Fetal Alcohol Synodrome Essay Example for Free

Fetal Alcohol Synodrome Essay Introduction It sounds simple: women who drink excessively while pregnant are at high risk for giving birth to children with birth defects. Therefore, to prevent these defects, women should stop drinking alcohol during all phases of pregnancy. Alternatively, women who drink alcohol should not become pregnant unless and until they can control their drinking. More than 20 years ago, when fetal alcohol syndrome (FAS) was first described in the published medical literature, there were high hopes for its prevention. In fact, this has not been simple, and the biomedical and public health communities are still struggling to eliminate a birth defect that should be absolutely preventable. HISTORY Although references to the effects of prenatal exposure to alcohol can be found in classical and biblical literature, fetal alcohol syndrome was first described in the medical literature in France by Lemoine et al. in 1968. Researchers in the United States soon also published a landmark report describing a constellation of birth defects in children born to alcoholic women (Jones and Smith, 1973). FAS has since been described in most countries of the world. Briefly, FAS refers to a constellation of physical abnormalities, most obvious in the features of the face (see Figure 1-1) and in the reduced size of the newborn, and problems of behavior and cognition. These latter features lead to the most concern. The degree of abnormality in any one measure can vary greatly between individuals and can change with time in the same individual. For example, people diagnosed with FAS can have IQs from well within the normal range to the severely mentally retarded range. The physical anomalies can be slight or quite striking. Some people with FAS live fairly normal lives if given adequate and structured support throughout their lives, whereas others are severely impaired. The defects may or may not be apparent or easily diagnosed at birth. Although the manifestations of the damage might change with age, FAS never completely disappears and, as with many developmental disabilities, there is no cure, although there might be some amelioration in some individuals. FAS does not refer to signs of acute alcohol exposure or withdrawal at birth. Newborns can have blood alcohol levels high enough to affect acutely their central nervous system function and not have FAS. Newborns can also have no alcohol in their bloodstream at time of delivery but still have FAS. FAS is not a drunk baby. The costs of FAS and related conditions can be quite high—for the individual, for the family, and for society. Three groups have tried to estimate these costs, and these estimates vary greatly (Bloss, 1994). These estimates are problematic, because of uncertainties regarding the incidence and prevalence of FAS and uncertainties related to the full extent of health (and other) problems experienced throughout the lifetime of people with FAS. Estimates of the occurrence of FAS in North American communities range from 0 per 1,000 (incidence; Abel and Sokol, 1987, 1991) to 120 per 1,000 (prevalence; Robinson et al. , 1987), although rates in several of the most complete studies are similar—on the order of 0. 5 to 3 cases per 1,000 births. Assuming an annual birth cohort of approximately 4 million, this translates into 2 to 12 thousand FAS births per year in this country. As described in the report, there is a lack of longitudinal data on the extent of possible problems of adults with FAS. Therefore, cost estimates for the United States range from $75 million (Abel and Sokol, 1991) to $9. 7 billion (Harwood and Napolitano, 1985). The total lifetime cost per typical case of FAS for a child born in 1980 was estimated to be $596,000 undiscounted1 (Harwood and Napolitano, 1985). These incidence and cost figures are offered not as established facts but they are intended to emphasize that regardless of the details, or any one specific estimate, the costs of FAS to the individual and society are high. FIGURE 1-1 Photographs of children with fetal alcohol syndrome. SOURCES: Figures 4C and 4D: Reprinted with permission from Jones et al. (1973). Copyright 1973 by the Lancet Ltd. Figure 4B: Reprinted with permission from Clarren and Smith (1978). Copyright 1978 by the New England Journal of Medicine, Massachusetts Medical Society. Since publication of the papers by Lemoine and by Jones and Smith, the biomedical, public health, research, and public policy communities have devoted much time and energy to a fascinating problem of teratology (the study of the effects of chemical exposure on the developing fetus), neurobiology, disease prevention, and social disarray. The U. S. Public Health Service has spent millions of dollars in research, public education, and service programs related to the topic. Important concepts have been established through research. For example, well-controlled research studies on rats, mice, and nonhuman primates have demonstrated that alcohol exposure causes FAS. However, while alcohol is the necessary teratogen, it alone may not be sufficient to produce FAS in humans or birth defects in animals. As with most teratogens, not every fetus exposed to significant amounts of alcohol is affected. The outcomes might be modulated by numerous biologic and environmental factors, such as nutrition, threshold, timing, genetic susceptibility, pattern of alcohol exposure, or fetal resilience. Further research is needed to fully elucidate the factors that influence the expression of alcohol teratogenesis. Public education campaigns have taught many women and their partners, as well as the medical community and society at large, that excessive alcohol consumption is dangerous during pregnancy. Reduction in the occurrence of substance abuse during pregnancy, reduction in the incidence of FAS, and an increase in the questioning of patients by health care providers about alcohol and other drug use are goals of the Public Health Services Healthy People 2000 initiative (U. S. Department of Health and Human Services, 1991). See Table 1-1. Prevention of birth defects as a salient public health goal presents some exemplary success stories. A good example is the advocacy for and impact of rubella immunizations for children and women of childbearing age with no history of natural rubella or rubella immunization. An outbreak in the United States in the mid-1960s resulted in an estimated 20,000 children born with congenital rubella syndrome (CRS). CRS occurs in 20 to 25 percent of babies born to mothers who get rubella in the first trimester of pregnancy and results in congenital heart disease, deafness, mental retardation, and other fetal abnormalities. An estimate of the lifetime cost of CRS is about $330,000 per case. With widespread introduction of rubella vaccines in the late 1960s and the requirement for rubella immunization prior to school entry, the number of reported cases of CRS in the United States hit a low of 225 in 1988. As another example, new findings that folic acid deficiency during pregnancy can result in neural tube defects have led to recommendations that grain be fortified with folic acid to prevent these birth defects. Availability of effective prevention strategies led to public policy debates and recommendations for action. The emergence of crack cocaine as a major medical and public health problem in the 1980s led to worries about a generation of crack babies who would cost the medical care system, primarily neonatal intensive care wards, huge amounts of money and who would overburden the education and social service systems with problems attributable to prenatal exposure to cocaine. Further research has shown that crack cocaine can lead to serious obstetrical complications and that some of the exposed newborns do have problems. TABLE 1-1 Examples of Healthy People 2000 Goals Relevant to Fetal Alcohol Syndrome (FAS) Objective 1987 Baseline. Target 2000 Incidence of FAS (per 1,000 live births) 0. 22 0. 12 Abstinence from alcohol during pregnancy 79% Increase by 20% Screening by obstetrician/gynecologist for alcohol use 34% 75% Referrals by obstetrician/gynecologist for alcohol treatment 24% 75% Screening by obstetrician/gynecologist for drug use 32% 75% Referrals by obstetrician/gynecologist for drug treatment 28% 75% Cocaine-exposed children have not been followed as extensively or for as long a time as alcohol-exposed children; what data have been published show some effects of prenatal cocaine exposure at three years of age, but the problems do not seem to be nearly as devastating as predicted, nor as severe as the long-term problems associated with alcohol exposure. In fact, some of the long-term effects associated with prenatal cocaine exposure may be due in part to the concurrent use of alcohol during pregnancy. The federal government invested millions of dollars in demonstration projects for services for substance-abusing women. Some of these programs included services for women who abuse alcohol, but the emphasis was usually on drugs, particularly illegal ones, other than alcohol, or on polydrug use. The attention to crack cocaine and its effects on the fetus is curious given that the percentage of pregnant women who drink (approximately 20 percent) far exceeds the percentage who use cocaine (approximately 1 percent; National Institute on Drug Abuse, 1994). At the time, however, the cocaine epidemic and its potential risks to unborn children led to heated public policy debates. Policies of mandatory urine testing in delivery wards, and subsequent removal of a child from the care of a mother who tested positive for illegal substances, were instituted in many places (Blume, in press; Chavkin, 1990). The unintended negative consequences of these actions have led to a reconsideration and reversal of these policies more recently. THE FEDERAL RESPONSIBILITY FOR FAS RESEARCH As will be described in many parts of this report, FAS is a complicated health and social problem, involving many different sectors of the government. The U. S. Public Health Service (USPHS) contains the agencies with primary responsibility for research in the area. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) of the National Institutes of Health (NIH) has the lead role in research on FAS. However, NIAAA is a relatively small institute of NIH. The NIAAA appropriation in 1993 was $177 million, compared with more than $400 million for the National Institute on Drug Abuse (NIDA) and slightly less than $2 billion for the National Cancer Institute (U. S. Department of Health and Human Services, 1993). NIAAA programs related to FAS include very basic animal research, which has been the mainstay of research in this area; clinical and epidemiologic research on the effects of low to moderate alcohol use by pregnant women; and prevention research. The alcohol and pregnancy program at NIAAA included $9. 8 million to $13. 5 million for approximately 70 grants in each of fiscal years 1990-1994. Most of these research grants were RO1, investigator-initiated awards. NIAAA funds one fetal alcohol research center. In addition, many research programs sponsored by NIAAA have ancillary importance to FAS, for example, the research it funds on the epidemiology of drinking by women or on general approaches to the prevention and treatment of alcohol abuse. As an example of the level of commitment by NIAAA to this issue, the prevention research program at NIAAA has ranged from $15 million to $19. 8 million annually in recent years. As the lead research agency on alcohol, the institute and the USPHS can serve as a bully pulpit for the prevention of FAS and other alcohol-related problems. In fact, this has been the case. The U. S. Surgeon General first issued a warning against the dangers of alcohol during pregnancy in 1981. In addition to funding and conducting research, NIAAA publishes information for the public on FAS, sponsors research workshops on FAS, and has its staff speak at public meetings. Other NIH institutes fund research relevant to, but not directly about, FAS. For example, NIDA funded a $4 million National Pregnancy and Health Survey on substance abuse, including alcohol, during pregnancy. The data on alcohol were a small part of the entire project. In addition, NIDA funds epidemiologic and clinical research on the effects of substance abuse during pregnancy, and alcohol is frequently one of the substances used by these populations. A rather large study funded by NIDA was the Perinatal 20 demonstration project assessing prevention of substance abuse during pregnancy. Although the major purpose was to look at the abuse of illegal substances, some data were collected on alcohol use, as well. Another key USPHS agency involved in FAS work is the Centers for Disease Control and Prevention (CDC). The FAS Prevention Section is housed in CDCs National Center for Environmental Health, Division of Birth Defects and Developmental Disabilities. CDCs role is to collect data to define the scope of the problem; support the development and evaluation of FAS prevention projects; and build state capacity for coordinated, state-based FAS surveillance and prevention programs (CDC submission to IOM committee). The CDC maintains and analyzes surveillance programs that include FAS, such as the Birth Defects Monitoring Program. In addition, CDC sponsors and supports efforts to prevent FAS. The CDC currently has FAS prevention and surveillance projects supported through states and universities. As with NIAAA, CDC has ancillary programs related to maternal and child health, alcohol abuse, and epidemiologic surveillance that can support and inform FAS programs. Other agencies in the USPHS maintain important programs related to FAS, but these programs have much less emphasis on research. The Indian Health Service, the Health Resources and Services Administration (HRSA), and the Substance Abuse and Mental Health Services Administration (SAMHSA) fund services or demonstration projects directly or indirectly related to FAS. At this time, no agency has been able to support research on the clinical aspects of FAS, on the medical treatment of children with FAS, or on the education and remediation of these children. A notable USPHS program is the Pregnant and Postpartum Women and Their Infants (PPWI) initiative. This program was authorized by the Anti-Drug Abuse Act, passed by Congress in 1988. The demonstration grant program focuses on the development of innovative, community-based models of drug prevention, education, and treatment, targeting pregnant and postpartum women and their infants (National Center for Education in Maternal and Child Health, 1993). The program is funded jointly by the Center for Substance Abuse Prevention (CSAP) of SAMHSA and the Maternal and Child Health Bureau of HRSA. It has funded 147 demonstration projects. The most common drug addressed was cocaine, followed by alcohol and polydrug use. Because demonstration projects are rigorously evaluated only infrequently, the nature, utility, and transferability of their findings are difficult to assess. The Center for Substance Abuse Treatment (CSAT), a part of SAMHSA, was charged by Congress to support grants for residential and outpatient substance abuse treatment for pregnant and postpartum women and their infants (information provided to the committee). CSAT funded 31 residential projects in 20 states in the PPWI program and 34 projects in 24 states in its Residential Treatment for Women and Their Children program. The five treatment programs that serve Native American women include comprehensive services specific to FAS. In addition, CSAT has other activities, such as its Treatment Improvement Protocols, relevant to FAS, but the abuse substance of focus is usually cocaine or opiates, not alcohol. CONGRESSIONAL INTEREST In recognition of the seriousness of this problem, which affects both the health and the societal functioning of many Americans, several times in the past few years, members of Congress have introduced legislation related to FAS (see Table 1-2). The bills have focused largely on creating an interagency task force on FAS and increasing resources for prevention programs and prevention research. These bills, with one exception, have never been passed. The U. S. Congress mandated in Section 705 of Public Law 102-321, the ADAMHA Reorganization Act, that the Institute of Medicine (IOM) of the National Academy of Sciences conduct a study of FAS and related birth defects. TABLE 1-2 Congressional Bills Related to Fetal Alcohol Syndrome (FAS) or Women and Alcohol Bill No. and Date Introduced Bill Name Major Sponsor Overview H. R. 1322 3/7/91. Comprehensive Indian Fetal Alcohol Syndrome Prevention and Treatment Act Campbell (D-CO) Authorize services for the prevention, intervention, treatment and aftercare of American Indian and Alaskan Native children and their families at risk for FAS and fetal alcohol effect (FAE). Authorization of grants to Native American tribes for training, prevention, and intervention programs. Convening of FAS/FAE task force including federal representation and representation from Native American tribes. Would have authorized $10 million annually for FY 1993-1995 and $15 million annually for FY 1996-2000. S. 923 5/7/93 Comprehensive Fetal Alcohol Syndrome Prevention Act Daschle (D-SD) Expand resources for basic and applied epidemiological research related to FAS/FAE. Establish programs to coordinate and support national, state, and community-based public awareness, prevention, and educational programs on FAS/FAE. Establish and facilitate a national surveillance program to monitor the incidence of FAS/FAE and the effectiveness of prevention programs. Establish a task force to foster coordination among federal agencies that conduct FAS/FAE research, prevention, and treatment. H. R. 3569 11/19/93 Women and Alcohol Research Equity Act of 1993 Morella (R-MD) Provide for an increase in the amount of federal funds expended to conduct research on alcohol abuse and alcoholism among women. Would have authorized up to $23,250,000 to enable NIAAA to increase such research. H. R. 3783 2/2/94 Comprehensive Fetal Alcohol Syndrome Prevention Act Richardson (D-NM) Establish a comprehensive program to help prevent FAS and FAE and to coordinate federal efforts to prevent FAS and FAE. CDC to coordinate and support applied epidemiologic research on FAS and FAE. NIAAA to conduct and support basic research targeted to developing data to improve prevention and treatment of FAS and FAE. Develop a plan to disseminate diagnostic criteria to health care and social services providers. Establish an interagency task force on FAS and FAE. SAMHSA to support, conduct, and evaluate training programs for professionals; and prevention and education programs for the public. S 170 1/5/95 Comprehensive Fetal Alcohol Syndrome Prevention Act Daschle (D-SD) Establish interagency task force on FAS and FAE. Organize a program of basic research on services and effective prevention, treatment and intervention for pregnant alcohol-dependent women and those with FAS or FAE [Originally introduced as S. 1821 in previous session but died in committee. ] H. R. 1649 5/16/95 Comprehensive Fetal Alcohol Syndrome Prevention Act Richardson (D-SD) Establish a program for the conduct and support of research and training and the dissemination of health information about the cause, diagnosis, prevention and treatment of FAS and related conditions. Establish an. Interagency Coordinating Committee on Fetal Alcohol Syndrome. Develop uniform criteria for the collection and reporting of data on FAS and related conditions. NOTE: CDC = Centers for Disease Control and Prevention; NIAAA = National Institute on Alcohol Abuse and Alcoholism; and SAMHSA = Substance Abuse and Mental Health Services Administration. The National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health funded the project. This report is in response to that mandate. The Committee to Study Fetal Alcohol Syndrome was convened in mid-1994. Committee expertise included pediatrics, developmental psychology and neurology, obstetrics, nosology, teratology, epidemiology, sociology, substance abuse prevention and treatment, and psychiatry. The charge to the committee was to improve the understanding of available research knowledge and experience on: †¢ tools and approaches for diagnosing FAS and related disorders, †¢ the prevalence of FAS and related disorders in the general population of the United States, †¢ the effectiveness of surveillance systems, and †¢ the availability and effectiveness of prevention and treatment programs for these conditions. As part of its work, the committee assessed and reviewed U. S. Department of Health and Human Services agency research on the topic and provided guidance for the future. SOME IMPORTANT DEFINITIONS Before going further, some clarification of terms is warranted. Several terms are used in this report to refer to drinking patterns and problems. The terms used here are intended to be consistent in spirit with an earlier IOM report Broadening the Base of Treatment for Alcohol Problems (IOM, 1990), particularly in their emphasis on the heterogeneity of alcohol problems, the course of alcohol use disorders, patterns of consumption, and etiology. In this schema, alcohol consumption is seen as ranging from none to light to moderate to heavy. Alcohol-related problems (e. g. , medical, legal, social, psychological) also range from none to mild to moderate to severe. Research has pointed to a positive correlation between level of alcohol consumption and level of alcohol problems, with the most severe problems generally seen at the highest levels of drinking. This relationship is, however, variable across individuals; that is, in some cases, severe problems can be seen at comparatively moderate levels of drinking. The fourth edition of the American Psychiatric Associations Diagnostic and Statistical Manual (DSM-IV; 1994) defines alcohol use disorders as alcohol dependence and alcohol abuse. In general, these terms refer to maladaptive patterns of drinking and consequences which constitute a syndrome, usually associated with moderate to heavy alcohol consumption and moderate to severe alcohol-related problems (Edwards et al. , 1981; IOM, 1990). In DSM-IV, alcohol dependence is diagnosed when the individual meets three or more of the following seven criteria in a 12-month period: (1) tolerance; (2) withdrawal; (3) drinking in larger amounts or over a longer period than intended; (4) persistent desire or unsuccessful efforts to cut down on drinking; (5) a great deal of time spent drinking or recovering from alcohol effects; (6) declining involvement in social, occupational, or recreational activities because of alcohol use; and (7) use of alcohol despite knowledge of a persistent or recurrent physical or psychological problem caused or exacerbated by that use. Alcohol abuse is a less severe syndrome characterized by significant adverse consequences associated with alcohol use and is diagnosed when at least one of the following four criteria is met recurrently during a 12-month period: (1) failure to fulfill major role obligations because of alcohol use; (2) recurrent alcohol use in situations when it is physically hazardous; (3) recurrent alcohol-related legal problems; or (4) continued use despite social or interpersonal problems. In addition, the symptoms have never met the criteria for alcohol dependence (American Psychiatric Association, 1994). Alcohol abuse and alcohol dependence have fairly specific meaning in DSM-IV. However, these terms are frequently used as umbrella terms for maladaptive patterns of alcohol use. In this report on FAS, the committee has chosen to use alcohol abuse as an umbrella term to indicate heavy drinking, including binge drinking, that is risky for the given individual circumstances. If it is clear that a strict DSM-IV diagnosis is intended, it will be so noted. Similar conventions will be used for substance abuse, which is treated very similarly in DSM-IV (American Psychiatric Association, 1994). DSM-IV does not define the term alcoholic, but the National Council on Alcoholism and Drug Dependence does (Morse et al. , 1992). Alcoholism, too, is used but only occasionally in this report. It should be noted that there are no specific levels of consumption associated with alcohol abuse, either as used in DSM-IV or as an umbrella term in this report. Survey data from 1992 show that approximately 4 percent of all women and approximately 4 percent of women between the ages of 30 and 44 years of age could be considered to satisfy the DSM-IV criteria for alcohol abuse and alcohol dependence (Grant et al., 1994). As described in the report, the relation between levels and patterns of drinking during pregnancy and the risk of delivering an infant with FAS is complex. In this report, terms such as heavy drinking and heavier drinking are used to refer to levels of drinking associated with the highest risk for delivering an infant with FAS. Binge drinking is used to refer to a pattern of episodic heavy drinking, which is also associated with higher risk for FAS. Terms such as risk drinking, or moderate drinking are used to indicate lower levels of drinking, usually not associated with FAS, but which may be associated with alcohol-related effects in infants. It is important to note that definitions of these terms have varied across studies, settings, and samples. In particular, operational definitions of terms used to describe the level and pattern of drinking in studies of pregnant women frequently have not corresponded to definitions for women in general, which in turn often do not correspond to definitions for men. For example, a prospective study of the effects of prenatal alcohol exposure defines heavy drinking as an average of one or more drinks per day (Day et al. , 1989); a seminal FAS prevention intervention project defined heavy drinking as five or six drinks on some occasions and at least 45 drinks per month (Rosett et al. , 1981); large-scale surveys of drinking in women usually define heavy drinking as two or more standard drinks per day, where a standard drink contains approximately 0. 5 ounce of absolute alcohol); some clinical research projects define heavy drinking in women as four or more drinks per day (Wilsnack et al. , 1994), which differs from parallel definitions of heavy drinking in men (six or more standard drinks per day). The lack of consistency in terms regarding level of alcohol consumption across studies has led to confusion regarding the relationship between specific levels of drinking and risk for fetal alcohol syndrome and alcohol-related effects (see Abel and Kruger, 1995 for a review of this problem). The committee defines the relevant history for diagnosis of FAS (see Chapter 4) as one of a pattern of excessive intake characterized by substantial, regular intake or heavy episodic drinking. Evidence of this pattern may include: frequent episodes of intoxication, development of tolerance or withdrawal, social problems related to drinking, legal problems related to drinking, engaging in physically hazardous behavior while drinking, or alcohol-related medical problems such as hepatic disease. REFERENCES Abel EL, Kruger ML. Hon v. Stroh Brewery Co. : What do we mean by moderate and heavy drinking? Alcoholism: Clinical and Experimental Research 1995; 19:1024-31. Abel EL, Sokol RJ. Incidence of fetal alcohol syndrome and economic impact of FAS-related anomalies. Drug and Alcohol Dependence 1987; 19:51-70. Abel EL, Sokol RJ. A revised conservative estimate of the incidence of FAS and its economic impact. Alcoholism: Clinical and Experimental Research 1991; 15:514-524. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders: 4th Edition. Washington, DC: American Psychiatric Association, 1994. Bloss G. The economic cost of FAS. Alcohol Health Research World 1994; 18:53-54. Blume SB. Women and Alcohol: Issues in Social Policy in Alcohol and Gender. R. W. Wilsnack and S. C. Wilsnack (eds. ). New Brunswick, New Jersey: Rutgers University Center of Alcohol Studies, in press. Chavkin W. Drug Addition and Pregnancy: Policy crossroads. American Journal of Public Health 1990; 80:483-487. Clarren SK, Smith DW. The fetal alcohol syndrome. New England Journal of Medicine 1978; 298; 1063-1067. Day NL, Jasperse D, Richardson G, Robles N, Sambamoorthis U, Taylor P et al. Prenatal exposure to alcohol: Effect on infant growth and morphologic characteristics. Pediatrics 1989; 84:536-541. Day NL, Robles N, Richardson G, Geva D, Taylor P, Scher M et al. The effects of prenatal alcohol use in the growth of children at three years of age. Alcoholism: Clinical and Experimental Research 1991; 15:67-71. Edwards G, Arif A, Hodgson R. Nomenclature and classification of drug- and alcohol-related problems: A WHO memorandum. Bulletin of the World Health Organization 1981; 59:225-242. Grant BF, Harford RC, Dawson DA, Chou P, Dufour M, Pickering R. Epidemiologic Bulletin No. 35: Prevalence of DSM-IV alcohol abuse and dependence: United States, 1992. Alcohol Health Research World 1994; 18:243-248. Alcohol (wine, beer, or liquor) is the leading known preventable cause of developmental and physical birth defects in the United States. When a woman drinks alcohol during pregnancy, she risks giving birth to a child who will pay the price — in mental and physical deficiencies — for his or her entire life. Yet many pregnant women do drink alcohol. Its estimated that each year in the United States, 1 in every 750 infants is born with a pattern of physical, developmental, and functional problems referred to as fetal alcohol syndrome (FAS), while another 40,000 are born with fetal alcohol effects (FAE). Fetal alcohol syndrome (FAS) is a condition that results from alcohol exposure during pregnancy. Problems that may be caused by fetal alcohol syndrome include physical deformities, mental retardation, learning disorders, vision difficulties and behavioral problems. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are irreversible. There is no amount of alcohol thats known to be safe to consume during pregnancy. Early diagnosis may reduce the risk of problems, including learning difficulties and substance abuse. Signs and Symptoms Fetal alcohol syndrome isnt a single birth defect. Its a cluster of related problems and the most severe of a group of consequences of prenatal alcohol exposure. Collectively, the range of disorders is known as fetal alcohol spectrum disorders (FASDs). Fetal alcohol syndrome is a common — yet preventable — cause of mental retardation. The severity of mental problems varies, with some children experiencing them to a far greater degree than others. Signs of fetal alcohol syndrome may include: Distinctive facial features, including small eyes, an exceptionally thin upper lip, a short, upturned nose, and a smooth skin surface between the nose and upper lip Deformities of joints, limbs and fingers Slow physical growth before and after birth Vision difficulties or hearing problems Small head circumference and brain size (microcephaly) Poor coordination Mental retardation and delayed development Learning disorders Abnormal behavior, such as a short attention span, hyperactivity, poor impulse control, extreme nervousness and anxiety Heart defects low birth weight failure to thrive developmental delay organ dysfunction facial abnormalities, including smaller eye openings, flattened cheekbones, and indistinct philtrum (an underdeveloped groove between the nose and the upper lip) . Epilepsy poor coordination/fine motor skills poor socialization skills, such as difficulty building and maintaining friendships and relating to groups lack of imagination or curiosity learning difficulties, including poor memory, inability to understand concepts such as time and money, poor language comprehension, poor problem-solving skills behavioral problems, including hyperactivity, inability to concentrate, social withdrawal, stubbornness, impulsiveness, and anxiety. The facial features seen with fetal alcohol syndrome may also occur in normal, healthy children. Distinguishing normal facial features from those of fetal alcohol syndrome requires expertise. Doctors may use other terms to describe some of the signs of fetal alcohol syndrome. An alcohol-related neurodevel.

The Opposing Goals of Comfort and Power in Shakespeares Macbeth :: GCSE English Literature Coursework

The Opposing Goals of Comfort and Power in Macbeth  Ã‚  Ã‚   People have a hard time getting what they want; in fact, the things they want can be incompatible with each other and any attempt to reach one of these goals hurt the other.   In William Shakespeare’s Macbeth (1606), the protagonist is lured to murder the king, Duncan, by the desire for power, an appetite whetted by witch’s prophecies and his wife’s encouragement. But when he reaches the kingship, he finds himself insecure. He attempts to remove threats that decrease his security, including his companion Banquo and his son Fleance, prophesied to be king. His lords grow angry and revolt successfully, after witches lure Macbeth into a false sense of security by further foretelling. In Macbeth, we see that, despite appearances of paradox, man’s goals of comfort and power are forever opposed in increment, though the two may decline together. The power from knowledge causes discomfort. As often has been said, ignorance is bliss. After Macbeth is promised the throne, Banquo asks why Macbeth is less than ecstatic. "Good sir, why do you start, and seem to fear / Things that do sound so fair?" (Act I, Scene 3, p. 332) Macbeth’s new knowledge makes him uncomfortable, as he realizes the implications. His first thoughts considering murdering Duncan appear, and he is scared. After he commits the murder, Macbeth says, "To know my deed, 'twere best not know myself." (Act II, Scene 2, p. 347) Knowing that has committed such a vile act makes him uncomfortable. It will be difficult to act innocent and to deal with his guilt. When he later decides to murder Banquo and Fleance, he tells his wife, "Be innocent of the knowledge, dearest chuck, / Till thou applaud the deed." (Act III, Scene 2, p. 359) Hecate sets Macbeth up for his final fall, explaining her strategy, "As by the strength of their illusion Shall draw him on to his confusion. He shall spurn fate, scorn death, and bear His hopes 'bove wisdom, grace, and fear. And you all know security Is mortals' chiefest enemy." (Act III, Scene 5, p. 365) The security provided by the second set of predictions is only fleeting. Feeling there is no threat to his power, Macbeth acts wildly, bringing his downfall and loss of both comfort and security. The problem with knowledge was that it was power resulting in a decline in comfort. The Opposing Goals of Comfort and Power in Shakespeare's Macbeth :: GCSE English Literature Coursework The Opposing Goals of Comfort and Power in Macbeth  Ã‚  Ã‚   People have a hard time getting what they want; in fact, the things they want can be incompatible with each other and any attempt to reach one of these goals hurt the other.   In William Shakespeare’s Macbeth (1606), the protagonist is lured to murder the king, Duncan, by the desire for power, an appetite whetted by witch’s prophecies and his wife’s encouragement. But when he reaches the kingship, he finds himself insecure. He attempts to remove threats that decrease his security, including his companion Banquo and his son Fleance, prophesied to be king. His lords grow angry and revolt successfully, after witches lure Macbeth into a false sense of security by further foretelling. In Macbeth, we see that, despite appearances of paradox, man’s goals of comfort and power are forever opposed in increment, though the two may decline together. The power from knowledge causes discomfort. As often has been said, ignorance is bliss. After Macbeth is promised the throne, Banquo asks why Macbeth is less than ecstatic. "Good sir, why do you start, and seem to fear / Things that do sound so fair?" (Act I, Scene 3, p. 332) Macbeth’s new knowledge makes him uncomfortable, as he realizes the implications. His first thoughts considering murdering Duncan appear, and he is scared. After he commits the murder, Macbeth says, "To know my deed, 'twere best not know myself." (Act II, Scene 2, p. 347) Knowing that has committed such a vile act makes him uncomfortable. It will be difficult to act innocent and to deal with his guilt. When he later decides to murder Banquo and Fleance, he tells his wife, "Be innocent of the knowledge, dearest chuck, / Till thou applaud the deed." (Act III, Scene 2, p. 359) Hecate sets Macbeth up for his final fall, explaining her strategy, "As by the strength of their illusion Shall draw him on to his confusion. He shall spurn fate, scorn death, and bear His hopes 'bove wisdom, grace, and fear. And you all know security Is mortals' chiefest enemy." (Act III, Scene 5, p. 365) The security provided by the second set of predictions is only fleeting. Feeling there is no threat to his power, Macbeth acts wildly, bringing his downfall and loss of both comfort and security. The problem with knowledge was that it was power resulting in a decline in comfort.

Developmental psychology, Essay

It is important to keep evaluating learning activities as the child’s needs may change or your planning may not work and may need changing. Planning, teaching and evaluation is a cycle which gives structure to the learning process. Whilst in the planning process I need to know the learning objectives so that you are clear about that the pupils are expected to achieve. When evaluating you will need to look at whether the children were able to meet the leaning objectives in their task. If a child was to complete a task quickly this should be recorded. 1. 2 – Weakness – 1.   When planning a work activity I always take into account the children’s learning needs and levels, for example you could have a child in your group which lacks concentration and needs a more practical approach in order to show interest and for the task to be successful. For example: Child A – Lacks concentration Child B – Does not enjoy Literacy Child C – Find tasks difficult 1. 4 – All lesson plans should be made available to the LSA’s before the class starts, even if you do not have time to look at the plan you should discuss with the teacher what you are to do. Learning objectives – You must always be clear on the learning objectives of the lesson or what pupils are expected to be able to do. Leaning recourses required – The lesson plan should detail any materials which are different from those which are normally found in the classroom. Own role in supporting learning activities – It should be made clear what you are required to do whether it’s supporting a group or an individual. Specific information – you should have access to school reports about pupils learning and be able to refer to them if required whether its paper or electronic based. Sometimes changes need to be made to plan and this may happen last minute so you will need to be flexible. Any changes made to the children’s routine may affect their behaviour so you need to take this into consideration. 1. 5 2. 3 We should always be made aware of the health and safety issues especially when working with children; it is the main duty of all school employees to keep the children safe. Young children or children with additional needs may not be aware of certain hazards. Schools also have security measures in place such as gates and a signing in policy for all visitors. If you ever come across a unfamiliar face within the school grounds you should always approach them in a polite manor by saying. ‘Can I help you? ’ All storage areas should be kept tidy so they do not cause a hazard they should also be locked, spaces like cleaning cupboard especially as they store a lot of hazardous materials and can sometimes be left untidy as staff may not have enough time to tidy up or may not be sure where certain items should be. You must always make sure that no fire exits in the classrooms are blocked by chairs / tables, they should always be accessible. Describe the sorts of problems that might occur when supporting learning activities, and how to deal with these: Noise – Sometimes during classes children can become distracted by noise from within the classroom and from outside (such as another classroom, or people on the hallway). I help to combat this problem by closing the doors and any windows open to the noise, and also by reminding children to work as quietly as possible and raise their hand to speak rather than shout out. Insufficient resources – Many of the activities set by the teacher involve the use of multiple resources e. g. books, pencils & crayons, scissors, glue, rulers etc. Unfortunately there are not always enough resources for every student, resulting in there being a delay in the commencement of work (due to trying to locate extra supplies). This problem is managed by preparing for the lesson before it begins, ensuring there are sufficient resources for the class, and also by encouraging children to help to and share with each other whenever possible. Having an inclusive class with a wide spectrum of abilities – another problem which can occur when supporting learning activities, is ensuring that the all children are engaged, involved and fully understanding the task that has been set when there is such a wide spectrum of abilities. This can be dealt with in several ways, such as splitting the class into ability based groups, encouraging high ability children to help those who are struggling to keep pace (this also helps to keep the class working on a similar level), and also by setting achievable targets for work. Shy students – Children may suffer from shyness which can affect their ability to work individually (such as being worried about being wrong), and get involved with the class as a whole or participate in group work. Weather – The weather can always be a distraction to the children, if it’s hot and sunny out the children can get hot and agitated. 5. 1 The reasons why it is important to evaluate learning activities are: †¢ To see what is working and what needs removing or changing †¢ To assess how the activities are being delivered and how they could be improved †¢ To see how the activities are being received by the participants Evaluation is important as it helps out when planning and helps you to think about the learning that has taken place. Spending time going through the learning activities and seeing how students have responded to a certain task or question, can really help re-shape it for future classes. It is also important to look back at the learning objects so you can measure what the children have learned. If you do not think carefully about learning objectives at the planning stage, it will not always be possible to evaluate whether pupils have achieved them. Learning objectives need to be clear for this to be possible. Learners must understand what the outcomes mean. †¢ They must be achievable. †¢ We must be able to assess pupils against them. Evaluating helps you to see if something is succeeding or may need changing. If students whizzed through the activity and then looked rather bored then it would be obvious that the task was a bit too easy and not really suitable or beneficial for that group. Therefore you would need to try and make it more engaging and stimulating, perhaps by making it more difficult or time-consuming so the students really have to work to complete it. If the activities are taking longer than expected and you can see that the students are really struggling, things again would need to be addressed. Students may not meet the learning objective, but they could have a real enthusiasm for the subject and have participated fully in all aspects of the lesson. You will need to record this somewhere. 5. 2 5. 2 and 5. 4 Upon completion of the task, I then provided constructive feedback to the class teacher, and feedback on her participation and progress. I explained that the child was:  · Very pleased to be given individual support and was positively responsive to the support (smiled, listened intently, and produced the work expected through understanding)  · After a couple of examples was able to achieve the objective of drawing on the hands onto the clock face on the task sheet given  · Succeeded in progressing in the learning activity  · Went back into the classroom with a big proud smile as she had enjoyed the task and benefited from the support. I informed the teacher that she responded well to reassurance and lots of positive praise and was very happy to receive a sticker after the task. I explained that she had completed the given learning activity objective. I gave constructive feedback that she 5. 3 Difficulties which I came across – As I have not worked with this particular group before I found it hard to see what stage each child was at and what support each child needed and as the task was outside we faced a lot of distractions. Spring Work Aims / Objectives Children to identify features of spring Looking for signs of spring using senses I can see / smell / touch Share ideas With the whiteboards – Create senses poem I can see the blue sky Recourses White Boards White board pens Ipad – take pictures Evaluation The children found it a little hard to concentrate as they were taken outside and they were easily distracted ie. Wanted to run around and touch things.

Of Mice and Men Essay - 1273 Words

Ambitions of Another Life In today’s world, we have come to see that trial, error, pain, and the striving for living a glamorous life are common; we all know it’s an exhausting task. Everybody seems to â€Å"go through the motions† at one point or another; we all seem to have this point in life where everything seems like a black hole that’s going nowhere. In the book, Of Mice and Men, and play Death of a Salesman, we see this is common, among many other similarities. However, no story is ever the same between two people’s lives, and this is also shown in these two works of literature. In these two pieces, it is apparent that one of the main motifs is struggle. Steinbeck and Miller both intricately weave in the worries, desires, and hurt of†¦show more content†¦This main motif throughout these works implies that, in the end, struggle is a constant part of every ones life. It seems that when we’re in the middle of things and the issue is happening right at that very moment, we don’t stop and think of what the outcome could be very often. Willy briefly thought about what Biff would think: BEN. He’ll call you a coward. WILLY. No, that would be terrible. BEN. Yes, and a damned fool. WILLY. No, no, he mustn’t, I won’t have that! BEN. He’ll hate you, William. (Miller 2.811-815). But, in the end he chose to go through with his plan anyway. After Willy kills himself, we see that it really does impact his family. Linda makes that apparent here, â€Å"Why did you ever do that? Help me, Willy, I can’t cry. ...Why did you do it?† (Miller Requiem.28). We see this in Of Mice and Men too; George killed Lennie as a reflex without it entirely crossing his mind of what life would be like afterwards, and Slim shows compassion here, â€Å"You hadda, George. I swear you hadda. Come on with me† (Steinbeck 107). On the contrary, there are different ways of viewing life in the two pieces of literature. In Death of a Salesman, we see that Willy seems to think that just by being well-liked by people and having an alluring personality will help him rise to the top. He’s also constantly making his boys think that they need to be popular to be successful. Biff gets in a fightShow MoreRelatedOf Mice and Men1242 Words   |  5 PagesOf Mice and Men Thomas Hobbes in his Leviathan states that, in the state of nature mans life is nasty, brutish and short. In depression era America, no greater truth could be said. There were millions unemployed, largely unskilled and living on the margins of society. The lowest of the low were the migrant labourers travelling from place to place trying to scratch a living. They often had to travel illegally by freight car with all its consequent dangers. Their life expectancy was low, crimeRead MoreOf Mice and Men961 Words   |  4 PagesPeople have a tendency to lose sight of their goals and dreams. Mentally, people struggle to maintain their sanity in this game of life that has no set of rules. In the book Of Mice and Men, this story portrays the inequality between people’s dreams and what can actually be accomplished. John Steinbeck, the author Of Mice and Men, utilizes his general themes of friendship and loneliness, through his deep characterization and connection between characters i n order to illustrate â€Å"The American dream.† TheRead MoreOf Mice and Men1352 Words   |  6 PagesOf Mice and Men Essay - Fate or Choice? Choice is defined by the ‘Shorter Oxford Dictionary’ as; â€Å"The act of choosing; preferential determination between things proposed.† It also states the definition for fate; â€Å"The principle, power, or agency by which events are unalterably predetermined from eternity.† Is our life choice, can we determine our fate by choosing our path or is our destiny determined for us? John Steinbeck puts forward this question in his novella Of Mice and MenRead MoreMice and men1998 Words   |  8 PagesHey this essay is about me not having one and just wanting a free account.GCSE JOHN STEINBECK The first 200 words of this essay... à ¯Ã‚ »Ã‚ ¿Of Mice and Men Essay à ¢Of Mice and Menà ¢ is the fictional short novel written by John Steinbeck in 1937. Steinbeckà ¢s perspective when writing the novel could be based on the fact that he had once worked on a ranch and had a certain fascination about it. The novel is set in 1930s America and this can be seen as the cause of the very enduring culmination that takesRead MoreOf Mice and Men1006 Words   |  5 Pagesheart of every novel.† In your view, what are the distinctive ideas explored in Of Mice and Men? Explain how these ideas are developed throughout the novel. Themes are integral and fundamental aspects which render the literature valuable. They usually provide insight into the author’s perception and internalisations of the world in which they live. Set in California during the Great Depression, Of Mice and Men, by Steinbeck, illustrates the hardships experienced by individuals as they roamed theRead MoreOF MICE AND MEN1721 Words   |  7 Pagesï » ¿In the book Of Mice and Men, the single women that appeared in the book resented herself as an object. The statement Women today are more often treated by men as equals rather than objects can be true or false. A man that goes to Gentleman s Cubs every night is a different man that studies at Harvard Law School. A striper is going to be a different person than a CEO of a successful business. It’s all about how you present yourself. In Of Mice and Men, Curley s wife presents herself in a seductiveRead MoreOf Mice and Men1035 Words   |  5 PagesFriendship of George and Lenny The book Of Mice and Men focuses on the friendship of two migrant workers in California at a time when most of the work was done by people and not by machines.  Ã‚  George was a small man who acted worldly and wise.  Ã‚  Lennie was a huge man that had the mind of a child.  Ã‚  Together George and Lennie would bounce from job to job with no money in their pockets and only the dream of someday owning a place of their own to keep them going.  Ã‚  The two men were not able to stay in one placeRead MoreOf Mice and Men547 Words   |  2 PagesJohn Steinbeck’s landmark novel Of Mice and Men is perhaps best known for its revolutionary telling of two characters that are very different, but have come to rely on each other to survive during the Great Depression. The two characters are men named George and Lenny. George is somewhat of an average fellow who has no real special skills or attributes. Lenny is large and abnormally strong, but unfortunately has the mind of a child. Le nnie looks up to George as if he were a role model. This statementRead MoreMice and Men822 Words   |  4 Pagesâ€Å"Of Mice and Men† The Great Depression took place in the United States in the 1930s. Northern California, Salinas Valley was affected by the Great Depression. Many farmers lost their properties and were forced to find other work. Banks were forced to foreclose on mortgages’ and had to collect debts. Hundreds of thousands of farmers packed up their families and few belongings, and headed for California. The Great Depression left many people in poverty and caused them to face unpleasant eventsRead MoreOf Mice and Men1171 Words   |  5 PagesOf Mice and Men by John Steinbeck Q- â€Å"I never seen no piece of jail bait worse than her† what is the reader supposed to think about Curley’s wife? * How is she described by the other characters? * How the author describes her * How she speaks/behaves * Her dreams * Is she the cause of all the trouble Written By Ruqayyah Draey Curley’s wife is not well described and respected by the other characters. She is often looked down upon and discriminated