Mental health issues in fetal alcohol spectrum disorder

Fetal alcohol syndrome and population level health care usage in British Columbia, Canada

BACKGROUND

The literature indicates that youth with Fetal Alcohol Syndrome (FAS) may experience high rates of both physical and mental health issues compared to youth without FAS. However, there is little population level health data available for youth with FAS, particularly for youth transitioning from pediatric to adult healthcare services.

OBJECTIVE

The objective of this study was to compare health care usage of youth with Fetal Alcohol Syndrome to youth without any intellectual/developmental disabilities (IDD).

METHODS

This study used a retrospective cohort design and population-level administrative health data to examine five aspects of health care usage by youth with FAS and compare them to youth with no intellectual/developmental disability. The variables were medically required dental care, visits to emergency departments and visits for mental health issues. In addition, the study stratified data by age groups and examined the difference between youth aged 15-19 and youth aged 20-24.

RESULTS

Youth with FAS had higher adjusted odds of medically required dental care, visits to the emergency department and visits for anxiety/depression, psychotic illnesses and substance use disorders compared to youth with no IDD. The odds of a medically required dental visit, emergency department visit and visit for psychotic illness or substance use disorder were also higher for youth aged 20-24 years compared to youth aged 15-19 years.

CONCLUSIONS

These findings indicate that youth with FAS require urgent attention for each of the medically-related variables included in this study. The need for attention to their health care needs may increase as these youth transition from pediatric to adult health care services.

Assessing and supporting children and young people with probable or diagnosed fetal alcohol spectrum disorder: The experience of clinicians working within child and adolescent mental health services

BACKGROUND

Fetal alcohol spectrum disorders (FASD) are a group of conditions that occur due to prenatal alcohol exposure (PAE), which impacts physical, behavioral, and cognitive ability. The literature demonstrates that healthcare professionals lack knowledge and understanding of FASD, resulting in children and young people (CYP) often getting misdiagnosed with neurodevelopmental disorders or the diagnosis of FASD missed, increasing their risk of experiencing secondary mental health difficulties. Child and Adolescent Mental Health Services (CAMHS) are the commissioned service to diagnose neurodevelopmental conditions and support CYP with mental health difficulties, therefore, it is likely that CYP with probable or diagnosed FASD will present in CAMHS. There is currently no research exploring the awareness and understanding of FASD within these services.

METHODS

Constructivist grounded theory was utilized to explore the barriers and facilitators clinicians experience when assessing and supporting CYP with probable or diagnosed FASD within CAMHS. A sample of 12 CAMHS clinicians from an NHS Mental Health Trust situated in the Northeast of England were interviewed. Interviews were transcribed and analyzed and grounded theory techniques were utilized to generate an end model.

RESULTS

The end model was developed on a box analogy with four categories. 'Unable to Open the Box' captures barriers CAMHS clinicians experience when exploring FASD, 'Things that Help Open the Box' captures facilitators CAMHS clinicians experience when exploring FASD, 'Asking Others About the Box' captures systemic influences CAMHS clinicians may experience when exploring FASD, and 'Making the Box Easier to Open in Future' captures how we can support CAMHS clinicians moving forward to explore FASD.

CONCLUSIONS

This model provides new insights into the barriers and facilitators CAMHS clinicians experience when assessing and supporting CYP with probable or diagnosed FASD, highlighting key clinical implications. Recommendations for future research are outlined to expand the knowledge base for this area.

The Effects of Moderate Prenatal Alcohol Exposure on Performance in Hippocampal-Sensitive Spatial Memory and Anxiety Tasks by Adult Male and Female Rat Offspring

Moderate prenatal alcohol exposure (mPAE) results in structural alterations to the hippocampus. Previous studies have reported impairments in hippocampal-sensitive tasks, but have not compared performance between male and female animals. In the present study, performance in hippocampal-sensitive spatial memory and anxiety behavior tests were compared across adult male and female saccharin (SACC) control mPAE Long-Evans rat offspring. Two tests of spatial memory were conducted that were aimed at assessing memory for recently acquired spatial information: A delayed spatial alternation task using an M-shaped maze and a delayed match-to-place task in the Morris water task. In both tasks, rats in SACC and mPAE groups showed similar learning and retention of a spatial location even after a 2-hour interval between encoding and retention. A separate group of adult male and female SACC and mPAE rat offspring were tested for anxiety-like behaviors in the elevated plus-maze paradigm. In this test, both male and female mPAE rats exhibited a significantly greater amount of time and a greater number of head dips in the open arms, while locomotion and open arm entries did not differ between groups. The results suggest that mPAE produces a reduction in anxiety-like behaviors in both male and female rats in the elevated plus-maze.

Prevalence of co-occurring diagnoses in people exposed to alcohol prenatally: Findings from a meta-analysis

BACKGROUND

Individuals with prenatal alcohol exposure (PAE) commonly experience co-occurring diagnoses, which are often overlooked and misdiagnosed and have detrimental impacts on accessing appropriate services. The prevalence of these co-occurring diagnoses varies widely in the existing literature and has not been examined in PAE without an FASD diagnosis.

METHOD

A search was conducted in five databases and the reference sections of three review papers, finding a total of 2180 studies. 57 studies were included in the final analysis with a cumulative sample size of 29,644. Bayesian modeling was used to determine aggregate prevalence rates of co-occurring disorders and analyze potential moderators.

RESULTS

82 % of people with PAE had a co-occurring diagnosis. All disorders had a higher prevalence in individuals with PAE than the general population with attention deficit hyperactivity disorder, learning disorder, and intellectual disability (ID) being the most prevalent. Age, diagnostic status, and sex moderated the prevalence of multiple disorders.

LIMITATIONS

While prevalence of disorders is crucial information, it does not provide a direct representation of daily functioning and available supports. Results should be interpreted in collaboration with more individualized research to provide the most comprehensive representation of the experience of individuals with PAE.

CONCLUSIONS

Co-occurring diagnoses are extremely prevalent in people with PAE, with older individuals, females, and those diagnosed with FASD being most at risk for having a co-occurring disorder. These findings provide a more rigorous examination of the challenges faced by individuals with PAE than has existed in the literature, providing clinicians with information to ensure early identification and effective treatment of concerns to prevent lifelong challenges.

Machine learning algorithms to the early diagnosis of fetal alcohol spectrum disorders

Introduction

Fetal alcohol spectrum disorders include a variety of physical and neurocognitive disorders caused by prenatal alcohol exposure. Although their overall prevalence is around 0.77%, FASD remains underdiagnosed and little known, partly due to the complexity of their diagnosis, which shares some symptoms with other pathologies such as autism spectrum, depression or hyperactivity disorders.

Methods

This study included 73 control and 158 patients diagnosed with FASD. Variables selected were based on IOM classification from 2016, including sociodemographic, clinical, and psychological characteristics. Statistical analysis included Kruskal-Wallis test for quantitative factors, Chi-square test for qualitative variables, and Machine Learning (ML) algorithms for predictions.

Results

This study explores the application ML in diagnosing FASD and its subtypes: Fetal Alcohol Syndrome (FAS), partial FAS (pFAS), and Alcohol-Related Neurodevelopmental Disorder (ARND). ML constructed a profile for FASD based on socio-demographic, clinical, and psychological data from children with FASD compared to a control group. Random Forest (RF) model was the most efficient for predicting FASD, achieving the highest metrics in accuracy (0.92), precision (0.96), sensitivity (0.92), F1 Score (0.94), specificity (0.92), and AUC (0.92). For FAS, XGBoost model obtained the highest accuracy (0.94), precision (0.91), sensitivity (0.91), F1 Score (0.91), specificity (0.96), and AUC (0.93). In the case of pFAS, RF model showed its effectiveness, with high levels of accuracy (0.90), precision (0.86), sensitivity (0.96), F1 Score (0.91), specificity (0.83), and AUC (0.90). For ARND, RF model obtained the best levels of accuracy (0.87), precision (0.76), sensitivity (0.93), F1 Score (0.84), specificity (0.83), and AUC (0.88). Our study identified key variables for efficient FASD screening, including traditional clinical characteristics like maternal alcohol consumption, lip-philtrum, microcephaly, height and weight impairment, as well as neuropsychological variables such as the Working Memory Index (WMI), aggressive behavior, IQ, somatic complaints, and depressive problems.

Discussion

Our findings emphasize the importance of ML analyses for early diagnoses of FASD, allowing a better understanding of FASD subtypes to potentially improve clinical practice and avoid misdiagnosis.

Developmental alcohol exposure is exhausting: Sleep and the enduring consequences of alcohol exposure during development

Prenatal alcohol exposure is the leading nongenetic cause of human intellectual impairment. The long-term impacts of prenatal alcohol exposure on health and well-being are diverse, including neuropathology leading to behavioral, cognitive, and emotional impairments. Additionally negative effects also occur on the physiological level, such as the endocrine, cardiovascular, and immune systems. Among these diverse impacts is sleep disruption. In this review, we describe how prenatal alcohol exposure affects sleep, and potential mechanisms of those effects. Furthermore, we outline the evidence that sleep disruption across the lifespan may be a mediator of some cognitive and behavioral impacts of developmental alcohol exposure, and thus may represent a promising target for treatment.

Limbic brain subregions associated with mental health symptoms in youth with and without prenatal alcohol exposure

BACKGROUND

Prenatal alcohol exposure (PAE) can result in reduced brain volume and an increased risk of mental health challenges. Limbic brain structures such as the hippocampus, thalamus, and amygdala often exhibit smaller volumes in youth with PAE, and similar volume reductions are observed in unexposed youth with symptoms of depression, bipolar disorder, anxiety, and schizophrenia. However, the role of volume reductions in these brain regions in mental health challenges remains unclear for individuals with PAE.

METHODS

Thirty-four youth with PAE and 72 unexposed youth aged 7-16 years completed a T1-weighted magnetic resonance imaging scan. FreeSurfer was used to process and extract volumes for hippocampal subfields, thalamic subnuclei, and amygdalar subnuclei. Depression and anxiety symptoms were measured using the Behavioral Assessment System for Children (BASC-2/3-PRS), the Children's Depression Inventory, and the Multidimensional Anxiety Scale for Children. We tested whether limbic subregion volumes differed between youth with and those without PAE and whether volumes were associated with depression and/or anxiety symptoms, controlling for age and gender.

RESULTS

Multiple hippocampal and thalamic subregions, but not amygdalar subnuclei, were smaller in individuals with PAE. Multiple group-brain interactions were observed for depression symptoms and subregion volumes. Negative associations between anxiety and limbic subregions were observed across groups.

CONCLUSIONS

These findings show extensive volume reductions in the hippocampus and thalamus in youth with PAE. PAE also appears to disrupt the association between depression symptoms and limbic subregions in youth, which may have implications for interventions in these individuals. Anxiety symptoms in youth with and without PAE are similarly associated with limbic volumes.

Impact of the COVID-19 pandemic on adults with Fetal Alcohol Spectrum Disorder: linking immune function to mental health status

Prenatal alcohol exposure (PAE) is known to cause a variety of cognitive, behavioral, and neurological changes. Importantly, mental health problems are also overrepresented in individuals with Fetal Alcohol Spectrum Disorder (FASD), the group of neurodevelopmental conditions that can occur following PAE. Approximately 90% of individuals with FASD report experiencing mental health problems over their lifespan, compared to approximately 30% in the overall population. Individuals with FASD also display impairments in coping skills and increased vulnerability to stress. Here, we investigated whether the COVID-19 pandemic would have a differential impact on mental health and inflammation-to-mood associations in adults with FASD, compared to unexposed controls (no PAE). We capitalized on our pre-pandemic study examining health and immune function and invited past-participants to enroll in the current study. Participants completed mental health assessments and COVID-related questionnaires by phone. In addition, blood samples collected at baseline (pre-pandemic) were used to probe for inflammation-to-mood associations. Overall, our results indicate that lower SES was predictive of higher coronavirus anxiety scores, with no differences between adults with FASD and controls. In addition, while there were no differences in depression or anxiety measures at baseline (pre-pandemic) or during the pandemic, examination of inflammation-to-mood associations identified differential relationships in adults with FASD compared to unexposed controls. Specifically, there was a positive association between baseline neutrophil counts and both baseline and pandemic mental health scores in unexposed controls only. In addition, for unexposed controls there was also a negative association between baseline interferon-ɣ (IFN-ɣ) and pandemic mental health scores. By contrast, only adults with FASD showed positive associations between baseline interleukin-12p70 (IL-12p70), IL-8, soluble intercellular adhesion molecule-1 (sICAM-1), and soluble vascular cell adhesion molecule-1 (sVCAM-1) and pandemic mental health scores. Taken together, to our knowledge, this study is the first to examine the impact of the pandemic in adults with FASD. And while it may be too soon to predict the long-term effects of the pandemic on mental health, our data suggest that it will be important that future work also takes into account how immune function may be modulating mental health outcomes in this population.

Postnatal ethanol exposure impairs social behavior and operant extinction in the adult female mouse offspring

Fetal Alcohol Spectrum Disorder (FASD) comprises a group of neurodevelopmental deficits caused by alcohol exposure during pregnancy. Clinical studies suggest that while the male progeny experiences serious neurodevelopmental defects, female patients have more severe cognitive, social, and affective symptoms. Other than sex, dose, frequency, and timing of exposure determine the neurobehavioral outcomes in young and adult progeny. In this regard, human studies indicate that some individuals relapse during late-term gestational periods. In mice, this interval corresponds to the first 10 days after birth (postnatal, P0-P10). In our model of postnatal ethanol exposure (PEE^P0-P10), we tested whether adult female and male offspring show deficits in sociability, anxiety-like, reward consumption, and action-outcome associations. We report that female PEE^P0-P10 offspring have mild social impairments and altered extinction of operant responding in the absence of anxiety-like traits and reward consumption defects. None of these deficits were detected in the male PEE^P0-P10 offspring. Our data provide novel information on sex-specific neurobehavioral outcomes of postnatal ethanol exposure in female adult offspring.

Alcohol and lactation: Developmental deficits in a mouse model

It is well documented that prenatal ethanol exposure via maternal consumption of alcohol during pregnancy alters brain and behavioral development in offspring. Thus, the Centers for Disease Control (CDC) advises against maternal alcohol consumption during pregnancy. However, little emphasis has been placed on educating new parents about alcohol consumption while breastfeeding. This is partly due to a paucity of research on lactational ethanol exposure (LEE) effects in children; although, it has been shown that infants exposed to ethanol via breast milk frequently present with reduced body mass, low verbal IQ scores, and altered sleeping patterns. As approximately 36% of breastfeeding mothers in the US consume alcohol, continued research in this area is critical. Our study employed a novel murine LEE model, where offspring were exposed to ethanol via nursing from postnatal day (P) 6 through P20, a period correlated with infancy in humans. Compared to controls, LEE mice had reduced body weights and neocortical lengths at P20 and P30. Brain weights were also reduced in both ages in males, and at P20 for females, however, female brain weights recovered to control levels by P30. We investigated neocortical features and found that frontal cortex thickness was reduced in LEE males compared to controls. Analyses of dendritic spines in the prelimbic subdivision of medial prefrontal cortex revealed a trend of reduced densities in LEE mice. Results of behavioral tests suggest that LEE mice engage in higher risk-taking behavior, show abnormal stress regulation, and exhibit increased hyperactivity. In summary, our data describe potential adverse brain and behavioral developmental outcomes due to LEE. Thus, women should be advised to refrain from consuming alcohol during breastfeeding until additional research can better guide recommendations of safe maternal practices in early infancy.

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.

Adverse childhood experiences and neurodevelopmental disorders among youth with and without prenatal substance exposure: A longitudinal matched register-based cohort study

Background: Previous research has shown an association between adverse childhood experiences (ACEs) and secondary mental health problems in youth with prenatal substance exposure (PSE), but the association between ACEs and neurodevelopmental disorders is less clear. Methods: This longitudinal register-based cohort study investigated relationships between health at birth, ACEs (out-of-home care (OHC) and maternal adversities), and neurodevelopmental disorders among youth with PSE (alcohol/drugs, n = 615) and matched unexposed controls ( n = 1787). Hospital medical records and register data were merged and analysed using Cox regression models. Results: Conduct and emotional disorders (International Statistical Classification of Diseases and Related Health Problems ICD-10, F90–F94) were more common among the exposed than the controls but only when the exposed and controls with no OHC were compared. The difference appeared in hyperkinetic disorders (ADHD, F90), mixed disorders of conduct and emotions (F92) and emotional disorders with onset specific to childhood (F93). Among the exposed and controls with OHC, over 40% had received an F90–F94 diagnosis. Regarding specific developmental disorders (F80–F83, e.g., impairments in speech and language and scholastic skills) the moderate difference between the exposed and controls attenuated after adjustment for OHC. Again, the rates were highest among the exposed with OHC and the controls with OHC. OHC and maternal risks were interrelated and, together with male sex and low birth weight, were associated with neurodevelopmental disorders both among the exposed and controls and decreased the difference between them. Conclusions: A strong association between ACEs and neurodevelopmental disorders was found. Brain research is needed to examine whether ACEs worsen neurodevelopmental outcomes caused by PSE.

Fetal alcohol syndrome and the risk of neurodevelopmental disorders: A longitudinal cohort study

BACKGROUND

This hypothesis-testing study evaluated the relationship between fetal alcohol syndrome (FAS) and neurodevelopmental disorder (ND) diagnoses within the Independent Healthcare Research Database (IHRD).

METHODS

De-identified eligibility and claim healthcare records prospectively generated from the 1990-2012 Florida Medicaid system were analyzed using SAS software. There were 89,766 children continuously eligible with ≥10 outpatient office visits during the 120 month period following birth in the cohort examined. A total of 321 children were diagnosed with FAS. Autism spectrum disorder (ASD) (n = 922), tics (n = 551), attention deficit disorder/attention deficit-hyperactivity disorder (ADD/ADHD) (n = 20,260), mental retardation (MR) (n = 915), and specific delays in development (SDD) (n = 24,630) incidence rates were examined using frequency risk ratio (RR) and logistic regression models.

RESULTS

The incidence rate of tics (RR = 5.68), ADD/ADHD (RR = 2.30), MR (RR = 7.83), SDD (RR = 2.88), and ASD (RR = 6.74) were significantly increased among FAS diagnosed children as compared to undiagnosed children. Adjusted (for gender, race, residency, and date of birth) odds ratios (ORs) were significantly increased for tics (OR = 4.87), ADD/ADHD (OR = 3.40), MR (OR = 7.91), SDD (OR = 9.56), and ASD (OR = 6.87) when comparing the FAS diagnosed children to undiagnosed children.

CONCLUSION

Tens of thousands of American children with lifetime costs in the billions of US dollars were estimated to be impacted by FAS-associated NDs. These impacts are particularly tragic because FAS is dependent upon lifestyle.

Brain volume and magnetic susceptibility differences in children and adolescents with prenatal alcohol exposure

BACKGROUND

Prenatal alcohol exposure (PAE) can negatively affect brain development thereby increasing the risk of cognitive deficits, behavioral challenges, and mental health problems. Brain iron is important for a number of physiological processes for healthy brain development. Animal studies show that PAE reduced brain iron; however, this has not been investigated in human children with PAE.

METHODS

We studied 20 children and adolescents with PAE and 44 unexposed children and adolescents aged 7.5 to 15 years. All children underwent quantitative susceptibility mapping and T1-weighted magnetic resonance imaging scans. Susceptibility and volume measurements of the caudate, putamen, pallidum, thalamus, amygdala, hippocampus, and nucleus accumbens were extracted using FreeSurfer. ANCOVAs were used to compare volume and susceptibility between groups for each region of interest, controlling for age and gender. For structures where susceptibility differed by group, we also tested for an association between intelligence quotient (IQ) and susceptibility.

RESULTS

There were no significant group differences in susceptibility after multiple comparison correction, though the PAE group had higher susceptibility in the thalamus compared to unexposed participants before correction (p = 0.032, q = 0.230). There was no association between IQ and thalamus susceptibility. The PAE group had significantly lower volume in the bilateral caudate, bilateral pallidum, and left putamen.

CONCLUSIONS

These findings suggest susceptibility may be altered in children and adolescents with PAE, though more research is needed. Volume reductions are consistent with previous literature and likely underlie cognitive and behavioral deficits associated with PAE.

Identification of Seminal Physical Features of Prenatal Alcohol Exposure by Child Psychologists

Introduction

Prenatal alcohol exposure (PAE) impacts an estimated 5% or more children born in the USA and is associated with life-long neuropsychological deficits. Early identification is essential but access to diagnostic evaluation is limited. This study reports on the effectiveness of training child psychologists to identify and measure the salient physical features of PAE.

Methods

Children, 8–13 years, were divided into two groups: (1) children meeting criteria for PAE (n = 46) and (2) typically developing controls without PAE (TD; n = 36). Child psychologists were trained to reliability measure height, weight, occipital frontal circumference (OFC), and the characteristic facial features of FASD independent of knowledge of PAE history.

Results

Groups differed significantly on meeting the diagnostic criteria proposed by Hoyme et al. (Pediatrics, 138:e20154256, 2016) on height, OFC, upper vermillion border, philtrum, and palpebral fissure length. They did not differ on weight. All children in the alcohol exposed group could be classified as meeting criteria for an FASD whereas none in the unexposed group met criteria.

Discussion

This study demonstrated that child psychologists, blind to PAE history, could be reliably trained to assess the physical features of children with PAE. Because early diagnosis and intervention is of paramount importance, we propose that inclusive diagnostic criteria for FASD and the use of psychologists and other allied health professionals, trained to screen for the diagnosis, should be expanded in clinical practice.

Brain Iron and Mental Health Symptoms in Youth with and without Prenatal Alcohol Exposure

Prenatal alcohol exposure (PAE) negatively affects brain development and increases the risk of poor mental health. We investigated if brain volumes or magnetic susceptibility, an indirect measure of brain iron, were associated with internalizing or externalizing symptoms in youth with and without PAE. T1-weighted and quantitative susceptibility mapping (QSM) MRI scans were collected for 19 PAE and 40 unexposed participants aged 7.5–15 years. Magnetic susceptibility and volume of basal ganglia and limbic structures were extracted using FreeSurfer. Internalizing and Externalizing Problems were assessed using the Behavioural Assessment System for Children (BASC-2-PRS). Susceptibility in the nucleus accumbens was negatively associated with Internalizing Problems, while amygdala susceptibility was positively associated with Internalizing Problems across groups. PAE moderated the relationship between thalamus susceptibility and internalizing symptoms as well as the relationship between putamen susceptibility and externalizing symptoms. Brain volume was not related to internalizing or externalizing symptoms. These findings highlight that brain iron is related to internalizing and externalizing symptoms differently in some brain regions for youth with and without PAE. Atypical iron levels (high or low) may indicate mental health issues across individuals, and iron in the thalamus may be particularly important for behavior in individuals with PAE.

Suicidality and Associated Factors Among Individuals Assessed for Fetal Alcohol Spectrum Disorder Across the Lifespan in Canada

OBJECTIVE

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of complex neurodevelopmental, psychological, and socioenvironmental vulnerabilities. There is growing evidence that suicidal ideation, attempts, and death by suicide are significant concerns within this population. In this study, we (1) determined the rate of suicidal ideation/attempts in a large group of individuals with prenatal alcohol exposure (PAE) who were assessed for FASD in Canada and (2) investigated the associations between suicidal ideation/attempts and select demographic and biopsychosocial factors in this group.

METHOD

A secondary analysis of data from Canada's National FASD Database, a national repository of clinical information gathered through FASD assessment and diagnostic clinics across the country, was conducted. Descriptive analyses, chi-square/Fisher's exact tests, and binary logistic regression were used to examine demographic and biopsychosocial variables and their associations with suicidality.

RESULTS

In our sample of 796 participants (M_age = 17.7 years, range = 6-59; 57.6% male) assessed for FASD, 25.9% were reported to experience suicidal ideation/attempts. Numerous demographic and biopsychosocial factors were found to be significantly associated with suicidal ideation/attempts. The strongest associations with suicidal ideation/attempts were substance use, history of trauma/abuse, and impaired affect regulation.

CONCLUSIONS

With this study, we contribute to the emerging evidence of elevated risk of suicidality among individuals with PAE/FASD and improve our understanding of factors that may exacerbate this risk. Findings have relevance for improving screening, prevention, and proactive treatment approaches for individuals with PAE and FASD, their families, and wider support systems.

Evaluation of Brain Alterations and Behavior in Children With Low Levels of Prenatal Alcohol Exposure

IMPORTANCE

High levels of prenatal alcohol exposure (PAE) are associated with widespread behavioral and cognitive problems as well as structural alterations of the brain. However, it remains unclear whether low levels of PAE affect brain structure and function, and prior studies generally have not had well-matched control populations (eg, for sociodemographic variables).

OBJECTIVE

To compare structural brain alterations and behavioral changes in children with lower levels of PAE with those of well-matched controls with no PAE.

DESIGN, SETTING, AND PARTICIPANTS

In this cross-sectional study, participants were selected from the Adolescent Brain Cognitive Development study. Children with PAE were compared with controls matched for age, sex, family income, maternal educational level, and caregiver status. Neither group had prenatal exposure to other adverse substances (eg, tobacco, cannabis, illicit drugs). Data were collected from September 1, 2016, to November 15, 2018, and analyzed from October 14, 2020, to February 14, 2022.

EXPOSURES

Diffusion tensor imaging, resting-state functional magnetic resonance imaging (MRI), and Child Behavior Checklist (CBCL) administration.

MAIN OUTCOMES AND MEASURES

Fractional anisotropy (FA); mean, axial, and radial diffusivity from diffusion tensor imaging; brain functional signal variations from functional MRI; and several scores, including internalizing and externalizing behavior problems, from the CBCL. Spearman correlation coefficients between diffusion tensor imaging and functional MRI measures and the CBCL scores were calculated.

RESULTS

A total of 270 children were included in the analysis (mean [SD] age, 9.86 [0.46] years; 141 female [52.2%] and 129 male [47.8%]), consisting of 135 children with PAE (mean [SD] age, 9.85 [0.65] years; 73 female [54.1%] and 62 male [45.9%]) (mean exposure, 1 drink/wk) and 135 unexposed controls (mean [SD] age, 9.87 [0.04] years; 68 female [50.4%] and 67 male [49.6%]). Children with PAE had lower mean (SD) FA in white matter of the left postcentral (0.35 [0.05] vs 0.36 [0.04]; mean difference, -0.02 [95% CI, -0.03 to -0.01]), left inferior parietal (0.31 [0.07] vs 0.33 [0.06]; mean difference, -0.03 [95% CI, -0.04 to -0.01]), left planum temporale (0.26 [0.04] vs 0.28 [0.03]; mean difference, -0.02 [95% CI, -0.03 to -0.01]), left inferior occipital (0.30 [0.07] vs 0.32 [0.05]; mean difference, -0.03 [95% CI, -0.04 to -0.01]), and right middle occipital (0.30 [0.04] vs 0.31 [0.04]; mean difference, -0.01 [95% CI, -0.02 to -0.01]) areas compared with controls, and higher FA in the gray matter of the putamen (0.22 [0.03] vs 0.21 [0.02]; mean difference, 0.01 [95% CI, 0.005-0.02]). Externalizing behavior scores were higher (worse) in children with PAE than in controls (mean [SD], 45.2 [9.0] vs 42.8 [9.0]; mean difference, 2.39 [95% CI, 0.30-4.47]). Several of these regions had significant group-behavior interactions, such that the higher FA was associated with less problematic behaviors in controls (ρ range, -0.24 to -0.08) but no associations were present in the PAE group (ρ range, 0.02-0.16).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, children with low levels of PAE had lower FA and more behavioral problems compared with a well-matched control group. These results suggest that PAE, even in small amounts, has a measurable effect on brain structure in children.

Fetal alcohol spectrum disorders screening tools: A systematic review

BACKGROUND

Screening facilitates the early identification of fetal alcohol spectrum disorder (FASD) and prevalence estimation of FASD for timely prevention, diagnostic, and management planning. However, little is known about FASD screening tools.

AIMS

The aims of this systematic review are to identify FASD screening tools and examine their performance characteristics.

METHODS

Four electronic databases were searched for eligible studies that examined individuals with FASD or prenatal alcohol exposure and reported the sensitivity and specificity of FASD screening tools. The quality of the studies was assessed using the Quality Assessment of Diagnostic Studies-2 tool.

RESULTS

Sixteen studies were identified, comprising five fetal alcohol syndrome (FAS) and seven FASD screening tools. They varied in screening approach and performance characteristics and were linked to four different diagnostic criteria. FAS screening tools performed well in the identification of individuals at risk of FAS while the performance of FASD screening tools varied in the identification of individuals at risk of FASD.

CONCLUSION AND IMPLICATIONS

Results highlight the vast differences in the screening approaches performance characteristics, and diagnostic criteria linked to FASD screening tools. More research is needed to identify biomarkers unique to FASD to guide the development of accurate FASD screening tools.

Fetal alcohol spectrum disorders (FASD) and youth firesetting: A call on criminal justice, emergency responder, and fire prevention specialists to become informed

Central nervous system damage resulting from prenatal exposure to alcohol, often referred to as fetal alcohol spectrum disorders (FASD), commonly manifests as lacking cognitive functioning, problem solving, impulsivity, memory, executive functioning, and social skill deficits. For individuals with FASD, these brain-based deficits translate into impulsive behaviors and poorly thought-out decision-making, coupled with an inability to anticipate and recognize the sometimes very severe consequences of their behaviors. Not unexpectedly, individuals with FASD frequently find themselves disproportionately involved in the criminal justice system and mental health services. For some individuals with FASD, these behaviors can also include firesetting. First responders, like other health and legal professionals, are often unable to recognize the behavioral indicators of FASD, primarily due to a lack of training. As a result, firesetting behaviors are often attributed to deliberate, willful acts of delinquency, a desire to damage property, thrill seeking, or as attempts for personal gain, rather than being viewed as maladaptive attempts to solve problems by individuals who lack the tools to do this in more appropriate ways. These same skill deficits also present when individuals with FASD are interviewed about their involvement in such behaviors, sometimes resulting in confabulation, suggestibility, and false confessions. Further education and training in FASD are vital for first responders if they are to better support individuals with FASD and minimize their chances of becoming involved in firesetting behaviors. Furthermore, this training and education will help ensure that first responders can intervene in more appropriately when crisis situations do occur. This article will outline key behavioral symptoms of FASD as well as provide first responders with suggestions as to how to best support individuals when FASD is suspected. The brief quote that follows highlights some of the key challenges facing individuals with FASD and how poor decision-making and impulsiveness can result in severe consequences for the individual and those around them.

Rates and implications of fetal alcohol spectrum disorder among released offenders with mental disorder in Canada

Fetal alcohol spectrum disorder (FASD) is prevalent among individuals involved in the justice system. However, many of the characteristics of justice-involved individuals with FASD remain unknown. We assessed patients in a forensic mental health hospital (n = 26) for FASD before their release. The two objectives were to establish the prevalence of FASD in this unique environment and to describe the mental health and neurocognitive characteristics of individuals with FASD compared to patients with complex needs and those without FASD. The prevalence of FASD was 46%. We found the FASD group to have more than six impaired brain domains, greater than the other groups, and a higher prevalence of ADHD. Given the high prevalence of FASD reported in this study, along with the complexities and adversities associated with FASD and criminal justice involvement, this is a population that requires screening, assessment, and intervention.

Understanding the needs of justice-involved adults with fetal alcohol spectrum disorder in an Indigenous community

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of neurodevelopmental challenges, often compounded by social and environmental adversity. One of the most concerning outcomes that can be associated with FASD is involvement in the justice system, where individuals with FASD are vastly over-represented. Individuals with FASD who are both justice-involved and Indigenous experience added layers of marginalization. In this community-based study, we explored the needs of 16 adults who participated in an FASD-informed restorative justice program in an Indigenous community in Alberta, Canada. Clinical record reviews and client interviews were used to gather information. Diverse needs were identified, including pervasive neurodevelopmental difficulties, notable physical and mental health challenges, complex experiences of psychosocial trauma, and varied criminogenic needs. This study increases our understanding of the unique and complex biopsychosocial and criminogenic needs of Indigenous justice-involved adults with FASD. Such an understanding is a first step in developing tailored interventions for individuals with FASD and has important practice and policy implications for supporting positive outcomes. For Indigenous individuals with FASD, intervention efforts should be integrated within the community context to promote collective healing.

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.

Responding to the Unique Complexities of Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is a multifaceted disability, characterized not only by brain- and body-based challenges, but also high rates of environmental adversity, lifelong difficulties with daily living, and distinct sociocultural considerations. FASD is one of the most common neurodevelopmental disabilities in the Western world and associated with significant social and economic costs. It is important to understand the complexities of FASD and the ways in which FASD requires unique consideration in research, practice, and policy. In this article, we discuss our perspectives on factors that distinguish FASD from other disabilities in terms of complexity, co-occurrence, and magnitude. We provide an overview of select literature related to FASD as a socially rooted disability with intergenerational impacts and multiple layers of stigma. These social issues are intertwined with notable experiences of adversity across the lifespan and high rates of co-occurring health concerns for individuals with FASD, all of which present unique challenges for individuals, caregivers, families, service providers, and policy makers. Understanding these factors is the first step in developing and implementing specialized initiatives in support of positive outcomes for individuals with FASD and their families. Future directions are proposed for advancing research, practice, and policy, and responding to the unique complexities of FASD.

Intersection of Epigenetic and Immune Alterations: Implications for Fetal Alcohol Spectrum Disorder and Mental Health

Prenatal alcohol exposure can impact virtually all body systems, resulting in a host of structural, neurocognitive, and behavioral abnormalities. Among the adverse impacts associated with prenatal alcohol exposure are alterations in immune function, including an increased incidence of infections and alterations in immune/neuroimmune parameters that last throughout the life-course. Epigenetic patterns are also highly sensitive to prenatal alcohol exposure, with widespread alcohol-related alterations to epigenetic profiles, including changes in DNA methylation, histone modifications, and miRNA expression. Importantly, epigenetic programs are crucial for immune system development, impacting key processes such as immune cell fate, differentiation, and activation. In addition to their role in development, epigenetic mechanisms are emerging as attractive candidates for the biological embedding of environmental factors on immune function and as mediators between early-life exposures and long-term health. Here, following an overview of the impact of prenatal alcohol exposure on immune function and epigenetic patterns, we discuss the potential role for epigenetic mechanisms in reprogramming of immune function and the consequences for health and development. We highlight a range of both clinical and animal studies to provide insights into the array of immune genes impacted by alcohol-related epigenetic reprogramming. Finally, we discuss potential consequences of alcohol-related reprogramming of immune/neuroimmune functions and their effects on the increased susceptibility to mental health disorders. Overall, the collective findings from animal models and clinical studies highlight a compelling relationship between the immune system and epigenetic pathways. These findings have important implications for our understanding of the biological mechanisms underlying the long-term and multisystem effects of prenatal alcohol exposure, laying the groundwork for possible novel interventions and therapeutic strategies to treat individuals prenatally exposed to alcohol.

Long-term protective effect of PACAP in a fetal alcohol syndrome (FAS) model

Prenatal ethanol exposure provokes teratogenic effects, due to oxidative stress and massive neuronal apoptosis in the developing brain that result in lifelong behavioral abnormalities. PACAP exerts anti-oxidative and neuroprotective activities on neuronal cells, and prevents ethanol neurotoxicity. The present study focused on the ability of PACAP to protect the brain of 30-day-old mice (P30) from prenatal alcohol exposure induced oxidative damage and toxicity. Pregnant mice were divided randomly into 4 groups, i.e. control group, ethanol group (1.5 g/kg ip daily injection), PACAP group (5 μg intrauterine daily injection) and an ethanol plus PACAP group. Offspring prenatally exposed to ethanol had decreased body weight and reduced cell survival. Moreover, production of ROS was sharply enhanced in the brain of prenatal ethanol-exposed animals, associated with an elevation in the activity of the antioxidant enzymes, and an increase of oxidative damages as shown by the accumulation of the lipid oxidation marker malondialdehyde and of protein carbonyl compounds. Intrauterine administration of PACAP during the gestational period restored the endogenous antioxidant system, prevented ROS overproduction and promoted the survival of dissociated cells from animals prenatally exposed to ethanol. Behavioral tests revealed that P30 animals exposed to ethanol during the prenatal period exhibited reduced motor activity, altered exploratory interest and increased anxiety. However, PACAP treatment significantly attenuated these behavioral impairments. This study demonstrates that PACAP exerts a potent neuroprotective effect against alcohol toxicity during brain development, and indicates that PACAP and/or PACAP analogs might be a useful tool for treatment of alcohol intoxication during pregnancy.

Connecting People with People: Diagnosing Persons with Fetal Alcohol Spectrum Disorder Using Telehealth

Fetal alcohol spectrum disorder (FASD) is a diagnostic term used to describe an array of structural, neurocognitive, and behavioral effects that result from prenatal alcohol exposure. While ongoing efforts have been made to increase the capacity of communities to provide early FASD diagnosis, there continues to be on-going challenges, particularly for remote and rural communities. Telehealth is the use of technology to connect communities at a distance and has been effectively used in medicine for several decades. This literature review describes the use of telehealth in FASD and other developmental disabilities and makes recommendations for how telehealth can be used to facilitate the assessment and diagnosis of FASD in rural and remote communities.

Prenatal Exposure And Child brain and mental Health (PEACH) study: protocol for a cohort study of children and youth with prenatal alcohol exposure

INTRODUCTION

Fetal alcohol spectrum disorder (FASD), which is caused by prenatal alcohol exposure (PAE), affects an estimated 4% of North Americans, and is the most common preventable cause of intellectual disability. Mental health problems, including anxiety and depression, are experienced by nearly all individuals with FASD. However, there is very limited knowledge about effective mental health treatments for individuals with FASD; effective treatments are hindered in part due to a lack of understanding of the basic neurobiology underlying internalising disorders in youth with FASD.

METHODS AND ANALYSIS

The Prenatal Exposure And Child brain and mental Health (PEACH) study includes children aged 7-18 years. We will use longitudinal neuroimaging (anatomical T1-weighted, diffusion and passive viewing function MRI) and mental health assessments (Behaviour Assessment Scale for Children, Multi-dimensional Anxiety Scale for Children, Children's Depression Inventory (CDI-2), Kiddie Scale of Affective Disorders) to: (1) characterise brain development trajectories in youth with FASD, (2) determine whether brain alterations mediate increased anxiety and depression in youth with FASD and (3) identify baseline brain features that predict changes of anxiety and depression symptoms over the next 2 years. All of this will be done while considering sex and adverse postnatal experiences, which can significantly impact mental health and brain outcomes. This project will forge new understanding of FASD and mental health from a neurobiological perspective, highlighting key time periods (ie, sensitive windows) and brain regions (ie, that may be susceptible to neurostimulation), while identifying factors that predict individual trajectories of anxiety and depression symptoms.

ETHICS AND DISSEMINATION

This study was approved by the University of Calgary Conjoint Health Research Ethics Board and the University of Alberta Health Research Ethics Board. Study results will be disseminated in peer-reviewed journals, at relevant conferences and in conjunction with our knowledge mobilisation partners.

White matter alterations in young children with prenatal alcohol exposure

Prenatal alcohol exposure (PAE) can lead to cognitive, behavioural, and social-emotional challenges. Previous neuroimaging research has identified structural brain alterations in newborns, older children, adolescents, and adults with PAE; however, little is known about brain structure in young children. Extensive brain development occurs during early childhood; therefore, understanding the neurological profiles of young children with PAE is critical for early identification and effective intervention. We studied 54 children (5.21 ± 1.11 years; 27 males) with confirmed PAE (94% also had other prenatal exposures, 74% had adverse postnatal experiences) compared with 54 age- and sex-matched children without PAE. Children underwent diffusion tensor imaging between 2 and 7 years of age. Mean fractional anisotropy (FA) and mean diffusivity (MD) were obtained for 10 major white matter tracts. Univariate analyses of covariance were used to test group differences (PAE vs. control) controlling for age and sex. The PAE group had higher FA in the genu of the corpus callosum and lower MD in the bilateral uncinate fasciculus. The PAE group also had lower tract volume in the corpus callosum, the bilateral inferior fronto-occipital fasciculi, and the right superior longitudinal fasciculus. Our findings align with studies of newborns with PAE reporting lower diffusivity, but contrast those in older populations with PAE, which consistently report lower FA and higher MD. Further research is needed to understand trajectories of white matter development and how our results of higher FA/lower MD in young children connect with lower FA/higher MD observed at older ages.

Teacher-Reported Prevalence of FASD in Kindergarten in Canada: Association with Child Development and Problems at Home

The prevalence of Fetal Alcohol Spectrum Disorder (FASD) may be underestimated as it can be difficult to diagnose in early childhood possibly reflecting unique developmental trajectories relative to other Neurodevelopmental Disabilities (NDDs). Using data collected via the Early Development Instrument (EDI) between 2010 and 2015, we examined the prevalence of kindergarten children with FASD and their concurrent developmental outcomes. We found that the prevalence of FASD ranged from 0.01 to 0.31%. A greater percentage of children with FASD had teacher-reported home problems that interfered with their classroom functioning. Overall children with FASD had higher mean scores on the developmental domains compared to children with NDDs. Results of the current study can inform strategies and policies for early identification and intervention.

An Integrative Systems Approach to Enhancing Service Delivery for Individuals with Complex Needs

Purpose of Review

There are a lack of system-wide integrative services for individuals with complex needs and a corresponding demand for advancing cross-disciplinary practices in community settings. This demand is especially acute for individuals with fetal alcohol spectrum disorder (FASD) and a gap we have sought to address.

Recent Findings

We present findings from a literature scan to guide service delivery for individuals and families affected by FASD and other complex needs: four overarching guiding principles for policy decision-makers, seven guiding practices for organizations, and 23 guiding practices for service providers.

Summary

These identified principles and practices bridge diverse perspectives, with potential for their implementation to provide consistent, evidence-based services to underserved populations with complex needs.

Health, social and legal outcomes of individuals with diagnosed or at risk for fetal alcohol spectrum disorder: Canadian example

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) is a leading cause of lifelong developmental and physical disabilities and behavioural problems. This study describes the characteristics of individuals diagnosed with or at risk for FASD in British Columbia, Canada.

METHODS

A retrospective chart review and cross-sectional analysis were conducted on records of individuals diagnosed or at risk for FASD at the Asante Centre from January 2015 to July 2019. Descriptive statistics results were stratified by age, sex, and involvement with the criminal justice and child welfare systems. Logistic regression was used to investigate potential associations.

RESULTS

161 individuals with diagnosed or at risk for FASD, (53 % male; mean age = 15.7 years, SD = 9.1) were included in the analysis. High levels of psychological/developmental disabilities (78 %), physical comorbidities (38 %), substance use (50 %), and involvement in child welfare (75 %) and criminal justice systems (30 %) were found across the entire group. Individuals over 20 reported the greatest proportion of any past substance (60.9 %), alcohol use (39.1 %) and stimulant use (30.4 %), compared to individuals aged 10-19 (41.3 %; 12.0 %; 14.1 %, respectively). Involvement with the child welfare system was associated with higher chances of having anxiety (OR 4.1; 95 % CI: 1.25-15.00). Involvement with the criminal justice system was associated with higher rates of past substance and cannabis use.

CONCLUSION

Individuals with FASD demonstrate a significant need for access to mental health and addiction services, especially among those with involvement in the child welfare and criminal justice systems. These findings point to the importance of improving policies to support the unique needs of individuals with FASD.

Characterizing adverse childhood experiences among children and adolescents with prenatal alcohol exposure and Fetal Alcohol Spectrum Disorder

BACKGROUND

Individuals with Fetal Alcohol Spectrum Disorder (FASD) and prenatal alcohol exposure (PAE) face elevated rates of postnatal environmental adversity across the lifespan.

OBJECTIVE

We explored early adversity among children and adolescents with PAE.

PARTICIPANTS AND SETTING

Our sample included 333 children and adolescents with PAE assessed at a Canadian FASD diagnostic clinic, 66% of whom were diagnosed with FASD.

METHODS

Data were collected retrospectively via record review, and adversity was measured using the Adverse Childhood Experiences Questionnaire (ACE-Q).

RESULTS

Participants experienced high levels of adversity (mean ACE score of 3.4), which increased with age, mental health comorbidity, and number of living placements. Common ACEs included: not being raised by both biological parents (97.3%), caregiver disruption (88.5%), and exposure to household substance use (69.7%). Females had significantly higher rates of sexual abuse than males (p < .001, ø = -0.18). There was no difference in total ACE scores between participants diagnosed with FASD versus those not diagnosed, but participants with FASD were less likely to live with both biological parents (p < .001, ø = .19) or to have been exposed to household mental health problems (p = .007, ø = -0.15).

CONCLUSIONS

Children and adolescents with PAE experience high rates of early adversity. Practice and policy initiatives are needed to improve early detection of ACEs among children with PAE, and of PAE among children with ACEs. Targeted supports are needed to strengthen the early caregiving environment and mitigate the risks of adversity to support healthy outcomes for individuals with PAE and 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.

A Systematic Review of Interventions to Improve Mental Health and Substance Use Outcomes for Individuals with Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder

Individuals with fetal alcohol spectrum disorder (FASD) experience remarkably high rates of mental health and substance use challenges, beginning early in life and extending throughout adulthood. Proactive intervention can help to mitigate some of these negative experiences. Although the literature on FASD intervention is growing, there is currently a lack of consolidated evidence on interventions that may improve mental health and substance use outcomes in this population. Informed by a life course perspective, we undertook a systematic review of the literature to identify interventions that improve mental wellness through all developmental stages for people with prenatal alcohol exposure (PAE) and FASD. A total of 33 articles were identified, most of which were focused on building skills or strategies that underlie the well‐being of children with PAE and FASD and their families. Other interventions were geared toward supporting child and family wellness and responding to risk or reducing harm. There was a notable lack of interventions that directly targeted mental health and substance use challenges, and a major gap was also noted in terms of interventions for adolescents and adults. Combined, these studies provide preliminary and emerging evidence for a range of intervention approaches that may support positive outcomes for individuals with FASD across the life course.

Prenatal substance exposure, adverse childhood experiences and diagnosed mental and behavioral disorders - A longitudinal register-based matched cohort study in Finland

Both prenatal substance exposure (PSE, alcohol/drugs) and experiences during the first years of life have powerful effects on brain development. However, only a few studies have investigated the combined effect of PSE and adverse childhood experiences (ACEs) on mental and behavioral disorders among exposed adolescents and adults. This longitudinal register-based cohort study 1) compared the nature and extent of diagnosed mental and behavioral disorders among youth with PSE and matched unexposed controls, and 2) investigated the influence of PSE, health in infancy and ACEs (maternal risk factors and out-of-home care, OHC) on diagnoses of mental and behavioral disorders. The data consisted of 615 exposed youth aged 15-24 years and 1787 matched unexposed controls. Data from hospital medical records and nine registers were merged for the analysis. Descriptive analysis methods and Cox regression were used. The results showed that the prevalence of mental and behavioral disorders was twice as high among exposed compared with controls. The highest levels of mental and behavioral disorders and ACEs were found among exposed with at least one OHC episode. The difference in the risk of mental and behavioral disorders between exposed and controls diminished after controlling for the effect of ACEs. Low birth weight, maternal risk factors, and OHC were the strongest predictors of mental and behavioral disorders. The results suggest that PSE alone does not explain poorer mental health among exposed youth. Risk factors accumulate, and low birth weight and ACEs are strongly associated with increased risk of mental and behavioral disorders.

Performance Validity Testing in Justice-Involved Adults with Fetal Alcohol Spectrum Disorder

OBJECTIVES

A number of commonly used performance validity tests (PVTs) may be prone to high failure rates when used for individuals with severe neurocognitive deficits. This study investigated the validity of 10 PVT scores in justice-involved adults with fetal alcohol spectrum disorder (FASD), a neurodevelopmental disability stemming from prenatal alcohol exposure and linked with severe neurocognitive deficits.

METHOD

The sample comprised 80 justice-involved adults (ages 19-40) including 25 with confirmed or possible FASD and 55 where FASD was ruled out. Ten PVT scores were calculated, derived from Word Memory Test, Genuine Memory Impairment Profile, Advanced Clinical Solutions (Word Choice), the Wechsler Adult Intelligence Scale - Fourth Edition (Reliable Digit Span and age-corrected scaled scores (ACSS) from Digit Span, Coding, Symbol Search, Coding - Symbol Search, Vocabulary - Digit Span), and the Wechsler Memory Scale - Fourth Edition (Logical Memory II Recognition).

RESULTS

Participants with diagnosed/possible FASD were more likely to fail any single PVT, and failed a greater number of PVTs overall, compared to those without FASD. They were also more likely to fail based on Word Memory Test, Digit Span ACSS, Coding ACSS, Symbol Search ACSS, and Logical Memory II Recognition, compared to controls (35-76%). Across both groups, substantially more participants with IQ <70 failed two or more PVTs (90%), compared to those with an IQ ≥70 (44%).

CONCLUSIONS

Results highlight the need for additional research examining the use of PVTs in justice-involved populations with FASD.

Different brain profiles in children with prenatal alcohol exposure with or without early adverse exposures

Prenatal alcohol exposure (PAE) can alter brain development and impact mental health outcomes, and often occurs in conjunction with postnatal adversity (e.g., maltreatment). However, it is unclear how postnatal adverse exposures may moderate mental health and brain outcomes in children with PAE. T1‐weighted and diffusion magnetic resonance imaging were obtained from 66 participants aged 7–16 years. Twenty‐one participants had PAE and adverse postnatal exposures (PAE+), 12 had PAE without adverse postnatal exposures (PAE−), and 33 were age‐ and gender‐matched controls unexposed to either prenatal alcohol or postnatal adversity. Internalizing and externalizing mental health symptoms were assessed using the Behavioral Assessment System for Children II, Parent‐Rating Scale. ANCOVAs were used to compare mental health symptoms, limbic and prefrontal cortical volumes, and diffusion parameters of cortico‐limbic white matter tracts between groups, and to assess brain‐mental health relationships. Both PAE groups had worse externalizing behavior (higher scores) than controls. The PAE− group had lower fractional anisotropy (FA) in the bilateral cingulum and left uncinate fasciculus, and smaller volumes in the left anterior cingulate cortex than controls and the PAE+ group. The PAE− group also had higher mean diffusivity (MD) in the left uncinate than the PAE+ group, and smaller right anterior cingulate and superior frontal gyrus volumes than controls. These findings show different brain structure and mental health symptom profiles in children with PAE with and without postnatal adversity, highlighting the need to consider adverse postnatal exposures in individuals with PAE.

Sleep disturbance as a predictor of anxiety in children with Fetal Alcohol Spectrum Disorders and typically developing children

BACKGROUND

High levels of anxiety and sleep problems are common features of Fetal Alcohol Spectrum Disorders (FASD). The strong association between sleep and anxiety has been documented in typically developing (TD) populations and is thought to be bidirectional. The association between sleep and anxiety in children with FASD has not yet been examined.

METHODS

Caregivers of children with FASD (n = 91) and TD children (n = 103) aged 6-16 completed the Children's Sleep Habits Questionnaire (CSHQ), Spence Children's Anxiety Scale (SCAS), and a background questionnaire. Hierarchical multiple regression analyses, group comparisons and ANCOVA interaction models were used to test the associations between sleep and anxiety within and between the two groups.

RESULTS

Sleep disturbances and anxiety were at clinical levels for the majority of the FASD group, and significantly higher in the FASD group than the TD group. After controlling for age and sex, 27 % of the variance in anxiety scores in TD children was attributable to sleep problems, and 33 % in children with FASD.

CONCLUSION

This study highlights associations between parent-reported sleep and anxiety in FASD. Sleep disturbances were significant predictors of anxiety in both children with FASD and in TD children. Given the importance of sleep to healthy neurodevelopment, there is a pressing need for sleep intervention studies in children with FASD. Early identification and intervention for sleep problems in this condition should be a therapeutic priority.

The Demographic and Neurocognitive Profile of Clients Diagnosed With Fetal Alcohol Spectrum Disorder in PATCHES Paediatrics Clinics Across Western Australia and the Northern Territory

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a diagnosis relating to neurocognitive impairments associated with prenatal alcohol exposure. A key aspect of improving FASD diagnostic processes and management is understanding the demographic and neurocognitive profile of those living with FASD. The aim of this study was to describe the demographic and neurocognitive profile of the first 199 individuals diagnosed with FASD in PATCHES Paediatrics clinics.

METHODS

A retrospective cross-sectional descriptive study design was conducted with individuals diagnosed with FASD between 2013 and 2018 through a multidisciplinary team according to the Australian FASD Diagnostic Guidelines.

RESULTS

Participants were primarily male 133 (66.8%) and Aboriginal Australian 147 (73.9%), aged 2 to 31 (mean 10.5), with 94 (47.3%) from remote or very remote parts of Western Australia. Participants came from low 119 (59.8%), medium 48 (24.1%), and high 32 (16.1%) socioeconomic (SE) backgrounds. Low SE background was found to be a predictor of number of sentinel facial features (Wald χ² (1) = 4.03, p < 0.05). Most received a diagnosis of FASD with <3 sentinel features 165 (82.9%). Participants either had 6 or more 46 (23.1%), 5 44 (22.1%), 4 55 (27.6%), or 3 (27.1%) neurodevelopmental domains impaired. Executive functioning was the most commonly impaired neurodevelopmental domain 158 (79.4%), and 31 (61%) reported sleep disturbance. ADHD was the most observed comorbid condition (41.7%).

CONCLUSIONS

This study improves our current understanding of neurocognitive and demographic profiles in individuals with FASD that have been clinically referred for diagnosis within Western Australia and the Northern Territory, and highlights the importance of prevention and early assessment/diagnosis as well as guidance regarding more targeted interventions. FASD affects individuals from all cultural and SE backgrounds. Individuals from middle to higher SE groups are at risk of FASD with prevention efforts needing to target these sectors of society. Suggestions for future research directions are also provided.

Fetal Alcohol Spectrum Disorders in a Midwestern City: Child Characteristics, Maternal Risk Traits, and Prevalence

OBJECTIVE

To determine the characteristics of children with fetal alcohol spectrum disorders (FASD) and their mothers in a Midwestern city.

METHODS

Case-control samples were drawn from 2 separate first-grade cohorts (combined N = 4,047) in every city school using different methods. In Cohort Sample 1, all consented small children (≤25th centile on height, weight, and/or head circumference) entered the study along with a random sample from all enrolled students. Cohort Sample 2 was drawn totally at random. Child growth, dysmorphology, and neurobehavior were assessed using the Collaboration on FASD Prevalence (CoFASP) criteria, and mothers were interviewed.

RESULTS

For the samples combined, 891 children received dysmorphology examinations, and 692 were case-conferenced for final diagnosis. Forty-four children met criteria for FASD. Total dysmorphology scores differentiated diagnostic groups: fetal alcohol syndrome (FAS), 16.7; partial FAS, 11.8; alcohol-related neurodevelopmental disorder (ARND), 6.1; and typically developing controls, 4.2. Neurobehavioral tests distinguished children with FASD from controls, more for behavioral problems than cognitive delay. Children with ARND demonstrated the poorest neurobehavioral indicators. An adjusted regression model of usual prepregnancy drinking indicated that maternal reports of 3 drinks per drinking day (DDD) were significantly associated with a FASD diagnosis (p = 0.020, OR = 10.1, 95% CI = 1.44 to 70.54), as were 5 or more DDD (p < 0.001, OR = 26.47, 95% CI = 4.65 to 150.62). Other significant maternal risk factors included the following: self-reported drinking in any trimester; smoking and cocaine use during pregnancy; later pregnancy recognition and later and less prenatal care; lower maternal weight, body mass index (BMI), and head circumference; and unmarried status. There was no significant difference in FASD prevalence by race, Hispanic ethnicity, or socioeconomic status at this site, where the prevalence of FASD was 14.4 to 41.2 per 1,000 (1.4 to 4.1%).

CONCLUSION

This city displayed the lowest prevalence of FASD of the 4 CoFASP sites. Nevertheless, FASD were common, and affected children demonstrated a common, recognizable, and measurable array of traits.

Mental Health and Affect Regulation Impairment in Fetal Alcohol Spectrum Disorder (FASD): Results from the Canadian National FASD Database

AIMS

Individuals with fetal alcohol spectrum disorder (FASD) frequently have challenges with regulating emotional arousal, or affect regulation (AR), and experience high rates of mental health disorders. This study examined children and adults with FASD to investigate the relationship between AR impairment and several mental health problems and diagnoses.

METHODS

Data from the Canadian national FASD database was used for analysis. Seven mental health diagnoses, including attention-deficit/hyperactivity disorder, post-traumatic stress disorder, conduct disorder, attachment disorder, intellectual disability, and language disorder were examined. A history of suicidality was also examined. The prevalence of these mental health problems in individuals with and without AR impairment was compared.

RESULTS

Individuals with FASD and AR impairment were significantly more likely to be diagnosed with conduct disorder (OR 4.8), attachment disorder (OR 6.1), or post-traumatic stress disorder (OR 8.1) when compared to those without AR impairment. They were also more likely to have a history of suicidality (OR 8.6). AR impairment was most commonly found in those with greater overall neurodevelopmental impairment. Having AR impairment was associated with receiving a diagnosis of FASD at a later age, but was not related to gender, intellectual disability, or language disorder.

CONCLUSION

AR impairment is strongly related to several mental health diagnoses in those with FASD and presents some promising possibilities for targeted early intervention.

Immune network dysregulation associated with child neurodevelopmental delay: modulatory role of prenatal alcohol exposure

Background

Evidence suggests that cytokine imbalances may be at the root of deficits that occur in numerous neurodevelopmental disorders, including schizophrenia and autism spectrum disorder. Notably, while clinical studies have demonstrated maternal cytokine imbalances with alcohol consumption during pregnancy—and data from animal models have identified immune disturbances in alcohol-exposed offspring—to date, immune alterations in alcohol-exposed children have not been explored. Thus, here we hypothesized that perturbations in the immune environment as a result of prenatal alcohol exposure will program the developing immune system, and result in immune dysfunction into childhood. Due to the important role of cytokines in brain development/function, we further hypothesized that child immune profiles might be associated with their neurodevelopmental status.

Methods

As part of a longitudinal study in Ukraine, children of mothers reporting low/no alcohol consumption or moderate-to-heavy alcohol consumption during pregnancy were enrolled in the study and received neurodevelopmental assessments. Group stratification was based on maternal alcohol consumption and child neurodevelopmental status resulting in the following groups: A/TD, alcohol-consuming mother, typically developing child; A/ND, alcohol-consuming mother, neurodevelopmental delay in the child; C/TD, control mother (low/no alcohol consumption), typically development child; and C/ND, control mother, neurodevelopmental delay in the child. Forty cytokines/chemokines were measured in plasma and data were analyzed using regression and constrained principle component analysis.

Results

Analyses revealed differential cytokine network activity associated with both prenatal alcohol exposure and neurodevelopmental status. Specifically, alcohol-exposed children showed activation of a cytokine network including eotaxin-3, eotaxin, and bFGF, irrespective of neurodevelopmental status. However, another cytokine network was differentially activated based on neurodevelopmental outcome: A/TD showed activation of MIP-1β, MDC, and MCP-4, and inhibition of CRP and PlGF, with opposing pattern of activation/inhibition detected in the A/ND group. By contrast, in the absence of alcohol-exposure, activation of a network including IL-2, TNF-β, IL-10, and IL-15 was associated with neurodevelopmental delay.

Conclusions

Taken together, this comprehensive assessment of immune markers allowed for the identification of unique immune milieus that are associated with alcohol exposure as well as both alcohol-related and alcohol-independent neurodevelopmental delay. These findings are a critical step towards establishing unique immune biomarkers for alcohol-related and alcohol-independent neurodevelopmental delay.

Association of adverse childhood experiences and neurodevelopmental disorders in people with fetal alcohol spectrum disorders (FASD) and non-FASD controls

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a highly prevalent lifelong disorder with high rates of comorbid neurodevelopmental disorders. Individuals with FASD are often exposed to abuse, neglect and foster home placements which have uncertain effects on the lifelong course of FASD. In this study we compare the prevalence of adverse childhood events (ACEs) and neurodevelopmental disorders in subjects with fetal alcohol spectrum disorders (FASD) and non-FASD controls.

METHODS

A cross-sectional chart review of patients referred to a regional developmental center was used to identify people with FASD and non-FASD controls. We recorded the number of ACEs and neurodevelopmental disorders in each patient's chart. The most common diagnoses were attention deficit hyperactivity disorder, comprehension deficits, sleep disorders, and cognitive impairments. T-tests and a regression equation were utilized to determine significant differences between the groups.

RESULTS

The review identified 203 subjects, 98 with FASD and 105 non-FASD controls. Group mean age was 8.6 years and 64.5% were male. People with FASD were more likely to have any ACEs (mean 5.3) with ACE scores 3.7 points higher than non-FASD controls (mean 1.69) (t = 11.29; p < .001). Increased ACEs were associated with increased rates of neurodevelopmental disorders for people with FASD (R = .179, p = .026) but not for non-FASD controls (R = .130, p = .094).

CONCLUSIONS

Both FASD and subsequent exposure to ACEs are associated with increased risk for development of comorbid neurodevelopmental disorders. Prevention of ACEs during childhood may decrease risk for development of comorbid neurodevelopmental disorders.

Resistance of Postnatal Hippocampal Neurogenesis to Alcohol Toxicity in a Third Trimester-Equivalent Mouse Model of Gestational Alcohol Exposure

BACKGROUND

The adult hippocampal dentate is comprised of both developmentally generated dentate granule cells (dDGCs) and adult-generated dentate granule cells (aDGCs), which play distinct roles in hippocampal information processing and network function. EtOH exposure throughout gestation in mouse impairs the neurogenic response to enriched environment (EE) in adulthood, although the basal rate of adult neurogenesis under standard housing (SH) is unaffected. Here, we tested whether the production and/or survival of either dDGCs or aDGCs are selectively impaired following exposure of mice to EtOH vapors during early postnatal development (human third trimester-equivalent), and whether this exposure paradigm leads to impairment of EE-mediated dentate neurogenesis in adulthood.

METHODS

All experiments were performed using NestinCreER^T2 :tdTomato bitransgenic mice, which harbor a tamoxifen-inducible tdTomato (tdTom) reporter for indelible labeling of newborn hippocampal DGCs. We exposed all mice to EtOH vapor or room air (Control) for 4 h/d from postnatal day (PND) 3 through PND 15. This paradigm resulted in a mean daily postexposure blood EtOH concentration of ~160 mg/dl. One cohort of neonatal mice received a single injection of tamoxifen at PND 2 and was sacrificed at either PND 16 or PND 50 to assess the impact of EtOH exposure on the production and long-term survival of dDGCs born during the early postnatal period. A second cohort of mice received daily injections of tamoxifen at PND 35 to 39 to label aDGCs and was exposed to SH or EE for 6 weeks prior to sacrifice.

RESULTS

Early postnatal EtOH exposure had no statistically significant effect on the production or survival of tdTom⁺ dDGCs, as assessed at PND 16 or PND 50. Early postnatal EtOH exposure also had no effect on the number of tdTom+ aDGCs under SH conditions. Furthermore, early postnatal EtOH exposure had no significant impact on the adult neurogenic response to EE.

CONCLUSIONS

Both early postnatal dentate neurogenesis and adult dentate neurogenesis, as well as the adult neurogenic response to EE, are surprisingly resistant to early postnatal EtOH vapor exposure in mice.

Health, Social, Education, and Justice Outcomes of Manitoba First Nations Children Diagnosed with Fetal Alcohol Spectrum Disorder: A Population-Based Cohort Study of Linked Administrative Data

OBJECTIVE

To examine health services, social services, education, and justice system outcomes among First Nations children and youth with fetal alcohol spectrum disorder (FASD).

METHODS

In this retrospective cohort study, health and social services, education, and justice data were linked with clinical records on First Nations (FN) individuals aged 1 to 25 and diagnosed with FASD between 1999 and 2010 (n = 743). We compared the FN FASD group to non-FN individuals with FASD (non-FN FASD; n = 315) and to First Nations individuals (matched on age, sex, and income) not diagnosed with FASD (FN non-FASD; n = 2229). Rates and relative risks (RRs) were calculated using generalized linear models.

RESULTS

FN FASD individuals had similar health services use to non-FN FASD individuals but had greater involvement with child welfare (RR, 1.20; 95% confidence interval [CI], 1.02 to 1.41) and the justice system (RR, 1.37; 95% CI, 1.07 to 1.74) and were more likely to be charged with a crime (RR, 1.40; 95% CI, 1.05 to 1.86). There were no suicides/suicide attempts among the non-FN FASD individuals during the study, but the crude rate/100 person-years of suicides among FN FASD individuals (0.22 for females; 1.06 for males) was substantially higher than for FN non-FASD individuals (0.08 for females; 0.32 for males). There were no significant differences between groups in the education outcomes we measured.

CONCLUSIONS

Young people with FASD are at risk for poor health, education, and social outcomes, but First Nations young people with FASD face comparably higher risks, particularly with child welfare and justice system involvement. The study emphasizes a critical need for appropriate resources for First Nations children with FASD.

Glucocorticoid receptor expression in the stress-limbic circuitry is differentially affected by prenatal alcohol exposure and adolescent stress

The dense expression of glucocorticoid receptors (GR) within the amygdala, medial prefrontal cortex (mPFC) and paraventricular nucleus of hypothalamus (PVN) mediates many aspects of emotional and stress regulation. Importantly, both prenatal alcohol exposure (PAE) and adolescent stress are known to induce emotional and stress dysregulation. Little is known, however, about how PAE and/or adolescent stress may alter the expression of GR in the amygdala, mPFC, and PVN. To fill this gap, we exposed PAE and control adolescent male and female rats to chronic mild stress (CMS) and assessed GR mRNA expression in the amygdala, mPFC, and PVN immediately following stress or in adulthood. We found that the effects of PAE on GR expression were more prevalent in the amygdala, while effects of adolescent stress on GR expression were more prevalent in the mPFC. Moreover, PAE effects in the amygdala were more pronounced during adolescence and adolescent stress effects in the mPFC were more pronounced in adulthood. GR expression in the PVN was affected by both PAE and adolescent stress. Finally, PAE and/or adolescent stress effects were distinct between males and females. Together, these results suggest that PAE and adolescent CMS induce dynamic alterations in GR expression in the amygdala, mPFC, and PVN, which manifest differently depending on the brain area, age, and sex of the animal. Additionally, these data indicate that PAE-induced hyperresponsiveness to stress and increased vulnerability to mental health problems may be mediated by different neural mechanisms depending on the sex and age of the animal.