Consider William Blakes presentation of love in the poem The Clod and the Pebble Essay

(b) Paying close attention to language and form, write a critical appreciation of the following poem, considering William Blake’s presentation of love in the poem ‘The Clod and the Pebble’. The Clod and the Pebble â€Å"Love seeketh not itself to please, Nor for itself hath any care, But for another gives its ease, And builds a Heaven in Hell’s despair.† So sung a little Clod of Clay 5 Trodden with the cattle’s feet, But a Pebble of the brook Warbled out these metres meet: â€Å"Love seeketh only self to please, To bind another to its delight, 10 Joys in another’s loss of ease, And builds a Hell in Heaven’s despite.† The ostensible cuteness of the poem The Clod and the Pebble perhaps masks a more morbid and deeply cynical assessment of love by the poet William Blake. Initially, the contrast between the clod and the pebble’s speeches on love might encourage a positive response to the clod’s optimism about how love can rescue us from even the most hellish position. The pebble’s pessimism about love, on the other hand, is unpleasant and unsettling, but it’s also a more accurate reflection of the brutal nature of the world as it is depicted in the poem. Blake’s presentation of love, then, is ambivalent. While the ideal that love is able to overcome any circumstance is appealing, it might not be a realistic assessment in the context of the world’s cruelty. Blake’s personification of the clod and the pebble captures two very different human experiences. We are told that the clod is â€Å"trodden with the cattle’s feet.† With the word â€Å"trodden† Blake captures the experience of continual hardship, and being repeatedly downtrodden, subjugated and abused. There is also tactile imagery of weight and pressure from the â€Å"cattle’s feet,† restricting the clod and forcing it into a new shape. In this way, the clod is described as though it experiences human suffering. It makes us think about someone who has had to become flexible to fit the continual hardship of their circumstances – reflected in the physical properties of a soft clod of clay. It is then pleasantly surprising that the clod sings about love in the most optimistic way. On the one hand, the clod’s optimism concerning love is deeply admirable, and the parallel structure used to present this speech alongside the pebble’s emphasises that optimism in the most appealing way. The clod states that love â€Å"builds a Heaven in Hell’s despair,† while the pebble states that it â€Å"builds a Hell in Heaven’s despite.† The clod speaks from the context of a hellish existence that entails pain and suffering, and endows love with the capacity to transcend such an experience and create a heavenly existence of joy and happiness. The pebble, on the other hand, speaks from a comparatively heavenly existence and instead endows love with the capacity to corrupt that existence with the pain and suffering suggested by the word â€Å"Hell.† Our feeling that the clod is admirably optimistic ten evolves into a feeling that we too want and even believe that love will rescue and provide solace to this figure. Conversely, the parallel structure also helps to emphasise the pebble’s pessimism. The clod declares that â€Å"love seeketh not itself,† while the pebble answers that â€Å"love seeketh only self.† The phrases â€Å"not itself† and â€Å"only self† create a clear juxtaposition here of the two views of love. The first underscores it as essentially selfless, while the other underscores it as absolutely and solely selfish. Moreover, while the clod sings happily about how love â€Å"for another gives its ease† the pebble responds with how love â€Å"joys in another’s loss of ease.† The clod’s words suggest an action of willing self-sacrifice, while the pebble’s words suggest a selfish acquisition that leaves another diminished. Of course, the pebble’s view means that there is no hope for the clod and that love in fact provides no Heaven. Furthemore, the pebble’s assessment of love is deeply cynical and ugly. It is, however, true to both its own experience and that of the clod. The clod is â€Å"trodden† upon while the pebble is â€Å"of the brook.† We imagine a gentle and tranquil existence within the soft current of a stream. Traditionally, however, rivers also symbolise a journey from innocence to worldliness. The water represents the experience that flows over us during life, leaving us more aware. This experience has left the pebble implacable. We imagine someone who has become hardened from experience – and this is reflected in the physical properties of the pebble. Now the water is forced to bend around the pebble, just as the clod must bend around the feet of the cattle. This is a depiction of the world’s harshness and cruelty, and we cannot help but appreciate that it is the pebble’s assessment of love that more accurately reflects it. To conclude, perhaps the poem is as much about idealism and realism as it is about love. Love, after all, is subject to our tendency to be both idealistic and realistic. Ultimately though, it seems that the depiction of the world as harsh and brutal confirms a negative view of love as equally harsh and brutal. At the very least, the poem encourages us to be ambivalent of love and not suppose it to be a kind of saviour capable of transcending all.

My First Rifle Essay

My First Rifle Essay My First Rifle Essay My First Rifle When I was about thirteen years old, my dad gave me my first rifle, which was a Marlin thirty-thirty lever action carbine. I was so happy that I wanted to go out right then and hunt but my dad told me that I had to take my time and do target practice, then I would have to find the perfect spot to sit, and finally I had to take my time and take the best shot possible. I then though that I would hate what it would take to go hunting because it was at that moment that I realized that not every thing is as easy as you think it will be. My dad got me my first rifle when I was just thirteen and that was the greatest thing that I had ever got for my birthday. The gun was a thirty-thirty lever action Marlin carbine. I could not wait to go hunting; however, my dad said that there were a few things that I would have to due first which hearing that I was unhappy because I thought that all I had to do since I had a gun was go out and hunt. He told me that I had to first learn how to clean the gun before I would be aloud to go hunting I did not want to learn to clean the gun to me that sounded boring. I soon found out that the reason I had to learn to clean my rifle was so that it would be fully functional. Therefore, I learned how to disassemble and clean then reassemble my thirty-thirty. My dad then said that I had to sight it in which I thought ok that would not be hard. It took use a week to get it sighted in because the scope mounts were not mounted right. Therefore, when we got that fixed and finally got it sighted in I thought I was done. I was then informed that I had to be able to shoot the bull’s-eye at least eight out of ten times without a miss. It took me about three days of constant dedication to be able to hit the target at least eight times in a row and by that time I was determined to get the full ten

Grif Term Paper Essays - Military History By Country, Free Essays

Grif Term Paper Essays - Military History By Country, Free Essays The US-led Coalition Air Campaign Against ISIS Riley Stallings 4/20/18 In last decade, terrorism has gone up by a factor of a four. Its as simple as that. In that last six years, the number of fatalities from terrorist acts in the world increased from roughly 15,000 to a peak of almost 44,000 deaths in 2014. ( Max Roser, Mohamed Nagdy , Hannah Ritchie , 2018) This has coincided with the growth and increased activity of the Islamic State of Iraq and the Levant (Da ' esh, in Arabic), or ISIS as it is more commonly referred, in nations such as Iraq and Syria, where it ' s numbers are most prevalent. This Islamic state is a " transnational Sunni Islamist insurgent and terrorist group that controls large areas of Iraq and Syria . " (Christopher Blanchard, Carla Humud, Congressional Research Service, 2017) It has affiliates in several other countries, as well as large groups of supporters worldwide. The group has only since been recognized as one o f the largest threats to worldwide security and human rights in the last four years, despite its founding almost 20 years ago. In 2014, many nations of the world, lead by the United States, formed a coalition, which now has 75 partners worldwide, with the goal of " degrading and ultimately defeating Daesh. " (The Global Coalition, 2014) This coalition has coordinated efforts to reduce the size and power of the Islamic state through military action, and the development of strategies and tactics to reduce the number of personnel. This coalition and its actions, specifically its use of air strikes, have been called into question and have gained a lot of attention about the ethical responsibility of the coalition. Examination of the casualty data in the Middle East , from the nations that are the most afflicted by the Islamic State, has brought forward criticism of the ever-growing number of civilian lives taken by these airstrikes. The US-led coalition ' s air cam paign against the Islamic State has had a profound affect on not only the population of the Islamic state, but also the population of civilians living in and around territories occupied by the Islamic State. The Islamic state has a history of over a decade of power struggles, mostly relating to the changing over of leadership, and struggles with its affiliation with other groups in the Middle East . According to Kenneth Katzman, a specialist in Middle East ern Affairs at the Congressional Research Service, in 2006, a leader in the Al Qaeda organization, branched off of the organization and created the self-titled Al Qaeda in Iraq, which he later rebranded into the Islamic State in Iraq. This is the first emergence of the Islamic State in the Middle East . Later, in 2013, after the suicide bombing of the leader of the first Islamic State, Abu Ayyub Al-Masri, a new leader, Abu Bakr Al-Baghdadi, had taken over and, he rebrands the organization into the Islamic State in Iraq and Greater Syria, as we now know the terrorist organization. (Tara John, Time Magazine) According to Fawaz A Gerges, who wrote ISIS: A History , this organization began to extend their reach, spreading to and conquering the City of Mosul, the second largest city in Iraq. In the fighting for control of Mosul, the Islamic State reduced the size of the Iraqi Security Force, which was a US-trained and US-funded group, from roughly 280,000 active duty personnel to a mere 50,000 men. The author then goes on to talk about how the US president at the time, President Barack Obama, dismissed this somewhat obvious danger to international security as amateurish and that it did not present a serious threat to America ' s or its allies ' interests. In Barack Obama ' s exact words, " The analogy we use around here sometimes, and I think is accurate, is if a j.v. ' team puts on Lakers uniforms that doesn ' t make them Kobe Bryant. . . . I think there is a distinction between the capacity and reach of bin Laden and a network that is actively planning major terrorist plots against the homeland versus jihadists who are engaged in various

Customer service problem solving and alcohol management Essay

Customer service problem solving and alcohol management - Essay Example In this context, it is significant to develop a cohesive and strong staff. We train the employees in reference to the ways that we feel best for them to deal with the customers. Despite the fact that we realize that the staff has some prior experience before coming to work for us, we prefer to give them additional training so as to bring them up to par with the standards of restaurant management. We equip the staffs with the necessary information and skills that are critical in their line of work in the restaurant (Pattie 89). We are aware that customers are of different characteristics. In this sense, it is important to prepare for instances where one has to deal with customers of all types. There are customers who are stubborn while others are angry and in some cases there are violent ones. These are some of the worst customers that one has to deal with, but there are others who are sick or injured and these are calmer ones. Therefore, we also train the staff so as to aid them in dealing with these people. We advise the staff to make sure that they pay keen attention to the concerns of the customers and this means listening to the customers. Listening is an important step in the quest to find a resolution to the problems that affect the customers. We advise the staff that it is imperative to listen to the customers in order to understand their problem. After establishing the problem, it is also important to acknowledge the severity or fatality of the matter. Thus, the most applicable negotiating skills are listening and acknowledging the root of the problem (Pattie 127). The restaurant has several facilities that offer spots for relaxation for the clients. There is a bar that is fully stocked with all brands of alcohol ranging from wines, whiskey, vodka, gins among others. The bar is mostly for the middle age individuals who are looking for a place to relax as they

CRIMINAL LAW Barrister advice and defence statement Essay

CRIMINAL LAW Barrister advice and defence statement - Essay Example Mr. Olmeda saw the defendant, Joseph Wearn, hovering around a display of walking sticks. Mr. Wearn was looking around rather suspiciously. Mr. Olmeda contacted his colleague in the video control room to have the camera operator focus on Mr. Wearn. Mr. Olmeda then witnessed Mr. Wearn take a walking stick. Mr. Wearn camouflaged the walking stick and made a speedy exit through the front of the store without stopping to pay for the item. Mr. Olmeda followed Mr. Wearn all the way to the main concourse area inside Brent Cross shipping centre. Mr. Olmeda took hold of Mr. Wearn’s arm and cautioned him that he was the store detective and that he watched him remove a walking stick and exit the door without paying for it. Mr. Olmeda asked Mr. Wearn to step inside the store with him while he contacted the store manager, Mrs. Linda Levison. Mr. Olmeda retrieved the walking stick from Mr. Wearn when he stopped him outside of the store. Mr. Wearn repeatedly shouted obscenities while on the w ay to the store manager’s office, Mrs. Linda Levison’s office. Mr. Olmeda explained to Mrs. Levison what had just transpired and handed her the walking stick. The store manager, Mrs. Linda Levison, phoned the police who arrived at 12.50 hours. Mr. Olmeda explained what had transpired and then he returned to his post. Witness: Mrs. Linda Levison Occupation: Store manager of John Lewis, Brent Cross, London Statement taken: 9 December 2010 Summation: Mrs. Linda Levison is the store manager for John Lewis, Bent Cross, London. On 8 December 2010, Mrs. Levison was met in her office by store detective, Javi Olmeda. Mr. Olmeda informed her that he had apprehended Mr. Joseph Wearn for taking a walking stick from the store without paying for it. Mrs. Levison took Mr. Wearn, who was escorted by the store detective, Javi Olmeda, to her office. She proceeded to call the police who arrived on or about 12.50 hours. This is pursuant to the store policy of contacting the police wheneve r a theft is alleged. According to Mrs. Levison, the alleged perpetrator, Mr. Wearn was crying while they awaited the police to arrive. Once the police had arrived, Mr. Olmeda, the store detective, recounted the allegation and returned to his post. According to Mrs. Levison, the walking stick that she had been given by Mr. Olmeda was characterized by a prominent lion’s head handle. It also had the store’s label attached to it so that Mrs. Levison was able to ascertain that the item in question was indeed sold at her store and part of the inventory. With the information from the label of the walking stick, Mrs. Levison was able to identify it as part of the store inventory and that such a walking stick, according to computer records, was not sold on 8 December 2010. Mrs. Levison handed the walking stick over to one of the attending officers, PC May. She then witnessed Officer May arrest Mr. Wearn and watched them leave her office. Mrs. Levison is producing the computer records from 8 December 2010 (Exhibit LL/1), and is willing to give evidence in court. Witness: Richard Fairchild Occupation: Security camera operator Statement taken: 9 December 2010 Summation: Mr. Fairchild is employed as a security camera operator by Securigard PLC. On 8 December 2010, he was working at the John Lewis Partnership’s central office manning the camera desk. Mr. Fairchild is responsible for operating the security camera. The security camera is set up to monitor and record

Innocent smoothies Assignment Example | Topics and Well Written Essays - 500 words

Innocent smoothies - Assignment Example Innocent’s mini-kiosks were some of the few food outlets in the Olympic park offering healthy food alternatives to the millions of attendees. The company also ran a two-week campaign called ‘Tweet for A seat’ prior to the start of the Olympics (Eleftheriou-Smith, 2012). This was intended to have the fans regenerate the advertisements by tweeting pictures of the company’s products to their followers. In the campaign, Innocent called on its Twitter followers to suggest whom they wanted to take with them to the Olympics and the reason for a chance to win a seat for two. The campaign followed a decision by the company to scrap off its scheduled promotion through which it aimed to improve the sale of Olympic tickets. Smoothie had worked to be the official smoothie and juice sponsor of the Olympics. Before the start of 2012 Olympic, Innocent launched a healthy living campaign, which encouraged people to kick off the year with healthy lifestyles (Eleftheriou-Smith, 2011). The company features one retired athlete, Kris Akabusi in its video advert clips and billboards with a message to encourage people to get back into fitness through exercising. It gave away free day passes to the gyms of virgin active all over Europe (OReilly, 2014). Although this campaign was not geared to promoting the Olympics, it helped the company generate more revenue clocking 200 million pounds the following year. The company’s promotional campaigns have always focused on marketing its products as the best alternative healthy foods in Europe. It prompts people to focus on their health and watch their diet. Its tagline ‘tastes good, does good’ is meant to appeal to the buyers to buy the products and feel the tastes and effects of the product. By appealing to the healthy lifestyle, the company brands itself as the only one offering alternatives to longer living. This is a moral appeal

Fetal Alcohol Syndrome Essay Example for Free

Fetal Alcohol Syndrome Essay Fetal alcohol syndrome (FAS) is a set of physical and mental birth defects that can result when a woman drinks alcohol during her pregnancy. When a pregnant woman drinks alcohol, such as beer, wine, or mixed drinks, so does her baby. Alcohol passes through the placenta right into the developing baby. The baby may suffer lifelong damage as a result. FAS is characterized by brain damage, facial deformities, and growth deficits. Heart, liver, and kidney defects also are common, as well as vision and hearing problems. Individuals with FAS have difficulties with learning, attention, memory, and problem solving. Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical diagnosis. FASD covers other terms such as: Fetal alcohol syndrome (FAS) the only diagnosis given by doctors. Alcohol-related neurodevelopmental disorder (ARND) reserved for individuals with functional or cognitive impairments linked to prenatal alcohol exposure, including decreased head size at birth, structural brain abnormalities, and a pattern of behavioral and mental abnormalities Alcohol-related birth defects (ARBD) describes the physical defects linked to prenatal alcohol exposure, including heart, skeletal, kidney, ear, and eye malformations Fetal alcohol effects (FAE) a term that has been popularly used to describe alcohol-exposed individuals whose condition does not meet the full criteria for an FAS diagnosis What are the Statistics and Facts about FAS and FASD? FASD is the leading known preventable cause of mental retardation and birth defects. FASD affects 1 in 100 live births or as many as 40,000 infants each year. An individual with fetal alcohol syndrome can incur a lifetime health cost of over $800,000. In 2003, fetal alcohol syndrome cost the United States $5. 4 billiondirect costs were $3. 9 billion, while indirect costs added another $1. 5 billion. Children do not outgrow FASD. The physical and behavioral problems can last for a lifetime. FAS and FASD are found in all racial and socio-economic groups. FAS and FASD are not genetic disorders. Women with FAS or affected by FASD have healthy babies if they do not drink alcohol during their pregnancy. Can I drink alcohol when I am pregnant? No. Do not drink alcohol when you are pregnant. When you drink alcohol, such as beer, wine, or mixed drinks, so does your baby. Alcohol is a substance known to be harmful to human development. When it reaches the blood supply of the baby, it can cause permanent defects to the major organs and central nervous system. Is there any kind of alcohol that is safe to drink during pregnancy? No. Drinking any kind of alcohol can hurt your baby. Alcoholic drinks can include beer, wine, liquor, wine coolers, or mixed drinks. What if I am pregnant and have been drinking? If you drank alcohol before you knew you were pregnant, stop drinking now. Anytime a pregnant woman stops drinking, she decreases the risk of harm to the baby. If you are trying to get pregnant, do not drink alcohol. You may not know you are pregnant right away. What if I drank during my last pregnancy and my baby was fine? Every pregnancy is different. Drinking alcohol may hurt one baby more than another. You could have one child that is born healthy and another child that is born with problems. What if a friend, partner, spouse or family member is drinking while pregnant? Many women are unaware of the consequences of drinking during pregnancy. Some women believe wine or beer is not alcohol. In many cases, she may be suffering from alcoholism. She may need to know what effects alcohol can have on the baby. She also may need help getting into treatment. In such cases, you should contact a treatment professional at a local addiction center for advice on how to help. http://www. nofas. org/faqs. aspx? id=5 Copyright 2001-2004 National Organization on Fetal Alcohol Syndrome An individuals place, and success, in society is almost entirely determined by neurological functioning. A neurologically injured child is unable to meet the expectations of parents, family, peers, school, career and can endure a lifetime of failures. The largest cause of neurological damage in children is prenatal exposure to alcohol. These children grow up to become adults. Often the neurological damage goes undiagnosed, but not unpunished. Fetal Alcohol Syndrome (FAS), Fetal Alcohol Effects (FAE), Partial Fetal Alcohol Syndrome (pFAS), Alcohol Related Neurodevelopmental Disorders (ARND), Static Encephalopathy (alcohol exposed) (SE) and Alcohol Related Birth Defects (ARBD) are all names for a spectrum of disorders caused when a pregnant woman consumes alcohol. There are strategies that can work to help the child with an FASD compensate for some difficulties. Early and intensive intervention and tutoring can do wonders, but the need for a supportive structure is permanent. Studies on addiction in Ontario have shown about a 10 12% alcohol addiction rate among adults, with another 20% drinking to a level that places them at high risk. Legally intoxicated is defined as a Blood Alcohol Level of . 08%. A 100 lb (45 kg) female consuming 5 standard drinks (A drink equals a 12 oz. regular beer, 1 oz. shot of 100 proof liquor, 1. 5 oz. shot of 80 proof liquor, or 4 oz. glass of regular table wine) will reach a BAL of . 25% three times the legal limit. BAL reduces . 01% per hour. The Statistics Canada, Canadian Community Health Survey, 2000/01 found that: 6. 8% of girls ages 12 to 14 19. 8% of girls age 12 to 19 26. 0% ages 20 to 24 19. 9% ages 20 to 34 consumed 5 or more drinks on each occasion 12 or more times per year. An additional: 32. 2% ages 15 to 34 13. 8% of girls ages 12 to 14 consumed 5 or more drinks on each occasion 1 to 11 times per year. Copyright  © 2005 Journals and Procedural Research Branch Office of the Legislative Assembly of Ontario, Toronto, Ontario, Canada. Most girls are 2 to 3 months pregnant before they find out. Given the prime childbearing age range, the odds are very high that about 20% of babies have been exposed to multiple binges in high levels of alcohol in the first trimester, before the girl even knew she was pregnant. It is Party Hearty Time. The vast majority of these girls are NOT alcoholics. About 50% of pregnancies are unplanned. If you are drinking, stay out of the backseat as well as the drivers seat! Maternal prenatal alcohol consumption even at low levels is adversely related to child behavior. The effect was observed at average exposure levels as low as 1 drink per week. The Canadian Centre for Childrens Research at McMaster University Hospitals (Hamilton Ontario) states that 20% of Canadian children have serious mental health issues. Typical of school boards in Canada, a major southwestern Ontario School Board (urban / rural mix) with 28,000 Elementary and Secondary School students, has 6,000 students receiving services from the Special Education Department. Of the 6,000, only 250 are classified as Gifted with the balance having significant disabilities (20. 6%). While not all the individuals with disabilities are identified as the disabilities having been caused by prenatal exposure to alcohol, the vast majority of the disabilities are of types known to be caused by prenatal alcohol exposure. FASD is so grossly under-reported that the FAS statistics are almost meaningless. There are very few doctors who have received any training in diagnosing FASD and most prefer to use non-judgmental diagnoses such as ADD, ADHD, LD, MR, RAD, ODD, Bi-Polar, Tourettes, etc.. These diagnoses dont imply the mother has done something that could have affected her baby during pregnancy. However, they can also lead to inappropriate treatment and a lifetime of pain. Failure to identify the real source can lead to more children being born with the same issues to the same mothers and the cycle continuing into the next generation FASD children having FASD babies. Alcohol, hormones, a twitch in the kilt, poor impulse control and inability to predict consequences are a deadly combination. Accidents cause people. FASD is not a threshold condition. It is a continuum ranging from mild intellectual and behavioural issues to the extreme that often leads to profound disabilities or premature death. Denial is not just a river in Egypt. Alcohol as a Teratogen on the Baby ? http://www. acbr. com/fas/. Problem: Fetal Alcohol Syndrome (FAS) is a pattern of mental and physical defects which develops in some unborn babies when the mother drinks too much alcohol during pregnancy. A baby born with FAS may be seriously handicapped and require a lifetime of special care. Some babies with alcohol-related birth defects, including smaller body size, lower birth weight, and other impairments, do not have all of the classic FAS symptoms. These symptoms are sometimes referred to as Fetal Alcohol Effects (FAE). Researchers do not all agree on the precise distinctions between FAS and FAE cases. Cause of the Problem: Alcohol in a pregnant womans bloodstream circulates to the fetus by crossing the placenta. There, the alcohol interferes with the ability of the fetus to receive sufficient oxygen and nourishment for normal cell development in the brain and other body organs. Possible FAS Symptoms: Growth deficiencies: small body size and weight, slower than normal development and failure to catch up. The fact sheets below were developed by many different authors. In some cases, the fact sheets were placed on the web by a different organization than the one that wrote the document. However, all of the fact sheets are in the public domain to encourage wide distribution. You are free to copy and use these fact sheets. The following list of abbreviations was used to indicate the source of the document in the links provided on this page. Many of the sites listed contain additional information beyond the fact sheets that are listed on this page. We encourage you to explore each site. http://www. well. com/user/woa/fsfas. htm RSmith:02-15-94 MISSOURI DEPARTMENT OF MENTAL HEALTH Division of Alcohol and Drug Abuse 1706 East Elm; P. O. Box 687 Jefferson City, Missouri 65102 The following Fetal Alcohol Spectrum Disorders (FASD) are caused by drinking alcohol during pregnancy: FAS: Fetal Alcohol Syndrome Symptoms include small head/body, facial characteristics, brain damage FAE: Fetal Alcohol Effects Symptoms usually not visible, such as behavior disorders, attention deficits ARBD: Alcohol Related Birth Defects. Anomalies such as heart defects, sight/hearing problems, joint anomalies, etc. ARND: Alcohol Related Neurodevelopmental Disorders Disorders such as attention deficits, behavior disorders, obsessive/compulsive disorder, etc. FASD: Fetal Alcohol Spectrum Disorders All of the disorders named above are contained in the spectrum. Full FAS comprises only about 10% of the spectrum. The other 90% may have fewer physical symptoms but are at greater risk for developing serious secondary conditions later. (Streissguth, 1997) FAS is the leading cause of mental retardation in western civilization. But Most persons with FAS have an IQ in the normal range. (Streissguth, 1997). The incidence of Fetal Alcohol Syndrome in America is 1. 9 cases per 1,000 births (1/500). Incidence of babies with disabilities resulting from prenatal alcohol exposure: 1/100! FAS/FAE is a major health issue in western civilization today. More American babies are born with FAS than with Down Syndrome, MD, and HIV combined. Alcohol causes more neurological damage to the developing baby than any other substance. Lecture Summary Fetal alcohol syndrome is among the most common known causes of mental retardation and as such, it is a major public health problem. The purpose of this lecture is to provide a basic overview of what we know about the effects of prenatal alcohol exposure. It is certainly not meant to be comprehensive but rather to give a broad overview of current knowledge in the area, and of ongoing human and animal research in the area. Heavy prenatal alcohol exposure can result in the fetal alcohol syndrome and both changes in brain structure and behavior have been reported in these children. Importantly, current data indicate that individuals exposed to heavy doses of alcohol in utero, but without the facial characteristics of FAS, can also suffer from similar brain and behavioral changes. Animal models have proven to be an excellent research tool in this field, as there appears to be good concordance between the animal and human data. The animal models provide a means to examine mechanisms of alcohol damage, to control for factors not possible in most human studies, and to help answer important clinical questions. Fetal alcohol effects are preventable, and every child born with a defect related to prenatal alcohol exposure indicates a failure of the health care system. Lecturer Dr. Ed Riley http://rsoa. org/lectures/07/index. html Background Fetal alcohol syndrome is among the most common known causes of mental retardation and as such, it is a major public health problem. The purpose of this lecture is to provide a basic overview of what we know about the effects of prenatal alcohol exposure. It is certainly not meant to be comprehensive. For more detailed overview, the following references might be helpful. It is important to remember that as the mother consumes alcohol and her blood alcohol level rises, that alcohol is freely crossing the placenta and the embryo or fetus is being exposed to the same blood alcohol levels. References Stratton, K. , Howe, C. , Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press. Streissguth, A. P. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Paul H. Brookes Publishing Co. Background Fetal alcohol syndrome is among the most common known causes of mental retardation and as such, it is a major public health problem. The purpose of this lecture is to provide a basic overview of what we know about the effects of prenatal alcohol exposure. It is certainly not meant to be comprehensive. For more detailed overview, the following references might be helpful. It is important to remember that as the mother consumes alcohol and her blood alcohol level rises, that alcohol is freely crossing the placenta and the embryo or fetus is being exposed to the same blood alcohol levels. References Stratton, K. , Howe, C. , Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press. Streissguth, A. P. (1997). Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore: Paul H. Brookes Publishing Co. Background What each of these papers described was a common set of features that could occur in the offspring of mothers who drank heavily during their pregnancies. This constellation of features was named the Fetal Alcohol Syndrome in 1973 by Jones and colleagues. In order to be diagnosed as having FAS, the individual MUST meet all three criteria. There is a specific pattern of facial anomalies, which will be shown shortly. There is pre and or postnatal growth deficiency. Usually the children are born small (7drinks/week 5 or more drinks per occasion). The data on the left side of the slide come from Louise Floyd of the CDC. The first four studies were sponsored by the CDC and the other two estimates on the left side come from the IOM report (Stratton, 1996). AI/AN stands for American Indian/Alaska Native. The numbers on the right side are from a recent study by Sampson et al. , (1997). They demonstrated rates of FAS of at least 2. 8/1000 live births in Seattle, 4. 6/1000 in Cleveland, and between 1. 3 and 4. 8/1000 in Roubaix, France. Interestingly, in this study they estimate the prevalence in Seattle for FAS and ARND at 9. 1/1000 births. This would mean that nearly 1 in every 100 children is affected by prenatal alcohol exposure. The last number from South Africa is from recent work done by Phil May and colleagues. References Egeland G, Perham-Hester KA, Gessner BD, Ingle D, Berner JE,Middaugh JP. Fetal Alcohol Syndrome in Alaska, 1977 through 1992: An administrative prevalence derived from multiple data sources. American Journal of Public Health. 1998. 88(5): 781-786. Aberdeen IHS Area (1995) MMWR. vol 44(#):253-261. BDMP (1995): MMWR Vol. 44(13):249-253. Atlanta, Ga. (1997) MMWR Vol. 46(47): 1118-1120. Sampson, P. D. , Streissguth, A. P. , Bookstein, F. L. , Little, R. E. , Clarren, S. K. , Dehaene, P. , Hanson, J. W. , Graham, J. M. , Jr. (1997). Incidence of fetal alcohol syndrome and prevalence of alcohol-related neurodevelopmental disorder. Teratology, 56(5), 317-326. Stratton, K. , Howe, C. , Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy Press. Institute of Medicine: 1996 Clinic-based (page 89), American Indian/Alaskan Native (page 88) May, P. , Viljoen, D. , Gossage, J. , Brooke, L. , Croxford, J. (1999). An epidemiological analysis of data from children with fetal alcohol syndrome and controls in Wellington, South Africa. Alcoholism: Clinical and Experimental Research, 23 (5), 110A. May, P. , Viljoen, D. , Gossage, J. , Brooke, L. , Croxford, J (1999). An update on the maternal risk factors associated with the prevalence of fetal alcohol syndrome in Wellington, South Africa. Alcoholism: Clinical and Experimental Research, 23 (5), 91A Background It must be stressed that the facial characteristics basically define FAS. Without these facial features, one cannot be diagnosed with FAS. In particular, the discriminating features are short palpebral fissures (the length of the eye opening), a flat midface, an indistinct or flat philtrum (the ridge under the nose), and a thin upper vermilion (lip). While each of these can occur in a variety of disorders, the combination of these features appears to be consistent with heavy prenatal alcohol exposure. Children with FAS can also have other facial features, such as epicanthal folds (tiny folds of tissues along the eye opening), a low nasal bridge, an underdeveloped jaw and minor ear anomalies. These individuals can also have a variety of associated features. Heart defects, skeletal anomalies, altered palmar creases (those creases on your hands), and urogenital anomalies are among the anomalies found more frequently in FAS. Reference Streissguth, A. P. (1994). A long-term perspective of FAS , Alcohol Health Research World (Vol. 18, pp. 74-81). image Facies in fetal alcohol syndrome Background The brain on the left was obtained from a 5-day-old child with FAS while the brain on the right is a control. The effects are obvious. The brain on the left suffers from microencephaly (small brain) and migration anomalies (neural and glia cells did not migrate to their proper location in the brain, but instead many of them simply migrated to the top of the cortex). Although it cannot be seen here, there is also agenesis of the corpus callosum and the ventricles are dilated. The corpus callosum is the major fiber tract connecting the two hemispheres of the brain (more on this later). Major findings of other autopsies of children with FAS have found microcephaly, hydrocephaly, cerebral dysgenesis, neuroglial heterotopias, corpus callosum anomalies, ventricle anomalies, and cerebellar anomalies. It must be pointed out, however, that these autopsies have typically been conducted only on the most severe cases, since these children often have enough problems that they do not survive. The interested reader on the pathological changes that occur in FAS is referred to the following articles. References Clarren, S. K. (1986). Neuropathology in fetal alcohol syndrome. In J. R. West (Ed. ), Alcohol and Brain Development (pp. 158-166). New York: Oxford University Press. Roebuck, T. M. , Mattson, S. N. , and Riley, E. P. (1998). A review of the neuroanatomical findings in children with fetal alcohol syndrome or prenatal exposure to alcohol. Alcoholism: Clinical and Experimental Research, 22 (2),339-344. Image brain damage resulting from prenatal alcohol Background The image on the left is a normal midsaggital MRI scan of the human brain with the cerebrum and cerebellum pointed out. The data on the right show the reduction in size of the these two areas in children with FAS and PEA. PEA stands for Prenatal Exposure to Alcohol, and includes children with known histories of heavy prenatal alcohol exposure, but who lack the features necessary for a diagnosis of FAS. As can be seen, the extent of reduction in the volume of both the cerebrum and cerebellum is significant. While the PEA group shows a reduction in volume, with these sample sizes, this is not a significant difference. Other brain imaging studies indicate disproportionate size reductions in the basal ganglia, cerebellum, and corpus callosum. The data are presented as percent of normal matched controls. References Mattson, S. N. , Jernigan, T. L. , Riley, E. P. (1994a). MRI and prenatal alcohol exposure. Alcohol Health Research World, 18(1), 49-52. Archibald, S. L. , Fennema-Notestine, C. , Gamst, A. , Riley, E. P. , Mattson, S. N. , and Jernigan, T. L. (submitted, 2000). Brain dysmorphology in individuals with severe prenatal alcohol exposure. image change in brain size Background One anomaly that has been seen in FAS is agenesis of the corpus callosum. While not common, it occurs in FAS cases (~6%) more frequently than in the general population (0. 1%) or in the developmentally disabled population (2-3%). In fact it has been suggested that FAS may be the most common cause of agenesis of the corpus callosum. In the top left picture, is a control brain. The other images are from children with FAS. In the top middle the corpus callosum is present, but it is very thin at the posterior section of the brain. In the upper right the corpus callosum is essentially missing. The bottom two pictures are from a 9 year old girl with FAS. She has agenesis of the corpus callosum and the large dark area in the back of her brain above the cerebellum is a condition known as coprocephaly. It is essentially empty space. Most children with FAS do have a corpus callosum, although it may be reduced in size. The reduction in size occurs primarily in the front and rear portions (genu and splenium). One interesting item is that this same pattern of reduction in the genu and splenium has been found in ADHD children. The behavioral problems seen in FAS frequently are similar to those seen in ADHD. References Mattson, S. N. , Jernigan, T. L. , Riley, E. P. (1994a). MRI and prenatal alcohol exposure. Alcohol Health Research World, 18(1), 49-52. Mattson, S. N. , Riley, E. P. (1995). Prenatal exposure to alcohol: What the images reveal. Alcohol Health Research World, 19(4), 273-277. Riley, E. P. , Mattson, S. N. , Sowell, E. R. , Jernigan, T. L. , Sobel, D. F. , Jones, K. L. (1995). Abnormalities of the corpus callosum in children prenatally exposed to alcohol. Alcoholism: Clinical and Experimental Research, 19(5), 1198-1202. Background There have been over a dozen retrospective studies of children with FAS (total N = 269). Overall, these studies, such as the Seattle studies or studies out of Germany, reported an overall mean IQ of 72. 26 (range of means = 47. 4-98. 2). The data presented here were collected in San Diego, CA as part of a project at the Center for Behavioral Teratology. The mean IQ performances of children with FAS were compared to alcohol-exposed children with few if any features of FAS. All children in this study were exposed prenatally to high amounts of alcohol, however only the FAS group displayed the craniofacial anomalies and growth deficits associated with the diagnosis. The other group was designated as having prenatal exposure to alcohol (PEA) and had documented exposure to high levels of alcohol but were not dysmorphic, microcephalic, or growth-retarded. In comparison to normal controls, both groups of alcohol-exposed children displayed significant deficits in overall IQ measures as well as deficits on most of the subtest scores. While the PEA subjects usually obtained marginally higher IQ scores than those with FAS, few significant differences were found between the two alcohol-exposed groups. These results indicate that high levels of prenatal alcohol exposure are related to an increased risk for deficits in intellectual functioning and that these deficits can occur in children without all of the physical features required for a diagnosis of FAS. Our PEA subjects may be somewhat similar to individuals identified by other groups as having FAE, however individuals with PEA display few if any of the facial features of FAS, and are not growth retarded or microcephalic. References Streissguth AP, Aase JM, Clarren SK, Randels SP, LaDue RA, Smith DF (1991). Fetal alcohol syndrome in adolescents and adults. Journal of the American Medical Association 265:1961-1967. Mattson, S. N. , Riley, E. P. , Gramling, L. , Delis, D. C. , and Jones, K. L. (1997). Heavy prenatal alcohol exposure with or without physical features of fetal alcohol syndrome leads to IQ deficits. Journal of Pediatrics, 131 (5), 718-721. Mattson, S. N. and Riley, E. P. (1998). A review of the neurobehavioral deficits in children with fetal alcohol syndrome or prenatal exposure to alcohol. Alcoholism: Clinical and Experimental Research, 22 (2), 279-294. image general intellectual performance Background. This was a study of a broad range of neuropsychological tests, such as: The Wide Range Achievement Test- which assesses academic skills, the Peabody Picture Vocabulary Test and the Boston Naming test-both assessment of basic language functioning, the California Verbal Learning Test-a list learning and memory test, the Visual-Motor Integration Test which measures basic visual-perceptual skills, the Grooved Pegboard test-a test of fine-motor speed and coordination, and the Childrens Category Test-a measure of nonverbal learning. Along the x-axis are the tests included in the battery; for comparison purposes, all scores were converted to standard scores with a mean of 100 and an SD of 15. Children with FAS or PEA showed deficits in comparison to controls and they were very similar to each other. There does seem to be some indication that the nonverbal measures (on the right of the slide) are not as impaired as the verbal and academic measures, which are on the left and center of the slide. The take home message is that children with FAS and those exposed to high amounts of alcohol, but without the characteristics required for a diagnosis of FAS, are similarly impaired. The FAS children tend to be a bit worse than the PEA children, but the pattern of behavioral deificits is fairly similar over a wide range of tests. References Mattson, S. N. , Riley, E. P. , Gramling, L. , Delis, D. C. , Jones, K. L. (1998). Neuropsychological comparison of alcohol-exposed children with or without physical features of fetal alcohol syndrome. Neuropsychology, 12(1), 146-153. image neuropsychological performanceBackground In addition to the abilities already discussed, a few studies have documented other specific neuropsychological deficits in individuals with FAS. Children with prenatal alcohol exposure, with and without FAS, have demonstrated various deficits on measures of executive functioning. These measures have revealed problems in areas such as planning (tower task-shown above), cognitive flexibility (trails test), inhibition (stroop test), and concept formation and reasoning (word context tests). Generally, performance on these measures is characterized by increased errors and more difficulty adhering to rules. Therefore, children are less successful overall. For example, on the tower measure shown above (Tower of California-similar to Tower of London), children with FAS and PEA passed fewer items overall and made more rule violations than controls. The only two rules were to never place a larger piece on top of a smaller one and to move only one piece at a time. As can be seen the alcohol exposed children had many more rule violations. In addition, deficits have been found on the WCST (Wisconsin Card Sort Test), a nonverbal measure of problem solving. The WCST test requires both problem solving and cognitive flexibility and has been proposed to be sensitive to frontal system dysfunction. This test is a gold standard in the measure of executive functioning in neuropsychology. Children with prenatal exposure to alcohol made more errors and had more difficulty with the conceptual nature of the task than controls. New data indicate that they have trouble identifying and defining concepts. Finally, tests of planning ability are also thought to be sensitive to frontal systems dysfunction although few such studies have been done in individuals with FAS. On the Progressive Planning Test which is similar to the Tower of London test children with FAS/FAE had difficulty with planning ahead and tended to perseverate on incorrect strategies. So far the results could be summarized as: 1) Heavy prenatal alcohol exposure is associated with a wide range of neurobehavioral deficits including visuospatial functioning, verbal and nonverbal learning, and executive functioning 2) Heavy prenatal alcohol exposure causes microcephaly and disproportionate reductions in the corpus callosum, basal ganglia, and cerebellum 3) Children with and without physical features of the fetal alcohol syndrome display qualitatively similar deficits References Carmichael O. H. , Feldman JJ, Streissguth AP, Gonzalez RD: Neuropsychological deficits and life adjustment in adolescents and adults with fetal alcohol syndrome. Alcoholism: Clinical and Experimental Research 16:380, 1992 Kodituwakku PW, Handmaker NS, Cutler SK, Weathersby EK, Handmaker SD: Specific impairments in self-regulation in children exposed to alcohol prenatally. Alcoholism: Clinical and Experimental Research 19:1558-1564, 1995 Mattson, S. N. , Goodman, A. M. , Caine, C. , Delis, D. C. , Riley, E. P. (1999). Executive functioning in children with heavy prenatal alcohol exposure. Alcoholism, Clinical and Experimental Research, 23(11), 1808-1815. Background Secondary disabilities are those disabilities that the individual is not born with, and hopefully with appropriate intervention could be ameliorated. This slide illustrates the extent of these secondary disabilities as a function of age. These are individuals with FAS and FAE. As can be seen over 90% of these individuals have mental health problems and about 50% of those over the age of 12 have disrupted school experiences, trouble with the law, which is frequently severe enough to require confinement. They also engage in relatively high rates of inappropriate sexual behavior and a significant number have alcohol and drug abuse problems. Interestingly, the factors that are protective against these secondary disabilities are: Being raised in a stable, nurturant home, diagnosis before the age of 6, no sexual or physical abuse, not changing households every few years, not living in a poor quality home, and receiving Developmental Disabilities services. References Streissguth, A. P. , Barr, H. M. , Kogan, J. , Bookstein, F. L. (1996). Final Report: Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Seattle, WA: University of Washington Publication Services. Image secondary disabilities Background. Much of what we know about FAS and the effects of prenatal alcohol exposure is the result of work on animal models. After FAS was identified it became important to demonstrate that the effects were indeed the result of alcohol exposure and not due to factors such as other drugs, maternal conditions, or nutritional variables. The development of appropriate animal models was very important in this regard. Models were developed for assessing physical features of FAS as well as the behavioral, neuroanatomical, and neurochemical profiles of prenatal alcohol exposure. The ideal test animal would absorb, metabolize and eliminate alcohol similar to human, transport alcohol and metabolites across.