The clinical utility and specificity of parent report of executive function among children with prenatal alcohol exposure

Adaptive, Externalizing, and Internalizing Behavior of Children with Prenatal Alcohol Exposure: A Comparison of Three Parent-Report Questionnaires

This study compared the Behavior Assessment System for Children-Third Edition (BASC-3) to the Child Behavior Checklist (CBCL) and the Vineland Adaptive Behavior Scales-Third Edition (VABS-3) in children with and without histories of prenatal alcohol exposure. Data were collected from Collaborative Initiative on Fetal Alcohol Spectrum Disorders Phase 4 sites. Caregivers rated their child's behavior using three questionnaires: BASC-3, CBCL, and VABS-3. BASC-3 Adaptive Skills, Externalizing Problems, and Internalizing Problems scores were correlated with comparable scores from the CBCL (Externalizing and Internalizing Problems) and VABS-3 (Adaptive Skills) both within and across groups. Sensitivity, specificity, and positive and negative predictive values were calculated for the BASC-3. BASC-3 sensitivity rates were 78.1%, 80.5%, and 47.0% and specificity rates were 79.4%, 80.4%, and 81.5% for Adaptive Skills, Externalizing Problems, and Internalizing Problems, respectively. Positive predictive values were 87.1%, 88.0%, and 81.9% and negative predictive values were 67.0%, 69.8%, and 46.3% for Adaptive Skills, Externalizing Problems, and Internalizing Problems, respectively. Results replicated previous reports of behavioral and adaptive difficulties in children with prenatal alcohol exposure. These findings provide support for using the BASC-3 in this population.

Profiles of language and communication abilities in adolescents with fetal alcohol spectrum disorders

OBJECTIVE

Language and communication are largely understudied among youth with fetal alcohol spectrum disorders (FASD). Findings have been mixed, and have generally focused on more severely affected (i.e., children with FAS alone) or younger children. This study aimed to elucidate the profiles of language (i.e., receptive, expressive, general language) and communication (i.e., functional, social) abilities in adolescents with FASD.

METHOD

Participants aged 12-17 years with (AE = 31) and without (CON = 29) prenatal alcohol exposure were included. Receptive and expressive language were measured by the Clinical Evaluation of Language Fundamentals - Fifth Edition (CELF-5). Parents or caregivers completed the Children's Communication Checklist - Second Edition as a subjective measure of general language skills. Functional communication was measured by the Student Functional Assessment of Verbal Reasoning and Executive Strategies and parents or caregivers completed the Social Skills Improvement System Rating Scales as a measure of social communication. Multivariate analysis of variance determined the overall profiles of language and communication and whether they differed between groups.

RESULTS

The AE group performed significantly lower than the CON group on receptive language and parent report of general language while groups did not significantly differ on expressive language. Groups did not significantly differ on functional communication while social communication was significantly lower in the AE group.

CONCLUSIONS

Results of this study provide important information regarding the overall profile of basic language abilities and higher-level communication skills of adolescents with FASD. Ultimately, improving communication skills of youth with FASD may translate to better overall functioning.

Results of a screening tool for fetal alcohol spectrum disorders are associated with neuropsychological and behavioral measures

PURPOSE

This study assessed whether the outcome of a screening tool for fetal alcohol spectrum disorders (FASD), the FASD-Tree, was associated with neuropsychological and behavioral outcomes.

METHODS

Data for this study were collected as part of the fourth phase of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CIFASD-4). Participants (N = 175, 5 to 16 years) with or without histories of prenatal alcohol exposure were recruited from San Diego and Minneapolis. Each participant was screened using the FASD-Tree and administered a neuropsychological test battery; parents or guardians completed behavioral questionnaires. The FASD-Tree incorporates physical and behavioral measures and provides an outcome regarding the presence of FASD (FASD-Positive or FASD-Negative). Logistic regression was used to test whether the FASD-Tree outcome was associated with general cognitive ability, executive function, academic achievement, and behavior. Associations were tested in two groups: the whole sample and only correctly classified participants.

RESULTS

Results of the FASD-Tree were associated with neuropsychological and behavioral measures. Participants classified as FASD-Positive were more likely than those classified as FASD-Negative to have a lower IQ score and exhibit poorer performance on measures of executive and academic functions. Behaviorally, participants classified as FASD-Positive were rated as having more behavior problems and adaptive difficulties. Similar relationships were found for all measures when including only participants correctly classified by the FASD-Tree screening tool.

CONCLUSION

Results from the FASD-Tree screening tool were associated with neuropsychological and behavioral measures. Participants classified as FASD-Positive were more likely to have impairment in all domains tested. The results support the effectiveness of the FASD-Tree as a screening tool for use in clinical settings, providing an efficient and accurate way to identify patients in need of additional evaluation.

Children with lower ratings of executive functions have a greater response to the portion size effect

Deficits in executive functions (EFs), a set of cognitive processes related to self-regulation, are associated with the development of obesity. Prior studies from our group showed that lower food-cue related activation in brain regions implicated in self-regulation was related to a larger portion size effect. We tested the hypothesis that lower EFs in children would be positively related to the portion size effect. Healthy weight children aged 7-8 y (n = 88), who varied by maternal obesity status, participated in a prospective study. At baseline, the parent primarily in charge of feeding completed the Behavior Rating Inventory of Executive Function (BRIEF2) to assess child EFs, including Behavioral (BRI), Emotional (ERI), and Cognitive (CRI) indices. At 4 baseline sessions, children consumed meals in which the portion sizes of foods (pasta, chicken nuggets, broccoli, and grapes) varied by visit (total meal weight of 769, 1011, 1256, or 1492g). Intake increased with increasing portions in a linear trajectory (p < 0.001). EFs moderated the portion size effect such that lower BRI (p = 0.003) and ERI (p = 0.006) were associated with steeper increases in intake as portions increased. As amount of food increased, children in the lowest functioning tertiles for BRI and ERI increased intake by 35% and 36%, respectively, compared to children in the higher tertiles. Increases in intake among children with lower EFs were for higher- but not lower-energy-dense foods. Thus, in healthy weight children who varied by obesity risk, lower parentally reported EFs were associated with a larger portion size effect, and these results were independent of child and parent weight status. Therefore, EFs may be target behaviors that could be strengthened to help children moderate excess intake in response to large portions of energy-dense foods.

Identifying Prenatal Alcohol Exposure and Children Affected by It: A Review of Biomarkers and Screening Tools

PURPOSE

Early identification of prenatal alcohol exposure (PAE) and of those in need of services resulting from this exposure is an important public health concern. This study reviewed the existing literature on potential biomarkers and screening tools of PAE and its impact.

SEARCH METHODS

Electronic databases were searched for articles published between January 1, 1996, and November 30, 2021, using the following search terms: ("fetal alcohol" or "prenatal alcohol" or "FASD" or "alcohol-related neurodevelopmental disorder" or "ARND" or "ND-PAE") and ("screening" or "identification" or "biomarker"). Duplicate articles were electronically eliminated. Titles and abstracts were reviewed for appropriateness, and selected articles were retrieved for further analysis. Additional articles were added that were referenced in the reviewed articles or identified from expert knowledge. Information about the characteristics of the sample, the biomarker or screening tool, and the predictive validity outcome data were abstracted. A narrative analysis of the studies was then performed on the data.

SEARCH RESULTS

A total of 3,813 articles were initially identified, and 1,215 were removed as duplicates. Of the remaining articles, 182 were identified as being within the scope of the review based on title and abstract inspection, and 181 articles were successfully retrieved. Of these, additional articles were removed because they were preclinical (3), were descriptive only (13), included only self-report of PAE (42), included only mean group comparison (17), were additional duplicates (2), focused on cost analysis (9), missed predictive validity data (24), or for other reasons (23). The remaining articles (n = 48) were abstracted. An additional 13 manuscripts were identified from these articles, and two more from expert knowledge. A total of 63 articles contributed to the review.

DISCUSSION AND CONCLUSIONS

Biomarkers and screening tools of PAE and its impact fall short of ideal predictive validity characteristics. Higher specificity than sensitivity was found for many of the biomarkers and screening tools used to identify PAE and its impact, suggesting that current methods continue to under-identify the full range of individuals impacted by PAE. Exceptions to this were found in recent investigations using microRNAs related to growth and vascular development, proteomic changes associated with PAE, and combinations of markers estimating levels of various cytokines. Replications of these findings are needed across other samples to confirm the limited data available. Future research on biomarkers and screening tools should attend to feasibility and scalability of implementation. This article also recommends a systematic process of evaluation to improve early identification of individuals impacted by PAE so that harm reduction and habilitative care efforts can be implemented.

Interventions for improving executive functions in children with foetal alcohol spectrum disorder (FASD): A systematic review

Background

The consequences for children born with birth defects and developmental disabilities encompassed by foetal alcohol spectrum disorder (FASD) are profound, affecting all areas of social, behavioural and cognitive functioning. Given the strong evidence for a core deficit in executive functioning, underpinned by impaired self-regulation skills, there has been a growing focus on the development of interventions that enhance or support the development of executive functions (EFs).

Objectives

The primary objective of this review is to synthesise the evidence for structured psychological interventions that explicitly aim to improve EF in children. The review also sought to ascertain if the effectiveness of interventions were influenced by characteristics of the intervention, participants or type of EF targeted by the intervention.

Search Methods

Sixteen databases, 18 grey literature search locations and 9 trial registries were systematically searched to locate eligible studies (up to December 2020). These searches were supplemented with reference harvesting, forward citation searching, hand searches of topic-relevant journals and contact with experts.

Selection Criteria

Studies were included in the review if they reported on an impact evaluation of a psychological intervention aiming to improve EF in children 3-16 years who either had confirmed prenatal alcohol exposure or a formal diagnosis falling under the umbrella term of FASDs. Eligible study designs included randomised controlled trials (RCTs) and quasi-experimental designs with either no treatment, wait list control or an alternative treatment as a comparison condition. Single-group pre-post designs were also included.

Data Collection and Analysis

Standard methodological procedures expected by the Campbell Collaboration were used at all stages of this review. Standardised mean differences (SMDs) were used to estimate intervention effects, which were combined with random effects meta-analysis (data permitting). Risk of bias was assessed using the Cochrane Risk of Bias Tool (RoB2) and Cochrane Risk of Bias in Non-Randomised Studies-Interventions tool (ROBINS-I).

Main Results

The systematic search identified 3820 unique records. After title/abstract and full-text screening, 11 eligible studies (reported in 21 eligible documents) were deemed eligible, with a combined 253 participants. Of the 11 studies, 6 were RCTs, 1 was a quasi-experiment and 4 were single-group pre-post intervention designs. All studies were rated as having an overall high or serious risk of bias, with some variation across domains for RCTs. For RCT and quasi-experimental studies, the overall effect of EF interventions on direct and indirect measures of EF generally favoured the experimental condition, but was not statistically significant. There was no difference between intervention and comparison groups on direct measures of auditory attention (k = 3; SMD = 0.06, 95% confidence interval [CI] = -1.06, 1.18), visual attention (k = 2; SMD = 0.90, 95% CI = -1.41, 3.21), cognitive flexibility (k = 2; SMD = 0.23, 95% CI = -0.40, 0.86), attentional inhibition (k = 2; SMD = 0.04, 95% CI = -0.58, 0.65), response inhibition (k = 3; SMD = 0.47, 95% CI = -0.04, 0.99), or verbal working memory (k = 1; d = 0.6827; 95% CI = -0.0196, 1.385). Significant heterogeneity was found across studies on measures of auditory attention and visual attention, but not for measures of cognitive flexibility, attentional inhibition or response inhibition. Available data prohibited further exploration of heterogeneity. There was no statistical difference between intervention and comparison groups on indirect measures of global executive functioning (k = 2; SMD = 0.21, 95% CI = -0.40, 0.82), behavioural regulation (k = 2; SMD = 0.18, 95% CI = -0.43, 0.79), or emotional control (k = 3; SMD = 0.01, 95% CI = -0.33, 0.36). Effect sizes were positive and not significant for meta-cognition (k = 1; SMD = 0.23, 95% CI = -0.72, 1.19), shifting (k = 2; SMD = 0.04, 95% CI = -0.35, 0.43), initiation (k = 1; SMD = 0.04, 95% CI = -0.40, 0.49), monitoring (k = 1; SMD = 0.25, 95% CI = -0.20, 0.70) and organisation of materials (k = 1; SMD = 0.25, 95% CI = -0.19, 0.70). Effect sizes were negative and not statistically different for effortful control (k = 1; SMD = -0.53, 95% CI = -1.50, 0.45), inhibition (k = 2; SMD = -0.08, 95% CI = -0.47, 0.31), working memory (k = 1; SMD = 0.00, 95% CI = -0.45, 0.44), and planning and organisation (k = 1; SMD = -0.10, 95% CI = -0.55, 0.34). No statistically significant heterogeneity was found for any of the syntheses of indirect measures of EF. Based on pre-post single-group designs, there was evidence for small to medium sized improvements in EF based on direct measures (cognitive flexibility, verbal working memory and visual working memory) and indirect measures (behavioural regulation, shifting, inhibition and meta-cognition). However, these results must be interpreted with caution due to high risk of bias.

Authors' Conclusions

This review found limited and uncertain evidence for the effectiveness of interventions for improving executive functioning in children with FASD across 8 direct and 13 indirect measures of EF. The findings are limited by the small number of high-quality studies that could be synthesised by meta-analysis and the very small sample sizes for the included studies.

Combining neuroimaging and behavior to discriminate children with attention deficit-hyperactivity disorder with and without prenatal alcohol exposure

In many patients, ostensible idiopathic attention deficit-hyperactivity disorder (ADHD) may actually stem from covert prenatal alcohol exposure (PAE), a treatment-relevant distinction. This study attempted a receiver-operator characteristic (ROC) classification of children with ADHD into those with PAE (ADHD+PAE) and those without (ADHD-PAE) using neurobehavioral instruments alongside magnetic resonance spectroscopy (MRS) and diffusion tensor imaging (DTI) of supraventricular brain white matter. Neurobehavioral, MRS, and DTI endpoints had been suggested by prior findings. Participants included children aged 8-13 years, 23 with ADHD+PAE, 19 with familial ADHD-PAE, and 28 typically developing (TD) controls. With area-under-the-curve (AUC) >0.90, the Conners 3 Parent Rating Scale Inattention (CIn) and Hyperactivity/Impulsivity (CHp) scores and the Behavioral Regulation Index (BRI) of the Behavior Rating Inventory of Executive Function (BRIEF2) excellently distinguished the clinical groups from TD, but not from each other (AUC < 0.70). Combinations of MRS glutamate (Glu) and N-acetyl-compounds (NAA) and DTI mean diffusivity (MD), axial diffusivity (AD), radial diffusivity (RD), and fractional anisotropy (FA) yielded "good" (AUC > 0.80) discrimination. Neuroimaging combined with CIn and BRI achieved AUC 0.72 and AUC 0.84, respectively. But neuroimaging combined with CHp yielded 14 excellent combinations with AUC ≥ 0.90 (all p < 0.0005), the best being Glu·AD·RD·CHp/(NAA·FA) (AUC 0.92, sensitivity 1.00, specificity 0.82, p < 0.0005). Using Cho in lieu of Glu yielded AUC 0.83. White-matter microstructure and metabolism may assist efforts to discriminate ADHD etiologies and to detect PAE, beyond the ability of commonly used neurobehavioral measures alone.

Neuroimaging of Supraventricular Frontal White Matter in Children with Familial Attention-Deficit Hyperactivity Disorder and Attention-Deficit Hyperactivity Disorder Due to Prenatal Alcohol Exposure

Attention-deficit hyperactivity disorder (ADHD) is common in patients with (ADHD+PAE) and without (ADHD-PAE) prenatal alcohol exposure (PAE). Many patients diagnosed with idiopathic ADHD actually have covert PAE, a treatment-relevant distinction. To improve differential diagnosis, we sought to identify brain differences between ADHD+PAE and ADHD-PAE using neurobehavioral, magnetic resonance spectroscopy, and diffusion tensor imaging metrics that had shown promise in past research. Children 8-13 were recruited in three groups: 23 ADHD+PAE, 19 familial ADHD-PAE, and 28 typically developing controls (TD). Neurobehavioral instruments included the Conners 3 Parent Behavior Rating Scale and the Delis-Kaplan Executive Function System (D-KEFS). Two dimensional magnetic resonance spectroscopic imaging was acquired from supraventricular white matter to measure N-acetylaspartate compounds, glutamate, creatine + phosphocreatine (creatine), and choline-compounds (choline). Whole brain diffusion tensor imaging was acquired and used to to calculate fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity from the same superventricular white matter regions that produced magnetic resonance spectroscopy data. The Conners 3 Parent Hyperactivity/Impulsivity Score, glutamate, mean diffusivity, axial diffusivity, and radial diffusivity were all higher in ADHD+PAE than ADHD-PAE. Glutamate was lower in ADHD-PAE than TD. Within ADHD+PAE, inferior performance on the D-KEFS Tower Test correlated with higher neurometabolite levels. These findings suggest white matter differences between the PAE and familial etiologies of ADHD. Abnormalities detected by magnetic resonance spectroscopy and diffusion tensor imaging co-localize in supraventricular white matter and are relevant to executive function symptoms of ADHD.

Functional connectivity of the attention networks is altered and relates to neuropsychological outcomes in children with prenatal alcohol exposure

Cognitive and functional brain alterations can occur in children with prenatal alcohol exposure (PAE). We examined the functional connectivity (FC) among regions within and between attention networks, and whether inter- and intranetwork FC moderated cognition in children with PAE (n = 37; age 12.8 ± 2.8 years) and nonexposed controls (n = 40; age 13.2 ± 2.8 years). Participants completed standardized attention and executive functioning tasks and resting state functional MRI. Inter- and intra-network FC and graph-theoretical metrics were calculated among attention network regions. Relative to controls, PAE was associated with reduced FC between the left temporoparietal junction and left ventral frontal cortex and anterior insula/frontal operculum (aI/fO), and between the left intraparietal sulcus and bilateral aI/fO. PAE was associated with increased FC between the right precuneus and intraparietal lobes, the right anterior prefrontal cortex and left ventral frontal cortex and aI/fO, and the left thalamus and dorsal frontal cortex. Graph-theoretical metrics did not differ by group. FC predicted cognitive performance, negatively in the children with PAE and positively in controls. Increased intra-network together with reduced internetwork FC suggests inefficient network specialization and impaired long-range FC among attention network regions after PAE. Results further suggest that those alterations may underlie attention and executive dysfunction in children with PAE.

Validity and Reliability of Executive Function Measures in Children With Heavy Prenatal Alcohol Exposure: Correspondence Between Multiple Raters and Laboratory Measures

BACKGROUND

Rating scales are designed to complement traditional performance-based measures, and both can provide useful information about the functioning of youth with histories of prenatal alcohol exposure. Few studies, however, have compared ratings from multiple informants or the relationship between these subjective rating scale scores and the objective results from laboratory performance-based scales.

METHODS

The current study addressed both of these questions in 3 study groups: children with histories of prenatal alcohol exposure (n = 47), attention-deficit/hyperactivity disorder (ADHD; n = 41), and typically developing controls (CON; n = 73). All subjects completed a standardized neuropsychological test battery, including laboratory measures of executive functioning and a self-report measure of executive function behaviors. Parents and teachers completed corresponding rating scales of executive function behaviors for each subject. This study assessed the relationship between these behavior rating scales and corresponding neuropsychological tests, and interrater agreement among the multiple informants.

RESULTS

Weak correlations were found between the rating scales and laboratory measures, indicating poor convergent validity for the behavior rating scale. Interrater reliability was found but it differed by group. Agreement was found between parent and teacher ratings for children with prenatal alcohol exposure, whereas teacher-child agreement was found for those with ADHD.

CONCLUSIONS

Findings from this study indicate that behavior ratings can be used to supplement laboratory measures but may not be measuring cognitive abilities regardless of whether a clinical diagnosis is present. A multimethod approach should be used when measuring skills in this domain. This was one of the first studies to examine cross-informant agreement in a sample of children with prenatal alcohol exposure. Further research is necessary to understand why interrater agreement differed for children with prenatal alcohol exposure and those with ADHD.

Relationship Between Task-Based and Parent Report-Based Measures of Attention and Executive Function in Children with Fetal Alcohol Spectrum Disorders (FASD)

A majority of children with fetal alcohol spectrum disorders (FASD) have demonstrated attention and executive function deficits as measured by both parent report measures and performance on tasks requiring sustained levels of attention. However, prior studies have consistently reported a lack of association between parental report-based and task-based performance measures. The current study investigated whether changes in performance over time within-task (i.e., first-half versus second-half) better correspond to parental reports of executive function and temperament in children with FASD. Greater differences in split-half performance during a continuous performance task were found to be associated with higher parent-reported levels of behavioral regulation and inhibitory control. These findings suggest that within-task performance differences may more accurately reflect individual differences in executive function and temperament as measured by parental report and help to further inform the way in which cognitive processes are measured in children with FASD.

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.

Relation Between Oppositional/Conduct Behaviors and Executive Function Among Youth with Histories of Heavy Prenatal Alcohol Exposure

BACKGROUND

Youth with heavy prenatal alcohol exposure have high rates of behavioral concerns and psychopathology, including increased oppositional and conduct behaviors. The relation between those concerns and executive function (EF) deficits is unknown. We investigated the association of oppositional and conduct behavior and EF in adolescents to inform targeted intervention.

METHODS

Subjects (N = 267) ages 10 to 17 years comprised 3 groups: alcohol-exposed with oppositional/conduct behaviors (AE+), alcohol-exposed without oppositional/conduct behaviors (AE-), and controls (CON). Group differences on direct neuropsychological (Delis-Kaplan Executive Function System [D-KEFS]) and indirect parent-report (Behavior Rating Inventory of Executive Function [BRIEF]) EF measures were tested with multivariate analysis of covariances, followed by univariate analysis of variances and pairwise comparisons. The contribution of attention-deficit/hyperactivity disorder (ADHD) within the AE groups was assessed in secondary analyses.

RESULTS

On the D-KEFS, there was an omnibus main effect of group, with significant main effects on 3 of 6 variables (CON>AE+, AE-). Within the AE groups, ADHD did not alter the results. On the BRIEF, there was an omnibus significant main effect of group, with significant main effects on all scales (CON<AE-<AE+). Within the AE groups, the AE+ group had higher BRIEF scores (i.e., more difficulty) than the AE- group on 4 of 8 subscales when accounting for presence of ADHD.

CONCLUSIONS

EF deficits in youth with histories of prenatal alcohol exposure were confirmed using direct and indirect measures. Oppositional/conduct behaviors related to EF deficits on indirect but not direct EF measures. Greater understanding of the contribution of concurrent psychopathology to long-term outcomes for alcohol-exposed youth requires further investigation.

A meta-analysis on verbal working memory in children and adolescents with ADHD

Objective: Previous meta-analyses have demonstrated verbal working memory (WM) dysfunction in children and adolescents with attention deficit/hyperactivity disorder (ADHD); however, the findings are inconsistent. The main objective of this meta-analysis was to investigate the performance of children and adolescents with ADHD in the Digit Span Backwards (DSB) subtest from the Wechsler Intelligence Scale for Children or Wechsler Adult Intelligence Scale. We also sought to provide an updated meta-analysis on WM in children and adolescents with ADHD.Method: PubMed, PsyINFO, Scopus, and Web of Science were searched to locate studies published between 1990 and 2016 that report DSB scores both of children and adolescents with ADHD and matched controls. Potential moderator variables were also analyzed.Results: Forty-nine studies comparing children and adolescents with ADHD (n = 4956) against healthy controls (n = 3249) generated a medium-sized effect (Hedges' g) of 0.56 (95% CI [0.49, 0.64]), indicating poorer verbal WM performance in those with ADHD. A subgroup meta-analysis of studies with participants aged 8-16 years only demonstrated low heterogeneity (I² = 17.06, cf. 55.50 for the main analysis). Moreover, the meta-regression showed a negative association (β = -.05, p = .02) between DSB performance differences and increasing age, indicating that for every one year increase in age the effect size decreased by .05.Conclusion: These results, which emanated from the largest meta-analysis concerning verbal WM in ADHD reported to date, reinforce WM as a key domain of cognitive dysfunction in ADHD, and point to age as the main variable influencing DSB performance difficulties.

The Use of Functional Near-Infrared Spectroscopy to Differentiate Alcohol-Related Neurodevelopmental Impairment

Oxygenated (HBO) and deoxygenated hemoglobin (HBR) levels in the prefrontal cortex (PFC) were measured using functional near-infrared spectroscopy (fNIRS) to determine if PFC activity during a cognitive inhibition task distinguishes children with prenatal alcohol exposure (PAE, n = 26) from both typically developing controls (n = 19) and a contrast group of children with other neurobehavioral problems (n = 14). Despite showing evidence of increased PFC activity in the non-inhibitory condition relative to controls, children in the PAE group displayed reduced PFC HBO and increased HBR relative to both other groups in the inhibitory condition, suggesting reduced PFC activity but increased oxygen consumption without sufficient oxygen replacement.

Comparisons of the BRIEF parental report and neuropsychological clinical tests of executive function in Fetal Alcohol Spectrum Disorders: data from the UK national specialist clinic

Extant literature is sparse with regards to the relationship between caregiver reports and neuropsychological tests of executive functioning in Fetal Alcohol Spectrum Disorders (FASD). The goal of this paper was determining the clinical utilities of executive functioning measures used in the United Kingdom national FASD clinic. We examined relationships between outcomes on the Behavior Rating Inventory of Executive Function (BRIEF) and the Delis-Kaplan Executive Function System (D-KEFS), as part of an ongoing service evaluation. Profiles of executive functioning measures were reported in order to contribute to delineating a profile of executive dysfunction in FASD. Caregivers of 49 people with FASD completed the Parent BRIEF, and 61 people with FASD were administered the D-KEFS. Pearson's Correlations between all 11 BRIEF scales and the 18 selected D-KEFS subscales showed little relationship. The BRIEF showed a profile of clinically significant elevations in all three Index scores and seven out of the eight Scale scores. Several D-KEFS tests showed below average executive functioning. Both executive function measures have separate clinical utility in demonstrating executive function deficits in FASD. The sample population used in this study also show a similar pattern to FASD populations internationally, suggesting a similar neuropsychological profile is seen in the United Kingdom. However, caregiver reports display little relationship to neuropsychological tests. These measures likely monitor different aspects of executive functioning in different settings. Future research should focus on identifying tests that better relate findings from clinical settings to behavior in daily life.

Factors predictive of a fetal alcohol spectrum disorder diagnosis: Parent and teacher ratings

Diagnostic assessment in Fetal Alcohol Spectrum Disorder (FASD) is informed by multidisciplinary assessment incorporating objective (i.e., test measures) and subjective means, such as parent and teacher behavior ratings. The purpose of this study was to extend our previous neuropsychological test findings by identifying parent and teacher ratings of academic achievement, attention, executive functioning, and adaptive functioning as predictors of an FASD diagnosis. The charts of 315 children and adolescents with prenatal alcohol exposure (PAE) who underwent assessment for FASD were retrospectively reviewed. Direct logistic regressions analyzed the contribution of different ratings on the likelihood of an FASD diagnosis. The results suggest that a number of rating measures do contribute toward accurately differentiating those with FASD from within a PAE population, including teacher ratings of learning problems, inattention, and adaptive skills. The classification accuracy for each regression was clinically significant (59.1-70.8%). Children with worse ratings on these variables are approximately 1.5 to 2 times more likely to receive an FASD diagnosis. Only teacher ratings (not parent) significantly contributed to whether a diagnosis was made, suggesting that teacher observational rating scales are a critical component of an FASD assessment. Together with our previous research examining neuropsychological evaluation and FASD diagnostic assessment, this study helps to further guide decisions to streamline care in multidisciplinary assessment and intervention planning.

Evidence Supporting the Internal Validity of the Proposed ND-PAE Disorder

The internal validity of the proposed Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) was evaluated in children diagnosed with either Fetal Alcohol Syndrome (FAS) or partial FAS who were 3-10 years of age and had enrolled in a math intervention study. Symptoms were coded as present or absent using assessments conducted in the study, including standardized measures of neurocognitive and behavioral functioning, parent interview, and direct observations of the child. The number of endorsed ND-PAE symptoms was not related to environmental factors but was moderately related to the child's age. ND-PAE symptoms were highly consistent and this did not vary by age. Evidence suggested the ND-PAE adaptive symptoms may be too restrictive and only one symptom from this domain may be sufficient. Impulsiveness was not related to an endorsement of the ND-PAE disorder but research is needed with other clinical groups to establish the discriminative validity of this symptom.

Prefrontal cortical responses in children with prenatal alcohol-related neurodevelopmental impairment: A functional near-infrared spectroscopy study

OBJECTIVE

Disruption in the neural activation of the prefrontal cortex (PFC) in modulating arousal was explored in children with heavy prenatal alcohol exposure (PAE), who have known neurobehavioral impairment.

METHODS

During a task that elicits frustration, functional near-infrared spectroscopy (fNIRS) was used to measure PFC activation, specifically levels of oxygenated (HBO) and deoxygenated (HBR) hemoglobin, in children with PAE (n=18) relative to typically developing Controls (n=12) and a Clinical Contrast group with other neurodevelopmental or behavioral problems (n=14).

RESULTS

Children with PAE had less activation during conditions with positive emotional arousal, as indicated by lower levels of HBO in the medial areas of the PFC and higher levels of HBR in all areas of the PFC sampled relative to both other groups. Children in the Control group demonstrated greater differentiation of PFC activity than did children with PAE. Children in the Clinical Contrast group demonstrated the greatest differences in PFC activity between valences of task conditions.

CONCLUSIONS

Specific patterns of PFC activation differentiated children with PAE from typically developing children and children with other clinical problems.

SIGNIFICANCE

FNIRS assessments of PFC activity provide new insights regarding the mechanisms of commonly seen neurobehavioral dysfunction in children with PAE.

Neurodevelopmental profile of Fetal Alcohol Spectrum Disorder: A systematic review

Background

In an effort to improve the screening and diagnosis of individuals with Fetal Alcohol Spectrum Disorder (FASD), research has focused on the identification of a unique neurodevelopmental profile characteristic of this population. The objective of this review was to identify any existing neurodevelopmental profiles of FASD and review their classification function in order to identify gaps and limitations of the current literature.

Methods

A systematic search for studies published up to the end of December 2016 reporting an identified neurodevelopmental profile of FASD was conducted using multiple electronic bibliographic databases. The search was not limited geographically or by language of publication. Original research published in a peer-reviewed journal that involved the evaluation of the classification function of an identified neurodevelopmental profile of FASD was included.

Results

Two approaches have been taken to determine the pathognomonic neurodevelopmental features of FASD, namely the utilization of i) behavioral observations/ratings by parents/caregivers and ii) subtest scores from standardized test batteries assessing a variety of neurodevelopmental domains. Both approaches show some promise, with the former approach (which is dominated by research on the Neurobehavioral Screening Tool) having good sensitivity (63% to 98%), but varying specificity (42% to 100%), and the latter approach having good specificity (72% to 96%), but varying sensitivity (60% to 88%).

Conclusions

The current review revealed that research in this area remains limited and a definitive neurodevelopmental profile of FASD has not been established. However, the identification of a neurodevelopmental profile will aid in the accurate identification of individuals with FASD, by adding to the armamentarium of clinicians. The full review protocol is available in PROSPERO (http://www.crd.york.ac.uk/PROSPERO/); registration number CRD42016039326; registered 20 May 2016.

The Behavior Rating Inventory of Executive Function (BRIEF) to Identify Pediatric Acute Lymphoblastic Leukemia (ALL) Survivors At Risk for Neurocognitive Impairment

Neurocognitive problems, including executive dysfunction, are potential late effects of pediatric acute lymphoblastic leukemia treatment. Surveillance for neurocognitive impairment in a timely and efficient manner is imperative to ongoing clinical care. We sought to determine if the Behavior Rating Inventory of Executive Function (BRIEF) Parent Form identified leukemia survivors with cognitive impairment. In this 28-site cross-sectional study, parents of 256 children, a mean of 8.9±2.2 years after treatment for standard-risk precursor-B acute lymphoblastic leukemia and in first remission, completed the BRIEF. We used a multivariate logistic regression to calculate the association between elevated scores on 3 composite BRIEF indices (Behavioral Regulation Index, Metacognition Index, Global Executive Composite [GEC]) and special education and attention-deficit/hyperactivity disorder (ADHD) outcomes. All BRIEF index scores were significantly associated with receipt of special education services or ADHD. The BRI was most strongly associated with ADHD (odds ratios=4.33; 95% confidence interval, 1.72-10.9). The GEC was most strongly associated with ADHD (odds ratios=4.46; 95% confidence interval, 1.77-11.22). Elevated scores on the BRIEF GEC were associated with low sensitivity (24.1 to 39.1) for detecting the outcomes but better specificity (range, 87.7 to 89.3). These results suggest that the parent-completed BRIEF is associated with clinical outcomes but is not a sensitive tool to identify leukemia survivors that require a comprehensive neuropsychological assessment.

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.

A randomized trial of individual versus group-format exercise and self-management in individuals with Parkinson's disease and comorbid depression

BACKGROUND

Depression is common in people with Parkinson's disease (PD), and exercise is known to improve depression and PD. However, lack of motivation and low self-efficacy can make exercise difficult for people with PD and comorbid depression (PD-Dep). A combined group exercise and chronic disease self-management (CDSM) program may improve the likeli-hood that individuals will engage in exercise and will show a reduction in depression symptoms. The purpose of this study was to compare changes in depression in PD-Dep between individual versus group exercise plus CDSM and to examine participant adherence and perception of the interventions.

METHODS

Participants (N=30) were randomized to either Enhanced EXerCisE thErapy for PD (EXCEED; group CDSM and exercise) or self-guided CDSM plus exercise. Outcomes were change in depression assessed with the Montgomery-Asberg Depression Rating Scale (MADRS), cognition, apathy, anxiety, sleep, quality of life, motor function, self-efficacy, and patient satisfaction.

RESULTS

Both groups showed significant improvement in MADRS (P<0.001) with no significant group difference. Individuals in EXCEED group enjoyed the group dynamics but noted difficulty with the fixed-time sessions.

CONCLUSION

Both group CDSM plus exercise and self-guided CDSM plus exercise can improve depression in PD-Dep. These findings suggest that development of a remotely delivered group-based CDSM format plus manualized exercise program could be useful for this population.

Improving FASD Children's Self-Regulation: Piloting Phase 1 of the GoFAR Intervention

The initial parent training component of GoFAR, an intervention designed to improve the self-regulation and adaptive living skills of children with Fetal Alcohol Spectrum Disorders, was piloted in a small, randomized clinical trial of 28 participants assigned to either a time-lapsed control group or one of two parent training groups who differed on whether the child's computerized instruction was congruent or incongruent with the parent instruction. Parental compliance and achievement of therapy goals were indicators of improvement in the child's self-regulation skills. Children who received computerized instruction consistent with the parent training demonstrated greater self-regulation improvements than those receiving incongruent computerized instruction.

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE): Review of Evidence and Guidelines for Assessment

The effects of prenatal alcohol use have been well documented. In this review, we discuss the inclusion of Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) as a condition for further study in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5). We present a review of the evidence for impairment in three domains highlighted in ND-PAE: neurocognitive functioning, self2 regulation, and adaptive functioning. In addition, we provide guidelines for clinical assessment of each domain. When considering ND-PAE, it is essential to obtain as comprehensive an assessment as possible, including multidisciplinary/multimethod assessment of the individual by a qualified team. It is our aim to provide clinicians with a useful reference for assessing ND-PAE and highlight important guidelines to be followed when conducting neuropsychological assessment.

Developmental differences in relations between parent-reported executive function and unitized and non-unitized memory representations during childhood

Previous research has documented an association between executive functioning (EF) and memory for bound details. However, it is unknown if this relation varies as a function of the type of bound information (i.e., unitized versus non-unitized) and whether this association changes as a function of age during childhood, when both EF and memory undergo rapid development. The current study sought to address these gaps by examining whether relations between parent-reported EF differed for unitized versus non-unitized memory representations and if these relations differed between children who were 4, 6, or 8 years of age. Results revealed that EF was selectively associated with non-unitized associative memory in 8-year-old children; no significant relations between EF and either memory condition were evident in 4- or 6-year-olds. These results suggest relations between EF and memory may be specific to non-unitized representations and that this association may emerge across childhood as both EF and memory abilities develop.

Parent ratings of executive function in young preschool children with symptoms of attention-deficit/-hyperactivity disorder

BACKGROUND

Recent research has demonstrated that deficits in basic, self-regulatory processes, or executive function (EF), may be related to symptoms of attention-deficit/hyperactivity disorder (ADHD) already during the preschool period. As the majority of studies investigating these relations in young children have been based primarily on clinically administered tests, it is not clear how early symptoms of ADHD may be related to observations of EF in an everyday context. The preschool version of the Behavior Rating Inventory of Executive Function (BRIEF-P) was developed to provide information about EF through observable, behavioral manifestations of self-regulation, and is the most commonly used rating scale for EF assessment in children.

METHODS

Relations between symptoms of ADHD reported in the Preschool Age Psychiatric Assessment interview (PAPA), and EF as measured by the BRIEF-P (parent form), were investigated in a large, nonreferred sample of preschool children (37-47 months, n = 1134) recruited from the Norwegian Mother and Child Cohort Study (MoBa) at the Norwegian Institute of Public Health. The inventory's discriminative ability was examined in a subsample consisting of children who met the diagnostic criteria for either ADHD, oppositional defiant disorder (ODD) or anxiety disorder, and typically developing controls (n = 308). The four groups were also compared with regard to patterns of EF difficulties reported in the BRIEF-P.

RESULTS

Of the five BRIEF-P subscales, Inhibit and Working Memory were the two most closely related to ADHD symptoms, together explaining 38.5% of the variance in PAPA symptom ratings. Based on their scores on the Inhibit and Working Memory subscales (combined), 86.4% of the children in the ADHD and TD groups were correctly classified. ADHD symptoms were associated with more severe difficulties across EF domains, and a different EF profile in comparison to children with other symptoms (anxiety, ODD) and to typically developing controls.

CONCLUSIONS

Early symptoms of ADHD were linked to parent-reported difficulties primarily within inhibition and working memory, suggesting that deficiencies within these two EF domains characterize early forms of ADHD. Our findings support the clinical utility of the BRIEF-P as a measure of EF in young preschool children with symptoms of ADHD.