Anticipatory guidance for children and adolescents with Fetal Alcohol Spectrum Disorder (FASD): practice points for primary health care providers

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term that describes the range of effects that can occur in an individual who was prenatally exposed to alcohol and includes an array of complex neurodevelopmental and physical findings.

OBJECTIVES

To give primary healthcare providers (PHCP) evidence-based recommendations for supporting and managing the symptoms of FASD after patients have received a diagnosis. MethodsPrimary health recommendations for the management of children and adolescents with FASD were developed based on expert clinical judgment and supported by evidence-based research, where appropriate. The format was adapted from other health supervision practice guidelines as developed by the American Academy of Pediatrics. Clinical practice "Points" for the PHCP are highlighted. A reference table of anticipatory recommendations by age is presented.

RESULTS

In most cases, the initial screening and referral for diagnosis will be made by the PHCP, and they will be responsible for ongoing management. It is anticipated that these recommendations will provide the PHCP with evidence to support the longitudinal health care of children and adolescents with FASD and their families as they transition throughout all developmental stages.

CONCLUSION

There is a pressing need for the involvement of PHCP in the active care of children and adolescents with FASD and their families over the lifespan. PHCP are trained in screening, prevention, and management of health needs, and are in the position to coordinate sub-specialty referrals as needed. Engaging PHCP will provide a truly integrated care system for individuals with FASD and their families.

Evaluation of the neurobehavioral screening tool in children with fetal alcohol spectrum disorders (FASD)

BACKGROUND

There is a growing need for validated tools to screen children at risk of fetal alcohol spectrum disorders (FASD). The Neurobehavioral Screening Tool (NST) is one of several promising screening measures for FASD, though further evidence is needed to establish the tool's psychometric utility.

OBJECTIVE

To assess the predictive accuracy of the NST among children with an FASD diagnosis, with prenatal alcohol exposure (PAE) but no FASD diagnosis, and typically developing controls.

METHOD

The NST was completed by caregivers of children ages 6 to 17, including 48 with FASD, 22 with PAE, and 32 typically developing non-exposed controls. Predictive accuracy coefficients were calculated using Nash et al. (2006) criteria, and compared against controls. An alternative scoring scheme was also investigated to determine optimum referral thresholds using item-level total scores.

RESULTS

The NST yielded 62.5% sensitivity for participants with FASD and 50% for PAE. Specificity values were 100% with no typically developing control scoring positive. Within the FASD group there was a trend for higher sensitivity among adolescents aged 12 to17 (70.8%) compared with children aged 6 to 11 years (54.2%), p = 0.23.

CONCLUSION

The findings support a growing body of literature evidencing psychometric promise for the clinical utility of the NST as an FASD screening tool, though further research on possible age-effects is warranted. The availability of a validated clinical screening tool for FASD, such as the NST, would aid in accurately screening a large number of children and lead to a timelier diagnostic referral.

Longitudinal MRI reveals impaired cortical thinning in children and adolescents prenatally exposed to alcohol

Brain imaging studies suggest that cortical thickness decreases during childhood and adolescence, in concert with underlying structural and synaptic changes required for cognitive maturation and regional specialization of function. Abnormalities of this protracted developmental process may provide key insights into the cognitive and behavioral deficits that emerge in individuals with fetal alcohol spectrum disorders (FASD). Several studies have demonstrated cortical thickness differences in children and adolescents who were prenatally exposed to alcohol, though all have been cross sectional, limiting conclusions about cortical development with age. In this study, we analyze serially collected T1 -weighted MRI from 11 children with FASD and 21 controls, scanned twice each ∼2 to 4 years apart. Mixed-models analysis of cortical thickness measurements revealed age-by-group interactions in cortical thinning, with FASD participants undergoing less developmental thinning than controls across many regions of the cortex, particularly in medial frontal and parietal areas. These results provide further longitudinal evidence in humans that prenatal alcohol exposure is associated with altered patterns of brain development that persist during childhood and adolescence.

Working memory and visuospatial deficits correlate with oculomotor control in children with fetal alcohol spectrum disorder

Previous studies have demonstrated that children with Fetal Alcohol Spectrum Disorder (FASD) exhibit deficits in measures of eye movement control that probe aspects of visuospatial processing and working memory. The goal of the present study was to examine, in a large cohort of children with FASD, prenatal alcohol exposure (PAE) but not FASD, and typically developing control children, the relationship between performance in eye movement tasks and standardized psychometric tests that assess visuospatial processing and working memory. Participants for this dataset were drawn from a large, multi-site investigation, and included children and adolescents aged 5-17 years diagnosed with an FASD (n=71), those with PAE but no clinical FASD diagnosis (n=20), and typically developing controls (n=111). Participants completed a neurobehavioral test battery and a series of saccadic eye movement tasks. The FASD group performed worse than controls on the psychometric and eye movement measures of working memory and visuospatial skills. Within the FASD group, digit recall, block recall, and animal sorting were negatively correlated with sequence errors on the memory-guided task, and arrows was negatively correlated with prosaccade endpoint error. There were no significant correlations in the control group. These data suggest that psychometric tests and eye movement control tasks may assess similar domains of cognitive function, and these assessment tools may be measuring overlapping brain regions damaged due to prenatal alcohol exposure. The results of this study demonstrate that eye movement control tasks directly relate to outcome measures obtained with psychometric tests and are able to assess multiple domains of cognition simultaneously, thereby allowing for an efficient and accurate assessment.

Deficits in response inhibition correlate with oculomotor control in children with fetal alcohol spectrum disorder and prenatal alcohol exposure

Children with fetal alcohol spectrum disorder (FASD) or prenatal alcohol exposure (PAE) frequently exhibit impairment on tasks measuring inhibition. The objective of this study was to determine if a performance-based relationship exists between psychometric tests and eye movement tasks in children with FASD. Participants for this dataset were aged 5-17 years and included those diagnosed with an FASD (n=72), those with PAE but no clinical FASD diagnosis (n=21), and typically developing controls (n=139). Participants completed a neurobehavioral test battery, which included the NEPSY-II subtests of auditory attention, response set, and inhibition. Each participant completed a series of saccadic eye movement tasks, which included the antisaccade and memory-guided tasks. Both the FASD and the PAE groups performed worse than controls on the subtest measures of attention and inhibition. Compared with controls, the FASD group made more errors on the antisaccade and memory-guided tasks. Among the combined FASD/PAE group, inhibition and switching errors were negatively correlated with direction errors on the antisaccade task but not on the memory-guided task. There were no significant correlations in the control group. These data suggests that response inhibition deficits in children with FASD/PAE are associated with difficulty controlling saccadic eye movements which may point to overlapping brain regions damaged by prenatal alcohol exposure. The results of this study demonstrate that eye movement control tasks directly relate to outcome measures obtained with psychometric tests that are used during FASD diagnosis, and may therefore help with early identification of children who would benefit from a multidisciplinary diagnostic assessment.

Neuropsychological impairments on the NEPSY-II among children with FASD

BACKGROUND

We examined the pattern of neuropsychological impairments of children with FASD (compared to controls) on NEPSY-II measures of attention and executive functioning, language, memory, visuospatial processing, and social perception.

METHODS

Participants included 32 children with FASD and 30 typically developing control children, ranging in age from 6 to 16 years. Children were tested on the following subtests of the NEPSY-II: Attention and Executive Functioning (animal sorting, auditory attention/response set, and inhibition), Language (comprehension of instructions and speeded naming), Memory (memory for names/delayed memory for names), Visual-Spatial Processing (arrows), and Social Perception (theory of mind). Groups were compared using MANOVA.

RESULTS

Children with FASD were impaired relative to controls on the following subtests: animal sorting, response set, inhibition (naming and switching conditions), comprehension of instructions, speeded naming, and memory for names total and delayed, but group differences were not significant on auditory attention, inhibition (inhibition condition), arrows, and theory of mind. Among the FASD group, IQ scores were not correlated with performance on the NEPSY-II subtests, and there were no significant differences between those with and without comorbid ADHD.

CONCLUSIONS

The NEPSY-II is an effective and useful tool for measuring a variety of neuropsychological impairments among children with FASD. Children with FASD displayed a pattern of results with impairments (relative to controls) on measures of executive functioning (set shifting, concept formation, and inhibition), language, and memory, and relative strengths on measures of basic attention, visual spatial processing, and social perception.

An evaluation of social skills in children with and without prenatal alcohol exposure

BACKGROUND

The goal of this study was to examine social skills deficits among children with and without prenatal alcohol exposure (PAE) who were both referred to a respite programme.

METHODS

Thirty-seven children with PAE and 23 non-exposed children (aged 3 to 8 years) were evaluated on the Social Skills Rating System (SSRS) by their caregivers and respite workers.

RESULTS

As compared with the non-exposed children, those with PAE showed more deficits on caregiver ratings of responsibility, hyperactivity, internalizing problems and overall social skills, as well as respite worker ratings of hyperactivity. The social skills among the PAE group were not related to home placement variables. Among both groups, caregivers rated social skills lower than respite workers, and among the PAE group, girls tended to display more social skills deficits than boys.

CONCLUSIONS

The SSRS is useful in identifying unique social skills deficits among children with PAE.

Developmental cortical thinning in fetal alcohol spectrum disorders

Regional cortical thickness was evaluated using CIVET processing of 3D T1-weighted images (i) to compare the variation in cortical thickness between 33 participants with fetal alcohol spectrum disorders (FASD) aged 6-30 years (mean age 12.3 years) versus 33 age/sex/hand-matched controls, and (ii) to examine developmental changes in cortical thickness with age from children to young adults in both groups. Significant cortical thinning was found in the participants with FASD in large areas of the bilateral middle frontal lobe, pre- and post- central areas, lateral and inferior temporal and occipital lobes compared to controls. No significant cortical thickness increases were observed for the FASD group. Cortical thinning with age in a linear model was observed in both groups, but the locations were different for each group. FASD participants showed thinning with age in the left middle frontal, bilateral precentral, bilateral precuneus and paracingulate, left inferior occipital and bilateral fusiform gyri; while controls showed decreases with age in the bilateral middle frontal gyrus, right inferior frontal gyrus, bilateral precuneus gyrus, and bilateral occipital gyrus. A battery of cognitive assessments of memory, attention, motor, and verbal abilities was conducted with many of the FASD participants, but no significant correlations were found between these cognitive scores and regional cortical thickness. Non-invasive measurements of cortical thickness in children to young adults with FASD have identified both key regions of cortex that may be more deleteriously affected by prenatal alcohol exposure as well as cortical changes with age that differ from normal developmental thinning.

Extensive deep gray matter volume reductions in children and adolescents with fetal alcohol spectrum disorders

BACKGROUND

The link between the numerous cognitive, motor, and behavioral difficulties of individuals with fetal alcohol spectrum disorders (FASD) and underlying specific structural brain injuries can be investigated using high-resolution imaging. Differential sensitivity of the brain's "relay" stations, namely the deep gray matter structures, may play a key factor given their multifaceted role in brain function. The purpose of our study was to analyze differences in deep gray matter volumes of children and adolescents with FASD relative to age/sex-matched controls and to examine whether any volume differences were consistent across the age range of neurodevelopment.

METHODS

Children and adolescents (N = 28, 6 to 17 years) diagnosed with FASD and 56 age- and sex-matched healthy controls (i.e., 2 matched controls per FASD subject) underwent 3-dimensional T1-weighted MRI scans that were used for the automated volume measurement (FreeSurfer) of the intracranial space, total white matter, cortical gray matter, and 6 deep gray matter structures, namely the hippocampus, amygdala, thalamus, caudate, putamen, and globus pallidus, with left and right measured separately. Volumes were compared between FASD and controls, as well as changes with age.

RESULTS

Significant reductions of volume in FASD were observed for the intracranial vault (7.6%), total white matter (8.6%), total cortical gray matter (7.8%), and total deep gray matter (13.1%). All 6 deep gray matter structures showed significant volume reductions bilaterally with the caudate (approximately 16%) and globus pallidus (approximately 18%) being most affected. The hippocampus, thalamus, and globus pallidus showed reductions in all 3 age subgroups (6 to 9, 10 to 13, and 14 to 17 years) but the caudate and putamen had smaller volumes for FASD only within the 2 youngest subgroups; the amygdala was only smaller for FASD in the 2 oldest subgroups.

CONCLUSIONS

Significant, but variable, volume reductions throughout the deep gray matter are observed over a wide age range of 6 to 17 years in FASD.

Coping strategies in a strongly schooling fish, the common carp Cyprinus carpio

Individual common carp Cyprinus carpio were screened repeatedly for risk taking (rate of exploration of a novel, potentially dangerous environment) and for competitive ability (success in gaining access to a spatially restricted food source). Marked differences in behaviour were evident, and significant consistency in individual responses across trials was found for both risk taking and competitive ability. In addition, there was a significant positive relationship between individual performance in these two contexts, with fish that explored more quickly in the novel environment tending to be among the first to gain access to restricted food. In two follow-up studies, resting metabolic rate, blood lactate and glucose and the expression of the cortisol receptor gene in the head kidney and brain were compared in fish from the two extremes of the risk-taking spectrum. Mass-specific metabolic rate was significantly higher in risk-taking than in risk-avoiding fish, while plasma lactate and glucose concentrations and expression of the cortisol receptor gene were lower. It was concluded that a behavioural syndrome based on boldness and aggression exists in C. carpio, as it does in many other animals, and that this is associated with differences in metabolic and stress physiology (down to the genomic level) similar to those described in animals with different coping strategies.

The impact of an ADHD co-morbidity on the diagnosis of FASD

OBJECTIVE

Many children with Fetal Alcohol Spectrum Disorders (FASD) also have co-morbid ADHD. The goal of this study was to examine the impact of having a co-morbid ADHD diagnosis on FASD diagnostic results. We compared children with FASD to those with FASD and co-morbid ADHD across the neurobehavioral domains recommended by the Canadian Guidelines in the diagnosis of FASD.

METHODS

We retrospectively analyzed data from 52 children, aged 4 to 17 years, diagnosed with an FASD at a hospital FASD clinic. Thirty-three of these children had a co-morbid diagnosis of ADHD and 19 did not. Children with FASD and those with FASD and co-morbid ADHD were compared on the following neurobehavioral domains: sensory/motor, cognition, communication, academic achievement, memory, executive functioning, attention, and adaptive behavior.

RESULTS

Children with FASD and ADHD performed significantly worse than those without ADHD on attention but better on academic achievement. No other group differences were significant.

CONCLUSIONS

Having an ADHD co-morbidity had little effect on the FASD diagnosis. The results of this project will inform the diagnostic process for FASD and have implications for standardizing diagnostic processes across clinics.

The remarkably high prevalence of epilepsy and seizure history in fetal alcohol spectrum disorders

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is the umbrella term that describes the range of adverse developmental outcomes that may occur in the offspring of mothers who drink alcohol during pregnancy. FASD is associated with several comorbidities including epilepsy. The objective of the study was to evaluate the prevalence of epilepsy or a history of seizures in subjects with FASD and the contribution of relevant risk factors.

METHODS

A retrospective chart review was conducted on all active charts (N = 1063) at two FASD clinics. After exclusion of subjects without a confirmed diagnosis, a total of 425 subjects between the ages of 2-49 were included in the analysis. The relationships between FASD diagnosis and other risk factors for co-occurrence of epilepsy or a seizure disorder (e.g., extent of exposure to alcohol and other drugs, type of birth, and trauma) were examined using chi-square and multivariate multinomial logistic regression.

RESULTS

Twenty-five (5.9%) individuals in the study population had a confirmed diagnosis of epilepsy, and 50 (11.8%) had at least one documented seizure episode, yielding an overall prevalence of 17.7% in this population. Importantly, a history of epilepsy or seizures was not different across the three diagnostic subgroups. In those subjects with available maternal drinking histories, first trimester exposure or drinking throughout all three trimesters were the predominant forms of fetal exposure. None of the other risk factors were associated with a greater prevalence of epilepsy or seizures.

CONCLUSIONS

There is a remarkably high prevalence of epilepsy/seizures in the FASD population.

Memory strategy development in children with foetal alcohol spectrum disorders

OBJECTIVE

The goal of this study was to examine whether children with foetal alcohol spectrum disorders (FASD) show the same developmental transition from visual to verbal memory strategies as in non-FASD children and whether this transition was related to executive functioning and vocabulary skills.

METHODS

Younger (5-6 years) and older (8-10 years) children with FASD and non-FASD children were tested on a picture memory task.

RESULTS

Among both age groups, the non-FASD children performed better than those with FASD. Younger children with FASD appeared to use a visual approach, whereas older children with FASD appeared to use a verbal approach. However, among the non-FASD group both age groups appeared to use a verbal approach. Among the FASD group, the transition from a visual to verbal approach was correlated with executive functioning skills.

IMPLICATIONS

Strategies for classroom approaches as well as strategy training are discussed.

Diagnosing fetal alcohol spectrum disorder: History, challenges and future directions

Fetal alcohol spectrum disorder (FASD) is one of the most common preventable causes of developmental disability, and is currently one of the most pressing public health concerns in Canada. FASD refers to the range of physical, mental, behavioural and learning disabilities that an individual may acquire as a result of maternal alcohol consumption. In the present paper, the history of the diagnostic approach to alcohol-related disorders over the past 35 years is reviewed. Research supporting the importance of early diagnosis for the long-term outcomes and management of individuals with FASD is presented, and challenges that have plagued efforts to efficiently diagnose individuals with FASD are discussed. Finally, the study reviews the future directions and implications regarding current diagnostic strategies.

Brain diffusion abnormalities in children with fetal alcohol spectrum disorder

BACKGROUND

Children with fetal alcohol spectrum disorder (FASD) have a variety of cognitive, behavioral, and neurological impairments, including structural brain damage. Despite the importance of white matter connections for proper brain function, little is known about how these connections, and the deep gray matter structures that act as relay stations, are affected in children with FASD. The purpose of this study was to use diffusion tensor imaging, an advanced magnetic resonance imaging technique, to examine microstructural differences of white and deep gray matter in children with FASD.

METHODS

Subjects were 24 children aged 5-13 years previously diagnosed with FASD and 95 healthy children over the same age range. Diffusion tractography was used to delineate 10 major white matter tracts in each individual, and region-of-interest analysis was used to assess 4 deep gray matter structures. Fractional anisotropy, an indicator of white matter integrity, and mean diffusivity, a measure of the average water diffusion, were assessed in all 14 brain structures.

RESULTS

Diffusion tensor imaging revealed significant differences of diffusion parameters in several areas of the brain, including the genu and splenium of the corpus callosum, cingulum, corticospinal tracts, inferior fronto-occipital fasciculus, inferior and superior longitudinal fasciculi, globus pallidus, putamen, and thalamus. Reduced white and gray matter volumes, as well as total brain volume, were observed in the FASD group.

CONCLUSIONS

These results demonstrate diffusion abnormalities in FASD beyond the corpus callosum and suggest that several specific white matter regions, particularly commissural and temporal connections, and deep gray matter areas of the brain are sensitive to prenatal alcohol exposure.

Neurobehavioural outcomes of children with fetal alcohol spectrum disorders: A Canadian perspective

Fetal alcohol spectrum disorder (FASD) is one of the most common preventable causes of developmental disability and is currently one of the most pressing public health concerns in Canada. FASD refers to the range of physical, mental, behavioural and learning disabilities that an individual may acquire as a result of maternal alcohol consumption. Prenatal exposure to alcohol leads to numerous primary and secondary disabilities in affected children, which can result in poor long-term outcomes. The present paper reviews previous research on the neurobehavioural outcomes of children with FASD, particularly in terms of behavioural, mental health and adaptive outcomes. The role of risk and protective factors on these outcomes and the impact of FASD on the family are also examined. Finally, future directions and implications regarding outcomes research among children with FASD, particularly within a Canadian context, are discussed.

The effect of rehearsal training on working memory span of children with fetal alcohol spectrum disorder

A key area of weakness in individuals with fetal alcohol spectrum disorder (FASD) is working memory, thus the goal of this study was to determine whether teaching children (aged 4-11) with FASD verbal rehearsal would increase their memory. Rehearsal training has been effective in other populations with working memory difficulties, so we hypothesized that children with FASD would also benefit from rehearsal training. Children were divided into an Experimental group, who received rehearsal training and a Control group, who did not receive training. All children were tested on digit span tasks over three sessions: a pretest (baseline) and then post-test 1 and post-test 2 (where only the Experimental group received rehearsal training). The Experimental group showed a significant increase in performance across session but the Control group did not. Children in the Experimental group performed significantly higher than the Control group on post-test 2 but not on the pretest or post-test 1. More children in the Experimental group showed behavioral evidence and self-report of rehearsal after training. Rehearsal training was successful at increasing the memory for numbers among children with FASD and may help to ameliorate working memory difficulties in FASD, ultimately supporting academic and developmental growth of children with FASD.

Brief report: lie-telling in children with fetal alcohol spectrum disorder

OBJECTIVES

The lie-telling abilities of children with fetal alcohol spectrum disorder (FASD) (aged 4-8 years) were tested using a temptation resistance paradigm.

METHODS

Children were told not to peek at a forbidden toy while left alone in a room. Later children were asked if they peeked at the toy as well as follow-up questions to see if they could conceal their peeking behavior and maintain their lie in subsequent verbal statements.

RESULTS

Approximately 78% of the children peeked at the toy. However, 94% of the FASD children lied about peeking, a rate that is much higher than the non-FASD control group (72%). As age increased, FASD children were better at concealing their lies and maintaining semantic leakage control than non-FASD children.

CONCLUSIONS

This is the first study to specifically test lying in children with FASD and has implications for remediation and understanding secondary disabilities in these children, which will lead to further research in this area.

Evaluation of patient concerns before total knee and hip arthroplasty

The preoperative concerns of patients undergoing total knee or hip arthroplasty were evaluated in a cross-sectional study of 370 patients. Patients completed a questionnaire on 29 concerns, each rated on a scale of 1 (not concerned) to 4 (very concerned). Short Form 12 and Oxford hip or knee scores were also calculated. The results showed that the greatest concern for patients was cancellation of the surgery. This was followed by failure of the surgery to reduce pain, loss of a limb, and joint infection. Concerns regarding scar problems, nursing care, and preoperative tests were the lowest. Women showed statistically significant greater concerns in 9 areas. Younger patients (age, <65) showed increased concerns in 8 areas. Patients who had previously undergone joint arthroplasty were less concerned than those who had not undergone previous lower limb joint arthroplasty for 6 responses. They showed increased concern in 2 areas, nursing care and hospital food. Those undergoing total hip arthroplasty were more concerned about dislocation, dressing, and returning to work (all, P<.05). This study provides useful information for the preoperative counseling of patients and the production of preoperative literature.

Expect the best, prepare for the worst: surgeon and patient expectation of the outcome of primary total hip and knee replacement

A cross-sectional study of 100 surgeons and 370 patients awaiting primary total hip or knee replacement was carried out. Oxford hip or knee score questionnaires were sent to the surgeons and patients. They were asked to predict the level of symptoms expected 6 months following surgery. The Oxford scores derive a value of 12-60, with a greater score indicating worsening symptoms. The mean pre-operative score was 45.12 for the hip patients and 42.96 for the knee patients, and the patients expected this to drop to 23.70 and 25.66, respectively, 6 months' postoperatively. This was a significant difference for both groups. The surgeons expected the patients to have a mean postoperative score of 20.91 for the hip group and 22.19 for the knee group. The surgeons' scores were significantly lower than those from the patients. There was a significant difference between the patients' and surgeons' expectations of the results of total knee and hip replacement surgery. The surgeons expected better results than the patients. We believe that this is the first study that directly compares surgeon and patient expectations of lower limb arthroplasty.