A pilot community intervention for young women with fetal alcohol spectrum disorders

Parenting by individuals with fetal alcohol spectrum disorders and neurobehavioral outcomes in their offspring

BACKGROUND

The neurobehavioral health impairments associated with prenatal alcohol exposure are now known to persist through adulthood. However, little is known about how these impairments affect individuals' parenting abilities and the neurobehavioral health of their offspring. This study compares parents with fetal alcohol spectrum disorder (FASD) with socioeconomically matched, nonexposed parents on measures of parenting and family support and assesses the neurobehavioral health of the children in both groups.

METHODS

Forty-nine parent-child dyads were recruited from a longitudinal cohort of low socioeconomic status. Measures included the Parenting Styles and Dimensions Questionnaire, Family Support Scale, an in-depth psychosocial history, the Pediatric Symptom Checklist (PSC; parent and child reports), the Achenbach Child Behavior Checklist (CBCL), a screening psychiatric evaluation of the child, the NIH Toolbox Cognition Battery for Children, The Vineland Adaptive Behavior Scales-Third Edition caregiver rating form, and the Traumatic Events Screening Inventory (parent and child reports).

RESULTS

Cognitive functioning was impaired for both offspring of parents with FASD (x ¯  = 81.1, SD = 13.0) and control parents (x ¯  = 79.9, SD = 16.1), but despite similar impairments, children of parents with FASD were less likely to have an Individualized Education Plan than controls. Adaptive functioning was adequate for both groups (x ¯  = 92.1, SD = 15.4 in exposed vs.x ¯  = 94.3, SD = 12.3 in controls) and CBCL and PSC scores in both groups were within normal limits. Parents in both groups showed a predominantly authoritative parenting style. Despite a similar frequency of adverse childhood experiences in both groups, parents with FASD were less likely to recognize their child's adverse experiences.

CONCLUSION

Parents with FASD display notable strengths including a predominantly authoritative parenting style. However, parents with FASD underrecognize child trauma and underutilize developmental services compared to socioeconomically matched controls, despite similar neurocognitive impairments. Impairments in adaptive functioning in parents with FASD may translate into difficulties with child-parent communication and limit both insight into neurobehavioral problems and advocacy skills. There is a need to identify and support parents with FASD to optimize their parenting abilities in the context of their individual strengths and difficulties.

My Health Coach: Community members' perspectives on a mobile health tool for adults with fetal alcohol spectrum disorders

Objectives

Fetal alcohol spectrum disorders (FASD) affect the health and development of people across the lifespan. Adults with FASD experience significant barriers to care. Accessible and scalable solutions are needed. In partnership with members of the International Adult Leadership Collaborative of FASD Changemakers, an international group of adults with FASD, we developed a mobile health (mHealth) application based on self-determination theory (SDT), called "My Health Coach," to promote self-management and health advocacy.

Methods

This project follows an established user-centered design approach to app development and evaluation, allowing for feedback loops promoting iterative change. Research staff and ALC members co-led online focus groups (n = 26) and an online follow-up survey (n = 26) with adults with FASD to elicit feedback on completed design prototypes. Focus group transcriptions and surveys underwent systemic thematic and theoretical framework analysis.

Results

Analyses show overall positive impressions of the My Health Coach app. Participants were enthusiastic about the proposed features and tools the app will provide. Discussions and free responses revealed SDT constructs (autonomy, competence, relatedness) are a strong fit with participants' perceived outcomes shared in their evaluation of the prototype. Interesting recommendations were made for additional features that would further promote SDT constructs.

Conclusions

This project demonstrates advantages of community-engaged partnerships in FASD research. Adults with FASD have a strong interest in scalable mHealth tools and described the acceptability of our initial design. App features and tools promoted SDT constructs.

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.

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.

Unintended pregnancy prevention in women using psychoactive substances: A systematic review

This systematic review seeks to evaluate the efficacy of interventions aimed at preventing unintended pregnancies in women using psychoactive substances. Seven electronic databases (Medline, EMBASE, CINAHL, Web of Science Core Collection, PsycINFO, Cochrane CENTRAL database) were searched in October 2017. Twenty-two articles met our inclusion criteria. Interventions based on behavior change theory yielded an increase in the initiation of effective contraception as compared with provision of written information materials. The effect was more pronounced when the intervention provided on-site contraceptive counseling and free access to birth control. Financial incentives also seemed to effectively increase women's contraception intake. Case management interventions including pregnant and postpartum women with heavy levels of substance use showed promising results in terms of initiation of contraception, but rates of unintended pregnancy over long-term follow-up were nevertheless elevated. Finally, some interventions integrated family planning services into specialized centers taking care of pregnant and postpartum women with substance abuse. However, most studies aimed at postpartum and post-abortion contraception used a non-comparative design and had a number of methodological flaws. The risk of bias in most studies is high. All interventions with a primary or secondary focus on the prevention of unintended pregnancy in women using psychoactive substances short-term improvements in contraception intake, but it is unclear if these effects last or have any impact on unintended pregnancy rates in the long-term.

Fetal Alcohol Spectrum Disorders: A Case Study

This grand rounds manuscript reviews important considerations in developing case conceptualizations for individuals with a history of prenatal alcohol exposure. This case study provides an introduction to fetal alcohol spectrum disorders, diagnostic issues, a detailed description of the individual's history, presenting symptoms, neuropsychological test results, and an integrated summary. We describe a 9-year old girl diagnosed with a fetal alcohol spectrum disorder (FASD): Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). This patient is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility.

Biomarkers for the Detection of Prenatal Alcohol Exposure: A Review

Alcohol exposure during pregnancy can cause adverse effects to the fetus, because it interferes with fetal development, leading to later physical and mental impairment. The most common clinical tool to determine fetal alcohol exposure is maternal self-reporting. However, a more objective and useful method is based on the use of biomarkers in biological specimens alone or in combination with maternal self-reporting. This review reports on clinically relevant biomarkers for detection of prenatal alcohol exposure (PAE). A systematic search was performed to ensure a proper overview in existing literature. Studies were selected to give an overview on clinically relevant neonatal and maternal biomarkers. The direct biomarkers fatty acid ethyl esters (FAEEs), ethyl glucuronide (EtG), ethyl sulfate, and phosphatidylethanol (PEth) were found to be the most appropriate biomarkers in relation to detection of PAE. To review each biomarker in a clinical context, we have compared the advantages and disadvantages of each biomarker, in relation to its window of detectability, ease of collection, and the ease and cost of analysis of each biomarker. The biomarkers PEth, FAEEs, and EtG were found to be applicable for detection of even low levels of alcohol exposure. Meconium is an accessible matrix for determination of FAEEs and EtG, and blood an accessible matrix for determination of PEth.

Interventions in fetal alcohol spectrum disorders: An international perspective

Fetal alcohol spectrum disorders (FASD) are present across countries and cultures, with prevalence rates threatening to rise in the coming years. In order to support children and families with FASD around the world, researchers must work to disseminate and implement evidence-based interventions. However, each cultural context presents unique elements and barriers to the implementation process. This review considers the challenges of addressing FASD in an international context. It summarizes existing FASD interventions that have empirical support in the domains of parenting and education, attention and self-regulation, adaptive functioning, and nutrition and medication. It then outlines cultural barriers pertaining to FASD that may impede the implementation process and makes suggestions for using purveyors as cultural liaisons between researchers and local stakeholders. The review concludes with recommendations for moving forward with international dissemination and implementation of FASD interventions.

Intervention recommendations and subsequent access to services following clinical assessment for fetal alcohol spectrum disorders

BACKGROUND

Children with fetal alcohol spectrum disorders (FASD) and prenatal alcohol exposure (PAE) experience multiple difficulties requiring various interventions. Researchers have called for investigation into service use with respect to clinically recommended interventions.

AIMS

To examine intervention recommendations for children with FASD/PAE and subsequent access to these recommended interventions.

METHODS AND PROCEDURES

Intervention recommendations following FASD assessment were examined for children (1-17 years). Recommendations were compared according to diagnostic status and demographic and environmental variables. Subsequent access to several interventions was examined for 45 participants.

OUTCOMES AND RESULTS

A variety of recommendations were given. Children with FASD received more recommendations overall and received more education, anticipatory guidance, family support, and safety recommendations than undiagnosed children with PAE. Undiagnosed children received more mental health and reassessment recommendations. Older children received fewer family support and developmental therapy recommendations but more mental health recommendations than younger age groups. Many families accessed modified school programming, developmental therapy, psychiatry, child counseling, and parent support as recommended.

CONCLUSIONS AND IMPLICATIONS

Children with FASD and PAE have extensive needs and should receive individualized recommendations. An assessment is valuable even without an FASD diagnosis. Areas of high/low service access may provide insight into accessibility and perceived importance of interventions.

WHAT THIS PAPER ADDS

This study responds to important research questions regarding the intervention needs of individuals with FASD. It is novel in its exploration of intervention recommendations given to children prenatally exposed to alcohol without an FASD diagnosis (rather than only children with FASD) and in its examination of post-assessment service use patterns specifically in relation to clinical recommendations.

Cognitive factors contributing to spelling performance in children with prenatal alcohol exposure

OBJECTIVE

Heavy prenatal alcohol exposure is associated with impaired school functioning. Spelling performance has not been comprehensively evaluated. We examined whether children with heavy prenatal alcohol exposure demonstrate deficits in spelling and related abilities, including reading, and tested whether there are unique underlying mechanisms for observed deficits in this population.

METHOD

Ninety-six school-age children made up 2 groups: children with heavy prenatal alcohol exposure (AE, n = 49) and control children (CON, n = 47). Children completed select subtests from the Wechsler Individual Achievement Test-Second Edition and the NEPSY-II. Group differences and relations between spelling and theoretically related cognitive variables were evaluated using multivariate analysis of variance and Pearson correlations. Hierarchical regression analyses were used to assess contributions of group membership and cognitive variables to spelling performance. The specificity of these deficits and underlying mechanisms was tested by examining the relations between reading ability, group membership, and cognitive variables.

RESULTS

Groups differed significantly on all variables. Group membership and phonological processing significantly contributed to spelling performance, whereas for reading, group membership and all cognitive variables contributed significantly. For both reading and spelling, group × working memory interactions revealed that working memory contributed independently only for alcohol-exposed children.

CONCLUSION

Alcohol-exposed children demonstrated a unique pattern of spelling deficits. The relation of working memory to spelling and reading was specific to the AE group, suggesting that if prenatal alcohol exposure is known or suspected, working memory ability should be considered in the development and implementation of explicit instruction.

Positive Behavioral Interventions and Family Support for Fetal Alcohol Spectrum Disorders

Although the scientific community has recognized the effects of prenatal alcohol exposure on development for over 40 years, the empirical study of positive behavioral interventions and family support programs for people with fetal alcohol spectrum disorders (FASD) has only just emerged over the last 10 to 15 years. In this time, dedicated researchers have developed innovative programs that have generally produced large effects and have been acceptable to children with FASD and their families. This body of work demonstrates that children with FASD can benefit from interventions that are appropriately tailored to their neurodevelopmental disabilities. Despite this progress, much work lies ahead to meet the significant needs of people with FASD. This review evaluates available sources of information, including theoretical and Lived Experience models, empirical evidence on existing programs, and best practice guidelines, to guide future research priorities and clinical practice. Three priorities for future intervention research are offered.

Fetal alcohol spectrum disorders

Prenatal alcohol exposure (PAE) is one of the most prevalent and modifiable risk factors for somatic, behavioral, and neurological abnormalities. Affected individuals exhibit a wide range of such features referred to as fetal alcohol spectrum disorders (FASD). These are characterized by a more or less specific pattern of minor facial dysmorphic features, growth deficiency and central nervous system symptoms. Nevertheless, whereas the diagnosis of the full-blown fetal alcohol syndrome does not pose a major challenge, only a tentative diagnosis of FASD can be reached if only mild features are present and/or maternal alcohol consumption during pregnancy cannot be verified. The respective disorders have lifelong implications. The teratogenic mechanisms induced by PAE can lead to various additional somatic findings and structural abnormalities of cerebrum and cerebellum. At the functional level, cognition, motor coordination, attention, language development, executive functions, memory, social perception and emotion processing are impaired to a variable extent. The long-term development is characterized by disruption and failure in many domains; an age-adequate independency is frequently not achieved. In addition to primary prevention, individual therapeutic interventions and tertiary prevention are warranted; provision of extensive education to affected subjects and their caregivers is crucial. Protective environments are often required to prevent negative consequences such as delinquency, indebtedness or experience of physical/sexual abuse.

Foetal alcohol spectrum disorder: identifying the neurobehavioural phenotype and effective interventions

PURPOSE OF REVIEW

Since the first description of the foetal damage of alcohol in 1967, numerous studies have outlined different aspects of neurodevelopmental dysfunction, adversely affecting the lives of children worldwide. Although the cause of the syndrome is sorted out, the pathogenesis of brain damage is far from being clear. In contrast to children exhibiting the full facial dysmorphology, who are relatively easy to diagnose, in those presenting only with alcohol-related neurodevelopmental damage diagnosis is much more challenging due to poor specificity of the brain dysfunction. Hence, identifying the neurodevelopmental phenotype of foetal alcohol spectrum disorder (FASD) is a major challenge.

RECENT FINDINGS

Recently, a behavioural phenotype of FASD has been described and validated using items from the Child Behaviour Checklist. This tool has high sensitivity and specificity in separating children with FASD from those with ADHD and from healthy controls. In parallel, a number of intervention studies show promise in improving the abilities of children and adolescents with the syndrome to cope with daily tasks and improve their quality of life.

SUMMARY

The neurobehavioural screening test can facilitate screening for FASD and is an official screening tool in the FASD toolkit of the Public Health Agency of Canada. Promising new interventions may attenuate the long-term outcome of these children.

Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada

Background

Individuals with Fetal Alcohol Spectrum Disorder (FASD) constitute a special population that may be at particularly high risk for substance use. The purpose of the current study was to estimate the utilization of specialized addiction treatment services (SATS) and the associated cost, as a part of the total cost of health care associated with FASD in Canada.

Methods

The current study was a modeling study. Data on SATS by lifetime mental disorder status were obtained from the Drug and Alcohol Treatment Information System (DATIS) in Ontario, Canada for 2010/11. The number of clients with FASD who received SATS in Ontario in 2010/11 was estimated, assuming that approximately 37% (confidence interval: 21.6%-54.5%) of individuals with FASD abuse or are addicted to alcohol and/or drugs and that their utilization rate of SATS is the same as those for people with a lifetime mental disorder. The data from DATIS was then extrapolated to the total Canadian population.

Results

The cost of SATS for clients with FASD in Canada in 2010/11 ranged from $1.65 million Canadian dollars (CND) to $3.59 million CND, based on 5,526 outpatient visits and 9,529 resident days. When the sensitivity analysis was performed the cost of SATS ranged from $979 thousand CND to $5.34 million CND.

Conclusions

Special attention must be paid to at-risk groups of individuals such as those with FASD, in order to reduce the likelihood of the development of co-morbid substance abuse problems, and thus, reducing the overall burden on Canadian society.

Mental health issues in fetal alcohol spectrum disorder

BACKGROUND

High numbers of individuals with Fetal Alcohol Spectrum Disorders (FASD) have been described as having mental health problems.

AIMS

 This article summarizes research about mental health problems in FASD and considers related developmental and environmental issues.

METHOD

A computer-based literature search was conducted in the databases Medline, PsycINFO, Google Scholar, Academic Search Complete, and Education Resources Information Centre for articles addressing the prevalence and types of mental health issues in individuals affected by FASD.

RESULTS

 High rates of mental disorders within the FASD and prenatal alcohol exposure (PAE) population were found to be consistently reported for both internalizing and externalizing disorders. Moreover, problems that emerge in childhood may reflect a convergence of genetic, environmental, and neurophysiological factors that persist into adulthood.

CONCLUSIONS

Researchers are beginning to document the impacts of PAE on later mental health development. Further longitudinal study is needed to determine whether there is an increasing severity of mental health deficits and consequences with age, and whether any such changes reflect increasingly deteriorating environmental factors or brain-based factors. Additionally, research is needed to design interventions to better address the unique mental health needs of this population.

The effectiveness of a community-based intervention for parents with FASD

The purpose of this study was to evaluate the effectiveness of the Step by Step program in which mentors work with parents affected by Fetal Alcohol Spectrum Disorder (FASD) on a one-to-one basis. Mentors help clients identify and work towards meeting their needs and achieving their goals. Data from 24 closed client files was collected and analyzed and as predicted, the program was effective in helping clients reduce their needs and achieve their goals. The clients' reason for leaving the program as well as whether or not they had a formal FASD diagnosis had an impact on their success in the program. Data collected on additional mental health issues, experience of abuse and addictions helped to characterize the sample of clients and correlations were found between clients' experience of abuse and their past and/or present addictions issues. Limitations of this study as well as future implications were also discussed.

Prenatal alcohol exposure and chronic mild stress differentially alter depressive- and anxiety-like behaviors in male and female offspring

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) is associated with numerous neurobehavioral alterations, as well as disabilities in a number of domains, including a high incidence of depression and anxiety disorders. Prenatal alcohol exposure (PAE) also alters hypothalamic-pituitary-adrenal (HPA) function, resulting in increased responsiveness to stressors and HPA dysregulation in adulthood. Interestingly, data suggest that pre-existing HPA abnormalities may be a major contributory factor to some forms of depression, particularly when an individual is exposed to stressors later in life. We tested the hypothesis that exposure to stressors in adulthood may unmask an increased vulnerability to depressive- and anxiety-like behaviors in PAE animals.

METHODS

Male and female offspring from prenatal alcohol (PAE), pair-fed (PF), and ad libitum-fed control (C) treatment groups were tested in adulthood. Animals were exposed to 10 consecutive days of chronic mild stress (CMS), and assessed in a battery of well-validated tasks sensitive to differences in depressive- and/or anxiety-like behaviors.

RESULTS

We report here that the combination of PAE and CMS in adulthood increases depressive- and anxiety-like behaviors in a sexually dimorphic manner. PAE males showed impaired hedonic responsivity (sucrose contrast test), locomotor hyperactivity (open field), and alterations in affiliative and nonaffiliative social behaviors (social interaction test) compared to control males. By contrast, PAE and, to a lesser extent, PF, females showed greater levels of "behavioral despair" in the forced swim test, and PAE females showed altered behavior in the final 5 minutes of the social interaction test compared to control females.

CONCLUSIONS

These data support the possibility that stress may be a mediating or contributing factor in the psychopathologies reported in FASD populations.

Prevention of fetal alcohol spectrum disorders

Alcohol use among women of childbearing age is a leading, preventable cause of birth defects and developmental disabilities in the United States. Although most women reduce their alcohol use upon pregnancy recognition, some women report drinking during pregnancy and others may continue to drink prior to realizing they are pregnant. These findings emphasize the need for effective prevention strategies for both pregnant and nonpregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). This report reviews evidence supporting alcohol screening and brief intervention as an effective approach to reducing problem drinking and AEPs that can lead to fetal alcohol spectrum disorders. In addition, this article highlights a recent report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect that describes effective interventions to reduce alcohol use and AEPs, and outlines recommendations on promoting and improving these strategies. Utilizing evidence-based alcohol screening tools and brief counseling for women at risk for an AEP and other effective population-based strategies can help achieve future alcohol-free pregnancies.

Intervention for individuals with fetal alcohol spectrum disorders: treatment approaches and case management

Exposure to alcohol in utero is considered to be the leading cause of developmental disabilities of known etiology. The most severe consequence of such exposure, fetal alcohol syndrome (FAS), is characterized by a distinct constellation of characteristic facial anomalies, growth retardation, and central nervous system (CNS) dysfunction. Some individuals with prenatal alcohol exposure (PAE) do not meet the full criteria for FAS, but instead are diagnosed with partial FAS, alcohol related neurodevelopmental disorder (ARND), or alcohol related birth defects (ARBD). The entire continuum of effects from PAE is increasingly being referred to under the umbrella term of fetal alcohol spectrum disorders (FASDs). An extensive body of research has documented major cognitive, behavioral, adaptive, social, and emotional impairments among individuals with FASDs. Although FAS was identified in the U.S. over 35 years ago, the development, evaluation, and dissemination of evidence-based interventions for individuals with FASDs have lagged behind significantly. Encouragingly, however, in recent years there has been a marked increase in efforts to design and test interventions to remediate the impairments associated with prenatal alcohol exposure. This article will review treatment needs and considerations for individuals with FASDs and their families, current empirically tested treatment approaches, case management issues, and suggestions for future directions in research on the treatment of FASDs.

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.

Collaborative services: children experiencing neglect and the side effects of prenatal alcohol exposure

PURPOSE

The purpose of this article is to provide critical knowledge regarding children who are served by the child welfare system and how these children's specialized needs affect speech-language services. Specifically, the structure of social services system models is presented, with an emphasis on the cultural and systemic interactions between service providers and families. In addition, the role of special education for children who have experienced abuse, neglect, and prenatal drug or alcohol exposure is presented, with an emphasis on social service and special education legal issues.

METHOD

This article provides a critical analysis of the research literature to date regarding effective tools for providing collaborative intervention to children who are experiencing fetal alcohol syndrome disorder or abuse and/or neglect.

CLINICAL IMPLICATIONS

This article provides suggestions about the collaborative roles that speech-language pathologists should integrate into treatment milieu when delivering therapy to children with histories of abuse, neglect, and prenatal drug or alcohol exposure.

Detection of alcohol consumption during pregnancy—Current and future biomarkers

Alcohol, one of the most frequently reported addictions, is a significant public health problem in the USA. Early identification is important and would aid in intervention for the pregnant woman who continues to drink and for the affected infant. To date, there isn't a definitive test which identifies either alcohol abuse during pregnancy or newborns exposed to alcohol prenatally. The existing biomarkers can detect varying degrees of alcohol exposure but further research is needed to improve sensitivity/specificity and to validate these markers.