Neuropsychological Aspects of Prevention and Intervention for FASD: International Perspectives

Choline enhances elicited imitation memory performance in preschool children with prenatal alcohol exposure: a cumulative report of 3 randomized controlled trials

BACKGROUND

Fetal alcohol spectrum disorders (FASDs) are associated with neurocognitive deficits for which there are no biological treatments. Choline supplementation may attenuate these deficits.

OBJECTIVES

This study was aimed to evaluate choline as a neurodevelopmental intervention for preschool-aged children with FASD.

METHODS

We present combined data from 104 participants with FASD (aged 2.5-5.9 y) from 3 placebo randomized controlled trials (RCTs). Participants in RCT1 and RCT2 were randomly assigned to 9 mo choline (500 mg daily) or placebo. Participants in RCT3 were randomly assigned to 9 mo choline (19 mg/kg daily) or placebo. The primary outcome measure was an elicited imitation (EI) memory task.

RESULTS

Adherence was high (78% doses received). Adverse effects were similar across groups except fishy body odor: choline group, 36%; placebo group, 8%. We observed a trend-level choline advantage; participants receiving choline performed 25% better on EI short-delay adjacent pairs (sequential memory) than those on placebo, with a steeper increase in scores between 6 and 9 mo (ŷ = -10.06; P = 0.03; 95% CI: -19.13, -0.99). No sex difference in response was seen, nor did we observe a dose-response relationship. Age-moderated response to choline between baseline and 9 mo (ŷ = 10.02; P = 0.01; 95% CI: 2.47, 17.57), with greater response in younger (≤4.2 y) than that in older (>4.2 y) participants. Overall, choline showed a beneficial effect on memory but no impact on executive functioning or intelligent quotient.

CONCLUSIONS

The results support choline as a neurodevelopmental intervention for improvement of memory in young children exposed to alcohol prenatally. Specifically, the use of choline bitartrate as a supplement in the range of 260-500 mg/d in children between 2.5 and 5.9 y of age is supported. Future studies are needed to further define appropriate dosage as well as optimal lengths and developmental windows for supplementation. This trial was registered at clinicaltrials.gov as NCT01149538 and NCT02735473.

Fetal alcohol spectrum disorders: where we have come from, trends, and future directions

Fetal alcohol spectrum disorder (FASD) refers to a range of conditions caused by prenatal exposure to alcohol. First described in the 1970s as fetal alcohol syndrome, continuing progress has been made in the understanding, recognition and treatment of what is now recognized to be a range of related neurodevelopmental disorders. FASD is common, especially in countries with higher levels of alcohol consumption such as those in Europe and North America, where the prevalence is estimated to be around 3%. A number of diagnostic systems are in operation in different countries, and work is ongoing to develop an internationally agreed set of diagnostic criteria. People with FASD often have other developmental, mental and somatic conditions, and there appears to be a high rate of traumatic and other adverse experiences in this population. People with FASD are at increased risk of being involved in the criminal justice system, but they may be ill-equipped to successfully navigate it and are likely to provide false confessions, leading to wrongful convictions. Some interventions and treatments have been shown to be effective in improving functioning in children and families affected by FASD, which tend to take the form of coaching, education, advocacy and support. People with FASD have many strengths, which are often overlooked in research. They have been described as skilled musicians, artists and sportspeople with wide vocabularies who are resilient, compassionate, hard-working, and kind. Increasing attention is being paid to FASD but this is not enough. More research, diagnostic capacity, recognition, understanding, infrastructure and support are needed across the world.

Long-term follow-up of a randomized controlled trial of choline for neurodevelopment in fetal alcohol spectrum disorder: corpus callosum white matter microstructure and neurocognitive outcomes

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a lifelong condition. Early interventions targeting core neurocognitive deficits have the potential to confer long-term neurodevelopmental benefits. Time-targeted choline supplementation is one such intervention that has been shown to provide neurodevelopmental benefits that emerge with age during childhood. We present a long-term follow-up study evaluating the neurodevelopmental effects of early choline supplementation in children with FASD approximately 7 years on average after an initial efficacy trial.

METHODS

The initial study was a randomized, double-blind, placebo-controlled trial of choline vs. placebo in 2.5 to 5 year olds with FASD. Participants in this long-term follow-up study include 18 children (9 placebo; 9 choline) seen 7 years on average following initial trial completion. The mean age at follow-up was 11.0 years old. Diagnoses were 28% fetal alcohol syndrome (FAS), 28% partial FAS, and 44% alcohol-related neurodevelopmental disorder. The follow-up included measures of executive functioning and an MRI scan.

RESULTS

Children who received choline had better performance on several tasks of lower-order executive function (e.g., processing speed) and showed higher white matter microstructure organization (i.e., greater axon coherence) in the splenium of the corpus callosum compared to the placebo group.

CONCLUSIONS

These preliminary findings, although exploratory at this stage, highlight potential long-term benefits of choline as a neurodevelopmental intervention for FASD and suggest that choline may affect white matter development, representing a potential target of choline in this population.

TRIAL REGISTRATION

Prior to enrollment, this trial was registered with clinicaltrials.gov ( NCT01149538 ) on June 23, 2010.

Prenatal and Postnatal Choline Supplementation in Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is common and represents a significant public health burden, yet very few interventions have been tested in FASD. Cognitive deficits are core features of FASD, ranging from broad intellectual impairment to selective problems in attention, executive functioning, memory, visual–perceptual/motor skills, social cognition, and academics. One potential intervention for the cognitive impairments associated with FASD is the essential nutrient choline, which is known to have numerous direct effects on brain and cognition in both typical and atypical development. We provide a summary of the literature supporting the use of choline as a neurodevelopmental intervention in those affected by prenatal alcohol. We first discuss how alcohol interferes with normal brain development. We then provide a comprehensive overview of the nutrient choline and discuss its role in typical brain development and its application in the optimization of brain development following early insult. Next, we review the preclinical literature that provides evidence of choline’s potential as an intervention following alcohol exposure. Then, we review a handful of existing human studies of choline supplementation in FASD. Lastly, we conclude with a review of practical considerations in choline supplementation, including dose, formulation, and feasibility in children.

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.

A fetal alcohol spectrum disorder diagnostic service and beyond: Outcomes for families

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is of significant concern for Australians for many reasons, one being Australia's drinking culture which increases the potential for FASD to occur.

AIMS

The current study aimed to explore the lived experiences of Australian caregivers who received a FASD diagnosis for a child in their care, usingthe Australian Guide to the Diagnosis of FASD.

METHODS AND PROCEDURES

Semi-structured interviews were conducted with seven caregivers whose children were assessed for FASD by a multidisciplinary team. Interviews explored how families experienced the FASD diagnostic process, and sought insight into outcomes for families following diagnosis, particularly in relation to accessing supports and services.

OUTCOMES AND RESULTS

Through thematic analysis, five overarching themes were identified: (1) receiving a FASD diagnosis had a positive impact; (2) caregivers' evaluation of assessment process; (3) positive support services relative to FASD; (4) ongoing difficulties regardless of diagnosis; and (5) need for societal knowledge of FASD.

CONCLUSIONS AND IMPLICATIONS

Given the global need for standardised FASD diagnostic procedures and accurate reporting of prevalence rates, the current study provides a contribution to the emerging diagnostic FASD literature, and insight into families' experiences who have children diagnosed with FASD.

WHAT THIS PAPER ADDS

This study provides additional information to the developing pool of literature attempting to create a typical profile of FASD. Most importantly, this paper highlights the implementation of the Australian Guide to the Diagnosis of FASD, and evaluates caregivers' experiences of their child's FASD assessment process, within a public FASD diagnostic service, using the revised guidelines.

Behaviour and adaptive functioning in children and young people with fetal alcohol spectrum disorders: a UK study

Purpose

The purpose of this paper is to explore the profiles of behaviours and adaptive functioning in the UK children and young people with fetal alcohol spectrum disorders.

Design/methodology/approach

Data of 106 participants registered from 2005 to 2015 were extracted from a clinic database. In total, 99 individuals with confirmed prenatal alcohol exposure (PAE), aged from 5 to 25 years, were analysed using scaled scores of the Vineland Adaptive Behavior Scales-Second Edition (VABS-II), and the Developmental Behaviour Checklist-Primary Carer Version (DBC-P) and Teacher Version (DBC-T). Differences due to age, gender, IQ and family structure (adopted/living with birth parents) were also explored.

Findings

The mean composite adaptive behaviour score on the VABS-II was classified as “low” at 68.2 (SD=8.5), with the socialisation domain being the most impaired. Significantly lower VABS-II composite scores were found in individuals with lower IQ’s, older ages and in males. Disruptive behaviours were the most commonly observed on the DBCs, whereas primary carers scored significantly higher than teachers across all subscales. IQ, age and gender were not associated with the total percentile scores of both DBCs. Adoption made no differences compared to living with birth parents.

Research limitations/implications

Future studies would replicate these findings in a larger sample size including individuals without PAE and those living with birth parents.

Originality/value

This study is the first UK report that examines this issue.

Stigma as a dominant discourse in fetal alcohol spectrum disorder

Purpose

The purpose of this paper is to conduct a scoping review of the literature to explore the many ways stigma affects people with FASD and to highlight the disciplines and places where discourse on FASD and stigma is taking place.

Design/methodology/approach

Searches were conducted in PubMed, ERIC, Family & Society Studies Worldwide, Families Studies Abstracts and Google Scholar between 2008 and 2018. Search terms focused on stigma, shame and the connection to FASD with a view to looking across social and medical science literature.

Findings

Searches identified 39 full text manuscripts, 13 of which were included in the scoping review. Stigma toward people with FASD exists in multiple professional forums across disciplines. The relationship between mother’s use of alcohol and the lasting impact on the child is a focus in the articles identified from a public health perspective. The review showed there was limited cross-disciplinary discussion evident. In total 13 articles were selected for inclusion in this review.

Research limitations/implications

Negative discourses predominate with little attention being paid to possible areas of success as well as cases of lower FASD impacts. There is a significant void in work focusing on positive outcomes for people with FASD. Such discourse would support a better understanding of pathways to more positive outcomes.

Originality/value

This paper highlights the issue of FASD and stigma through identification of relevant literature and expands the conversation to offer insights into the challenging terrain that individuals with FASD must navigate. The issue of stigma is not linked only to individuals with FASD but also their support systems. It is critical to recognize the multiple attributions of stigma to FASD in order to effectively take up conversations across and between disciplines to promote new discourses focused on de-stigmatization.

The Role of Integrated Care in a Medical Home for Patients With a Fetal Alcohol Spectrum Disorder

Fetal alcohol spectrum disorder (FASD) is an umbrella term used to describe preventable birth defects and intellectual and/or developmental disabilities resulting from prenatal alcohol exposure. The American Academy of Pediatrics has a previous clinical report in which diagnostic criteria for a child with an FASD are discussed and tools to assist pediatricians with its management can be found. This clinical report is intended to foster pediatrician awareness of approaches for screening for prenatal alcohol exposure in clinical practice, to guide management of a child with an FASD after the diagnosis is made, and to summarize available resources for FASD management.