Prenatal alcohol and drug exposures in adoption

Mothers' alexithymia in the context of parental Substance Use Disorder: Which implications for parenting behaviors?

BACKGROUND

Maternal substance use disorder (SUD) represents a severe risk for caregiving, affecting diverse domains of parenting behaviors, such as sensitivity, structuring, intrusiveness, and hostility. Various studies highlighted that difficulties in parenting behaviors in the context of SUD are exacerbated by the co-occurrence of psychopathological symptoms. A large body of research points out the presence of high rates of alexithymia in individuals with SUD, and some studies provide evidence of an association between this psychopathological aspect and parenting. Nevertheless, no prior research has explored how alexithymic traits could affect quality of parenting behaviors in mothers with SUD.

OBJECTIVE

To investigate the impact of maternal alexithymia on parenting behaviors in mothers with SUD.

METHODS

Sixty women in residential treatment for SUD and their children participated in the study. The participants were assessed with respect to alexithymia, quality of parenting behaviors, and depressive symptoms.

RESULTS

Forty-three percent of the mothers reported the presence of alexithymia. These mothers presented with significantly low scores on sensitivity (β = -.25, p < .05) and structuring (β = -.32, p < .05). After controlling for depressive symptomatology, the effect of alexithymia on parenting behaviors remained only for structuring (β=.35, p < .05).

CONCLUSIONS

In the context of SUD, maternal alexithymia significantly impacts the quality of parenting behaviors, specifically structuring, indicating that difficulties in becoming aware of one's own feelings jeopardize the ability to scaffold interactions and set age-appropriate limits in an emotionally attuned way. Clinical implications of the findings are discussed.

The causal web of foetal alcohol spectrum disorders: a review and causal diagram

Foetal alcohol spectrum disorders (FASDs) are a leading cause of developmental disability. Prenatal alcohol use is the sole necessary cause of FASD, but it is not always sufficient. Multiple factors influence a child's susceptibility to FASD following prenatal alcohol exposure. Much of the FASD risk factor literature has been limited to discussions of association, rather than causation. While knowledge of predictor variables is important for identifying who is most at risk of FASD and for targeting interventions, causal knowledge is important for identifying effective mechanisms for prevention and intervention programmes. We conducted a systematic search and narrative synthesis of the evidence and used this to create a causal diagram (directed acyclic graph; DAG) to describe the causal pathways to FASD. Our results show that the aetiology of FASD is multifaceted and complex. FASD risk is determined by a range of lifestyle, sociodemographic, maternal, social, gestational, and genetic factors. The causal diagram that we present in this review provides a comprehensive summary of causal risk factors for FASD and can be used as a tool to inform data collection and statistical modelling strategies to minimise bias in future studies of FASD.

Attachment to Parents and Aggressiveness in Adopted Adolescents: A Multi-Sample Comparison Study

This study examined adopted adolescents' levels of attachment security to parents and aggressiveness as compared to those of community nonadopted adolescents and of clinical nonadopted adolescents. Three different subsamples participated (n = 262): 101 community nonadopted adolescents (48.5% girls), 80 community adopted teens (65.0% girls), and 81 nonadopted counterparts (35.8% girls) who participated in a treatment program for youth with behavioral problems. There were no differences between community groups in attachment security or aggressiveness, whereas clinical nonadopted adolescents showed less attachment security and more aggressiveness than the other two groups. The implications of these results are discussed in terms of the potential healing impact that living with adoptive families could have on adopted teenagers' risk of maladaptive outcomes.

Comprehensive Health Evaluation of the Newly Adopted Child

Children who join families through the process of adoption, whether through a domestic or international route, often have multiple health care needs. Pediatricians and other health care personnel are in a unique position to guide families in achieving optimal health for the adopted children as families establish a medical home. Shortly after placement in an adoptive home, it is recommended that children have a timely comprehensive health evaluation to provide care for known medical needs and identify health issues that are unknown. It is important to begin this evaluation with a review of all available medical records and pertinent verbal history. A complete physical examination then follows. The evaluation should also include diagnostic testing based on findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screenings may include, but are not limited to, newborn screening panels and hearing, vision, dental, and formal behavioral and/or developmental screenings. The comprehensive assessment may occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children can be referred to other medical specialists as deemed appropriate. The Council on Adoption, Foster Care, and Kinship Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

Cognitive outcomes in prenatal methamphetamine exposed children aged six to seven years

BACKGROUND

Methamphetamine use among pregnant women has become a significant problem. Research delineating the cognitive outcomes of prenatal methamphetamine exposure (PME) in early childhood is limited, however. The aim of this study was to examine effects of PME on cognition in six-to-seven-year-old children.

METHODS

PME children (n=23) and unexposed controls (n=22) completed a battery of neurocognitive tests, which included the Kaufman Assessment Battery for Children, Boston Naming Test, Beery Developmental Test of Visual-Motor Integration, and Grooved Pegboard Test.

RESULTS

Independent samples t-tests revealed that PME children scored significantly worse than controls on the measures of IQ, learning and memory, confrontation naming, visual-motor integration, and fine motor coordination. Hierarchical regression analyses that included potential confounding sociodemographic, co-exposure and anthropometric variables confirmed that PME impacts negatively on cognitive performance.

CONCLUSIONS

The study confirms that PME has deleterious effects on cognition in several broad cognitive domains, likely by altering underlying brain circuitry in development. These effects may be particularly pronounced at the time when children enter formal schooling. Extended follow-ups into late childhood might help elucidate the developmental trajectory of cognitive dysfunction in PME, and subsequent effects on everyday functioning.

Internationally adopted children: not only infectious diseases!

Information on prevalence of special needs in internationally adopted children (IAC) is incomplete. We reviewed data from 422 IAC screened at a single Centre in Italy in 2015-16. Prevalence of special needs reached 17.1% (n = 72). Among these children, the most frequent conditions were fetal alcohol spectrum disorders (FASD; n = 30; 7.1%), cleft lip palate (n = 8; 1.9%) and other congenital malformations (n = 20; 4.7%). Worrisomely, 25 out of 52 (48.1%) Russian children presented with FASD.

The Essential Role of Growth Deficiency in the Diagnosis of Fetal Alcohol Spectrum Disorder

Background:

Laboratory studies confirm prenatal alcohol exposure (PAE) causes growth deficiency (GD). GD has traditionally been a core diagnostic feature of fetal alcohol spectrum disorders (FASD), but was removed from the Canadian and Australian FASD diagnostic guidelines in 2016. This study aimed to empirically assess the clinical role and value of GD in FASD diagnosis.

Methods:

Data from 1814 patients with FASD from the University of Washington Fetal Alcohol Syndrome Diagnostic & Prevention dataset were analyzed to answer the following questions: 1) Is there evidence of a causal association between PAE and GD in our clinical population? 2) Is GD sufficiently prevalent among individuals with PAE to warrant its inclusion as a diagnostic criterion? 3) Does GD aid the diagnostic team in identifying and/or predicting which individuals will be most impaired by their PAE?

Results:

GD significantly correlated with PAE. GD was as prevalent as the other core diagnostic features (facial and CNS abnormalities). GD occurred in all FASD diagnoses and increased in prevalence with increasing severity of diagnosis. The most prevalent form of GD was postnatal short stature. GD was as highly correlated with, and predictive of, severe brain dysfunction as the FAS facial phenotype. Individuals with GD had a two to three-fold increased risk for severe brain dysfunction. Sixty percent of patients with severe GD had severe brain dysfunction. GD accurately predicted which infants presented with severe brain dysfunction later in childhood

Conclusions:

GD is an essential diagnostic criterion for FASD and will remain in the FASD 4-Digit Code.

Ethanol, Neurodevelopment, Infant and Child Health (ENRICH) prospective cohort: Study design considerations

BACKGROUND

While intervention is the leading factor in reducing long-term disabilities in children with fetal alcohol spectrum disorder (FASD), early identification of children affected by prenatal alcohol exposure (PAE) remains challenging. Deficits in higher-order cognitive domains (e.g. executive function) might be more specific to FASD than global neurodevelopmental tests, yet these functions are not developed in very young children. Measures of early sensorimotor development may provide early indications of atypical brain development during the first two years of life.

METHODS

This paper describes the novel methodology of the Ethanol, Neurodevelopment, Infant and Child Health (ENRICH) prospective cohort study of 120 maternal-infant pairs with a goal to identify early indices of functional brain impairment associated with PAE. The cohort is established by recruiting women early in pregnancy and classifying them into one of three study groups: patients on opioid-maintenance therapy who consume alcohol during pregnancy (Group 1), patients on opioid-maintenance therapy who abstain from alcohol during pregnancy (Group 2), and healthy controls (Group 3). After the initial prenatal assessment (Visit 1), patients are followed to Visit 2 occurring at delivery, and two comprehensive assessments of children at six (Visit 3) and 20 months (Visit 4) of age. ENRICH recruitment started in November 2013 and 87 women were recruited during the first year. During Year 1, the biospecimen (maternal whole blood, serum, urine, dry blood spots of a newborn) collection rate was 100% at Visit 1, and 97.6% for those who completed Visit 2.

DISCUSSION

The tiered screening approach, evaluation of confounders, neurocognitive and magneto-/electro-encephalography (MEG/EEG) outcomes, and ethical considerations are discussed.

Executive function and mental health in adopted children with a history of recreational drug exposures

Adoptive children are at increased risk for problematic behaviors but the origin of these individual differences in neurobehavioral function is unclear. This investigation examined whether adopted children with prenatal exposure to a wide variety of recreational drugs exhibited higher scores (i.e. more problems) with executive function and psychiatric symptomology. Caregivers of children ages 5 to 18 completed an online survey with items about use of alcohol, nicotine, or methamphetamine during pregnancy followed by the Behavior Rating Inventory of Executive Function (BRIEF, N = 437 including 59 adoptive parents) or the Child Behavior Checklist (CBCL, N = 549 including 54 adoptive parents). Relative to a comparison group of children raised by their biological parents, adoptive children that were polysubstance exposed during prenatal development exhibited higher rates of academic difficulties and were behind their classmates in math and reading. Adoptive children had statistically and clinically significant higher BRIEF ratings and this pattern was similar for boys and girls. CBCL ratings were significantly increased in adoptive children, particularly for Externalizing and Attention problems. Adoptive children with a history of polysubstance exposures including alcohol, nicotine, and methamphetamine are at heightened risk for difficulties with executive function as well as various psychopathologies. These findings suggest that increased monitoring to identify and implement remediation strategies may be warranted for adopted children with a history of in utero drug exposures.

Prenatal substance abuse: short- and long-term effects on the exposed fetus

Prenatal substance abuse continues to be a significant problem in this country and poses important health risks for the developing fetus. The primary care pediatrician's role in addressing prenatal substance exposure includes prevention, identification of exposure, recognition of medical issues for the exposed newborn infant, protection of the infant, and follow-up of the exposed infant. This report will provide information for the most common drugs involved in prenatal exposure: nicotine, alcohol, marijuana, opiates, cocaine, and methamphetamine.

Review article: a decision-making algorithm for the management of pregnancy in the inflammatory bowel disease patient

BACKGROUND

Inflammatory bowel disease affects patients who are in their reproductive years. There are many questions regarding the management of IBD patients who are considering or who are already pregnant. These include the effect of the disease and the medications on fertility and on the pregnancy outcome.

AIM

To create an evidence-based decision-making algorithm to help guide physicians through the management of pregnancy in the IBD patient.

METHODS

A literature review using phrases that include: 'inflammatory bowel disease', 'Crohn's disease', 'ulcerative colitis', 'pregnancy', 'fertility', 'breast feeding', 'delivery', 'surgery', 'immunomodulators', 'azathioprine', 'mercaptopurine', 'biologics', 'infliximab', 'adalimumab', 'certolizumab'.

CONCLUSIONS

The four decision-making nodes in the algorithm for the management of pregnancy in the IBD patient, and the key points for each one are as follows: (i) preconception counselling - pregnancy outcome is better if patients remain in remission during pregnancy, (ii) contemplating pregnancy or is already pregnant - drugs used to treat IBD appear to be safe during pregnancy, with the exception of methotrexate and thalidomide, (iii) delivery and (iv) breast feeding - drugs used to treat IBD appear to be safe during lactation, except for ciclosporin. Another key point is that biological agents may be continued up to 30 weeks gestation. The management of pregnancy in the IBD patient should be multi-disciplinary involving the patient and her partner, the family physician, the gastroenterologist and the obstetrician.

Comprehensive health evaluation of the newly adopted child

Children who join families through the process of adoption often have multiple health care needs. After placement in an adoptive home, it is essential that these children have a timely comprehensive health evaluation. This evaluation should include a review of all available medical records and a complete physical examination. Evaluation should also include diagnostic testing based on the findings from the history and physical examination as well as the risks presented by the child's previous living conditions. Age-appropriate screens should be performed, including, for example, newborn screening panels, hearing, vision, dental, and formal behavioral/developmental screens. The comprehensive assessment can occur at the time of the initial visit to the physician after adoptive placement or can take place over several visits. Adopted children should be referred to other medical specialists as deemed appropriate. The Section on Adoption and Foster Care is a resource within the American Academy of Pediatrics for physicians providing care for children who are being adopted.

Clinical challenges of adoption: Views from Montreal and Tel Aviv

Adoption is accompanied by well-known risk factors that contribute to unique clinical challenges for children, parents, and clinicians. Adoption also serves to illustrate issues that remain relatively "silent" in the typical transition to parenthood. In this article, the authors review the normal developmental challenges that parents face during adoption, the adoption-related risk factors that may impinge on the child's development and attachment process, and the impact of adoption on the child's development of identity and filiations. We will review and illustrate clinical conditions often associated with adoption. In many countries, adoptive parents are reluctant to consult mental health clinicians during the first year of the adoption. The cases presented here illustrates the need to implement routine clinical programs for early detection and intervention of adoptive parent-infant dyads and triads at risk.

Fetal alcohol syndrome, Tourette syndrome, and hyperactivity in nine adopted children

Much attention has been paid in recent years to the role of prenatal exposure to alcohol. Fetal alcohol syndrome is one of the most severe afflictions resulting from such exposure. The present report documents the cases of adopted children diagnosed with fetal alcohol syndrome who developed both Tourette syndrome and attention deficit-hyperactivity disorder. Out of a population of 138 adopted children with behavior issues whose clinical histories were reviewed retrospectively, 9 children (6.5%) presented this constellation. Epidemiologic data, clinical data, neurologic examination findings, complementary testing, and developmental data were recorded. All nine patients studied had initial psychomotor retardation, despite the frequent case of subsequent intelligence quotient normalization. From a behavioral perspective, half of the cases presented obsessive-compulsive disorder and problems with social relations. Aggressive behavior was common. These cases also presented a high degree of severity of both tics and hyperactivity. The most common drug treatment was methylphenidate. This constellation of fetal alcohol syndrome, Tourette syndrome, and attention deficit-hyperactivity disorder is scantly reported in the literature and is likely underdiagnosed. This particular constellation poses its own prognosis and requires its own treatment.

Management of inflammatory bowel disease in the pregnant patient

Inflammatory bowel disease (IBD) is a chronic disorder affecting young adults in their reproductive years. Many young women with IBD express concern about the effect their disease will have on fertility, pregnancy course and fetal development. This article presents an approach to management of IBD in the pregnant patient, including counseling and investigation, and summarizes existing data on the safety of medications used to treat IBD in pregnancy and breastfeeding.

Problem behaviors of children adopted from the former Soviet Union

INTRODUCTION

Although current meta-analyses of problem behavior of internationally adopted children exist, few children adopted from the former Soviet Union have been included in these reports. A significant concern is that 13 children adopted from the former Soviet Union have died at the hands of their American adoptive parents since 1996.

METHOD

A cohort of 105 children adopted from the former Soviet Union has been assessed at two points in time by telephone and postal surveys to measure the impact of risk and protective factors on problem behavior.

RESULTS

Pre-adoptive risk factors have declined in importance (except for birth weight) and protective factors (operationalized as aspects of family environment) have increased in influence over time. Problem behavior scores declined slightly at Time 2, despite the children having entered adolescence.

DISCUSSION

Families play a significant role in the behavior of children adopted from the former Soviet Union. Nurses should counsel families to shape the child's environment during the transition from orphanage to homes in the United States, especially for children who are low birth weight.

Prenatal drug exposure effects on subsequent vulnerability to drug abuse

Research has shown that both prenatal alcohol and tobacco exposure are associated with increased risk of significant adverse medical, developmental, and behavioral outcomes including substance abuse. Research on the outcomes of prenatal exposure to illicit drugs (PNDE) has also found increased physical and behavioral problems for gestationally drug-exposed children. However, a clear picture has not emerged on whether the consequences of PNDE are independent from those associated with having a substance abusing parent and whether PNDE increases vulnerability to drug abuse. Because of its typical co-occurrence with factors inherent in having a drug-abusing parent, PNDE is at least a marker of significant increased risk for a range of negative outcomes including greater vulnerability to substance abuse. Although a review of the relevant research literatures indicates that the direct consequences of PNDE appear to be generally both subtle and nonglobal, PNDE does appear to have negative developmental and behavioral outcomes, and there is evidence that it is a modest direct contributor to increased substance abuse vulnerability.