FASD: What types of intervention and rehabilitation are useful?

The Impact of Oxidative Stress on the Epigenetics of Fetal Alcohol Spectrum Disorders

Fetal alcohol spectrum disorders (FASD) represent a continuum of lifelong impairments resulting from prenatal exposure to alcohol, with significant global impact. The "spectrum" of disorders includes a continuum of physical, cognitive, behavioral, and developmental impairments which can have profound and lasting effects on individuals throughout their lives, impacting their health, social interactions, psychological well-being, and every aspect of their lives. This narrative paper explores the intricate relationship between oxidative stress and epigenetics in FASD pathogenesis and its therapeutic implications. Oxidative stress, induced by alcohol metabolism, disrupts cellular components, particularly in the vulnerable fetal brain, leading to aberrant development. Furthermore, oxidative stress is implicated in epigenetic changes, including alterations in DNA methylation, histone modifications, and microRNA expression, which influence gene regulation in FASD patients. Moreover, mitochondrial dysfunction and neuroinflammation contribute to epigenetic changes associated with FASD. Understanding these mechanisms holds promise for targeted therapeutic interventions. This includes antioxidant supplementation and lifestyle modifications to mitigate FASD-related impairments. While preclinical studies show promise, further clinical trials are needed to validate these interventions' efficacy in improving clinical outcomes for individuals affected by FASD. This comprehensive understanding of the role of oxidative stress in epigenetics in FASD underscores the importance of multidisciplinary approaches for diagnosis, management, and prevention strategies. Continued research in this field is crucial for advancing our knowledge and developing effective interventions to address this significant public health concern.

Clinical Diagnosis and Management of Fetal Alcohol Spectrum Disorder and Sensory Processing Disorder in Children

Fetal alcohol spectrum disorder (FASD) is commonly misdiagnosed because of the complexity of presentation and multiple diagnostic criteria. FASD includes four categorical entities (fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol related neurodevelopmental disorder, and alcohol related birth defects). The four FASD diagnostic criteria are facial dysmorphology, growth deficiency, central nervous system dysfunction, and prenatal alcohol exposure. Sensory processing disorders (SPDs) are common in FASD and are observed as inappropriate behavioral responses to environmental stimuli. These can be either a sensory-based motor disorder, sensory discrimination disorder, or sensory modulation disorder. A child with SPD may experience challenges with their fine motor coordination, gross motor coordination, organizational challenges, or behavioral regulation impairments. FASD requires a multidimensional approach to intervention. Although FASD cannot be cured, symptoms can be managed with sleep-based therapies, sensory integration, and cognitive therapies. This paper reviews SPDs in FASD and the interventions that can be used by practitioners to help improve their therapeutic management, although it is unlikely that any single intervention will be the right choice for all patients.

Impact of low-level prenatal alcohol exposure and maternal stress on autonomic regulation

BACKGROUND

Prenatal alcohol exposure (PAE) impacts the neurodevelopment of the fetus, including the infant's ability to self-regulate. Heart rate variability (HRV), that is, the beat-to-beat variability in heart rate, is a non-invasive measurement that can indicate autonomic nervous system (ANS) function/dysfunction.

METHODS

The study consisted of a subset of our ENRICH-2 cohort: 80 participants (32 PAE and 48 Controls) who had completed three visits during pregnancy. The participants completed a comprehensive assessment of PAE and other substances throughout pregnancy and assessments for stress, anxiety, and depression in the third trimester. At 24 h of age, infant HRV was assessed in the hospital during the clinically indicated heel lance; 3- to 5-min HRV epochs were obtained during baseline, heel lancing, and recovery episodes.

RESULTS

Parameters of HRV differed in infants with PAE compared to Controls during the recovery phase of the heel lance (respiratory sinus arrhythmia (RSA) and high-frequency (HF), p < 0.05). Increased maternal stress was also strongly associated with abnormalities in RSA, HF, and low-frequency / high-frequency (LF/HF, p's < 0.05).

CONCLUSIONS

Alterations in ANS regulation associated with PAE and maternal stress may reflect abnormal development of the hypothalamic-pituitary-adrenal axis and have long term implications for infant responsiveness and self-regulation.

IMPACT

Previous studies have focused on effects of moderate to heavy prenatal alcohol exposure (PAE) on autonomic dysregulation, but little is known about the effects of lower levels of PAE on infant self-regulation and heart rate variability (HRV). Prenatal stress is another risk factor for autonomic dysregulation. Mild PAE impacts infant self-regulation, which can be assessed using HRV. However, the effect of prenatal stress is stronger than that of mild PAE or other mental health variables on autonomic dysregulation.

Examining the effects of prenatal alcohol exposure on performance of the sustained attention to response task in children with an FASD

Prenatal alcohol exposure (PAE), the leading known cause of childhood developmental disability, has long-lasting effects extending throughout the lifespan. It is well documented that children prenatally exposed to alcohol have difficulties inhibiting behavior and sustaining attention. Thus, the Sustained Attention to Response Task (SART), a Go/No-go paradigm, is especially well suited to assess the behavioral and neural functioning characteristics of children with PAE. In this study, we utilized neuropsychological assessment, parent/guardian questionnaires, and magnetoencephalography during SART random and fixed orders to assess characteristics of children 8-12 years old prenatally exposed to alcohol compared to typically developing children. Compared to neurotypical control children, children with a Fetal Alcohol Spectrum Disorder (FASD) diagnosis had significantly decreased performance on neuropsychological measures, had deficiencies in task-based performance, were rated as having increased Attention-Deficit/Hyperactivity Disorder (ADHD) behaviors and as having lower cognitive functioning by their caretakers, and had decreased peak amplitudes in Broadmann's Area 44 (BA44) during SART. Further, MEG peak amplitude in BA44 was found to be significantly associated with neuropsychological test results, parent/guardian questionnaires, and task-based performance such that decreased amplitude was associated with poorer performance. In exploratory analyses, we also found significant correlations between total cortical volume and MEG peak amplitude indicating that the reduced amplitude is likely related in part to reduced overall brain volume often reported in children with PAE. These findings show that children 8-12 years old with an FASD diagnosis have decreased amplitudes in BA44 during SART random order, and that these deficits are associated with multiple behavioral measures.

FASDetect as a machine learning-based screening app for FASD in youth with ADHD

Fetal alcohol-spectrum disorder (FASD) is underdiagnosed and often misdiagnosed as attention-deficit/hyperactivity disorder (ADHD). Here, we develop a screening tool for FASD in youth with ADHD symptoms. To develop the prediction model, medical record data from a German University outpatient unit are assessed including 275 patients aged 0-19 years old with FASD with or without ADHD and 170 patients with ADHD without FASD aged 0-19 years old. We train 6 machine learning models based on 13 selected variables and evaluate their performance. Random forest models yield the best prediction models with a cross-validated AUC of 0.92 (95% confidence interval [0.84, 0.99]). Follow-up analyses indicate that a random forest model with 6 variables - body length and head circumference at birth, IQ, socially intrusive behaviour, poor memory and sleep disturbance - yields equivalent predictive accuracy. We implement the prediction model in a web-based app called FASDetect - a user-friendly, clinically scalable FASD risk calculator that is freely available at https://fasdetect.dhc-lab.hpi.de .

Infants, children, and youth in foster care with prenatal substance exposure: a synthesis of two scoping reviews

Background: Infants, children, and youth in foster care have frequently experienced prenatal substance exposure (PSE), neglect, and maltreatment as well as disruptions in their relationships with families. They also have great capacity for overcoming early adversities. In this synthesis of two previously conducted scoping reviews, we aimed to identify and describe literature that identifies a range of interventions that support the health and development of this population. Methods: This review integrates and extends two previously conducted scoping reviews, one focusing on infants and one focusing on children and youth, to synthesize themes across these developmental stages. The Joanna Briggs Institute scoping review methodology was employed for the current and previous reviews. A three-step search strategy identified published studies in the English language from January 2006 to February 2020. Results: One-hundred and fifty-three sources were included in this review. Four themes were identified: (1) early screening, diagnosis, and intervention; (2) providing theoretically grounded care; (3) supporting parents and foster care providers; and (4) intersectoral collaboration. Conclusion:Infants, children, and youth with PSE are overrepresented in foster care. Child welfare system planning should take a multi-sectoral approach to addressing the cumulative needs of this population and their care providers over developmental ages and stages. Although research remains limited, early screening, diagnosis, and developmentally and fetal alcohol spectrum disorder-informed intersectoral interventions are critical for optimizing outcomes.

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.

Fetal alcohol spectrum disorder resources for educators: A scoping review

Children with foetal alcohol spectrum disorder (FASD) can experience neurodevelopmental, physical, psychological and behavioural impairments that can result in a disrupted school experience. However, educators often have limited knowledge or experience in the identification and support of students with FASD, and there is a critical need for effective tools and resources to ensure students with FASD are supported in their ongoing learning and development. This scoping review aimed to identify and evaluate publicly available educator resources that aid in the identification, and support of students with FASD in primary/elementary school. In addition, educators and FASD experts were consulted to obtain feedback on currently available resources, and key issues and priorities for FASD resources. In total, 124 resources were identified by searching peer‐reviewed and grey literature databases, app stores, podcast services and contacting FASD experts. Information was found on identification (23 resources) and support of students with FASD (119 resources). No resources provided information on the referral. Most resources were average (40%) to good (33%) quality, as measured by a composite tool based on adaptions of the NHMRC FORM Framework and iCAHE Guideline Quality Checklist. A minority of resources had been formally evaluated (7%). Review findings and consultations with experts and educators indicate a critical need for referral guides, evidence‐based short‐format resources and centralised access for school communities to high‐quality resources. Taken together, this study has identified key areas for future resource development and research to better support primary school students with FASD.

Behavior regulation skills are associated with adaptive functioning in children and adolescents with prenatal alcohol exposure

Children with prenatal alcohol exposure (PAE) experience a range of adverse outcomes that impact multiple domains of functioning, including cognitive, physical, mental health, behavioral, social-emotional, communication, and learning. To inform tailored clinical intervention, the current study examined the relation between caregiver-reported cognitive skills (executive function; EF) and adaptive functioning. The study conducted a secondary analyses of data provided by caregivers of 87 children and adolescents (aged 5-18 years, M = 11.7; 52% male) with confirmed PAE, including a subset (n = 70) with Fetal Alcohol Spectrum Disorder (FASD), who reported on their child's EF (Behavior Rating Inventory of Executive Function) and adaptive function (Adaptive Behavior Assessment System, 2nd Edition) skills. Findings from the current study showed that caregivers reported significantly poorer EF and adaptive functioning skills for children with PAE as compared to normative samples. Poorer behavior regulation skills were associated with all aspects of adaptive functioning (i.e., practical, conceptual, and social skills). Specifically, shifting skills emerged as the best predictor of adaptive functioning among children with PAE. These results highlight the possibility that targeting particular EF domains among individuals with PAE may benefit behavior regulation, which may also extend to adaptive skills. This highlights the need to develop EF interventions for children and adolescents who have been prenatally exposed to alcohol.

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.

Covariation Between Brain Function (MEG) and Structure (DTI) Differentiates Adolescents with Fetal Alcohol Spectrum Disorder from Typically Developing Controls

The behavioral, cognitive, and sensory difficulties experienced by individuals exposed to alcohol prenatally currently fail to provide early identification for fetal alcohol spectrum disorder (FASD). Attempting to advance this pursuit through a multivariate analysis, we collected magnetoencephalography (MEG) data during auditory, somatosensory, visual paradigms, DTI, and behavior in adolescents ages 12-21 years (FASD: N = 13; HC: N = 20). We assessed the relationship between brain function (MEG) and structure (fractional anisotropy (FA)) utilizing joint independent component analysis (jICA), and examined how this measure relates to behavior. We identified 5 components that reveal group differences in co-variation between MEG and FA. For example, component 5 (t = 3.162, p = 0.003, Hedges' g = 1.13) contained MEG activity corresponding to all three sensory modalities, most robustly in occipital lobes, and DTI-derived cerebellar FA, underlying the role of the cerebellum in sensory processing. Further, in HCs component 5's loading factor was positively correlated with verbal ability (r = 0.646, p = 0.002), indicating higher covariation was associated with better verbal performance. Interestingly, this relationship is lacking in FASD (r = 0.009, p = 0.979). Also, component 5 loading factor negatively correlated with impulsivity (r = -0.527, p = 0.002), indicating that stronger function-structure associations were associated with individuals with lower impulsivity. These findings suggest that multimodal integration of MEG and FA provides novel associations between structure and function that may help differentiate adolescents with FASD from HC.

Comparing Executive Functioning in Children and Adolescents With Fetal Alcohol Spectrum Disorders and ADHD: A Meta-Analysis

Objective: Fetal alcohol spectrum disorders (FASD) and Attention-Deficit/Hyperactivity Disorder (ADHD) are associated with a range of neurocognitive impairments. Executive functioning deficits are a hallmark feature of both disorders. Method: The present meta-analysis was undertaken to disentangle the behavioral phenotype of FASD and ADHD by quantitatively differentiating executive functioning differences between these two groups. The current meta-analysis reviews 15 studies comparing children and adolescents with FASD and ADHD to typically developing (TD) samples, on a variety of executive function measures. Results: Results indicate that when compared with TD samples, FASD and ADHD samples demonstrate significant executive function deficits (d = 0.82 and d = 0.55, respectively). In addition, FASD samples experience significantly greater deficits when compared with ADHD samples (d = 0.25). Results were moderated by IQ and socioeconomic status. Conclusion: These findings further our understanding of the cognitive differences between FASD and ADHD samples and have the potential to influence future basic research, assessment, and intervention.

A therapeutic approach to learning through creative storytelling

Purpose

The purpose of this paper is to provide an overview of a Learning Programme designed around the animation film-making process, contextualising abstract concepts to address the cognitive limitations of children with foetal alcohol spectrum disorders (FASD).

Design/methodology/approach

Animation production is tactile, multimodal and multisensory which allows for wide application alongside traditional learning tools, targeting multiple learning pathways with its visual, auditory and kinaesthetic approach. Individuals with FASD require information to be explained in a concrete way to enable them to process and understand. Most information can be drawn, providing a visual to assist the individual, but we must also consider abstract concepts which require further explanation or a series of drawings to display the concepts development. Animation, however, allows us the opportunity to make abstract concepts concrete, contextualising the concept in a visualisation of the child’s story, narrated with their voice and designed to represent their world, in a film produced entirely by them, therefore allowing opportunity for a therapeutic approach to learning through storytelling. This learning tool is designed to be implemented in a specifically designed therapeutic learning environment to enhance the benefits of participation from both educational and therapeutic perspectives.

Findings

A review of relevant literature highlights a significant connection between animation, the learning needs of those with FASD and the need for a therapeutic learning environment. This is a proof of concept study, demonstrating the value and potential of animation film making in this new area of practical application. The study closely considers the learning environment from a therapeutic perspective and aims not only to develop a learning tool but to also define the optimum therapeutic learning environment. The study is therefore untested at this stage.

Practical implications

Phase 2 of this ongoing research study seeks to explore additional benefits of participation and engagement with the process in an educational and therapeutic context. Considerations of the therapeutic learning environment will be further explored to determine the optimum setting to support the ongoing learning of this pedagogically bereft (Carpenter, 2011) population. Phase 2 also aims to clarify therapeutic benefits as additional outcomes of participation in this programme.

Originality/value

The proposed learning tool and therapeutic learning environment outlined in this paper is an original contribution to knowledge and if found to be successful, could offer significant opportunities for a therapeutic approach to education for this population and others.

The past, present, and future of fetal alcohol spectrum disorder work in Newfoundland and Labrador: A landscape paper for change

OBJECTIVES

In this paper, we provide an overview of best practices in FASD prevention, diagnostic, and interventions and supports. In Canada, people diagnosed with Fetal Alcohol Spectrum Disorder (FASD) represent a fraction people living with FASD. While social stigma may deter people from seeking an FASD diagnosis, other deterrents include the lack of screening and diagnostic referrals, cost of travelling to a clinic, and lack of clarity of how a diagnosis may improve supports and services. Preventing FASD and improving lifelong outcomes for people living with FASD requires a coordinated approach between prevention, diagnostic, intervention, and support efforts.

METHODS

Using the example of Newfoundland and Labrador, a province where 60% of the population lives in rural communities and benefits from being involved in national initiatives and partnerships, we discuss efforts underway in other Canadian provinces to address FASD.

RESULTS

We make three recommendations that begin to address FASD-specific needs in both rural and urban regions: a) a provincial FASD consultant position, b) an explicit partnership between provincial government and fasdNL, and c) increased access to FASD diagnostic teams.

CONCLUSION

While the recommendations are both modest and essential first steps, we also suggest that collaborations and resource-sharing in FASD prevention and supports are more about doing things differently, rather than doing more.

An investigation of intra-individual variability in children with fetal alcohol spectrum disorder (FASD)

Intra-individual variability (IIV) is defined as systematic within-person variation in performance either across test sessions (e.g., test/retest performance on the same task) or in one session (e.g., variations in performance on multiple trials of a single task). Higher levels of IIV have been noted as a characteristic of neurodevelopmental disorders such as attention deficit/hyperactivity disorder​ (ADHD), but IIV is yet to be investigated in fetal alcohol spectrum disorder (FASD). FASD is a term used to describe a range of conditions resulting from prenatal exposure to alcohol. As part of a comprehensive neuropsychological battery, four study groups (1. fetal alcohol syndrome/partial fetal alcohol syndrome; 2. static encephalopathy/alcohol exposed; 3. neurobehavioral disorder/alcohol exposed as diagnosed using the University of Washington FASD 4-Digit Code; 4. typically-developing (TD) age-matched children with no prenatal alcohol exposure) were administered measures of motor response and inhibitory control, attention, and adaptive behavior. The results indicate increased levels of IIV in those with FASD compared to the TD controls. It was found that IIV uniquely contributes to predicting adaptive behavior above and beyond attention, while attention partially mediates the relationship between IIV and adaptive behavior. This is the first study to the authors' knowledge to show the presence of increased IIV in children with FASD. It additionally provides evidence that IIV measures some inherent variability in performance independent of poor attention in children with FASD.

Study protocol for a self-controlled cluster randomised trial of the Alert Program to improve self-regulation and executive function in Australian Aboriginal children with fetal alcohol spectrum disorder

INTRODUCTION

While research highlights the benefits of early diagnosis and intervention for children with fetal alcohol spectrum disorders (FASD), there are limited data documenting effective interventions for Australian children living in remote communities.

METHODS AND ANALYSIS

This self-controlled cluster randomised trial is evaluating the effectiveness of an 8-week Alert Program school curriculum for improving self-regulation and executive function in children living in remote Australian Aboriginal communities. Children in grades 1-6 attending any of the eight participating schools across the Fitzroy Valley in remote North-West Australia (N ≈ 363) were invited to participate. Each school was assigned to one of four clusters with clusters randomly assigned to receive the intervention at one of four time points. Clusters two, three and four had extended control conditions where students received regular schooling before later receiving the intervention. Trained classroom teachers delivered the Alert Program to students in discrete, weekly, 1-hour lessons. Student outcomes were assessed at three time points. For the intervention condition, data collection occurred 2 weeks immediately before and after the intervention, with a follow-up 8 weeks later. For control conditions in clusters two to four, the control data collection matched that of the data collection for the intervention condition in the preceding cluster. The primary outcome is change in self-regulation. FASD diagnoses will be determined via medical record review after the completion of data collection. The results will be analysed using generalised linear mixed modelling and reported in accordance with Consolidated Standards of Reporting Trials (CONSORT) guidelines.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Western Australia (WA) (RA/4/1/7234), WA Aboriginal Health Ethics Committee (601) and WA Country Health Service (2015:04). The Kimberley Aboriginal Health Planning Forum Research Sub-Committee and WA Department of Education also provided approval. The results will be disseminated through peer-reviewed journals, conference presentations, the media and at forums.

TRIAL REGISTRATION NUMBER

ACTRN12615000733572; Pre-results.

Strain-specific programming of prenatal ethanol exposure across generations

Behavioral consequences of prenatal alcohol exposure (PAE) can be transmitted from in utero-exposed F1 generation to their F2 offspring. This type of transmission is modulated by genetic and epigenetic mechanisms. This study investigated the intergenerational consequences of prenatal exposure to a low ethanol dose (1 g/kg) during gestational days 17-20, on ethanol-induced hypnosis in adolescent male F1 and F2 generations, in two strains of rats. Adolescent Long-Evans and Sprague-Dawley male rats were tested for sensitivity to ethanol-induced hypnosis at a 3.5-g/kg or 4.5-g/kg ethanol dose using the loss of righting reflex (LORR) paradigm. We hypothesized that PAE would attenuate sensitivity to ethanol-induced hypnosis in the ethanol-exposed animals in these two strains and in both generations. Interestingly, we only found this effect in Sprague-Dawley rats. Lastly, we investigated PAE related changes in expression of GABA_A receptor α1, α4, and δ subunits in the cerebral cortex of the PAE sensitive Sprague-Dawley strain. We hypothesized a reduction in the cerebral cortex GABA_A receptor subunits' expression in the F1 and F2 PAE groups compared to control animals. GABA_A receptor α1, α4, and δ subunits protein expressions were quantified in the cerebral cortex of F1 and F2 male adolescents by western blotting. PAE did not alter cerebral cortical GABA_A receptor subunit expressions in the F1 generation, but it decreased GABA_A receptor α4 and δ subunits' expressions in the F2 generation, and had a tendency to decrease α1 subunit expression. We also found correlations between some of the subunits in both generations. These strain-dependent vulnerabilities to ethanol sensitivity, and intergenerational PAE-mediated changes in sensitivity to alcohol indicate that genetic and epigenetic factors interact to determine the outcomes of PAE animals and their offspring.

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.

Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure

Children and adolescents affected by prenatal exposure to alcohol who have brain damage that is manifested in functional impairments of neurocognition, self-regulation, and adaptive functioning may most appropriately be diagnosed with neurobehavioral disorder associated with prenatal exposure. This Special Article outlines clinical implications and guidelines for pediatric medical home clinicians to identify, diagnose, and refer children regarding neurobehavioral disorder associated with prenatal exposure. Emphasis is given to reported or observable behaviors that can be identified as part of care in pediatric medical homes, differential diagnosis, and potential comorbidities. In addition, brief guidance is provided on the management of affected children in the pediatric medical home. Finally, suggestions are given for obtaining prenatal history of in utero exposure to alcohol for the pediatric patient.

Special Education of Children with Fetal Alcohol Spectrum Disorder

The current study aimed to estimate the cost associated with special education among children (5 to 14 years) with Fetal Alcohol Spectrum Disorder (FASD) in elementary and middle school by sex, age group, and province and territory in Canada. It was estimated that there were 6,520 students with FASD receiving special education in Canada in 2011-2012. The cost of special education among these students was 53.5 million Canadian dollars. Implications for decision- and policymakers, educational systems and school staff are discussed.

Effects of prenatal substance exposure on neurocognitive correlates of inhibitory control success and failure

Adolescents with prenatal substance (drug and alcohol) exposure exhibit inhibitory control (IC) deficits and aberrations in associated neural function. Nearly all research to date examines exposure to individual substances, and a minimal amount is known about the effects of heterogeneous exposure-which is more representative of population exposure levels. Using functional magnetic resonance imaging (fMRI), we investigated IC (Go/NoGo) in heterogeneously exposed (n = 7) vs. control (n = 7) at-risk adolescents (ages 13-17). The fMRI results indicated multiple IC processing differences consistent with a more immature developmental profile for exposed adolescents (Exposed  >  Nonexposed: NoGo > Go: right ventrolateral prefrontal cortex, right cuneus, and left inferior parietal lobe; NoGo > false alarm: occipital lobe; Go > false alarm: right anterior prefrontal cortex). Simple effects suggest exposed adolescents exhibited exaggerated correct trial but decreased incorrect trial activation. Results provide initial evidence that prenatal exposure across substances creates similar patterns of atypical brain activation to IC success and failure.

Research Review: Executive function deficits in fetal alcohol spectrum disorders and attention-deficit/hyperactivity disorder - a meta-analysis

BACKGROUND

Attention-deficit/hyperactivity disorder (ADHD)-like symptoms are common in fetal alcohol spectrum disorders (FASD). FASD and ADHD groups both display executive function impairments; however, there is ongoing debate whether the pattern and magnitude of executive function deficits differs between these two types of disorders.

METHODS

An electronic literature search was conducted (PubMed, PsychInfo; 1972-2013) to identify studies comparing the executive functioning of children with FASD with ADHD or control groups. FASD groups included those with and without dysmorphy (i.e., FAS, pFAS, ARND, and other FASD diagnoses). Effect sizes (Hedges' g, standardized mean difference) were calculated. Random effects meta-analytic models were performed using the metafor package for R.

RESULTS

Fifty-one studies met inclusion criteria (FASD N = 2,115; ADHD N = 453; controls N = 1,990). Children with FASD showed the strongest and most consistent deficits in planning, fluency, and set-shifting compared to controls (Hedges' g = -0.94, -0.78) and children with ADHD (Hedges' g = -0.72, -0.32). FASD was associated with moderate to large impairments in working memory, compared to controls (Hedges' g = -.84, -.58) and small impairments relative to groups with ADHD (Hedges' g = -.26). Smaller and less consistent deficits were found on measures of inhibition and vigilance relative to controls (Hedges' g = -0.52, -0.31); FASD and ADHD were not differentiated on these measures. Moderator analyses indicated executive dysfunction was associated with older age, dysmorphy, and larger group differences in IQ. Sex and diagnostic system were not consistently related to effect size.

CONCLUSIONS

While FASD is associated with global executive impairments, executive function weaknesses are most consistent for measures of planning, fluency, and set-shifting. Neuropsychological measures assessing these executive function domains may improve differential diagnosis and treatment of FASD.

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.

The Knowledge of Rehabilitation Professionals Concerning Fetal Alcohol Spectrum Disorders

The purpose of this study was to explore rehabilitation professionals' knowledge regarding signs and symptoms, prevention, and intervention of fetal alcohol spectrum disorders (FASD). Participants were 111 rehabilitation practitioners (e.g., occupational therapy, physical therapy, and speech-language pathology practitioners) recruited through email using a quantitative online survey design with purposive, snowball sampling. Results showed the majority of participants' demonstrated accurate knowledge of the signs and symptoms of FASD. Since professionals who received formal education on FASD reported significantly higher feelings of preparedness to identify children with FASD and manage/coordinate intervention plans, this study suggests rehabilitation professionals may be better prepared to treat individuals with FASD if they participate in formal training.

Maternal factors predicting cognitive and behavioral characteristics of children with fetal alcohol spectrum disorders

OBJECTIVE

To provide an analysis of multiple predictors of cognitive and behavioral traits for children with fetal alcohol spectrum disorders (FASDs).

METHOD

Multivariate correlation techniques were used with maternal and child data from epidemiologic studies in a community in South Africa. Data on 561 first-grade children with fetal alcohol syndrome (FAS), partial FAS (PFAS), and not FASD and their mothers were analyzed by grouping 19 maternal variables into categories (physical, demographic, childbearing, and drinking) and used in structural equation models (SEMs) to assess correlates of child intelligence (verbal and nonverbal) and behavior.

RESULTS

A first SEM using only 7 maternal alcohol use variables to predict cognitive/behavioral traits was statistically significant (B = 3.10, p < .05) but explained only 17.3% of the variance. The second model incorporated multiple maternal variables and was statistically significant explaining 55.3% of the variance. Significantly correlated with low intelligence and problem behavior were demographic (B = 3.83, p < .05) (low maternal education, low socioeconomic status [SES], and rural residence) and maternal physical characteristics (B = 2.70, p < .05) (short stature, small head circumference, and low weight). Childbearing history and alcohol use composites were not statistically significant in the final complex model and were overpowered by SES and maternal physical traits.

CONCLUSIONS

Although other analytic techniques have amply demonstrated the negative effects of maternal drinking on intelligence and behavior, this highly controlled analysis of multiple maternal influences reveals that maternal demographics and physical traits make a significant enabling or disabling contribution to child functioning in FASD.

From research to practice: an integrative framework for the development of interventions for children with fetal alcohol spectrum disorders

Since fetal alcohol syndrome was first described over 35 years ago, considerable progress has been made in the delineation of the neurocognitive profile in children with prenatal alcohol exposure. Preclinical investigators have made impressive strides in elucidating the mechanisms of alcohol teratogenesis and in testing the effectiveness of pharmacological agents and dietary supplementation in the amelioration of alcohol-induced deficits. Despite these advances, only limited progress has been made in the development of evidence-based comprehensive interventions for functional impairment in alcohol-exposed children. Having performed a search in PubMed and PsycINFO using key words, interventions, treatment, fetal alcohol syndrome, prenatal alcohol exposure, and fetal alcohol spectrum disorders, we found only 12 papers on empirically-based interventions. Only two of these interventions had been replicated and none met the criteria of "well-established," as defined by Chambless and Hollon (Journal of Consulting and Clinical Psychology 66(1):7-18, 1998). There has been only limited cross-fertilization of ideas between preclinical and clinical research with regard to the development of interventions. Therefore, we propose a framework that allows integrating data from preclinical and clinical investigations to develop comprehensive intervention programs for children with fetal alcohol spectrum disorders. This framework underscores the importance of multi-level evaluations and interventions.

Children with Fetal Alcohol Spectrum Disorders in the Dependency Court System: Challenges and Recommendations

Children with Fetal Alcohol Spectrum Disorders (FASD) are at a greatly increased risk for developmental delays, learning disabilities, and behavioral, social, and emotional problems. High rates of secondary disabilities have been reported in this population, including mental health problems, school failure, delinquency, plus alcohol and substance abuse problems. Long-term outcomes for adolescents and adults with FASD include increased risk for unemployment, suicidal ideation and behavior, and confinement in psychiatric facilities and correctional institutions. Many children impacted by prenatal alcohol exposure are raised in out-of-home placements, and thus will likely have extensive involvement with the child welfare and dependency court systems. However, child welfare agencies and dependency courts are often not well-equipped to handle cases involving these children. This article will address the challenges that children with FASD and their families face in those systems, as well as recommendations for improvements in how those systems respond to the needs of these highly vulnerable children.

A neurodevelopmental framework for the development of interventions for children with fetal alcohol spectrum disorders

Despite considerable data published on cognitive and behavioral disabilities in children with fetal alcohol spectrum disorders (FASD), relatively little information is available on behavioral or pharmacological interventions for alcohol-affected children. The main goals of this article, therefore, are to summarize published intervention studies of FASD and to present a neurodevelopmental framework, based on recent findings from a number of disciplines, for designing new therapies for alcohol-affected children. This framework assumes a neuroconstructionist view, which posits that reciprocal interactions between neural activity and the brain's hardware lead to the progressive formation of intra- and interregional neural connections. In this view, behavioral interventions can be conceptualized as a series of guided experiences that are designed to produce neural activation. Based on evidence from cognitive neuroscience, it is hypothesized that specific interventions targeting executive attention and self-regulation may produce greater generalizable results than those aimed at domain-specific skills in children with FASD. In view of reciprocal interactions between environmental effects and neural structures, the proposed framework suggests that the maximum effects of interventions can eventually be achieved by optimally combining behavioral methods and cognition-enhancing drugs.

Children and youth with fetal alcohol spectrum disorders: summary of intervention recommendations after clinical diagnosis

Children with fetal alcohol spectrum disorders (FASDs) present with a wide range of developmental disabilities; however, clinical standards of care after a diagnosis are not well established. This retrospective review summarizes the types of intervention recommendations generated by an interdisciplinary FASD diagnostic team for 120 children ages 0.2 to 16.5 years receiving an FASD diagnosis at the University of Washington FAS Diagnostic & Prevention Network Clinic. Intervention recommendations documented in a FASD diagnostic summary report and submitted to each patient's medical record were subject to masked review and content analysis. Intervention recommendations were compared across 3 FASD diagnostic groups and selected demographic variables. The results show the type and frequency of services, supports, and resources recommended to a clinical sample of children with FASD.

Brief alcohol intervention to prevent drinking during pregnancy: an overview of research findings

PURPOSE OF REVIEW

The aim is to describe the theory and practice of brief alcohol interventions and provide a summary of the current evidence base, including details about the four randomized controlled trials that have been conducted with pregnant women. Opportunities for providing alcohol interventions for pregnant women in antenatal care are also addressed.

RECENT FINDINGS

Brief intervention has emerged as a promising approach to provide early intervention, before or soon after the onset of alcohol-related problems. There is convincing evidence for the efficacy and effectiveness of brief intervention in various healthcare settings. The findings from four randomized brief intervention trials that have been conducted with pregnant women are consistent with the broader literature on brief intervention. The interventions were effective in reducing alcohol consumption, but control group participants also reduced their consumption to the degree that statistically significant differences between the groups were difficult to detect.

SUMMARY

Pregnant women are generally believed to be highly motivated to reduce their alcohol intake, and the contextual change provided by the pregnancy provides an opportunity to break habitual drinking behaviour. There is an empirical and theoretical support for providing brief intervention in antenatal care to achieve reduced or no alcohol consumption during pregnancy.

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.

Psychiatric conditions associated with prenatal alcohol exposure

Since the identification of fetal alcohol syndrome (FAS) over 35 years ago, mounting evidence about the impact of maternal alcohol consumption during pregnancy has prompted increased attention to the link between prenatal alcohol exposure (PAE) and a constellation of developmental disabilities that are characterized by physical, cognitive, and behavioral impairments. These disabilities include a continuum of developmental disorders known as fetal alcohol spectrum disorders (FASDs). Longitudinal studies suggest that individuals with FASDs are at a greatly increased risk for adverse long-term outcomes, including mental health problems and poor social adjustment. This review summarizes the existing literature on mental health outcomes for individuals with PAE across the lifespan, including findings in infancy and early childhood, middle childhood, and adolescence and early adulthood. Research on the psychiatric disabilities suffered by individuals with FASDs throughout development highlights the need for training of mental health professionals in the identification and the provision of specific treatments to address the unique features of this developmental disability since early identification and treatment have been demonstrated to be protective against more serious secondary disabilities. It is hoped that with greater awareness of the mental health problems experienced by individuals with FASDs, these individuals can receive appropriate and early treatment resulting in more adaptive and rewarding lives.

Interventions for children with fetal alcohol spectrum disorders (FASDs): overview of findings for five innovative research projects

It is well established that prenatal exposure to alcohol causes damage to the developing fetus, resulting in a spectrum of disorders known as fetal alcohol spectrum disorders (FASDs). Although our understanding of the deficits and disturbances associated with FASDs is far from complete, there are consistent findings indicating these are serious, lifelong disabilities-especially when these disabilities result from central nervous system damage. Until recently, information and strategies for interventions specific to individuals with FASDs have been gleaned from interventions used with people with other disabilities and from the practical wisdom gained by parents and clinicians through trial and error or shared through informal networks. Although informative to a limited degree, such interventions have been implemented without being evaluated systematically or scientifically. The purpose of this article is to provide a brief overview of a general intervention framework developed for individuals with FASDs and the methods and general findings of five specific intervention research studies conducted within this framework. The studies evaluated five different interventions in five diverse locations in the United States, with different segments of the FASD population. Nonetheless, all participants showed improvement in the target behaviors or skills, with four studies achieving statistical significance in treatment outcomes. Important lessons emerged from these five interventions that may explain success: including parent education or training, teaching children specific skills they would usually learn by observation or abstraction, and integration into existing systems of treatment. A major implication of these research studies for families dealing with FASDs is that there are now interventions available that can address their children's needs and that can be presented as scientifically validated and efficacious to intervention agents such as schools, social services, and mental health providers. In the field of FASD research and clinical service, a common theme reported by families has been that clinicians and professionals have been reluctant to diagnose their children because there were no known effective treatments. Results of these five studies dispel that concern by demonstrating several interventions that have been shown to improve the lives of individuals with FASDs and their families.

Systematic review of interventions for children with Fetal Alcohol Spectrum Disorders

BACKGROUND

Children with Fetal Alcohol Spectrum Disorders (FASD) may have significant neurobehavioural problems persisting into adulthood. Early diagnosis may decrease the risk of adverse life outcomes. However, little is known about effective interventions for children with FASD. Our aim is to conduct a systematic review of the literature to identify and evaluate the evidence for pharmacological and non-pharmacological interventions for children with FASD.

METHODS

We did an electronic search of the Cochrane Library, MEDLINE, EMBASE, PsychINFO, CINAHL and ERIC for clinical studies (Randomized controlled trials (RCT), quasi RCT, controlled trials and pre- and post-intervention studies) which evaluated pharmacological, behavioural, speech therapy, occupational therapy, physiotherapy, psychosocial and educational interventions and early intervention programs. Participants were aged under 18 years with a diagnosis of a FASD. Selection of studies for inclusion and assessment of study quality was undertaken independently by two reviewers. Meta-analysis was not possible due to diversity in the interventions and outcome measures.

RESULTS

Twelve studies met the inclusion criteria. Methodological weaknesses were common, including small sample sizes; inadequate study design and short term follow up. Pharmacological interventions, evaluated in two studies (both RCT) showed some benefit from stimulant medications. Educational and learning strategies (three RCT) were evaluated in seven studies. There was some evidence to suggest that virtual reality training, cognitive control therapy, language and literacy therapy, mathematics intervention and rehearsal training for memory may be beneficial strategies. Three studies evaluating social communication and behavioural strategies (two RCT) suggested that social skills training may improve social skills and behaviour at home and Attention Process Training may improve attention.

CONCLUSION

There is limited good quality evidence for specific interventions for managing FASD, however seven randomized controlled trials that address specific functional deficits of children with FASD are underway or recently completed.

Approaches to assessment of alcohol intake during pregnancy in Swedish maternity care--a national-based investigation into midwives' alcohol-related education, knowledge and practice

OBJECTIVE

to evaluate how much education midwives in Sweden have undertaken to help them assess alcohol intake during pregnancy, and what tools they use to identify women who may be at risk of drinking during pregnancy.

DESIGN

a national survey was conducted in March 2006, using a questionnaire constructed by a Swedish team of researchers and clinicians.

SETTING

maternity health-care centres in Sweden.

PARTICIPANT

2106 midwives.

FINDINGS

nearly all midwives stated that they had excellent or good knowledge concerning the risks associated with drinking during pregnancy. They considered themselves less knowledgeable about detecting pregnant women with risky alcohol consumption before pregnancy. The majority of the midwives had participated in some education in handling risky drinking. Almost half of the midwives assessed women's alcohol intake before pregnancy. Important facilitators for increased activity concerned recommendations and decisions at different levels (national, local and management) on how to address alcohol with expectant parents and work with risky drinkers.

KEY CONCLUSIONS

more education was associated with more common use of a questionnaire for assessment of women's alcohol intake before pregnancy, and more frequent counselling when identifying a pregnant woman whose pre-pregnancy consumption was risky.

Peptidergic agonists of activity-dependent neurotrophic factor protect against prenatal alcohol-induced neural tube defects and serotonin neuron loss

INTRODUCTION

Prenatal alcohol exposure via maternal liquid diet consumption by C57BL/6 (B6) mice causes conspicuous midline neural tube deficit (dysraphia) and disruption of genesis and development of serotonin (5-HT) neurons in the raphe nuclei, together with brain growth retardation. The current study tested the hypothesis that concurrent treatment with either an activity-dependent neurotrophic factor (ADNF) agonist peptide [SALLRSIPA, (SAL)] or an activity-dependent neurotrophic protein (ADNP) agonist peptide [NAPVSIPQ, (NAP)] would protect against these alcohol-induced deficits in brain development.

METHODS

Timed-pregnant B6 dams consumed alcohol from embryonic day 7 (E7, before the onset of neurulation) until E15. Fetuses were obtained on E15 and brain sections processed for 5-HT immunocytochemistry, for evaluation of morphologic development of the brainstem raphe and its 5-HT neurons. Additional groups were treated either with SAL or NAP daily from E7 to E15 to assess the potential protective effects of these peptides. Measures of incomplete occlusion of the ventral canal and the frequency and extent of the openings in the rhombencephalon were obtained to assess fetal dysraphia. Counts of 5-HT-immunostained neurons were also obtained in the rostral and caudal raphe.

RESULTS

Prenatal alcohol exposure resulted in abnormal openings along the midline and delayed closure of ventral canal in the brainstem. This dysraphia was associated with reductions in the number of 5-HT neurons both in the rostral raphe nuclei (that gives rise to ascending 5-HT projections) and in the caudal raphe (that gives rise to the descending 5-HT projections). Concurrent treatment of the alcohol-consuming dams with SAL prevented dysraphia and protected against the alcohol-induced reductions in 5-HT neurons in both the rostral and caudal raphe. NAP was less effective in protecting against dysraphia and did not protect against 5-HT loss in the rostral raphe, but did protect against loss in the caudal raphe.

CONCLUSIONS

These findings further support the potential usefulness of these peptides for therapeutic interventions in pregnancies at risk for alcohol-induced developmental deficits. Notably, the ascending 5-HT projections of the rostral raphe have profound effects in regulating forebrain development and function, and the descending 5-HT projections of the caudal raphe are critical for regulating respiration. Protection of the rostral 5-HT-system may help prevent structural and functional deficits linked to abnormal forebrain development, and protection of the caudal systems may also reduce the increased risk for sudden infant death syndrome associated with prenatal alcohol exposure.

Socio-cognitive habilitation using the math interactive learning experience program for alcohol-affected children

BACKGROUND

Fetal alcohol syndrome (FAS) has been recognized as a disabling condition with a significant impact on the neurobehavioral functioning of affected individuals, including cognition, behavior, and academic functioning, but little research has been performed on targeted interventions for these children.

METHODS

A socio-cognitive habilitative program focused on improving behavior and math functioning in children 3 to 10 years of age (n=61) was developed and evaluated. The intervention provided parental instruction on FAS, advocacy, and behavioral regulation via workshops and interactive math tutoring with children. All families received parental instruction and were then randomly assigned to either the math instruction or standard psychoeducational care groups.

RESULTS

Satisfaction with workshops was very high, with over 90% agreeing that trainers were knowledgeable and materials easy to understand and helpful. Significant gains in knowledge were found for information provided in the instructional groups. At posttesting, caregivers reported fewer problem behaviors on the Achenbach Child Behavior Checklist, Internalizing Problem Behavior, Externalizing Problem Behavior, and Total Problem Behavior summary scales. After 5 months, both groups of children demonstrated gains in math knowledge but significantly higher gains were found in the group receiving direct math instruction. The math treatment group was also more likely to demonstrate a gain of over 1 standard deviation on any of the 4 math outcome measures used.

CONCLUSIONS

These findings suggest that parents of children with fetal alcohol spectrum disorders (FAS(D)) benefit from instruction in understanding their child's alcohol-related neurological damage and strategies to provide positive behavioral supports and that targeted psychoeducational programs may be able to remediate some of the math deficits associated with prenatal alcohol exposure.