Prevalence and screening in obstetic and child psychiatric

Prevalence and screening in obstetic and child psychiatric clinics SUN-JIN JO, Ph. D Dept. of Prevetive Medicine, College of Medicine The Catholic University of Korea

Contents • Backgrounds • Methods • Prevalence and Screening – High risk drinking in the obstetric clinic settings for prenatal care – FAS in the child psychiatric clinic settings • Discussion 2

Backgrounds

Young women’s high risk drinking in Korea % Year 4

Young women’s alcohol use disorder in Korea 6. 0% 5. 7% 5. 0% 4. 0% 3. 0% 2. 0% 1. 8% 1. 0% 0. 4% 18 -29 30 -39 40 -49 50 -59 0. 6% 60 -69 One year prevalence of alcohol use disorder 5

Alcohol use during pregnancy in Korean 42% 45% 40% 35% 30% 22% 25% 20% 15% 13% 15% 10% 5% 0% Kim et al (2011) Do et al (2011) Kim et al (2012) Han et al (2012) Experience of drinking alcohol in current pregnancy 6

Prevalence of Fetal Alcohol Syndrome • 1. 8 -5. 0 per 1, 000 in elementary school-based epidemiologic survey in Korea (Lee et al. , 2013) • 14% of children and adolescents in special institutional settings* (Lee et al. , 2015) * Four institutions for children and adolescents with intellectual disability, two orphanages, and one school providing special education for the handicapped 7

What about in child psychiatric settings? • FAS shares a common pathology and similar clinical symptoms with ADHD or MR. • Cases not satisfied psychiatric disorders, and difficult to control symptoms

What we need but never have is. . • Public guidance related to alcohol use during pregnancy • Clinical guideline related to – Screening of alcohol use problem in pregnant women – Screening and diagnosis of FAS in child and adolescent during pregnancy • Even Korean version of instruments for screening those conditions 9

Objectives • At obstetric prenatal care clinic settings – Prevalence of alcohol use during current pregnancy – Standardization of the screening tool for pregnant women’s alcohol – Impact of fetal alcohol expose to fetus via maternal blood and meconium (preliminary study) • At child and adolescent psychiatric settings – Prevalence of FAS – Standardize the screening tool for FAS, FASQ and NST 10

Methods

Participants Life Course Fetus Newborn Child Setting Obstetrics Pediatrics Child Psychiatrics Participants 542 Pregnant women from two prenatal care clinic 315 samples of meconium from newborn baby 216 Patients from two child psychiatric clinics (and their mother) Data collection Selfadministered Bio-specimen sampling Examination or selfadministered From pregnant mother From baby & pregnant mother

Measure Life Course Fetus Newborn Child Setting Obstetrics Pediatrics Child Psychiatrics (Expose) Evaluation Screener Alcohol use (Impact) (Outcome) FAEE in meconium FASQ, NST TWEAK, T-ACE (FAS) (High risk drinking) From pregnant mother Physical exam From baby & pregnant mother

Data analysis • Point prevalence of – Alcohol use during pregnancy in OB settings – FAS, deferred FAS in child psychiatric settings • Chi-square test for testing the association between FAS/deferred FAS and psychiatric disorders • Diagnostic validity test via sensitivity and specificity, and AUC analysis on the TWEAK/T-ACE • Discriminant validity test via chi-square test on the FASQ/NST 14

Prevalence and Screening tool

High risk drinking in the obstetric settings for prenatal care

General characteristics Variable 17. 9 194 35. 9 191 35. 3 59 10. 9 -12 116 23. 2 137 27. 3 27 - 248 49. 5 No 253 47. 1 Yes 284 52. 9 No 275 50. 8 Yes Depression 97 13 -26 Delivery -29 40 - Planned pregnancy % 35 -39 Pregnancy(wk) N 30 -34 Age(yr) Categories 266 49. 2 Negative 458 88. 9 Positive 57 11. 1 17

Alcohol use Variable Drinking in pregnancy 24 4. 5 515 95. 5 No 79 14. 7 460 85. 3 No 492 91. 6 45 8. 4 No 515 95. 5 Yes 1 -month binge drinking No Yes 1 -month drinking % Yes Lifetime binge drinking N Yes Lifetime drinking Categories 24 4. 5 No 418 77. 4 -12 wk 111 20. 6 23 -26 wk 11 2. 0 18 18

Alcohol use in pregnancy and related factors Variable Categories Drinking in pregnancy No FAS 45 15. 5 78 30. 1 57 21. 5 65 23. 2 Positive 16 27. 1 Negative 103 22. 0 Yes 50 31. 1 No after 18. 8 No pregnancy 48 Yes in 19. 1 Yes Acquaintance’s drinking 27 No Depression(PHQ-9) 37. 4 27 - Delivery 43 12 -26 Planned pregnancy % -12 Pregnancy(wk) n 74 18. 9 Yes 28 56. 0 P-value <0. 001 0. 633 0. 376 0. 002 <0. 001 19

TWEAK & T-ACE Instrument TWEAK T-ACE Cut-off score 2 2 Positive rate 63. 8% 47. 8% Sensitivity 100. 0% 70. 6% Specificity 38. 9% 53. 9% AUC 79. 3% 70. 7% 20

TAC_selection of items Instrume Question AUC Sensitivity Specificity Selection TWEAK T 73. 2% 100. 0% 46. 5% V 　 W 59. 3% 38. 2% 80. 4% 　　 E 53. 7% 11. 8% 95. 6% 　　 A 70. 8% 70. 6% 71. 0% 　　 K 68. 7% 76. 5% 60. 8% 　 T-ACE T 58. 5% 58. 8% 58. 2% 　　 A 63. 0% 35. 3% 90. 7% V 　 C 74. 5% 76. 5% 72. 5% V nt 21

TAC Questions Tolerance: How many drinks can you hold? T Categories □ⓞ below 3 drinks (평소_임신 전) 주량이 어느 정도 되었습니까? □② 3 drinks or (주종: 소주, 맥주, 와인, 동동주 등) more Have people annoyed you by criticizing your drinking? A 당신이 술 마시는 것에 대해 주변 사람들이 잔소리를 해서 □① Yes □ⓞ No 기분 나빴던 적이 있습니까? Have you felt you ought to cut down on your C drinking? 술 마시는 것을 줄여야겠다고 느끼신 적이 있습니까? □① Yes □ⓞ No 22

Criterion-related validity of the TAC Cut-off score* Sensitivity Specifici ty 1 100. 0% 42. 9% 2 100. 0% 46. 3% 3 76. 5% 74. 4% 4 35. 3% 92. 5% * Optimal cut-off: 3 (positive rate- 28. 9%) AUC: 82. 5% 23

Convergent validity of the TAC AUDIT-C TWEAK TAC T-ACE r=0. 846 r=0. 790 r=0. 764 P<0. 001 (Before pregnancy) 24

Fetal Alcohol Syndrome in the pediatric psychiatric clinic settings

General characteristics Variables 113 68. 1 Girls 53 31. 9 Exposed 20 12. 0 95 57. 2 49 29. 5 Tic 20 12. 0 18 10. 8 Behavioral dso. Age(yr, mean) Boys MR Psychiatric Dignosis % Mood dso. / Anxiety dso. Drinking in pregnancy N ADHD Sex Categories 13 7. 8 11. 0 ± 4. 2 Maternal age(yr, mean) 43. 9 ± 9. 6 26

Prevalence of FASD Variables N % FASD Categories 5 3. 0 Deferred FASD 32 19. 3 Non FASD 129 77. 7 27

Discriminant validity of FASQ & NST 점수 (평균 ± SD) Instrument P-value FASD, Deferred FASD non-FASD 23. 39 ± 17. 38 18. 25 ± 14. 73 0. 06 NST-Domain A 4. 32 ± 2. 14 3. 29 ± 2. 42 <0. 05 Domain B 0. 85 ± 0. 61 0. 74 ± 0. 84 0. 44 Domain C 2. 41 ± 1. 28 1. 78 ± 1. 42 <0. 05 Domain D 0. 73 ± 0. 45 0. 48 ± 0. 50 <0. 01 FASQ total score 28

Do you remember?

Discussion

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Enablers or inhibitors to alcohol use and misuse Dimensions of Host, Agent/Vehicle and Environment in Preventing Alcohol Problems 32 • Source: Cisler RA, Hargarten SH. Public Health Strategies to Reduce and Prevent Alcohol-Related Illness, Injury and Death in Wisconsin and Milwaukee County. Wisconsin Medical Journal. 2000.

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Guidelines/recommendations on alcohol use during pregnancy • Research of the International Center for Alcohol Policies – Nine of the 16 countries have national guideline/recommendation • In Korea, – No national guideline on alcohol use – No recommendation on alcohol use in pregnancy 34

Evidence-based recommendations “ Universal screening for alcohol consumption should be done periodically for all pregnant women and women of child-bearing age. Ideally, at-risk drinking could be identified before pregnancy, allowing for change. (II-2 B)” ( Alcohol use and pregnancy consensus clinical guideline, 2010)

1. Why screening? (1) • Higher recurrent risk of FAS for families who already have children affected by FAS • Early detection and intervention is needed for ‘here and now’, and for ‘the future baby & mom’ 36

1. Why screening? (2) • Possibility of FAS in child and adolescent patients with psychiatric symptoms unmatted the diagnostic criteria of ADHD or MR, and with difficulties to control those symptoms • Regarded as Not normal nor disorder Negative feedback forward to the hidden FAS children Vicious circle • Increased importance of the early detection and clinical intervention according to the concept of FASD 37

1. Why screening? (3) • Continuous processes Before pregnancy Abstinence of alcohol use Early detection of At-risk / High risk drinking among pregnant women Early detection of FAS among child Stop alcohol use during pregnancy Zero FAS risk Enable Primary & Secondary Prevention Decrease of FAS risk Minimization of disability Tertiary Prevention

2. How? (1) Settings • Prenatal care settings – 95% of pregnant women take prenatal care (2012) • Child psychiatric setting – Concentration of FAS high risk children based on the FAS/deferred FAS prevalence 39

2. How? (2) Instruments • “TAC” – Valid & brief instruments to screen high risk drinking for pregnant women – Enables to decrease psychological resistance toward evaluation of alcohol use during pregnancy. 40

2. How? (2) Instruments • FASQ, NST – First standardization work for FAS screening tool in Korea – Adequate convergent validity with the CBCL, the ADHD Rating Scale, and the Children’s Global Assessment Scale – Needs to be highly elaborate and precise because FAS shares symptoms with that of ADHD or MR – Limits in the discriminant validity of the FASQ and cutoff score in this study further study needed 41

3. After-screening service system • Who perform the brief intervention after screening on risky alcohol use during pregnancy? Do we have the “service system”? • Do we have “trained clinicians enough” for diagnosis of the FAS? 42

4. Connection to long-term after-care • How can we manage the ‘continuous process’ from prenatal care and pediatric settings to child psychiatric clinics? • Do we have chance to deliver the information via existed system? 43

Future directions • Biologic marker analysis • Diagnostic accuracy of the screening tools – Predictive validity as well as concurrent validity • Larger prospective cohort study 44

Fundamentals of screening • Does the condition causes significant morbidity or mortality? • Can it be effectively treated? • Is prevalence not too rare? • Is earlier detection critical? ü ü Screening instrument Staffing and referral network Quality assurance Legal and ethical issues

Ignorance Is bliss? Knowledge is power! 46

Thank you for your attention! SUN-JIN JO, JUNG YEOL HAN, YEUN HEE KIM, E-JIN PARK, SOO-YOUNG BHNAG, HYEON WEUNG LEE, HAE-KOOK LEE