another important thing to remember. I'm going to say again, fetal alcohol spectrum disorders are the leading cause of preventable birth defects in the United States. Preventable, 100%. 100% preventable. The best time to target prevention is prior to conception, right? And guidelines recommend no alcohol from the time that conception is planned. So it's simple enough, right? All right, so then we're going to say, so we're going to come back to that. How much alcohol is too much alcohol, right? So quantity of alcohol consumed, particularly over a short time, is a major factor, right? So we know that if you're drinking a lot in a short period of time, and we know this because populations with the highest rates of binge drinking have been found to have the greatest number of babies that are born with fetal alcohol syndrome. That are born with fetal alcohol spectrum disorders. Now, I didn't put this slide in, but I want to remind you all that there is no such thing as no-risk drinking. You have a low-risk drinking. Does anybody know what, if you can raise your hands, what low-risk drinking is? People are always shocked by this. So here's what is considered low-risk drinking. For men, it is no more than 14 drinks a week, and no more than four drinks in one day, in one sitting, right? So both of those have to be true. And for women, it's, for different livers, seven drinks a week and no more than three drinks in a day. That's low-risk drinking. So I would say, I used to say to people, and they're like, kind of looking, right? Like, oh no, I drink more than that. I drank more than that, like, you know, last night. Which is, you start to become a higher-risk drinker. The United States, binge drinks. We have a lot, we have a binge drinking issue. They think about 38 million adults in the United States drinks too much. That's, I hate judgmental language, right? But would be higher-risk drinkers, right? They would start meeting criteria, but only one in six even talks to a healthcare professional about it. Oh, it is in here. So you can see what the low-risk drinking is. Any pregnant, any kids, 21. I tell my 16-year-old all the time, you're not supposed to be drinking because your brain is still developing, right? Like, this is why it's not a random number. We're just trying to kind of get your brain to be as healthy as possible. In the United States, we drink about 17 billion binge drinks total a year, which is about 470 per binge drinker. And it's about half, what does it say? About half of the total binge drinks are done by people over 35, which means the other half is people that are less than 35. So there's that spot of women who are of childbearing age. So the next slide, I thought was very interesting. So take this in for a minute. This study, and it was looking at drinking. So in the United States, 30% of people do not drink at all, none, for whatever reason, right? They never did drink. They have a health reason. They used to drink and stopped drinking, and they fall down into that category. The next 30% average two drinks a week or less. So you're looking at 60% of the population that is really not drinking much. And then you can see that it goes up significantly, particularly in the last tenth, right? So one in ten people in the United States is averaging 74 drinks per week. There is a huge jump. It's still not great down there at, you know, 15 drinks a week, right? You're still kind of over the limit, and people have been drinking those. It's a problem. But that is, you can see, three cases of beer with 24 cans, 18 bottles of wine, or four and a half, basically, handles of Jack, right? Jack Daniels. That's a lot of drinking. It's like you're drinking all the time. So you're averaging, you know, 10 drinks a day. And again, binge drinking is a lot of that. That is an enormous amount when you think about one in ten people, right? It's not just one in ten drinkers, but one in ten people, right? You're looking at that kind of alcohol consumption here in the United States. So what do we say? Higher rates of binge drinking. We have a lot of binge drinking in this country. You have more kids that are born with FASD. Four in five, this came from the CDC, four in five adults who binge drink were not advised to reduce their drinking by a healthcare provider, right? I always would think when I went in, now I know as an addiction psychiatrist, right, I take a very extensive substance use history, I get it. But I always thought it was interesting, even as a med student, that you talk about people's drinking in the social history and you sort of said, do you drink? Yes or no? Great, yes. And then you just kind of keep going, right? And that was the extent of it. Do you drink or smoke cigarettes or do any drugs, right? I think anybody knows that is not the way to ask about their use, right? And there's techniques to do that, but we are not asking about it. We're not talking about it at all in general, right? So we're not talking about it in general and we know all the issues with talking, how hard it is if an adult talks to a pregnant woman, what is that going to look like? So we know that the interventions, right, if we're going to try to prevent this in talking to women, we've got to talk about drinking behavior and contraception use. So what does that look like? Binge drinking is very common of women, so one in eight women, that's nearly 13, 14 million women binge drink about three times a month. And one in five high school girls are binge drinking and women average six drinks when they're binge drinking. This was 2023 Morbidity and Mortality Weekly Report. This is from the CDC found that 80 percent, so 80 percent of pregnant women were asked about alcohol use. So I'm like, what about the other 20 percent? Why are we not asking 100 percent of pregnant women about their alcohol use? What was more disturbing was that of those that reported drinking, only 16 percent of them were advised to cut down or stop drinking. So we're asking, are you drinking when you're pregnant? And they just kind of go on, which is problematic. It is a missed opportunity every time. And again, why are we not asking that question? I was like blown away by this. I couldn't wrap my brain fully around what was happening, that we're not having the conversation. When you think about the biggest risk, I could have gone again, yet another talk about all the risks of like women who are going to have babies with FASD and all of them. But the biggest risk was their plan, right? It was the plan for pregnancy was the biggest predictor of risk, which makes sense. So now we know, though, that among women not intending pregnancy, 20 percent are not using or inconsistently using contraception when having sex with a male partner, right? So 45 percent of all pregnancies in the United States, it's still high, are unintended. Of those 45 percent, 40 percent, we're going to see this number go down, were voluntarily terminated. So that kind of leads to a number, this is about a third of all pregnancies that lead to birth are unintended. We know that if you're non-pregnant women, alcohol exposed pregnancy risk, 2.3 for those not intending to get pregnant and 33.7 percent for those who are intending to get pregnant. So the risk is a lot higher if you are trying to get pregnant. They have especially high risk because they continue to drink, right? Until they find out they're pregnant, which you can be four, six, eight weeks in beforehand, and that is a real vital time in fetal development. So the damage could possibly already be done before you even know. If we're going to talk about contraception, right, there was a great page I found on the site, one of the Senate sites, and it was 2 million unplanned pregnancies are prevented by publicly funded birth control, and every dollar spent on contraception saves $6 of public spending, right, through unwanted pregnancies. That's a lot. So what's going on? Just a little reminder of where we're at with contraception. So women's plan for pregnancy being the biggest predictor. In 2008, the Affordable Care Act said that you would guarantee women's preventive services, including birth control and contraceptive counseling, at no cost. And there was the little provision for houses of worship and other religions that object for faith-based reasons. In 2018, Trump expanded that to include anybody who just said they had a moral problem with women using birth control. They did not have to let women have birth control. And just this year, Biden is trying to pull that back and also create. So not only would we bring it back just to sort of the very specific faith-based, but then provide a pathway for the women who are stuck in those systems to then be able to get access to free contraception. Brings up that point, you can't have it both ways. You can't not let women have contraception and then not hope they just don't use substances. Lots of complicated things. And then the last thing I'll say is we know what happened with Dobbs. And I think was it South Carolina just, I think, yesterday passed a six-week ban. So it's just going to get more and more difficult for women to have any kind of control over their reproduction, which is incredibly important in this situation. Right? Advocacy and education. There's a lot. There's some really good organizations that are out there. FACET, United, it used to be like the, I forget what they used to call it, NOFAS. But I heard a woman that came from the national organization to our chapter in Delaware. And she does talks all over the country. And she was in recovery from her alcohol use disorder and had five children with fetal alcohol syndrome. She had five children. And she was now continuing to raise these five children. And I could cry when I think about hearing her talk. It was one of the most powerful talks I've ever seen. Because this woman was full on like, yep, I was drinking. And it was a problem. And this is what happened. And I'm trying to do the best I can to raise my kids, but help does not happen. To educate people, to see that this is what it really looks like. It was incredibly, incredibly powerful. It doesn't happen like that all the time. It is still really hard with stigma. But I was heartened by this woman who was willing to put herself out there. So the national organization is very, very good. They have expanded a little bit. So they're talking about neonatal abstinence syndrome and stuff. Because they told me, there's money out there. And they're not giving any money for FASD. But you can get lots and lots of money for neonatal abstinence syndrome. So they're like, well, if we expand, then we can bring some of that money in here, which is sort of appalling. Because there should be money for FASD, given that it is way more common, incredibly more common, and far more devastating than what we see with babies who come on board with opioids. They have a great website. They have a Center for Justice. They have a policy center that they're going out and doing advocacy. These are great places to go and get some education. And I work for the state of Delaware. And this is being recorded, so I should probably be careful. But I've gotten a look up close at the intersection, less so of government and health care, but of politics and health care. And there's a big difference between government and health care and politics and health care, and what looks good in an election year, and what people want to hear. And this is the sort of thing that we need to be talking about, because it's horrifying that they have to try to get SOAR money, opioid response money, to take care of fetal alcohol spectrum disorders. We need to do better. There's affiliates all over the country. So if your state's up there, you probably have a branch somewhere in your state that's doing this work, maybe more than one. And I just gave these examples here. The proofalliance.org is out of, was it Minnesota? And they have the facetcenter.org, where they're doing some equity work. And they do a bunch of research. They had a big research project coming on. So they came to our affiliate branch in Delaware and told us all about it, and gave us the information that if we knew people that we thought would be appropriate to call in and be in these studies. So they do a lot of really good work out of there. So it's a great resource to get some information and some more education for yourself. Raise your hand if you remember being taught anything about fetal alcohol spectrum disorders in medical school. That's good. How about residency? A little bit. I always thought FASD is a good boards question. It'll be great. It's really good. Don't drink while you're pregnant. You're like, yeah, it's a giveaway. So it's easy. But does anybody remember really talking about it? And hey, this is what we can do to prevent it. Something that is 100% preventable. And we're not talking to women about their use. It's a paper about women and their civil rights. And are we trampling on them? Complicated, but we need to do that. There are states that are doing things. This was out of Colorado, the pink one. They were asking the Colorado legislature to re-up funds looking at fetal alcohol spectrum disorders and providing research and funding for programs. And Louisiana was having a summit. So this is all grassroots. People are coming, and they're involved, and they kind of get these things started. OK. Final takeaways. I think these are common, 100% preventable. Education and screening, vital to prevention. Proper diagnosis leads to better outcomes, as it does with most things. And advocating is really important. They're estimating 1 in 20 kids, and they think that this is a very low estimate of kids who are living with some sequelae from prenatal alcohol exposure. So it's probably important that we address that. And that is the end. Does anybody have any questions or thoughts, please? Thanks for such a great talk. It was so interesting. That's such a pity it was so poorly attended. My question really comes from my role as a general adult psychiatrist, where referrals for ADHD have just skyrocketed exponentially. And I guess I'm sitting here feeling extremely embarrassed, because I can't think of many, if any, of that huge group. Clearly, a big proportion of them would also be either comorbidly fetal alcohol or purely fetal alcohol, which has just gone completely over my head, embarrassingly. But have you got any tips that might help me to better identify the adults presenting with ADHD-like symptoms who are likely to have a significant component of their problems attributable to fetal alcohol? And if so, if there are any treatment recommendations that would be different fetal alcohol and adults versus ADHD? That's a great question. So first of all, if anybody in the audience has something to contribute to that, I know that one of the things that I do when I'm screening for, as an addiction psychiatrist, there's a huge overlap between substance use disorders and ADHD. Because we know kids with ADHD are higher risk of developing substance use disorder, particularly if it's untreated. And so I see a lot of folks that would meet criteria. And it's complicated by it being a myriad of other things. So I never use the adult screen for ADHD, because I always joke and think you'd have to be an idiot not to get a diagnosis of ADHD with the eight questions. I'm like, I don't use that. So I have used for years now the WENDER Utah rating scale, which is like 60-something questions. And only 25 of them actually pertain to ADHD. You ask people to fill it out when you were a kid. And if I can, I ask if they have a parent that could fill it out as well, and not talk to each other, and just sort of see if the parents saw the same kind of things, and if they meet the criteria. And it has a pretty good specificity. And the other one, I'm sorry. Yes, it's a pretty good test. It's been well-validated. And I use that one a lot, because it makes me feel better about they didn't. It's hard. You can't fake the test. And I see a largely Medicaid population when I practice. And so I'm not sending them all out for neuropsych testing, or these things online that they can sign up and do, that you can test their cognitive stuff. And I can't. It's great. There's a lot of things out there. You could test for ADHD. I think that where I get stuck, and this is the only answer that I have, is that I started to wonder about two things, FASD and then head injury in general, because I would then have somebody where I'm like, oh, it wasn't another resident I was talking to. When I was in Boston, we had this kid, Matt. And I will never forget Matt. And Matt was real sweet. And I was like, I cannot help Matt. He is a mess, no matter what I do. It's an ADHD. I even tried to treat that, and I couldn't do it. And I remember saying to Matt one day, does he ever get hit in the head? And he was like, oh my god, yeah, I got hit in the head once. The police hit me with a pipe. And he had like five times he got hit in the head. Twice he lost consciousness. I'm like, oh, dear lord. So is this a brain injury? Hey, Matt, what was your mom like, right? Yeah, you grew up in a house where people were using drugs, right? And often, they don't talk about drinking, right? But I always go like, eh, where there's people using drugs, there's usually some alcohol. So it's very possible that that was the case. And then you're sort of kind of containing people, right? And try to educate them about how some of this is just going to be really, really hard. But when you have your adults, it's hard to get a good history. It's also really hard when you're like, hey, was your mother a big drunk and drink the whole time? Because that's what they hear, right? Don't talk about my mom like that. I've had that when I've asked a question. The guys get really upset with me. But again, kind of approaching it like, hey, it could have only been a little bit. We just sort of need to know, is this something about your brain? And is there a change in your brain? But as I'm saying this to you, I ask every patient that comes in about head injuries. And I think it's a good time to put in like, hey, was your mom a drinker, right? Was she someone who drank? And asking that question as well, because it gives you a piece of information. That's a great question. I just want to add a couple of things to what Dr. Nykkel was saying. So kids with FASD will be more treatment resistant, actually, to a lot of ADHD meds. So if you're like, nothing's really working, I would really be suspicious of that, either like a head concussion or FASD. The other thing is, a lot of these kids will also have learning disabilities and just have a hard time communicating with other kids. So that's something you can also be on the lookout for. So it won't just be purely ADHD. Hopefully, that helps. And one way they were looking at the differences, like say, between kids with FASD and autism in terms of their social interactions, right? You see that a lot. People who were like, they really want to interact. I think about that with Matt. Really wanted to have friends. Nobody could stand him, because he couldn't read any of his signals. He couldn't hold information. He couldn't calm down, no matter what we did. Yes. Hi. Thank you all so much. I think this is a super important topic. I'm a child psychiatry fellow in New Mexico. And something that I think a lot about, and as you mentioned, not discussed very much in adult general psych residency. And now that I am more familiar with it and screening for it, I mean, sometimes I'm thinking about these formulations. And they're really complex, right? There's a utero exposure. And I think something that's really hard in the studies is taking that apart from early trauma and neglect. I saw Rad mentioned, but certainly like a whole spectrum of trauma disorders. And so my question is related to the other question mentioned is, so on one hand, I'm like, well, my understanding is the treatment recommendations are essentially the same, these really high risk kids, where there's maybe TBI, and trauma, and in utero exposure, and maybe after utero exposure. And the recommendations are OT, PT, speech, therapy, counseling, all the things. But are you aware, have there been many studies looking at FASD specific interventions that seem to be particularly helpful or big need in that area? Do you know of any? Yeah, that's a great question. That's something we also pondered about. So there's not that many resources out there specifically for FASD, there's not. And you're right, essentially, the treatment is the same. For example, kids with autism spectrum disorder, for example. However, it is still very important to know that the underlying cause is FASD as opposed to something else. Why? Because then you don't get frustrated that treatments are not working. There's a lot of treatments, for example, ADHD, like Stratera works equally, like Adderall worked for autism spectrum disorder. However, none of them may work for FASD. So just having that knowledge makes someone less frustrated, the family less frustrated, and the prognosis is better in that sense. It's just a more positive environment. As far as resources are concerned, every state is different. I'm not sure what's out there. Maybe Dr. Michael knows. Well, I guess in Delaware, I don't think there's that many. I mean, there's not a whole lot of resources anywhere. So one of the problems is that unless you are the kid who has fetal alcohol syndrome that is diagnosed by the FACES, that 10%, and you're like, that's what it is, you don't know. There's no way to know. So you can't say, like, I did a study with all these kids that I know that had some kind of fetal alcohol spectrum disorder, because you'll never really, really know. That's the problem. So I think that, and even finding an expert. So we came up against this. Like, what do we do? These people come in. They say, I think my kid has a fetal alcohol spectrum disorder. Like, where's the specialist? There isn't one, right? There's just not enough of that. So it kind of begs the point of, like, why we need to talk about this, and be educated about it, and know the questions to ask, and what you're looking for. Because it's just, it's, there are pockets, right? But it is not nearly enough for 1 in 20 kids. Yeah, and also just to add on top of that, the thing is pediatric addiction, I feel like is going to take off. Because we're finding that most addiction starts in the adolescence or young adult years. And what better way to treat addiction than to prevent it, right? So the more we're talking about fetal alcohol syndrome and spectrum disorders right now, the more people are aware of it. And I'm hoping that it takes, it gains speed. And then we actually start getting programs which are very common at the state level, and national level, and regional levels. And I wish I had the numbers in front of me. But we were working with David. So there was a young man that was doing these talks for one of our substance abuse treatment providers. And they came over to work for the state and got involved in our affiliate. And we sort of grew from there. But he, we took his data, because he would hand out sheets before and after he gave his talk. And so we were like, it's not official or anything. But we're like, let's bring it all together. And yeah, teenage girls know nothing. I mean, it was astounding how little that they knew. Nor did, and David was really good, and we didn't say enough about this. It has been shown that if partners, male partners, are also educated, and they drink, they stop drinking, the women, it supports the women, they're more likely to drink less or stop drinking as well. So there's this piece that says, don't forget about the partners, because they need to be educated as well as to why this is important and be supportive of a woman who is now not going to be using any substances. But yeah, it was, even that little talk, though we talked about brief interventions, it was amazing how we could see the difference in what the teenagers knew. But when you saw the first numbers, it was like, it's dangerous to drink during pregnancy. It's not like, if you get pregnant, like, no, it's fine, right? It's not a big deal. It's legal, right? Why would it be bad for you? Heroin is bad, because all those babies, we got to give all this money to moms whose babies had heroin. Like, that must be really bad. But alcohol, nobody's talking about that at all. And I can buy it at the store. Everybody can have it. So there was a lot of that kind of thinking that's out there that we have to educate. So if you're out there working with adolescents, they've got to get it into their heads, because they do not know this. Yeah, and right now, there are some sort of fancy studies being done on diagnostic factors when it comes to FASD, like certain genetics and all that, and also certain treatments like PEA, which is something which works with the endocannabinoid system in the brain of how to reduce cravings for not just cannabis, but also alcohol and pretty much substances in general. But I don't see that many studies, if at all, on the actual treatments or cures for FASD, because once you have it, you pretty much have it. That's the scary part. So we're still the infancy of this whole field. So we're not even just making people aware of it is huge, because then you can prevent it. Any other questions or thoughts? So I didn't put it up here, but if you want me to send you the slides, I can't believe I didn't put my email up, and I didn't. My email is drsherry, N as in Nancy, YK, IEL, at Gmail. If you look in the thing, it says Dr. Sherry Michael, the speaker, at Gmail. Send me an email, and I will send them out to you. We just finished them yesterday. I was caught in it. So we really very much appreciate everybody staying on the last day, and thanks for your attention. Thank you so much, everyone. Thank you.

alcohol use during pregnancy

Fetal Alcohol Spectrum Disorders

prefrontal cortex development

Fetal Alcohol Syndrome

Alcohol-Related Neurodevelopmental Disorder

binge drinking prevalence

health warnings labeling

early intervention

screening and intervention

education and advocacy

policy and support resources