Forty Years of Assessing Neurodevelopmental and Behavioral Effects of Prenatal Alcohol Exposure in Infants: What Have We Learned?

Early developmental trajectory of children with prenatal alcohol and opioid exposure

BACKGROUND

With significant increases in opioid use/misuse and persistent high prevalence of prenatal alcohol exposure (PAE), identifying infants at risk for long-term developmental sequelae due to these exposures remains an urgent need. This study reports on developmental outcomes in young children from a prospective cohort, ENRICH-1, which recruited pregnant women and followed up maternal-infant pairs.

METHODS

Subjects were assigned to four study groups based on prenatal use of medications for opioid use disorder (MOUD), PAE, MOUD+PAE, and unexposed controls (UC). Mixed effects modeling was used to evaluate changes in the Bayley Scales of Infant Development-III (BSID-III) Cognitive, Language, and Motor scores between 6 and 20 months.

RESULTS

There was a significant three-way interaction (MOUD-by-PAE-by-Time) with respect to the BSID-III Cognitive (p = 0.045) and Motor (p = 0.033) scales. Significant changes between the two evaluations were observed for MOUD group in Cognitive and Language scores; for PAE group in Cognitive, Language, and Motor scores, and for MOUD+PAE group in Language scores after adjusting for child sex and family socio-economic status. The developmental scores for the UC remained stable.

CONCLUSION

Observed decline in neurodevelopmental scores during the first 2 years of life emphasizes the importance of a longitudinal approach when evaluating children with prenatal polysubstance exposure.

IMPACT

BSID-III scores were stable during the first 2 years of life for unexposed children. BSID-III scores declined for children with prenatal exposures to alcohol and/or opioids. Standard developmental tests may not be sensitive enough during the first year of life. Findings emphasize the need for repeated evaluations of children who are at high risk.

Developmental, sensory and behavioral outcomes among infants and toddlers with prenatal alcohol exposure

BACKGROUND

Prenatal alcohol exposure (PAE) can disrupt children's neurodevelopment and exert lasting influences on overall child well-being and family functioning. A comprehensive exploration of developmental outcomes in infants/toddlers with PAE seen for a diagnosis on the fetal alcohol spectrum can inform early identification and intervention.

AIMS

To describe the prevalence and patterns of neurodevelopment, sensory processing, and emotional and behavioral functioning in a clinical sample of infants/toddlers with PAE.

METHODS

In this retrospective analysis, clinical data from 125 infants/toddlers with PAE, aged 2-42 months, assessed at the University of Washington Fetal Alcohol Syndrome Diagnostic and Prevention Network clinic were analyzed.

RESULTS

Seventy-four to 87% of infants/toddlers demonstrated delayed development in one or more domains of the Bayley Scales of Infant and Toddler Development (n = 125). Adverse developmental outcomes were significantly correlated with PAE and/or postnatal risk factors. All 93 infants/toddlers with a complete Infant/Toddler Sensory Profile obtained definite difference scores in at least one quadrant/section. Over half of infant/toddlers with a completed Child Behavior Checklist/1½- 5 had total problem scores in the borderline or clinical range.

CONCLUSIONS

Findings suggest that several domains of child functioning may be vulnerable to the teratogenic impact of PAE, and that these delays are evident in the first years of life. Early screening, ongoing monitoring and comprehensive assessment is needed to facilitate earlier identification and guide clinical intervention.

Breastfeeding and neurodevelopment in infants with prenatal alcohol exposure

BACKGROUND

Few studies have evaluated the differential benefits of breastfeeding on infant neurodevelopment at varying levels of prenatal alcohol exposure (PAE). This study examined whether the association between breastfeeding and neurodevelopment is modified by prenatal drinking pattern.

METHODS

The study included 385 infants from Ukraine born to women prospectively enrolled in a cohort study during pregnancy. Neurodevelopment was assessed at six and 12 months using the Bayley Scales of Infant Development II (BSID-II) Mental Developmental Index (MDI) and Psychomotor Developmental Index (PDI). Linear regression modeling with interaction terms and stratification by PAE group was used to determine the relationship between breastfeeding, PAE, and neurodevelopment.

RESULTS

A significant interaction between PAE and breastfeeding was observed for the MDI and PDI at six and 12 months. Infants with high PAE who were breastfed at least four months had BSID-II scores 14 or more points higher compared to those never breastfed. Counterintuitively, those with moderate PAE had poorer performance on the BSID-II at 12 months when breastfed longer.

CONCLUSION

There was a significant joint effect of PAE and breastfeeding on infant neurodevelopment at six and 12 months. Breastfeeding may provide distinct benefits to infants exposed to high levels of PAE.

IMPACT

We found a positive effect of breastfeeding on infant neurodevelopment among infants with prenatal alcohol exposure (PAE), particularly those exposed to higher levels during gestation. This study is one of the first to evaluate whether breastfeeding mitigates harm caused by PAE. Breastfeeding may provide distinct benefits to infants with higher levels of PAE.

Concerns and Strengths: Caregiver Perceptions of Their Infant/Toddler with Prenatal Alcohol Exposure

Caregiver-reported assessments provide opportunities for caregivers to share concerns and identify the strengths of their infant/toddler regarding prenatal alcohol exposure (PAE). These insights may reveal under-recognized concerns and inform a strengths-based approach to early intervention. The purpose of this study was to describe the type and frequency of caregiver-reported concerns and strengths in a sample of infants/toddlers at the time of their fetal alcohol spectrum disorder (FASD) diagnostic evaluation. Caregivers' concerns and strengths were identified in the context of two parent-report questionnaires, the Infant Toddler Sensory Profile and Child Behavior Checklist/1½-5. By using content analysis, caregivers' open-ended responses were identified, coded, and analyzed. The frequencies of all the coded concerns and strengths were counted. The data were compared across the two age groups (<2 years and ≥2 years) and caregiver status. Caregivers (n = 117) identified numerous concerns and strengths across multiple categories. The most frequently reported concerns were related to aggressive behavior, language/communication, and sensory processing. The most frequently reported strengths were related to happiness, sociability, and love. The type of concerns and strengths reported were relatively consistent across age and caregiver status. These findings reinforce the value of caregivers' perspectives and offer a reminder to practitioners that infants/toddlers with PAE and their caregivers have many strengths that can be harnessed, in addition to a range of challenges that must be addressed.

Psychotropic Medication Utilization Among Children Diagnosed With Fetal Alcohol Spectrum Disorder

BACKGROUND AND OBJECTIVES

To date, there has been no large, population-based study estimating the prevalence of psychotropic medication use and cooccurring medical conditions among children with fetal alcohol syndrome disorder (FASD). In addition, it is not known how psychotropic medication use varies by mental health status of the children with FASD and their health insurance coverage. This study attempts to fill this gap by analyzing a large health insurance claims database covering Medicaid and private insurance.

METHODS

The study used the 2017 IBM Watson Health MarketScan Multistate Medicaid and Commercial Claims databases. The sample for the analysis includes children between the ages of 0 and 17 with either an FASD diagnosis or a mental health diagnosis (N = 848 721 Medicaid; N = 511 061 private insurance).

RESULTS

More than half of the children with an FASD diagnosis were prescribed psychotropic medications (63% Medicaid; 57% private). Utilization rates of psychotropic medication among children with cooccurring FASD and a mental health condition (79% Medicaid; 71% private) were higher compared to children with a mental health diagnosis but no FASD (57% Medicaid; 57% private). Stimulants were the most commonly prescribed. Encephalopathy, attention deficit hyperactivity disorder, and epilepsy were the 3 most common cooccurring diagnosis among children with FASD using psychotropic medication under Medicaid compared to encephalopathy, attention deficit hyperactivity disorder, and anxiety with private insurance.

CONCLUSIONS

These results exemplify the complexity of the neurobehavioral profile of children with FASD and the challenge of treatment. Future studies may determine how supportive services for these children will affect psychotropic medication use.

[Formula: see text]Parental interaction style, child engagement, and emerging executive function in fetal alcohol spectrum disorders (FASD)

Children with fetal alcohol spectrum disorders (FASD) are known to experience cognitive and neurobehavioral difficulties, including in areas of executive function and social skills development. Interventions for these challenges have focused on a number of areas, including parent-based training. Despite the general consensus that specific parenting styles consistent with an "authoritative" - warm but firm - parenting approach may influence behavioral self-regulation, it is not known what specific parental interaction styles are associated with child engagement and emerging executive function in this population. The current study used an observation-based behavioral coding scheme during parent-child play interactions and associated parent report-based executive function measures in children with FASD. Here, we demonstrate that parental interaction styles with increased responsive/child-oriented behavior and parental affect are associated with higher levels of child play engagement, while parental interaction that has increased achievement-orientation is associated with higher levels of emerging executive function in children with FASD. These findings help inform future studies on behavioral targets in parent-based training programs and highlight the importance of considering certain parental interaction styles during parent-child play.

Balancing the story of fetal alcohol spectrum disorder: A narrative review of the literature on strengths

For many years, researchers have explored the complex challenges experienced by individuals with fetal alcohol spectrum disorder (FASD). This research has been important for documenting the brain- and body-based impacts of prenatal alcohol exposure and the psychosocial vulnerabilities and environmental adversities frequently associated with FASD. It has also supported advocacy efforts and highlighted the necessity of providing FASD services and supports. However, with the focus on deficits and needs, there is a considerable gap in the literature on the strengths and successes of individuals with FASD. The lack of strengths-based FASD research has likely perpetuated the stress and stigma experienced by individuals with FASD and their families. Thus, there is a critical need to shift the direction of the field. Here we provide a narrative review of the literature on strengths in FASD. Our goals are to: (1) understand the state of strengths-based research related to individuals with FASD across the lifespan, and (2) describe positive characteristics, talents, and abilities of individuals with FASD that may be cultivated to promote their fulfillment and well-being. We identified a total of 19 studies, most of which were conducted to explore the lived experiences of adults with FASD. This preliminary but critical body of evidence highlights the intrinsic strengths of individuals with FASD, including strong self-awareness, receptiveness to support, capacity for human connection, perseverance through challenges, and hope for the future. Despite the importance of this emerging evidence, appraisal of the literature indicates a need for more intentional, methodologically rigorous, participatory, and theory-driven research in this area. Findings from this study, including the identified gaps in the literature, can be used to inform research, practice, and policy to meaningfully advance the field of FASD and promote positive outcomes in this population.

Maternal verbal scaffolding: association with higher language skills for 20-month-old children with prenatal polysubstance exposure

BACKGROUND

The number of children with prenatal polysubstance exposure is increasing. Supportive mother-child interaction is a protective factor, which can ameliorate adverse effects of prenatal polysubstance exposure on developmental outcomes.

AIM

To examine the role of maternal verbal scaffolding on cognitive and language development in children with prenatal polysubstance exposure.

STUDY DESIGN

Pregnant women were recruited, and we prospectively followed mother-child dyads to 20 months of age. This analysis included 66 dyads (33 healthy controls and 33 with prenatal polysubstance exposure). Multivariable linear regression modelling was used to examine the cross-sectional association between maternal scaffolding and Bayley Scales of Infant and Toddler Development (BSID-III) score, as well as an interaction between the study group and scaffolding score.

OUTCOME MEASURES

The BSID-III cognitive and language score was used. Videotaped mother-child play was coded to obtain a maternal verbal scaffolding score. Effect sizes were measured using average differences in scores between groups.

RESULTS

There was no evidence of an association between study group and maternal scaffolding scores. Children in the polysubstance exposure group had lower cognitive and language scores compared to controls, but this association was not statistically significant after controlling for maternal education. Maternal scaffolding was predictive of language scores, with scores increasing by 1.24 points on average (95% CI: 0.42, 2.06) for every 1-point increase in scaffolding score after adjustment for covariates. There was no evidence of a study group-by-scaffolding interaction with respect to the language or cognitive scores.

CONCLUSIONS

Maternal scaffolding during play was associated with language development in children with and without prenatal polysubstance exposure.

Structural and functional brain network alterations in prenatal alcohol exposed neonates

Prenatal alcohol exposure leads to alterations in cognition, behavior and underlying brain architecture. However, prior studies have not integrated structural and functional imaging data in children with prenatal alcohol exposure. The aim of this study was to characterize disruptions in both structural and functional brain network organization after prenatal alcohol exposure in very early life. A group of 11 neonates with prenatal alcohol exposure and 14 unexposed controls were investigated using diffusion weighted structural and resting state functional magnetic resonance imaging. Covariance networks were created using graph theoretical analyses for each data set, controlling for age and sex. Group differences in global hub arrangement and regional connectivity were determined using nonparametric permutation tests. Neonates with prenatal alcohol exposure and controls exhibited similar global structural network organization. However, global functional networks of neonates with prenatal alcohol exposure comprised of temporal and limbic hubs, while hubs were more distributed in controls representing an early default mode network. On a regional level, controls showed prominent structural and functional connectivity in parietal and occipital regions. Neonates with prenatal alcohol exposure showed regionally, predominant structural and functional connectivity in several subcortical regions and occipital regions. The findings suggest early functional disruption on a global and regional level after prenatal alcohol exposure and indicate suboptimal organization of functional networks. These differences likely underlie sensory dysregulation and behavioral difficulties in prenatal alcohol exposure.

A review of studies exploring fetal alcohol spectrum disorders through eye tracking measures

The widespread cognitive and cerebral consequences of prenatal alcohol exposure have been established during the last decades, through the exploration of fetal alcohol spectrum disorders (FASD) using neuropsychological and neuroscience tools. This research field has recently benefited from the emergence of innovative measures, among which eye tracking, allowing a precise measure of the eye movements indexing a large range of cognitive functions. We propose a comprehensive review, based on PRISMA guidelines, of the eye tracking studies performed in populations with FASD. Studies were selected from the PsycINFO, PubMed and Scopus databases, and were evaluated through a standardized methodological quality assessment. Studies were classified according to the eye tracking indexes recorded (saccade characteristics, initial fixation, number of fixations, dwell time, gaze pattern) and the process measured (perception, memory, executive functions). Eye tracking data showed that FASD are mostly associated with impaired ocular perceptive/motor abilities (i.e., altered eye movements, centrally for saccade initiation), lower accuracy as well as increased error rates in saccadic eye movements involving working memory abilities, and reduced inhibitory control on saccades. After identifying the main limitations presented by the reviewed studies, we propose guidelines for future research, underlining the need to increase the standardization of diagnosis and evaluation tools, and to improve the methodological quality of eye tracking measures.

Self-regulation and emotional reactivity in infants with prenatal exposure to opioids and alcohol

BACKGROUND

Infants with prenatal substance exposure are at increased risk for developmental problems, with self-regulatory challenges being some of the most pronounced. The current study aimed to investigate the extent to which prenatal substance exposure (alcohol, opioids) impacts infant self-regulation during a relational stressor and the association between self-regulation and infant affect.

METHODS

Participants were 100 mother-child dyads recruited prenatally (Mean = 23.8 gestational weeks) and completed the Still Face Paradigm (SFP) when infants were 5 to 8 months of age (Mean = 6.9 months) as part of an ENRICH prospective birth cohort study. Based on prospective repeated assessment of maternal substance use in pregnancy, infants were grouped into: 1) Unexposed controls; 2) Alcohol-exposed; 3) Opioid-exposed due to maternal use of medications for opioid use disorder (MOUD) with or without other opioids; 4) MOUD and alcohol. Infant stress reactivity (negative affect) and self-regulation were assessed during the validated 5-episode SFP. Mixed effects linear models were used to analyze differences in the percent of self-regulation and percent of negative affect among the study groups across SFP episodes, as well as the group-by-self-regulation interaction with respect to infant negative affect.

RESULTS

The MOUD+Alcohol group demonstrated significantly lower self-regulation at baseline compared to controls (p < 0.05). There was a significant group-by-self-regulation interaction (p = 0.028). Higher self-regulation was associated with lower negative affect across SFP episodes in the MOUD+Alcohol group (p = 0.025) but not other groups.

CONCLUSION

Self-regulation skills are particularly important for emotional modulation in infants with prenatal polysubstance exposure, highlighting the development of these skills as a promising intervention target.

Relationship Between Task-Based and Parent Report-Based Measures of Attention and Executive Function in Children with Fetal Alcohol Spectrum Disorders (FASD)

A majority of children with fetal alcohol spectrum disorders (FASD) have demonstrated attention and executive function deficits as measured by both parent report measures and performance on tasks requiring sustained levels of attention. However, prior studies have consistently reported a lack of association between parental report-based and task-based performance measures. The current study investigated whether changes in performance over time within-task (i.e., first-half versus second-half) better correspond to parental reports of executive function and temperament in children with FASD. Greater differences in split-half performance during a continuous performance task were found to be associated with higher parent-reported levels of behavioral regulation and inhibitory control. These findings suggest that within-task performance differences may more accurately reflect individual differences in executive function and temperament as measured by parental report and help to further inform the way in which cognitive processes are measured in children with FASD.

Recent developments in fetal alcohol spectrum disorder

PURPOSE OF REVIEW

To highlight research, publications, and medical advancements in fetal alcohol spectrum disorder (FASD) over the past 18 months.

RECENT FINDINGS

Prevalence numbers have been updated, allowing for a more accurate account of the societal impact. Further work on diagnostic techniques and the underlying mechanisms will allow us to better understand the pathophysiology of FASD and could translate into treatments for the condition. Continued research on new treatments and interventions is needed to improve the affected individual's health care and quality of life. Measurable outcomes allow us to tangibly measure improvements for individuals and families affected by FASD.

SUMMARY

The current review highlights recent publications from January 2018 to August 2019 showing continued medical advancement in improving the care for children and families affected by FASD.