Preliminary Findings that a Targeted Intervention Leads to Altered Brain Function in Children with Fetal Alcohol Spectrum Disorder

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.

Dog-Assisted Therapy vs Relaxation for Children and Adolescents with Fetal Alcohol Spectrum Disorder: A Randomized Controlled Study

The rationale of this study was to evaluate the efficacy of Dog-assisted Therapy (DAT) in children and adolescents with Fetal Alcohol Spectrum Disorder (FASD). We conducted a randomized controlled trial in a cohort of 71 children and adolescents with FASD. Participants were randomly assigned either to DAT group (n = 38) or Relaxation Group (control group) (n = 33). Results revealed that participants who were assigned to the DAT group experienced significantly reduced externalizing symptoms (CBCL Externalizing Inattention: t (69) = 2.81, p = .007; d = 0.7); CBCL Opposition: t (69) = 2.54, p = .013; d = 0.6), reduced internalizing symptoms (CBCL Social problems: t (69) = 3.21, p = .002; d = 0.8) as well as improvements on social skills (SSIS-P Problem behavior: t (68) = 2.55, p = .013; d = 0.6), and quality of life (KidScreen Autonomy and Parents: t (51) = - 2.03, p = .047; d = 0.5) compared to the relaxation control group. The relaxation control group obtained significant differences between the pre- and post-treatment evaluation, diminishing withdraw symptoms (t (32) = 3.03, p = .005; d = 0.2). Results suggest that DAT and relaxation may be promising adjunctive treatments for children and adolescents with FASD.Clinical trial registration information: http://clinicaltrials.gov/ ; NCT04038164.

Feasibility and Efficacy of the Alert Program® for Children with Attention-Deficit/Hyperactivity Disorder

This study explored the feasibility and initial efficacy of a sensorimotor intervention to improve symptoms of attention-deficit/hyperactivity disorder (ADHD). Twenty-seven children (ages 8-12 years) with ADHD and their parents participated in an 8-week group intervention based on The Alert Program® for Self-Regulation (AP). Families were taught to recognize child arousal states and to use sensorimotor strategies to manage levels of alertness. Parent and teacher reports of child attention symptoms were collected at baseline, before and after intervention. Objective ratings of child problem behaviours and use of sensorimotor strategies during computerized tasks of visual and auditory attention were also coded before and after intervention. Parents and children endorsed high acceptability and satisfaction for the AP treatment. Parental ratings indicated increased knowledge and use of sensorimotor strategies, and decreased child ADHD symptoms at home from pre-AP to post-AP. However, no significant changes in child outcomes were reported by teachers. Unexpectedly, observed child problem behaviours during the visual attention task increased from pre-AP to post-AP. The AP was received positively by parents and children with improvements in regulation strategies and child attention at home, but more work needs to be done to generalize the effects to school and other peer settings.

Inhibitory control in young adult women with fetal alcohol syndrome: Findings from a pilot functional magnetic resonance imaging study

BACKGROUND

Executive dysfunction, especially impaired inhibitory control, is a common finding in individuals with fetal alcohol syndrome (FAS). Previous research has mostly focused on neural correlates of inhibitory deficits in children and adolescents. We investigated inhibitory functions and underlying cerebral activation patterns in young adult women with FAS.

METHODS

Task performance and functional magnetic resonance imaging (fMRI) data were acquired during a Go/NoGo (GNG) inhibition task in 19 young adult women with FAS and 19 healthy female control subjects. Whole-brain activation and task performance analyses were supplemented by region of interest (ROI) analyses of fMRI data within a predefined cognitive control network (CCN).

RESULTS

Task performance did not differ significantly between groups on errors of commission, associated with inhibitory control. Similarly, overall activation within the preselected ROIs did not differ significantly between groups for the main inhibitory contrast NoGo > Go. However, whole-brain analyses revealed activation differences in the FAS group when compared to controls under inhibitory conditions. This included hyperactivations in the left inferior frontal, superior temporal, and supramarginal gyri in the FAS group. Likewise, lateralization tendencies toward right-hemispheric ROIs were weaker in FAS subjects. In contrast to comparable inhibitory performance, attention-related errors of omission were significantly higher in the FAS group. Correspondingly, FAS subjects had lower activity in attention-related temporal and parietal areas.

CONCLUSIONS

The known alterations of inhibitory functions associated with prenatal alcohol exposure in children and adolescents were not seen in this adult sample. However, differential brain activity was observed, reflecting potential compensatory mechanisms. Secondary results suggest that there is impaired attentional control in young adult women with FAS.

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.

[Formula: see text]Parental interaction style, child engagement, and emerging executive function in fetal alcohol spectrum disorders (FASD)

Children with fetal alcohol spectrum disorders (FASD) are known to experience cognitive and neurobehavioral difficulties, including in areas of executive function and social skills development. Interventions for these challenges have focused on a number of areas, including parent-based training. Despite the general consensus that specific parenting styles consistent with an "authoritative" - warm but firm - parenting approach may influence behavioral self-regulation, it is not known what specific parental interaction styles are associated with child engagement and emerging executive function in this population. The current study used an observation-based behavioral coding scheme during parent-child play interactions and associated parent report-based executive function measures in children with FASD. Here, we demonstrate that parental interaction styles with increased responsive/child-oriented behavior and parental affect are associated with higher levels of child play engagement, while parental interaction that has increased achievement-orientation is associated with higher levels of emerging executive function in children with FASD. These findings help inform future studies on behavioral targets in parent-based training programs and highlight the importance of considering certain parental interaction styles during parent-child play.

Brain functional connectivity in children with developmental coordination disorder following rehabilitation intervention

BACKGROUND

Children with developmental coordination disorder (DCD) show improved motor function after Cognitive Orientation to Occupational Performance (CO-OP) intervention; however, the neural basis for these improvements is unknown.

METHODS

In this randomized waitlist-controlled trial, 78 children with DCD (with/without ADHD) were randomly assigned to either a treatment or waitlist group and underwent three resting-state MRI scans over six months. The treatment group received intervention between the first and second scan; the waitlist group received intervention between the second and third scan.

RESULTS

After CO-OP intervention, children with DCD [13 male, 8 female; mean (SD) age: 10.0 (1.7) years] showed increased functional connectivity between the default mode network and right anterior cingulate gyrus (p < 0.01). Additional gains were noted at follow-up three months after the intervention, with greater functional connectivity between the dorsal attention network and precentral gyrus (p < 0.02). However, children with DCD + ADHD [18 male, 1 female; mean (SD) age: 10.0 (1.14) years] did not show brain changes following CO-OP.

CONCLUSION

For children with DCD, increased functional connectivity in networks associated with self-, emotion-, and attention-regulation may underlie motor skill improvements observed after CO-OP intervention. Modifications to the CO-OP protocol may be required to induce similar brain changes in children with DCD + ADHD.

IMPACT

This study provides neuroscientific evidence for the Cognitive Orientation to Occupational Performance (CO-OP) approach as an effective rehabilitation intervention to induce brain and behavioral changes in children with DCD. While children with DCD ± ADHD showed improved motor function after CO-OP, only children with DCD showed brain changes after intervention. Children with DCD showed increased functional connectivity in networks associated with self-, emotion-, and attention-regulation after the intervention. Treatment modifications may be required to induce similar brain changes in children with DCD + ADHD. Pediatricians are encouraged to refer children with DCD  with and without ADHD for CO-OP intervention to improve their motor skills.

Training-Induced Neural Plasticity in Youth: A Systematic Review of Structural and Functional MRI Studies

Experience-dependent neural plasticity is high in the developing brain, presenting a unique window of opportunity for training. To optimize existing training programs and develop new interventions, it is important to understand what processes take place in the developing brain during training. Here, we systematically review MRI-based evidence of training-induced neural plasticity in children and adolescents. A total of 71 articles were included in the review. Significant changes in brain activation, structure, microstructure, and structural and functional connectivity were reported with different types of trainings in the majority (87%) of the studies. Significant correlation of performance improvement with neural changes was reported in 51% of the studies. Yet, only 48% of the studies had a control condition. Overall, the review supports the hypothesized neural changes with training while at the same time charting empirical and methodological desiderata for future research.

Fetal Alcohol Exposure Alters BOLD Activation Patterns in Brain Regions Mediating the Interpretation of Facial Affect

BACKGROUND

Although deficits in the interpretation of affective facial expressions have been described clinically and in behavioral studies of fetal alcohol spectrum disorders (FASD), effects of prenatal alcohol exposure on the neural networks that mediate affective appraisal have not previously been examined.

METHODS

We administered a nonverbal event-related fMRI affective appraisal paradigm to 64 children (mean age = 12.5 years; 18 with fetal alcohol syndrome (FAS) or partial FAS (PFAS), 18 nonsyndromal heavily exposed (HE), and 28 controls). Happy, sad, angry, fearful, and neutral faces and pixelated control images were presented sequentially in a randomized order. The child indicated whether the currently displayed face showed the same or different affect as the previous one.

RESULTS

Data from whole-brain analyses showed that all groups activated the appropriate face processing neural networks. Region of interest analyses indicated that, compared to HE and control children, the FAS/PFAS group exhibited greater blood oxygenation level-dependent (BOLD) signal changes when processing neutral faces than pixelated images in 2 regions that form part of the visual sensory social brain network, which plays an important role in the initial processing of facial affect. By contrast, BOLD signal when processing angry faces was weaker for the FAS/PFAS group in a region involved in the processing of facial identity and facial expressions and in a region involved in the recognition and selection of behavioral responses to aggressive behavior.

CONCLUSIONS

These findings of greater BOLD signal in the FAS/PFAS group in response to neutral faces suggest less efficient neural processing of more difficult to interpret emotions, and the weaker BOLD response to angry faces suggests altered processing of angry stimuli. Although behavioral performance did not differ in this relatively simple affective appraisal task, these data suggest that in children with FAS and PFAS, the appraisal of neutral affect and anger is likely to be more effortful in more challenging and dynamic social contexts.

School-based intervention to address self-regulation and executive functioning in children attending primary schools in remote Australian Aboriginal communities

Executive functioning and self-regulation influence a range of outcomes across the life course including physical and mental health, educational success, and employment. Children prenatally exposed to alcohol or early life trauma (ELT) are at higher risk of impairment of these skills and may require intervention to address self-regulation deficits. Researchers partnered with the local Aboriginal health organization and schools to develop and pilot a manualized version of the Alert Program® in the Fitzroy Valley, north Western Australia, a region with documented high rates of fetal alcohol spectrum disorder and ELT. This self-controlled cluster randomized trial evaluated the effect of an 8-week Alert Program® intervention on children's executive functioning and self-regulation skills. Following parent or caregiver consent (referred to hereafter as parent), 271 students were enrolled in the study. This reflects a 75% participation rate and indicates the strong community support that exists for the study. Teachers from 26 primary school classrooms across eight Fitzroy Valley schools received training to deliver eight, one-hour Alert Program® lessons over eight-weeks to students. Student outcomes were measured by parent and teacher ratings of children's behavioral, emotional, and cognitive regulation. The mean number of lessons attended by children was 4.2. Although no significant improvements to children's executive functioning skills or behavior were detected via the teacher-rated measures as hypothesized, statistically significant improvements were noted on parent-rated measures of executive functioning and behavior. The effectiveness of future self-regulation programs may be enhanced through multimodal delivery through home, school and community based settings to maximize children's exposure to the intervention. Despite mixed findings of effect, this study was an important first step in adapting and evaluating the Alert Program® for use in remote Australian Aboriginal community schools, where access to self-regulation interventions is limited.

Dog-Assisted Therapy for Children and Adolescents With Fetal Alcohol Spectrum Disorders a Randomized Controlled Pilot Study

Objective

The rationale of this study was to evaluate the efficacy of dog-assisted therapy (DAT) combined with pharmacological treatment in children and adolescents with fetal alcohol spectrum disorder (FASD).

Method

We conducted a randomized, rater-blinded, controlled pilot trial in a cohort of 33 children and adolescents with FASD. Participants were randomly assigned either to DAT group (n = 17) or Treatment as Usual (TAU control group) (n = 16).

Results

Of the initial 39 participants enrolled, 33 completed treatment. A mixed-effects model analysis revealed that participants who were assigned to the DAT group experienced significantly improvements on social skills (SSIS-P social skills: p = 0.02, d = 0.8), reductions on externalizing symptoms (CBCL externalizing: p = 0.03; d = 0.56), and lower scores on FASD severity (CGI-S clinician: p = 0.001, d = 0.5).

Conclusion

DAT is a promising adjunctive treatment for children and adolescents with FASD.

Clinical Trial Registration

Dog-assisted therapy for children and adolescents with fetal alcohol spectrum disorders: a randomized controlled pilot study; http://clinicaltrials.gov/, identifier NCT04038164.

The NKCC1 antagonist bumetanide mitigates interneuronopathy associated with ethanol exposure in utero

Prenatal exposure to ethanol induces aberrant tangential migration of corticopetal GABAergic interneurons, and long-term alterations in the form and function of the prefrontal cortex. We have hypothesized that interneuronopathy contributes significantly to the pathoetiology of fetal alcohol spectrum disorders (FASD). Activity-dependent tangential migration of GABAergic cortical neurons is driven by depolarizing responses to ambient GABA present in the cortical enclave. We found that ethanol exposure potentiates the depolarizing action of GABA in GABAergic cortical interneurons of the embryonic mouse brain. Pharmacological antagonism of the cotransporter NKCC1 mitigated ethanol-induced potentiation of GABA depolarization and prevented aberrant patterns of tangential migration induced by ethanol in vitro. In a model of FASD, maternal bumetanide treatment prevented interneuronopathy in the prefrontal cortex of ethanol exposed offspring, including deficits in behavioral flexibility. These findings position interneuronopathy as a mechanism of FASD symptomatology, and posit NKCC1 as a pharmacological target for the management of FASD.

The Distribution of Available Prevention and Management Interventions for Fetal Alcohol Spectrum Disorder (2007 to 2017): Implications for Collaborative Actions

The global prevalence of Fetal Alcohol Spectrum Disorder (FASD) remains high despite the various preventive and management interventions that have been designed and implemented to tackle the issue in various settings. The aim of the scoping review is to identify and classify prevention and management interventions of FASD reported globally across the life span and to map the concentration of these interventions across the globe. We searched some selected databases with predefined terms. Framework and narrative approaches were used to synthesize and report on the findings. Thirty-two prevention intervention studies and 41 management interventions studies were identified. All the interventions were reported to be effective or showed promising outcomes for the prevention and management of FASD, except four. Although Europe and Africa have a relatively higher prevalence of FASD, the lowest number of interventions to address FASD were identified in these regions. Most of the interventions for FASD were reported in North America with comparatively lower FASD prevalence. The uneven distribution of interventions designed for FASD vis-à-vis the burden of FASD in the different regions calls for a concerted effort for knowledge and intervention sharing to enhance the design of contextually sensitive preventive and management policy in the different regions.