A meta-analytic review of adaptive functioning in fetal alcohol spectrum disorders, and the effect of IQ, executive functioning, and age

Fetal alcohol spectrum disorder (FASD) and the criminal justice system: A guide for legal professionals

Fetal Alcohol Spectrum Disorder (FASD) is a lifelong disorder caused by prenatal alcohol exposure (PAE) and is one of the most common causes of brain damage and developmental disability. FASD has been characterized by an array of symptoms that negatively affects cognitive, social, and adaptive functioning. Individuals living with FASD, relative to the general population, are more likely to become entangled in the legal system due to challenges associated with the disorder. Moreover, symptomology of FASD often contributes to these individuals struggling in successfully navigating various stages of the legal system, including arrest, interrogation, working with their defense counsel, and courtroom appearances. The difficulties faced by defendants living with FASD are exacerbated by systemic failure from legal professionals in recognizing and accommodating for the extent and complexities of this disorder. Consequently, defendants living with FASD often do not receive effective due process of law in comparison to their neurotypical peers. Moreover, attempts at punishment and deterrence through probation and jail terms are often ineffective for individuals living with FASD because of the effects of their disorder. This article is intended to provide valuable information and best practices for professionals in the legal system, particularly judges, prosecutors, defense attorneys, social workers/mitigation specialists, and psychologists, who are likely to encounter individuals living with FASD or suspected FASD early in the judicial process.

Positive behavior support (PBS) with children with fetal alcohol spectrum disorders: Characterizing caregivers' use of PBS using follow-up clinical trial data

BACKGROUND

Fetal alcohol spectrum disorders (FASD) are associated with neurodevelopmental challenges leading to difficulties with everyday life tasks. The Families Moving Forward (FMF) Program teaches caregivers to use positive behavior support (PBS), integrated with other techniques. However, it is unknown how caregivers retain and use these PBS strategies after the intervention.

METHODS

About 4.5 months after completing the FMF Program, twenty-three caregivers of children with FASD aged 4-12 were interviewed about problem behaviors targeted during the FMF Program and their continued use of PBS strategies. Interviews were recorded and coded thematically by a five-coder team. Higher-level pattern codes were developed to facilitate themes across descriptive codes.

RESULTS

Caregivers commonly targeted task incompletion and rule breaking, and problem behaviors were often complex or combined. Caregivers identified environmental and interpersonal triggers for problem behavior. They used many accommodations to prevent problem behaviors, most often related to task or environment simplification. Caregivers also used consequence-based strategies.

CONCLUSIONS

This study is the first to characterize caregivers' use of PBS strategies for children with FASD using mixed methods. Problem behaviors such as rule breaking were more difficult to target. Caregivers found most success when using a combination of multiple different accommodations per problem behavior.

WHAT THIS PAPER ADDS

This is the first study to use mixed methods to characterize how caregivers of children with fetal alcohol spectrum disorders (FASD) use positive behavior support (PBS) strategies to target problem behavior after completion of the empirically validated Families Moving Forward (FMF) Program. Among other techniques involved in the FMF Program, PBS strategies are taught to caregivers and are used to target two distinct, caregiver-identified problem behaviors. This data provides essential information about behaviors responsive to PBS supports, for children with FASD, to inform clinical intervention and research. Notably, multiple problem behaviors often occurred together, emphasizing complexity of behavior challenges in this population and the resulting need for individualized supports. This study is the first to describe commonly observed triggers (antecedents) and commonly used supports (accommodations) from the perspective of caregivers of children with FASD. Importantly, results indicate that use of a wide variety of accommodations, or antecedent-based strategies, are effective in supporting behavior in children with FASD. However, success was most common when caregivers used multiple accommodations for any given concerning behavior. Findings represent 'real-world' strategies caregivers use to support adaptive behavior in their children several months after completion of the FMF Program, suggesting these strategies are applicable to clinical practice.

Alcohol Toxicity in the Developing Cerebellum

The impact of ethanol on the fetus is a significant concern as an estimated 2-5% of live births may be affected by prenatal alcohol exposure. This exposure can lead to various functional and structural abnormalities in the cerebral cortex, basal ganglia, diencephalon, and cerebellum, resulting in region-specific symptoms. The deficits relate to the motor and cognitive domains, affecting, in particular, general intelligence, attention, executive functions, language, memory, visual perception, and social skills-collectively called the fetal alcohol spectrum disorder (FASD). Recent studies suggest that damage to the developing cerebellum (in form of alcohol exposure) can impair the cortical targets of the cerebello-thalamo-cortical tract. This malfunction in the cerebello-cerebral loop optimization may be due to disruptions in the formation of the foundational elements of the internal model within the developing cerebellum. Alcohol exposure targets multiple nodes in the reciprocal loops between the cerebellum and cerebral cortex. Here, we examine the possibility that prenatal alcohol exposure damages the developing cerebellum and disrupts the connectivity within the cerebello-cerebral neuronal circuits, exacerbating FASD-related cortical dysfunctions. We propose that malfunctions between cerebellar internal model (critically involved in predictions) and cerebral regions contribute to the deficits observed in FASD. Given the major role of the cerebellum in motor, cognitive, and affective functions, we suggest that therapies should target these malfunctions to mitigate the burden of FASD. We discuss the concept of therapies oriented towards malfunctioning cerebello-cerebral loops (TOMCCLs), emphasizing anti-inflammatory strategies and treatments aimed at modulating cerebellar myelination to restore optimal and predictive cerebello-cerebral functions.

Questioning cognitive heterogeneity and intellectual functioning in fetal alcohol spectrum disorders from the Wechsler Intelligence Scale for Children

Introduction: Fetal Alcohol Spectrum Disorders (FASD) are characterized by a variety of multiple cognitive and behavioral impairments, with intellectual, attentional, and executive impairments being the most commonly reported. In populations with multiple neurodevelopmental disorders, the Full Scale Intelligence Quotient (FSIQ) may not be a proper measure of intellectual abilities, rarely interpreted in FASD clinical practice because the heterogeneity of the cognitive profile is deemed too strong. We propose a quantitative characterization of this heterogeneity, of the strengths and weaknesses profile, and a differential analysis between global cognitive (FSIQ) and elementary reasoning abilities in a large retrospective monocentric FASD sample. Methods: Using clinical and cognitive data (Wechsler Intelligence Scale for Children) from 107 children with FASD, we characterized subject heterogeneity (variance and scatter of scaled/composite scores), searched for strengths and weaknesses, and specified intellectual functioning in terms of FSIQ and elementary reasoning (General Abilities Index, Highest Reasoning Scaled Score), in comparison with standardization norms and a Monte-Carlo-simulated sample from normalization data. Results: Performance of children with FASD was lower on all subtests, with a significant weakness in working memory and processing speed. We found no increase in the variance and scatter of the scores, but a discordance between the assessment of global cognitive functioning (28% borderline, 23% deficient) and that of global and elementary reasoning abilities (23-9% borderline, 15-14% deficient). Conclusion: Our results question the notion of WISC profile heterogeneity in FASD and point to working memory and processing speed over-impairment, with global repercussions but most often preserved elementary reasoning abilities.

Transcranial magnetic stimulation as a feasible, non-invasive, neuromodulatory intervention in fetal alcohol spectrum disorders. A very first proof of concept

INTRODUCTION

A neurobiological feature of Fetal Alcohol Spectrum Disorder (FASD) is a global decrease in neuronal connectivity, which leads to significant impairments in everyday functionality. Non-invasive repetitive transcranial magnetic stimulation (rTMS) could potentially positively influence neuronal plasticity but has not yet been studied in FASD. The present trial addresses this gap, making it the first-ever study of rTMS in FASD.

MATERIALS AND METHODS

The prospective clinical trial was conducted at the LMU University Hospital Munich and enrolled eight FASD participants aged 6-16. Six sessions of 1 Hz-rTMS over the left dorsolateral prefrontal cortex were administered two times a week for three weeks consisting of 1500 pulses at 90 % of resting motor threshold in four trains of 375s. Outcome measures investigated feasibility and treatment response of rTMS on executive functions, attention/impulsivity, social-emotional regulation and quality of life (QoL) via standardized tests and the FASD parents' app.

RESULTS

Adherence and retention rate were 100 %. Adverse events (AEs) were mild and self-limiting, resulting in a per-session risk of 53.3 %, with local paraesthesia accounting for 54.2 % of the AEs. There were individual relevant but no significant group-level improvements in the investigated functional cerebral domains or participants' QoL. The FASD parents' app showed no significant change in participants' daily functioning or caregivers' QoL. Caregivers' parental stress decreased significantly.

CONCLUSION

FASD is a very complex disorder that is difficult to treat. In addition, comorbidities as atypical responses to pharmacotherapies are frequent. For this reason, non-invasive, innovative therapies for children with FASD have to be developed. For the first time, rTMS was shown to be safe, tolerable, and acceptable and thus well feasible in paediatric patients with FASD. Further clinical studies with larger samples are needed to identify effective stimulation protocols and to evaluate treatment response.

Fetal alcohol spectrum disorders prevention and clinical guidelines research-workshop report

It is estimated that up to 1 in 20 people in the United States are affected by fetal alcohol spectrum disorders (FASD), an array of cognitive, emotional, physical and social disorders caused by exposure to alcohol during prenatal development. Common diagnoses encompassed within FASD include mood and behavioral disorders, memory and central nervous system deficits, attention-deficit/hyperactivity disorder (ADHD), slow growth and low body weight. While this condition affects a broad range of individuals and families, it is of particular concern in the military community, where cultural factors including an increased prevalence of alcohol misuse pose a unique set of challenges. To shed light on these issues and provide an overview of the existing research, programs, and clinical practice guidelines surrounding FASD, the Uniformed Services University of the Health Sciences (USUHS), in conjunction with FASD United, hosted the Workshop on Fetal Alcohol Spectrum Disorders Prevention and Clinical Guidelines Research on 21 September 2022 in Washington, DC. More than 50 attendees from academia, healthcare, federal agencies, and consumer advocacy organizations gathered to share research findings, lived experiences, and strategies for improving FASD prevention, diagnosis, interventions, and support.The workshop began with a series of presentations on FASD risk factors and causes, strategies for diagnosis and interventions, and impacts and lived experiences. Individuals and families affected by FASD spoke about the ways FASD, its symptoms, and the social stigma associated with it influences their daily lives, experiences at school and work, and access to healthcare. Several speakers highlighted the work of non-profit organizations and advocacy groups in supporting families affected by FASD and other challenges faced by military families more broadly. The workshop closed with a discussion of federal agency perspectives highlighting initiatives aimed at advancing research and access to care for women and families at-risk and those currently affected by FASD.

Common developmental trajectories and clinical identification of children with fetal alcohol spectrum disorders: A synthesis of the literature

At an estimated prevalence of up to five percent in the general population, fetal alcohol spectrum disorders (FASD) are the most common neurodevelopmental disorder, at least if not more prevalent than autism (2.3%). Despite this prevalence in the general population, pediatricians and other developmental specialists have thus far failed to diagnose this disability, leaving most children and adults without the supports provided for most other disabilities. This paper will provide a review of clinically relevant literature that describes the developmental challenges of children with fetal alcohol spectrum disorders and addresses similarities to and differences of FASD from other neurodevelopmental disorders such as autism and attention deficit hyperactivity disorder. A subsequent discussion will describe how a diagnosis of an FASD can establish a basis for understanding the developmental and behavioral challenges of children with an FASD, and how specific interventions can help support child development and maximize adult independence.

Latent classes of neurodevelopmental profiles and needs in children and adolescents with prenatal alcohol exposure

BACKGROUND

Fetal alcohol spectrum disorder (FASD) resulting from prenatal alcohol exposure (PAE) is a common neurodevelopmental disorder, but substantial interindividual heterogeneity complicates timely and accurate assessment, diagnosis, and intervention. The current study aimed to identify classes of children and adolescents with PAE assessed for FASD according to their pattern of significant neurodevelopmental functioning across 10 domains using latent class analysis (LCA), and to characterize these subgroups across clinical features.

METHODS

Data from the Canadian National FASD Database, a large ongoing repository of anonymized clinical data received from diagnostic clinics across Canada, was analyzed using a retrospective cross-sectional cohort design. The sample included 1440 children and adolescents ages 6 to 17 years (M = 11.0, SD = 3.5, 41.7% female) with confirmed PAE assessed for FASD between 2016 and 2020.

RESULTS

Results revealed an optimal four-class solution. The Global needs group was characterized by high overall neurodevelopmental impairment considered severe in nature. The Regulation and Cognitive needs groups presented with moderate but substantively distinguishable patterns of significant neurodevelopmental impairment. The Attention needs group was characterized by relatively low probabilities of significant neurodevelopmental impairment. Both the Global and Regulation needs groups also presented with the highest probabilities of clinical needs, further signifying potential substantive differences in assessment and intervention needs across classes.

CONCLUSIONS

Four relatively distinct subgroups were present in a large heterogeneous sample of children and adolescents with PAE assessed for FASD in Canada. These findings may inform clinical services by guiding clinicians to identify distinct service pathways for these subgroups, potentially increasing access to a more personalized treatment approach and improving outcomes.

Initial study on quantitative electroencephalographic analysis of bioelectrical activity of the brain of children with fetal alcohol spectrum disorders (FASD) without epilepsy

Fetal alcohol spectrum disorders (FASD) are spectrum of neurodevelopmental conditions associated with prenatal alcohol exposure. The FASD manifests mostly with facial dysmorphism, prenatal and postnatal growth retardation, and selected birth defects (including central nervous system defects). Unrecognized and untreated FASD leads to severe disability in adulthood. The diagnosis of FASD is based on clinical criteria and neither biomarkers nor imaging tests can be used in order to confirm the diagnosis. The quantitative electroencephalography (QEEG) is a type of EEG analysis, which involves the use of mathematical algorithms, and which has brought new possibilities of EEG signal evaluation, among the other things-the analysis of a specific frequency band. The main objective of this study was to identify characteristic patterns in QEEG among individuals affected with FASD. This study was of a pilot prospective study character with experimental group consisting of patients with newly diagnosed FASD and of the control group consisting of children with gastroenterological issues. The EEG recordings of both groups were obtained, than analyzed using a commercial QEEG module. As a results we were able to establish the dominance of the alpha rhythm over the beta rhythm in FASD-participants compared to those from the control group, mostly in frontal and temporal regions. Second important finding is an increased theta/beta ratio among patients with FASD. These findings are consistent with the current knowledge on the pathological processes resulting from the prenatal alcohol exposure. The obtained results and conclusions were promising, however, further research is necessary (and planned) in order to validate the use of QEEG tools in FASD diagnostics.

Global intellectual ability and adaptive functioning in children with FASD with and without sentinel facial features

Background: Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder characterized by cognitive and adaptive impairment. FASF can be presented or not with sentinel facial features (SFF). The presence of such SFF have been positively correlated with cognitive impairment in children with FASD.Objectives: The current study explores difference in global intellectual functioning and how cognition affects adaptive behavior in children with and without SFF.Methods: A total of 88 children and adolescents (55 males, 33 females) with confirmed FASD diagnosis were included in the study, of which 16 had sentinel facial features. Childrens' neuropsychological functioning was assessed using the Wechsler Intelligence Scale for Children (WISC-V) and The Behavioral Assessment of the Dysexecutive Syndromes for Children (BADS-C). Adaptive behavior was explored through the Adaptive Behavior Assessment System (ABAS-3).Results: Children with SFF performed more poorly in tasks assessing processing speed (t = 2.495, t = .020) and executive functioning (t = 4.147, t = .001). Those children also had lower IQ scores than children without SFF (t = 2.658, t = .016). BADS-C overall scaled score was related to three of the four domains of the ABAS scale (conceptual, social, and practical) but only in the group of FASD children without SFF (B = 0.547, t = .020; B = 0.544,t = .049; B = 0.431,t = .040, respectively).Conclusions: The present study founds poorer cognitive outcomes in children who have FASD with sentinel facial features. In children without SFF, stronger executive functioning is also related to significantly stronger reported conceptual, social, and practical adaptive behaviors. Better understanding of cognitive and adaptive functioning in children with FASD may help in the design of tailored evidenced-based interventions.

How Alcohol Damages Brain Development in Children

The world over, people drink in order to socialize, celebrate, and relax, despite the negative health effects of alcohol. Three periods of dynamic brain changes are evidenced to be particularly sensitive to the harmful effects of alcohol: gestation (from conception to birth), later adolescence (15-19 years), and older adulthood (over 65 years). This article is concentrated only on the negative effects of alcohol in children who have been exposed to alcohol before birth, known as foetal alcohol syndrome (FAS). This is a review based on published data in PubMed over the last two decades and is an analysis of more than 150 published papers. Alcohol use during pregnancy can cause miscarriage, stillbirth, and a range of lifelong physical, behavioural, and intellectual disabilities. The effects of ethanol are expressed on a set of molecules involved in neuroinflammation, myelination, neurotransmission, and neuron function. Modern neuroimaging techniques are able to specify some fine structural changes in the affected areas of the brain: volume reductions in the frontal lobe, including the middle frontal gyri in the prefrontal cortex, hippocampal structure, interhemispheric connectivity, abnormalities in glial cells, white matter deficits etc. Corpus callosum myelination is affected, resulting in a lack of the inter-hemispheric connectivity. This is known to facilitate autism, stroke, schizophrenia, as well as dementia, disrupts cognitive performance, and may lead to neurobehavioral deficits. It was pointed out that many symptoms and neuroimaging characteristics are similar in ADHD and FAS, thus the anamnesis for prenatal alcohol and nicotine exposure must be taken very seriously in order to better understand and interpret clinical symptoms.

Fetal alcohol spectrum disorders and access to regional center services in San Diego County

BACKGROUND

Fetal alcohol spectrum disorders (FASD) are developmental disabilities that are estimated to occur in 2-5% of elementary school children and that negatively impact a child's ability to function without support. Timely diagnosis-informed interventions are crucial to optimizing the developmental trajectory of children with FASD. The true prevalence of FASD among children receiving services for developmental disabilities is unknown.

METHODS

An FASD prevalence study was carried out between 2011 and 2014 among a sample of 5- to 7-year-old children who were receiving services provided by the California State Regional Center for Developmental Disabilities in San Diego County. Children whose parent or caregiver consented were evaluated using the Collaboration on Fetal Alcohol Spectrum Disorders Prevalence study assessment protocol and classification criteria.

RESULTS

Among 216 eligible caregiver-child dyads, 44 completed assessments that were sufficient to obtain a classification for FASD, including fetal alcohol syndrome (FAS), partial FAS, alcohol-related neurodevelopmental disorder, or no fetal alcohol spectrum disorder. Fifteen children were classified as meeting the criteria for an FASD. A minimum FASD prevalence rate of 69.4 per 1000 (6.9%) among all eligible children was estimated. None of the children classified as FASD were receiving services because of an FASD diagnosis, and none had previously been diagnosed with FASD. Autism was the most common qualifying diagnosis for which children classified as FASD were receiving services.

CONCLUSIONS

The 6.9% prevalence estimate among Regional Center clients was higher than the prevalence estimate of 2.3% in the same community among 5- to 7-year-old children in the general population, though the estimate was based on only 20% of eligible dyads. All children in the sample were receiving Regional Center services for another diagnosis. Barriers to eligibility for services for children with FASD may lead to less than optimum care for these children. Study findings support the facilitation of access to developmental services for children with FASD.

Nutritionists' Practices and Knowledge about the Risks of Alcohol Consumption during Pregnancy: An Israeli Survey

Fetal alcohol spectrum disorders (FASDs) are lifelong disabilities and the leading preventable cause of developmental disabilities. Antenatal care providers may influence pregnant women’s dietary practices and their awareness of the risks of alcohol consumption during pregnancy. This study aimed to assess nutritionists’ self-reported knowledge about the risks of drinking alcohol during pregnancy, professional practices in this respect, and self-perceived competence to assess and guide women about alcohol consumption during pregnancy in Israel. A sample of 526 professional nutritionists completed an anonymous online questionnaire. Results showed significant differences between the nutritionists’ knowledge and professional practices scores. About 349 (66.3%) of the sample agreed (to any degree) that they did not have enough knowledge to guide pregnant women regarding drinking alcohol. The number of years of experience, combined with self-perceived competence and the mean knowledge score, explained 18% of the variance in professional practices. Nutritionists and other health professionals may have a crucial role in preventing FASD and should prioritize appropriate screening for prenatal alcohol use. Eliminating alcohol consumption at any point in pregnancy would reduce the risk for FASDs.