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

Contents Backgrounds Methods Discussion 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 % yr Year 4

Young women’s alcohol use disorder in Korea One year prevalence of alcohol use disorder 5

Alcohol use during pregnancy in Korean 13% Oksoo Kim et al, 2011 15% 도은영 et al, 2011 22% 김일영 et al, 2012 42% 한정열 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 임신 중 음주여부 확인 관련 지침 無 현재 우리나라는 임신부의 음주 및 음주로 인한 폐해에 대한 국가나 민간수준의 체계화된 지침이 존재하지 않음. 임상현장에서 임산부의 음주에 대하여 조사 시에 사용할 표준화된 설문도구나 문항이 존재하지 않아, 이에 대한 체계적 조사가 이루어지지 못함.   임신 중 알코올 노출로 인한 문제 관련 조기선별 지침 無 외국에서는 TWEAK 등 표준화된 도구를 통해 임산부 음주문제를 선별하고 있으며, 한국중독정신의학회에서 펴낸 중독치료지침서에서도 TWEAK 등 표준화된 도구의 사용을 권장하고 있으나 실제 임상에서 사용되지 않고 있음. 태아알코올스펙트럼증후군에 대한 조기선별, 진단지침 無 태아알코올증후군은 지적장애의 가장 흔한 원인이라고 알려져 있음. 또한 임신 중 음주가 정신질환의 취약성을 높여 ADHD 등 아동에서의 정신장애의 발병을 유발할 수 있다고 알려져 있음. 우리나라에서는 소아청소년과나 소아정신건강의학과 세팅에서 태아알코올증후군에 대한 선별검사나 확인 등이 이루어지지 않고 있음. 태아알코올영향에 대한 신경생물학적 이상을 조기에 발견하기 위한 선별도구의 개발과 표준화가 필요함 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 Fetus Newborn Child Obstetrics Pediatrics Setting Life Course Fetus Newborn Child Setting Obstetrics Pediatrics Child Psychiatrics Partici-pants 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) 주요 발달 징후 신체 검진 Data collection Self-administered Bio-specimen sampling Examination or self-administered From pregnant mother From baby From baby & pregnant mother

Measure Fetus Newborn Child Obstetrics Pediatrics Alcohol use Life Course Fetus Newborn Child Setting Obstetrics Pediatrics Child Psychiatrics (Expose) (Impact) (Outcome) Evaluation Alcohol use FAEE in meconium Physical exam 주요 발달 징후 신체 검진 TWEAK, T-ACE FASQ, NST Screener (High risk drinking) (FAS) From pregnant mother From baby 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 Categories N % Age(yr) -29 97 17.9 30-34 194 35.9 35-39 191 35.3 40- 59 10.9 Pregnancy(wk) -12 116 23.2 13-26 137 27.3 27- 248 49.5 Planned pregnancy No 253 47.1 Yes 284 52.9 Delivery 275 50.8 266 49.2 Depression Negative 458 88.9 Positive 57 11.1 양성(10점이상) 17

Alcohol use 20.6 2.0 Variable Categories N % Lifetime drinking No 24 4.5 Yes 515 95.5 Lifetime binge drinking 79 14.7 460 85.3 1-month drinking 492 91.6 45 8.4 1-month binge drinking Drinking in pregnancy 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 P-value n % Pregnancy(wk) -12 43 37.4 <0.001 12-26 27 19.1 27- 48 18.8 Planned pregnancy No 45 15.5 Yes 78 30.1 Delivery 57 21.5 0.633 65 23.2 Depression(PHQ-9) Positive 16 27.1 0.376 Negative 103 22.0 Acquaintance’s drinking in pregnancy 50 31.1 0.002 74 18.9 No FAS after acquaintance’s drinking in pregnancy 28 56.0 54 17.3 19

TWEAK & T-ACE Instrument TWEAK T-ACE Cut-off score 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 Instrument 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 58.5% 58.8% 58.2% 63.0% 35.3% 90.7% C 74.5% 72.5% 51.3% 5.9% 96.8% 21

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

Criterion-related validity of the TAC Cut-off score* Sensitivity Specificity 1 100.0% 42.9% 2 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 TWEAK T-ACE AUDIT-C (Before pregnancy) TAC r=0.846 P<0.001 r=0.790 r=0.764 24

Fetal Alcohol Syndrome in the pediatric psychiatric clinic settings

General characteristics  Variables Categories N % Sex Boys 113 68.1 Girls 53 31.9 Drinking in pregnancy Exposed 20 12.0 Psychiatric Dignosis ADHD 95 57.2 Mood dso. / Anxiety dso. 49 29.5 Tic MR 18 10.8 Behavioral dso. 13 7.8 Age(yr, mean)   11.0 ± 4.2 Maternal age(yr, mean) 43.9 ± 9.6 26

Prevalence of FASD 3.0 Variables Categories N % FASD 5 Deferred FASD 32 19.3 Non FASD 129 77.7 27

Discriminant validity of FASQ & NST Instrument 점수 (평균 ± SD) P-value FASD, Deferred FASD non-FASD FASQ total score 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 Domain D 0.73 ± 0.45 0.48 ± 0.50 <0.01 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 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. 32

마케팅/광고도, 변하고 있다  사회기술/적응기술도 변화 (지식 경험(직접, 간접)) 33

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 국가수준의 공식적인 지침/권고 마련 그래서! Brief screening 프로그램이 필요하다! 16개국 조사 (북미,호주,유럽등) 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-2B)” ( 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’ 한번 FAS 가진 엄마 담번 임신 때도 술 계속 마실 위험 높아. FAS 들어봤어도 임신중 음주 여부 차이 無 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 Early detection of At-risk / High risk drinking among pregnant women Early detection of FAS among child Abstinence of alcohol use Zero FAS risk Stop alcohol use during pregnancy Decrease of FAS risk Minimization of disability Enable Primary & Secondary Prevention Tertiary Prevention

gateway efficient 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 gateway 산전수전율: 임신 중 한번이라도 임신과 관련 진찰을 받은 경험이 있는 비율 불임률 Infertility couple: 15% of childbearing age : 95% x 85% = 80%; 가임연령부부의 80%는 산전관리를 받는다!!! (다시계산 요) FAS 5명(3.3%), FAS deferred 35명(22.9%) efficient 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. *TAC 도구의 의미 -준거기간 없이 조사하는 것의 의미 -임신기간중 음주를 물어보는 것 -말하도록 하는 것 자체가 치료적 효과 40

2. How? (2) Instruments  further study needed 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 cut-off score in this study  further study needed CBCL 아동행동평가척도 ADHD Rating Scale 주의렵결핍과잉행동장애 평정척도 Children’s Global Assessment Scale 소아전반적 평가척도 다만, 변별 타동도 측면에서는 신경행동선별도구는 비교적 합리적 수준의 변별력을 가지는 반면, 복합발달지연증후군 설문은 변별력 적용에 한계가 있고, cut off 점수 등에 차이가 필요하며, 추가적인 연구가 더 필요할 것으로 판단됨 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 Larger prospective cohort study Biologic marker analysis Diagnostic accuracy of the screening tools Predictive validity as well as concurrent validity Larger prospective cohort study 낙인 감소 audit-c or TAC? 연구 필요 시범적용 보건소 모자보건실 산전클리닉 미혼모시설 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? 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