From research to practice: an integrative framework for the development of interventions for children with fetal alcohol spectrum disorders

Effectiveness of interventions for school-aged-children and adolescents with fetal alcohol spectrum disorder: a systematic review and meta-analysis

PURPOSE

To describe allied health and educational interventions and their effectiveness for children and adolescents with fetal alcohol spectrum disorder (FASD). To appraise the quality and strength of studies.

METHODS

Electronic databases were searched between 2005 and March 2022, identifying non-pharmacological studies supporting function, activity, or participation for FASD participants aged 5-18 years using any quantitative research design. Outcomes were coded using International Classification of Functioning, Disability and Health, family of Participation Related Constructs and behaviour categories. Multi-level random-effects meta-analysis examined intervention effects. Study methodological quality was evaluated using Cochrane risk of bias tools, RoBiNT, AMSTAR 2 and NHMRC Hierarchy levels of evidence. Certainty of findings were synthesised using GRADE approach.

RESULTS

The systematic review included 25 studies with 735 participants, 10 of which were analysed by meta-analysis. Body function and structure, activity, behaviour, and sense of self outcomes were pooled. A small, positive effect favouring interventions was found (g = 0.29, 95% CI = 0.15-0.43), however the GRADE certainty was rated as low. No participation outcomes were identified.

CONCLUSIONS

Some interventions targeting body function and structure, activity and behaviour outcomes were effective. Evidence of interventions that support children's and adolescent's participation as an outcome is lacking.

Interventions for improving executive functions in children with foetal alcohol spectrum disorder (FASD): A systematic review

Background

The consequences for children born with birth defects and developmental disabilities encompassed by foetal alcohol spectrum disorder (FASD) are profound, affecting all areas of social, behavioural and cognitive functioning. Given the strong evidence for a core deficit in executive functioning, underpinned by impaired self-regulation skills, there has been a growing focus on the development of interventions that enhance or support the development of executive functions (EFs).

Objectives

The primary objective of this review is to synthesise the evidence for structured psychological interventions that explicitly aim to improve EF in children. The review also sought to ascertain if the effectiveness of interventions were influenced by characteristics of the intervention, participants or type of EF targeted by the intervention.

Search Methods

Sixteen databases, 18 grey literature search locations and 9 trial registries were systematically searched to locate eligible studies (up to December 2020). These searches were supplemented with reference harvesting, forward citation searching, hand searches of topic-relevant journals and contact with experts.

Selection Criteria

Studies were included in the review if they reported on an impact evaluation of a psychological intervention aiming to improve EF in children 3-16 years who either had confirmed prenatal alcohol exposure or a formal diagnosis falling under the umbrella term of FASDs. Eligible study designs included randomised controlled trials (RCTs) and quasi-experimental designs with either no treatment, wait list control or an alternative treatment as a comparison condition. Single-group pre-post designs were also included.

Data Collection and Analysis

Standard methodological procedures expected by the Campbell Collaboration were used at all stages of this review. Standardised mean differences (SMDs) were used to estimate intervention effects, which were combined with random effects meta-analysis (data permitting). Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2) and Cochrane Risk of Bias in Non-Randomised Studies-Interventions tool (ROBINS-I).

Main Results

The systematic search identified 3820 unique records. After title/abstract and full-text screening, 11 eligible studies (reported in 21 eligible documents) were deemed eligible, with a combined 253 participants. Of the 11 studies, 6 were RCTs, 1 was a quasi-experiment and 4 were single-group pre-post intervention designs. All studies were rated as having an overall high or serious risk of bias, with some variation across domains for RCTs. For RCT and quasi-experimental studies, the overall effect of EF interventions on direct and indirect measures of EF generally favoured the experimental condition, but was not statistically significant. There was no difference between intervention and comparison groups on direct measures of auditory attention (k = 3; SMD = 0.06, 95% confidence interval [CI] = -1.06, 1.18), visual attention (k = 2; SMD = 0.90, 95% CI = -1.41, 3.21), cognitive flexibility (k = 2; SMD = 0.23, 95% CI = -0.40, 0.86), attentional inhibition (k = 2; SMD = 0.04, 95% CI = -0.58, 0.65), response inhibition (k = 3; SMD = 0.47, 95% CI = -0.04, 0.99), or verbal working memory (k = 1; d = 0.6827; 95% CI = -0.0196, 1.385). Significant heterogeneity was found across studies on measures of auditory attention and visual attention, but not for measures of cognitive flexibility, attentional inhibition or response inhibition. Available data prohibited further exploration of heterogeneity. There was no statistical difference between intervention and comparison groups on indirect measures of global executive functioning (k = 2; SMD = 0.21, 95% CI = -0.40, 0.82), behavioural regulation (k = 2; SMD = 0.18, 95% CI = -0.43, 0.79), or emotional control (k = 3; SMD = 0.01, 95% CI = -0.33, 0.36). Effect sizes were positive and not significant for meta-cognition (k = 1; SMD = 0.23, 95% CI = -0.72, 1.19), shifting (k = 2; SMD = 0.04, 95% CI = -0.35, 0.43), initiation (k = 1; SMD = 0.04, 95% CI = -0.40, 0.49), monitoring (k = 1; SMD = 0.25, 95% CI = -0.20, 0.70) and organisation of materials (k = 1; SMD = 0.25, 95% CI = -0.19, 0.70). Effect sizes were negative and not statistically different for effortful control (k = 1; SMD = -0.53, 95% CI = -1.50, 0.45), inhibition (k = 2; SMD = -0.08, 95% CI = -0.47, 0.31), working memory (k = 1; SMD = 0.00, 95% CI = -0.45, 0.44), and planning and organisation (k = 1; SMD = -0.10, 95% CI = -0.55, 0.34). No statistically significant heterogeneity was found for any of the syntheses of indirect measures of EF. Based on pre-post single-group designs, there was evidence for small to medium sized improvements in EF based on direct measures (cognitive flexibility, verbal working memory and visual working memory) and indirect measures (behavioural regulation, shifting, inhibition and meta-cognition). However, these results must be interpreted with caution due to high risk of bias.

Authors' Conclusions

This review found limited and uncertain evidence for the effectiveness of interventions for improving executive functioning in children with FASD across 8 direct and 13 indirect measures of EF. The findings are limited by the small number of high-quality studies that could be synthesised by meta-analysis and the very small sample sizes for the included studies.

Fetal alcohol spectrum disorder and confabulation in psycholegal settings: A beginner's guide for criminal justice, forensic mental health, and legal interviewers

Fetal alcohol spectrum disorders (FASD) are neurodevelopmental/neurobehavioral conditions caused by prenatal alcohol exposure (PAE). Impairments caused by PAE contribute to the over-representation of individuals with FASD in the United States juvenile and adult criminal justice systems. These same impairments can equally impact on individuals with FASD who are witnesses to or victims of crime who also have to navigate the complexities of the criminal justice system. Difficulties include increased susceptibility to confabulation throughout the legal process that, in turn, can contribute to increased rates of poor outcomes including false confessions and wrongful convictions. Individuals with FASD are particularity at risk of confabulation when they are subjected to tactics, such as stressful and anxiety-provoking situations, threats, and leading, suggestive, or coercive questioning. Many professionals in the forensic context are unfamiliar with FASD or related confabulation risk and may unintentionally utilize tactics that intensify impacts of pre-existing impairment. This article serves as a beginner's guide for professionals working in criminal justice settings by (a) providing research-based overviews of FASD and confabulation, (b) describing how FASD may lead to confabulation, and (c) suggesting ways that professionals can modify protocols when interacting with individuals with FASD. Suggestions in this article hold the potential to decrease the risk of confabulation in the criminal justice system and decrease problematic outcomes, such as false confessions and wrongful convictions among individuals with FASD.

Functional and Structural Correlates of Impaired Enrichment-Mediated Adult Hippocampal Neurogenesis in a Mouse Model of Prenatal Alcohol Exposure

Background:

Fetal alcohol spectrum disorders (FASDs) are associated with a wide range of cognitive deficiencies.

Objective:

We previously found that gestational exposure to moderate levels of alcohol in mice throughout the 1st-2nd human trimester-equivalents for brain development results in profound impairment of the hippocampal neurogenic response to enriched environment (EE) in adulthood, without altering baseline neurogenesis rate under standard housing (SH). However, the functional and structural consequences of impaired EE-mediated neurogenesis in the context of prenatal alcohol exposure (PAE) have not been determined.

Results:

Here, we demonstrate that PAE-EE mice display impaired performance on a neurogenesis-dependent pattern discrimination task, broadened behavioral activation of the dentate gyrus, as assessed by expression of the immediate early gene, c-Fos, and impaired dendritic branching of adult-generated dentate granule cells (aDGCs).

Conclusions:

These studies further underscore the impact of moderate gestational alcohol exposure on adult hippocampal plasticity and support adult hippocampal neurogenesis as a potential therapeutic target to remediate certain neurological outcomes in FASD.

Unisensory and Multisensory Responses in Fetal Alcohol Spectrum Disorders (FASD): Effects of Spatial Congruence

While it is generally accepted that structural and functional brain deficits underlie the behavioral deficits associated with Fetal Alcohol Spectrum Disorders (FASD), the degree to which these problems are expressed in sensory pathology is unknown. Electrophysiological measures indicate that neural processing is delayed in visual and auditory domains. Furthermore, multiple reports of white matter deficits due to prenatal alcohol exposure indicate altered cortical connectivity in individuals with FASD. Multisensory integration requires close coordination between disparate cortical areas leading us to hypothesize that individuals with FASD will have impaired multisensory integration relative to healthy control (HC) participants. Participants' neurophysiological responses were recorded using magnetoencephalography (MEG) during passive unisensory or simultaneous, spatially congruent or incongruent multisensory auditory and somatosensory stimuli. Source timecourses from evoked responses were estimated using multi-dipole spatiotemporal modeling. Auditory M100 response latency was faster for the multisensory relative to the unisensory condition but no group differences were observed. M200 auditory latency to congruent stimuli was earlier and congruent amplitude was larger in participants with FASD relative to controls. Somatosensory M100 response latency was faster in right hemisphere for multisensory relative to unisensory stimulation in both groups. FASD participants' somatosensory M200 responses were delayed by 13 ms, but only for the unisensory presentation of the somatosensory stimulus. M200 results indicate that unisensory and multisensory processing is altered in FASD; it remains to be seen if the multisensory response represents a normalization of the unisensory deficits.

NGF and BDNF Alterations by Prenatal Alcohol Exposure

Background

It is now widely established that the devastating effects of prenatal alcohol exposure on the embryo and fetus development cause marked cognitive and neurobiological deficits in the newborns. The negative effects of the gestational alcohol use have been well documented and known for some time. However, also the subtle role of alcohol consumption by fathers prior to mating is drawing special attention.

Objective

Both paternal and maternal alcohol exposure has been shown to affect the neurotrophins' signalling pathways in the brain and in target organs of ethanol intoxication. Neurotrophins, in particular nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF), are molecules playing a pivotal role in the survival, development and function of the peripheral and central nervous systems but also in the pathogenesis of developmental defects caused by alcohol exposure.

Methods

New researches from the available literature and experimental data from our laboratory are presented in this review to offer the most recent findings regarding the effects of maternal and paternal prenatal ethanol exposure especially on the neurotrophins' signalling pathways.

Results

NGF and BDNF changes play a subtle role in short- and long-lasting effects of alcohol in ethanol target tissues, including neuronal cell death and severe cognitive and physiological deficits in the newborns.

Conclusion

The review suggests a possible therapeutic intervention based on the use of specific molecules with antioxidant properties in order to induce a potential prevention of the harmful effects of the paternal and/or maternal alcohol exposure.

The Distribution of Available Prevention and Management Interventions for Fetal Alcohol Spectrum Disorder (2007 to 2017): Implications for Collaborative Actions

The global prevalence of Fetal Alcohol Spectrum Disorder (FASD) remains high despite the various preventive and management interventions that have been designed and implemented to tackle the issue in various settings. The aim of the scoping review is to identify and classify prevention and management interventions of FASD reported globally across the life span and to map the concentration of these interventions across the globe. We searched some selected databases with predefined terms. Framework and narrative approaches were used to synthesize and report on the findings. Thirty-two prevention intervention studies and 41 management interventions studies were identified. All the interventions were reported to be effective or showed promising outcomes for the prevention and management of FASD, except four. Although Europe and Africa have a relatively higher prevalence of FASD, the lowest number of interventions to address FASD were identified in these regions. Most of the interventions for FASD were reported in North America with comparatively lower FASD prevalence. The uneven distribution of interventions designed for FASD vis-à-vis the burden of FASD in the different regions calls for a concerted effort for knowledge and intervention sharing to enhance the design of contextually sensitive preventive and management policy in the different regions.

Hyperlocomotion and anxiety- like behavior induced by binge ethanol exposure in rat neonates. Possible ameliorative effects of Omega 3

Maternal alcohol consumption during pregnancy may cause neurocognitive and behavioral disorders that can persist until adulthood. Epidemiological data has revealed an alarming increase in the frequency of alcohol intake in pregnant women. Nutritional variables may also have an impact on the behavioral alterations occasioned by alcohol during development. Moreover, omega-3, a polyunsaturated fatty acid necessary for normal brain development, is deficient in ethanol-treated animals. Although studies have shown that omega-3 supplementation after prenatal ethanol (EtOH) treatment improves some disorders, there are no reports about acute treatment with omega-3 in binge alcohol neurotoxic models during postnatal development. The goal of this study was to determine whether an administration of omega-3, after an acute ethanol dose in neonates, would be able to attenuate alcohol effects in offspring. Male/ female rats were administered ethanol (2.5 g/kg s.c. at 0 and 2 h) or saline on postnatal day (PND) 7, with a single dose of omega-3 (720 mg/kg) 15 min after the last alcohol injection. It was have found that EtOH-treated animals showed hyperlocomotion on PND 14 (pre-juvenile), and anxiety-like behavior was observed at all the three ages studied. Administration of omega-3 after EtOH treatment reduced hyperlocomotion and the anxiety-like behaviors on PND 14, but did not diminish the anxiety on either PND 20 or 30 (juvenile). In conclusion, acute ethanol exposure produced neurobehavioral alterations that persisted in the offspring, with omega-3 able to ameliorate these effects on PND 14. These data are relevant considering that omega-3 administration may have therapeutic effects through mitigating some of ethanol´s damaging consequences.

FAST Club: The Impact of a Physical Activity Intervention on Executive Function in Children With Fetal Alcohol Spectrum Disorder

Physical activity (PA) has been demonstrated to have positive effects on cognitive function, particularly executive function (EF) skills. Animal models suggest PA may be effective in ameliorating some of the neuropsychological effects of fetal alcohol spectrum disorder (FASD), but this approach has not been extended to humans. The purpose of this study was to develop a PA program, FAST Club, for children with FASD and to evaluate its effect on a measure of EF. Using a wait-list control design, 30 children age 7-14 yr participated in FAST Club for 2 × 1.5-hr sessions/week for 8 weeks. EF was assessed using the Children's Color Trails Test. Significant improvements in T scores on the Children's Color Trails Test were seen immediately postprogram, and this improvement was sustained at 3 months postprogram. These findings provide evidence to support the use of PA as a means to improve EF in children with FASD.

GoFAR: improving attention, behavior and adaptive functioning in children with fetal alcohol spectrum disorders: Brief report

OBJECTIVE

This brief report describes the GoFAR intervention designed to improve attention, behavior, and adaptive functioning in children with FASD, ages 5 to 10 years.

METHODS

Thirty children were randomized to one of three conditions: GoFAR; FACELAND, and CONTROL; 25 completed the interventions. Over 10 sessions children and caregivers learned a metacognitive strategy (FAR) designed to improve cognitive control of behavior and adaptive functioning and practiced it during behavior analog therapy. Attention, behavior problems, and adaptive skills were measured pre- and post-intervention.

RESULTS

From pre- to post-testing the GoFAR intervention group improved on the Test of Variables of Attention (TOVA). Both intervention groups improved in Daily Living Skills.

CONCLUSION

This pilot study demonstrated that children with FASD and their caregivers benefit from a focused intervention designed to improve effortful control of behavior. The study suggests the need for a larger clinical trial to evaluate the intervention's effectiveness.

Study protocol for a self-controlled cluster randomised trial of the Alert Program to improve self-regulation and executive function in Australian Aboriginal children with fetal alcohol spectrum disorder

INTRODUCTION

While research highlights the benefits of early diagnosis and intervention for children with fetal alcohol spectrum disorders (FASD), there are limited data documenting effective interventions for Australian children living in remote communities.

METHODS AND ANALYSIS

This self-controlled cluster randomised trial is evaluating the effectiveness of an 8-week Alert Program school curriculum for improving self-regulation and executive function in children living in remote Australian Aboriginal communities. Children in grades 1-6 attending any of the eight participating schools across the Fitzroy Valley in remote North-West Australia (N ≈ 363) were invited to participate. Each school was assigned to one of four clusters with clusters randomly assigned to receive the intervention at one of four time points. Clusters two, three and four had extended control conditions where students received regular schooling before later receiving the intervention. Trained classroom teachers delivered the Alert Program to students in discrete, weekly, 1-hour lessons. Student outcomes were assessed at three time points. For the intervention condition, data collection occurred 2 weeks immediately before and after the intervention, with a follow-up 8 weeks later. For control conditions in clusters two to four, the control data collection matched that of the data collection for the intervention condition in the preceding cluster. The primary outcome is change in self-regulation. FASD diagnoses will be determined via medical record review after the completion of data collection. The results will be analysed using generalised linear mixed modelling and reported in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Western Australia (WA) (RA/4/1/7234), WA Aboriginal Health Ethics Committee (601) and WA Country Health Service (2015:04). The Kimberley Aboriginal Health Planning Forum Research Sub-Committee and WA Department of Education also provided approval. The results will be disseminated through peer-reviewed journals, conference presentations, the media and at forums.

TRIAL REGISTRATION NUMBER

ACTRN12615000733572; Pre-results.

The effect of prenatal substance use and maternal contingent responsiveness on infant affect

BACKGROUND

The effects of prenatal substance exposure on neurobehavioral outcomes are inherently confounded by the effects of the postnatal environment, making it difficult to disentangle their influence. The goal of this study was to examine the contributing effects of prenatal substance use and parenting style (operationalized as contingent responding during the play episodes of the Still-face paradigm [SFP]) on infant affect.

METHODS

A prospective cohort design was utilized with repeated assessment of substance use during pregnancy and the administration of the SFP, which measures infant response to a social stressor, at approximately 6months of age. Subjects included 91 dyads classified into four groups: 1) Control (n=34); 2) Medication assisted therapy for opioid dependence (MAT; n=19); 3) Alcohol (n=15); 4) Alcohol+MAT (n=23). Mean % of positive infant affect and mean % of maternal responsiveness (watching, attention seeking, and contingent responding) was compared among the five SFP episodes across the four study groups by MANOVA. Mixed effects modelling was used to estimate the contributing effects of the study groups and maternal responsiveness on infant affect.

RESULTS

Maternal contingent responding was associated with increase (β̂=0.84; p<0.0001) and attention seeking with decrease (β̂=-0.78; p<0.0001) in infant positive affect. The combined effect of prenatal exposures and covariates explained 15.8% of the variability in infant positive affect, while the model including contingent responding and covariates explained 67.1% of the variability.

CONCLUSIONS

Higher maternal responsiveness was a much stronger predictor of infant behavior than prenatal exposures, providing the basis for future intervention studies focusing on specific parenting strategies.

Alcohol exposure during pregnancy altered childhood developmental trajectories in a rural South African community

AIM

This study examined the effects of prenatal alcohol exposure on childhood development trajectories in a rural South African community between 2003 and 2008.

METHODS

We assessed 121 children at 7-12 months (year one) and 5-6 years (year five) using the Griffiths Mental Developmental Scales - Extended Revised, which measures sensorimotor, cognitive and social development, with lower scores indicating developmental delay. We also interviewed their mothers or caregivers. Three groups were identified: 29 with foetal alcohol syndrome (FAS) or partial FAS (pFAS), 57 more who had been exposed to alcohol and 35 controls who had not.

RESULTS

The scale's total score was higher in the controls than in the FAS/pFAS group at year one and year five and in the alcohol-exposed group at year five. Many groups' trajectories declined when compared with global norms, but the trajectories in the FAS/pFAS and the alcohol-exposed groups declined more than the controls for eye-hand and performance and total score. Earlier pregnancy recognition in the FAS/pFAS group correlated strongly (r = -0.77) with higher GQ in year five.

CONCLUSION

FAS/pFAS and prenatal alcohol exposure affected the Griffiths scores more than the control group. Efforts are needed to detect pregnancy early and reduce alcohol exposure.

Acute oligodendrocyte loss with persistent white matter injury in a third trimester equivalent mouse model of fetal alcohol spectrum disorder

Alcohol exposure during central nervous system (CNS) development can lead to fetal alcohol spectrum disorder (FASD). Human imaging studies have revealed significant white matter (WM) abnormalities linked to cognitive impairment in children with FASD; however, the underlying mechanisms remain unknown. Here, we evaluated both the acute and long-term impacts of alcohol exposure on oligodendrocyte number and WM integrity in a third trimester-equivalent mouse model of FASD, in which mouse pups were exposed to alcohol during the first 2 weeks of postnatal development. Our results demonstrate a 58% decrease in the number of mature oligodendrocytes (OLs) and a 75% decrease in the number of proliferating oligodendrocyte progenitor cells (OPCs) within the corpus callosum of alcohol-exposed mice at postnatal day 16 (P16). Interestingly, neither mature OLs nor OPCs derived from the postnatal subventricular zone (SVZ) were numerically affected by alcohol exposure, indicating heterogeneity in susceptibility based on OL ontogenetic origin. Although mature OL and proliferating OPC numbers recovered by postnatal day 50 (P50), abnormalities in myelin protein expression and microstructure within the corpus callosum of alcohol-exposed subjects persisted, as assessed by western immunoblotting of myelin basic protein (MBP; decreased expression) and MRI diffusion tensor imaging (DTI; decreased fractional anisotropy). These results indicate that third trimester-equivalent alcohol exposure leads to an acute, albeit recoverable, decrease in OL lineage cell numbers, accompanied by enduring WM injury. Additionally, our finding of heterogeneity in alcohol susceptibility based on the developmental origin of OLs may have therapeutic implications in FASD and other disorders of WM development.

Fetale Alkoholspektrumstörungen – Diagnose, neuropsychologische Testung und symptomorientierte Förderung

Zusammenfassung. Laut den aktuellen Studien zur Gesundheit in Deutschland (GEDA) haben knapp 20 % der schwangeren Frauen einen „moderaten Alkoholkonsum“ und knapp 8 % einen riskanten Alkoholkonsum. 12 % der Schwangeren geben ein Rauschtrinken (≥ 5 Getränke pro Gelegenheit) seltener als einmal pro Monat, knapp 4 % jeden Monat und 0.1 % mindestens jede Woche an. Zurückhaltende, strenge Schätzungen ergeben, dass ca. 1 % aller Kinder intrauterin durch Alkohol geschädigt werden. Extrapoliert aus dieser Schätzung bedeutet dies, dass in Deutschland ca. 0.8 Millionen Menschen, davon 130 000 Kinder, mit einer Fetalen Alkoholspektrumstörung (FASD) leben. Die Mehrzahl der betroffenen Kinder werden nicht oder erst spät richtig diagnostiziert. Professionelle Helfer im Gesundheits- und Sozialsystem sind bislang über die Symptome und die notwendige Diagnostik der FASD nur unzureichend informiert. Ziel dieses Übersichtsartikels ist die Erläuterung der ärztlichen und psychologischen diagnostischen Möglichkeiten und Notwendigkeiten bei Kindern und Jugendlichen mit FASD. Eine frühzeitige Diagnose und ein konstantes förderndes und gewaltfreies Umfeld sind als wichtigste protektive Faktoren für den Langzeit-Outcome von Menschen mit FASD identifiziert worden.

Differential Recruitment of Brain Regions During Response Inhibition in Children Prenatally Exposed to Alcohol

BACKGROUND

Response inhibition is a distinct aspect of executive function that is frequently impaired in children with fetal alcohol spectrum disorders (FASD). We used a Go/NoGo (GNG) task in a functional MRI protocol to investigate differential activation of brain regions in the response inhibition network in children diagnosed with full or partial fetal alcohol syndrome (FAS/PFAS), compared with healthy controls.

METHODS

A rapid, event-related task with 120 Go and 60 NoGo trials was used to study children aged 8 to 12 years-8 with FAS/PFAS, 17 controls. Letters were projected sequentially, with Go and NoGo trials randomly interspersed across the task. BOLD signal in the whole brain was contrasted for the correct NoGo minus correct Go trials between the FAS/PFAS and control groups.

RESULTS

Compared to the FAS/PFAS group, controls showed greater activation of the inferior frontal and anterior cingulate network linked to response inhibition in typically developing children. By contrast, the FAS/PFAS group showed greater BOLD response in dorsolateral prefrontal cortex and other middle prefrontal regions, suggesting compensation for inefficient function of pathways that normally mediate inhibitory processing. All group differences were significant after control for potential confounding variables. None of the effects of prenatal alcohol exposure on activation of the regions associated with response inhibition were attributable to the effects of this exposure on IQ.

CONCLUSIONS

This is the first FASD GNG study in which all participants in the exposed group met criteria for a diagnosis of full FAS or PFAS. Although FASD is frequently comorbid with attention deficit hyperactivity disorder, the pattern of brain activation seen in these disorders differs, suggesting that different neural pathways mediate response inhibition in FASD and that different interventions for FASD are, therefore, warranted.

Fetal Alcohol Spectrum Disorders: A Case Study

This grand rounds manuscript reviews important considerations in developing case conceptualizations for individuals with a history of prenatal alcohol exposure. This case study provides an introduction to fetal alcohol spectrum disorders, diagnostic issues, a detailed description of the individual's history, presenting symptoms, neuropsychological test results, and an integrated summary. We describe a 9-year old girl diagnosed with a fetal alcohol spectrum disorder (FASD): Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). This patient is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility.

Interventions in fetal alcohol spectrum disorders: An international perspective

Fetal alcohol spectrum disorders (FASD) are present across countries and cultures, with prevalence rates threatening to rise in the coming years. In order to support children and families with FASD around the world, researchers must work to disseminate and implement evidence-based interventions. However, each cultural context presents unique elements and barriers to the implementation process. This review considers the challenges of addressing FASD in an international context. It summarizes existing FASD interventions that have empirical support in the domains of parenting and education, attention and self-regulation, adaptive functioning, and nutrition and medication. It then outlines cultural barriers pertaining to FASD that may impede the implementation process and makes suggestions for using purveyors as cultural liaisons between researchers and local stakeholders. The review concludes with recommendations for moving forward with international dissemination and implementation of FASD interventions.

Prenatal alcohol exposure alters synaptic activity of adult hippocampal dentate granule cells under conditions of enriched environment

Prenatal alcohol exposure (PAE) results in fetal alcohol spectrum disorder (FASD), which is characterized by a wide range of cognitive and behavioral deficits that may be linked to impaired hippocampal function and adult neurogenesis. Preclinical studies in mouse models of FASD indicate that PAE markedly attenuates enrichment-mediated increases in the number of adult-generated hippocampal dentate granule cells (aDGCs), but whether synaptic activity is also affected has not been studied. Here, we utilized retroviral birth-dating coupled with whole cell patch electrophysiological recordings to assess the effects of PAE on enrichment-mediated changes in excitatory and inhibitory synaptic activity as a function of DGC age. We found that exposure to an enriched environment (EE) had no effect on baseline synaptic activity of 4- or 8-week-old aDGCs from control mice, but significantly enhanced the excitatory/inhibitory ratio of synaptic activity in 8-week-old aDGCs from PAE mice. In contrast, exposure to EE significantly enhanced the excitatory/inhibitory ratio of synaptic activity in older pre-existing DGCs situated in the outer dentate granule cell layer (i.e., those generated during embryonic development; dDGCs) in control mice, an effect that was blunted in PAE mice. These findings indicate distinct electrophysiological responses of hippocampal DGCs to behavioral challenge based on cellular ontogenetic age, and suggest that PAE disrupts EE-mediated changes in overall hippocampal network activity. These findings may have implications for future therapeutic targeting of hippocampal dentate circuitry in clinical FASD. © 2016 Wiley Periodicals, Inc.

Establishment of the South-Eastern Norway Regional Health Authority Resource Center for Children with Prenatal Alcohol/Drug Exposure

This paper presents a new initiative in the South-Eastern Health Region of Norway to establish a regional resource center focusing on services for children and adolescents aged 2–18 years with prenatal exposure to alcohol or other drugs. In Norway, the prevalence of fetal alcohol spectrum (FAS) is not known but has been estimated to be between 1 and 2 children per 1000 births, while the prevalence of prenatal exposure to illicit drugs is unknown. The resource center is the first of its kind in Scandinavia and will have three main objectives: (1) provide hospital staff, community health and child welfare personnel, and special educators with information, educational courses, and seminars focused on the identification, diagnosis, and treatment of children with a history of prenatal alcohol/drug exposure; (2) provide specialized health services, such as diagnostic services and intervention planning, for children referred from hospitals in the South-Eastern Health Region of Norway; and (3) initiate multicenter studies focusing on the diagnostic process and evaluation of interventions.

Positive Behavioral Interventions and Family Support for Fetal Alcohol Spectrum Disorders

Although the scientific community has recognized the effects of prenatal alcohol exposure on development for over 40 years, the empirical study of positive behavioral interventions and family support programs for people with fetal alcohol spectrum disorders (FASD) has only just emerged over the last 10 to 15 years. In this time, dedicated researchers have developed innovative programs that have generally produced large effects and have been acceptable to children with FASD and their families. This body of work demonstrates that children with FASD can benefit from interventions that are appropriately tailored to their neurodevelopmental disabilities. Despite this progress, much work lies ahead to meet the significant needs of people with FASD. This review evaluates available sources of information, including theoretical and Lived Experience models, empirical evidence on existing programs, and best practice guidelines, to guide future research priorities and clinical practice. Three priorities for future intervention research are offered.

Central nervous system deficits in fetal alcohol spectrum disorder

"Fetal alcohol spectrum disorders" is a nondiagnostic umbrella term encompassing the wide variations in clinical presentation among individuals that are prenatally exposed to alcohol. This article discusses brain development and central nervous system abnormalities and reviews prevention and interventions for these neurologic manifestations.

Self-regulation therapy increases frontal gray matter in children with fetal alcohol spectrum disorder: evaluation by voxel-based morphometry

Children with fetal alcohol spectrum disorder show executive function (EF) deficits, particularly in self-regulation skills, and abnormalities in brain regions critical for these skills. None of the validated EF interventions for these children has been evaluated with regards to impacts on brain structure. Twenty-nine children with FASD were assigned to either an immediate-treatment (TX) or delayed-treatment control (DTC) group (DTC). Nineteen typically developing children served as healthy controls (CT). All received a structural MRI scan and baseline neuropsychological testing, following which the TX group underwent 12 weekly 1.5-h sessions of the Alert Program for Self-Regulation(®). After treatment or a period of ~14 weeks, all received a repeat scan and post-intervention testing. Whole-brain and region-of-interest analyses using voxel-based morphometry evaluated group differences and changes over time in gray matter (GM). Exploratory analyses revealed significant group changes: (1) At baseline, combined TX and DTC groups demonstrated global GM reductions compared with the CT group. (2) Region-of-interest analysis using a frontal mask, comparing post-intervention to pre-intervention results, showed significantly increased GM in the left middle frontal gyrus (BA10), right frontal pole (BA11), and right anterior cingulate (BA32) in the TX group. Similar results were not found in the DTC or CT groups. (3) At post-intervention, both TX and CT groups showed larger GM volumes than the DTC group in the left superior frontal gyrus (BA9), which was smaller in the FASD group at baseline. These results suggested that Alert led to improvements in post-intervention testing of self-regulation skills and typical brain development in treated children.

Fetal alcohol spectrum disorders

Prenatal alcohol exposure (PAE) is one of the most prevalent and modifiable risk factors for somatic, behavioral, and neurological abnormalities. Affected individuals exhibit a wide range of such features referred to as fetal alcohol spectrum disorders (FASD). These are characterized by a more or less specific pattern of minor facial dysmorphic features, growth deficiency and central nervous system symptoms. Nevertheless, whereas the diagnosis of the full-blown fetal alcohol syndrome does not pose a major challenge, only a tentative diagnosis of FASD can be reached if only mild features are present and/or maternal alcohol consumption during pregnancy cannot be verified. The respective disorders have lifelong implications. The teratogenic mechanisms induced by PAE can lead to various additional somatic findings and structural abnormalities of cerebrum and cerebellum. At the functional level, cognition, motor coordination, attention, language development, executive functions, memory, social perception and emotion processing are impaired to a variable extent. The long-term development is characterized by disruption and failure in many domains; an age-adequate independency is frequently not achieved. In addition to primary prevention, individual therapeutic interventions and tertiary prevention are warranted; provision of extensive education to affected subjects and their caregivers is crucial. Protective environments are often required to prevent negative consequences such as delinquency, indebtedness or experience of physical/sexual abuse.

Fetal alcohol spectrum disorders and neuroimmune changes

The behavioral consequences of fetal alcohol spectrum disorders (FASD) are serious and persist throughout life. The causative mechanisms underlying FASD are poorly understood. However, much has been learned about FASD from human structural and functional studies as well as from animal models, which have provided a greater understanding of the mechanisms underlying FASD. Using animal models of FASD, it has been recently discovered that ethanol induces neuroimmune activation in the developing brain. The resulting microglial activation, production of proinflammatory molecules, and alteration in expression of developmental genes are postulated to alter neuron survival and function and lead to long-term neuropathological and cognitive defects. It has also been discovered that microglial loss occurs, reducing microglia's ability to protect neurons and contribute to neuronal development. This is important, because emerging evidence demonstrates that microglial depletion during brain development leads to long-term neuropathological and cognitive defects. Interestingly, the behavioral consequences of microglial depletion and neuroimmune activation in the fetal brain are particularly relevant to FASD. This chapter reviews the neuropathological and behavioral abnormalities of FASD and delineates correlates in animal models. This serves as a foundation to discuss the role of the neuroimmune system in normal brain development, the consequences of microglial depletion and neuroinflammation, the evidence of ethanol induction of neuroinflammatory processes in animal models of FASD, and the development of anti-inflammatory therapies as a new strategy for prevention or treatment of FASD. Together, this knowledge provides a framework for discussion and further investigation of the role of neuroimmune processes in FASD.

Fate analysis of adult hippocampal progenitors in a murine model of fetal alcohol spectrum disorder (FASD)

Prenatal alcohol exposure can lead to fetal alcohol spectrum disorder (FASD) and associated behavioral impairments that may be linked to disruptions in adult hippocampal neurogenesis. Social and physical enrichment has been proposed as a potential therapeutic approach toward reversing behavioral deficits associated with FASD and is also a potent stimulator of adult hippocampal neurogenesis. In the present study, we utilized a genetic fate mapping approach in nestin-CreER^T2/YFP bitransgenic mice to identify the stage-specific impact of prenatal alcohol exposure on the stepwise maturation of adult hippocampal progenitors. Using a limited alcohol access “drinking-in-the-dark” model of FASD, we confirm previous findings that moderate prenatal alcohol exposure has no effect on adult neurogenesis under standard housing conditions, but abolishes the neurogenic response to enriched environment (EE). Furthermore, we demonstrate that this effect is primarily due to failed EE-mediated survival of postmitotic neurons. Finally, we demonstrate that the neurogenic deficit is associated with impaired spatial pattern recognition, as demonstrated by delayed learning of FASD-EE mice in an A–B contextual discrimination task. These results identify a potential maturational stage-specific mechanism(s) underlying impaired neurogenic function in a preclinical model of FASD, and provide a basis for testing regulatory pathways in this model through conditional and inducible manipulation of gene expression in the adult hippocampal progenitor population.

White matter microstructure abnormalities and executive function in adolescents with prenatal cocaine exposure

Children with prenatal exposure to cocaine are at higher risk for negative behavioral function and attention difficulties, and have demonstrated brain diffusion abnormalities in frontal white matter regions. However, brain regions beyond frontal and callosal areas have not been investigated using diffusion tensor imaging (DTI). DTI data were collected on 42 youth aged 14-16 years; subjects were divided into three groups based on detailed exposure histories: those with prenatal exposure to cocaine but not alcohol (prenatal cocaine exposure (PCE), n=12), prenatal exposure to cocaine and alcohol (cocaine and alcohol exposure (CAE), n=17), and controls (n=13). Tractography was performed and along-tract diffusion parameters were examined for group differences and correlations with executive function measures. In the right arcuate fasciculus and cingulum, the CAE group had higher fractional anisotropy (FA) and/or lower mean diffusivity (MD) than the other two groups. The PCE group demonstrated lower FA in the right arcuate and higher MD in the splenium of the corpus callosum than controls. Diffusion parameters in tracts with group differences correlated with measures of executive function. In conclusion, these diffusion differences in adolescents with prenatal cocaine exposure suggest localized, long-term structural brain alterations that may underlie attention and response-inhibition difficulties.

Rehabilitation training using complex motor learning rescues deficits in eyeblink classical conditioning in female rats induced by binge-like neonatal alcohol exposure

BACKGROUND

Effective treatments for the behavioral and cognitive deficits in children with fetal alcohol spectrum disorders (FASD) are lacking, and translational approaches using animal models can help develop rational interventions. One such model, binge-like alcohol exposure in neonatal rats during the period of brain development comparable with that of the human third trimester, causes structural and functional damage to the cerebellum and disrupts cerebellar-dependent eyeblink classical conditioning. The eyeblink conditioning deficits first demonstrated in this rat model predicted the similar deficits subsequently demonstrated in children with FASD.

METHODS

The current study extends this translational approach by testing the hypothesis that rehabilitation training involving 20 days of training on traversal of an obstacle course (complex motor learning) would ameliorate the deficits on classical conditioning of eyeblink responses produced by the neonatal alcohol exposure. We have previously shown that this training stimulates cerebellar synaptic plasticity and improves alcohol-induced deficits on motor coordination tasks.

RESULTS

The current studies found that rehabilitation training significantly attenuated alcohol-induced deficits in acquisition of eyeblink conditioning in females but not in males. These results are consistent with normalization of cerebellar-dependent learning, at least in alcohol-exposed females.

CONCLUSIONS

These findings extend previous studies in this model suggesting that rehabilitation of adolescents with FASD using training with complex motor learning tasks could be effective in ameliorating functional impairments associated with cerebellar damage. Eyeblink classical conditioning deficits are now well documented in children with FASD and could serve as an evaluation measure to continue to develop therapeutic interventions such as complex motor learning.

Neonatal alcohol exposure impairs contextual fear conditioning in juvenile rats by disrupting cholinergic function

The context preexposure facilitation effect (CPFE) is a variant of context fear conditioning in which context preexposure facilitates conditioning to immediate foot shock. Learning about context (preexposure), associating the context with shock (training), and expression of context fear (testing) occur in successive phases of the protocol. The CPFE develops postnatally, depends on hippocampal NMDA receptor function, and is highly sensitive to neonatal alcohol exposure during the weanling/juvenile period of development [15,16]. The present study examined some behavioral and pharmacological mechanisms through which neonatal alcohol impairs the CPFE in juvenile rats. We found that a 5-min context preexposure plus five 1-min preexposures greatly increases the levels of conditioned freezing compared to a single 5-min exposure or to five 1-min preexposures (Experiment 1). Increasing conditioned freezing with the multiple- exposure CPFE protocol does not alter the neonatal alcohol-induced deficit in the CPFE (Experiment 2). Finally, systemic administration of 0.01 mg/kg physostigmine prior to all three phases of the CPFE reverses this ethanol-induced deficit. These findings show that impairment of the CPFE by neonatal alcohol is not confined to behavioral protocols that produce low levels of conditioned freezing. They also support recent evidence that this impairment reflects a disruption of cholinergic function [18].

Biobehavioral markers of adverse effect in fetal alcohol spectrum disorders

Identification of children with fetal alcohol spectrum disorders (FASD) is difficult because information regarding prenatal exposure is often lacking, a large proportion of affected children do not exhibit facial anomalies, and no distinctive behavioral phenotype has been identified. Castellanos and Tannock have advocated going beyond descriptive symptom-based approaches to diagnosis to identify biomarkers derived from cognitive neuroscience. Classical eyeblink conditioning and magnitude comparison are particularly promising biobehavioral markers of FASD-eyeblink conditioning because a deficit in this elemental form of learning characterizes a very large proportion of alcohol-exposed children; magnitude comparison because it is a domain of higher order cognitive function that is among the most sensitive to fetal alcohol exposure. Because the neural circuitry mediating both these biobehavioral markers is well understood, they have considerable potential for advancing understanding of the pathophysiology of FASD, which can contribute to development of treatments targeted to the specific deficits that characterize this disorder.

Fetal alcohol spectrum disorders: neuropsychological and behavioral features

Heavy prenatal alcohol exposure can cause alterations to the developing brain. The resulting neurobehavioral deficits seen following this exposure are wide-ranging and potentially devastating and, therefore, are of significant concern to individuals, families, communities, and society. These effects occur on a continuum, and qualitatively similar neuropsychological and behavioral features are seen across the spectrum of effect. The term fetal alcohol spectrum disorders (FASD) has been used to emphasize the continuous nature of the outcomes of prenatal alcohol exposure, with fetal alcohol syndrome (FAS) representing one point on the spectrum. This paper will provide a comprehensive review of the neuropsychological and behavioral effects of heavy prenatal alcohol exposure, including a discussion of the emerging neurobehavioral profile. Supporting studies of lower levels of exposure, brain-behavior associations, and animal model systems will be included when appropriate.