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

Effectiveness of interventions for school-aged-children and adolescents with fetal alcohol spectrum disorder: a systematic review and meta-analysis

PURPOSE

To describe allied health and educational interventions and their effectiveness for children and adolescents with fetal alcohol spectrum disorder (FASD). To appraise the quality and strength of studies.

METHODS

Electronic databases were searched between 2005 and March 2022, identifying non-pharmacological studies supporting function, activity, or participation for FASD participants aged 5-18 years using any quantitative research design. Outcomes were coded using International Classification of Functioning, Disability and Health, family of Participation Related Constructs and behaviour categories. Multi-level random-effects meta-analysis examined intervention effects. Study methodological quality was evaluated using Cochrane risk of bias tools, RoBiNT, AMSTAR 2 and NHMRC Hierarchy levels of evidence. Certainty of findings were synthesised using GRADE approach.

RESULTS

The systematic review included 25 studies with 735 participants, 10 of which were analysed by meta-analysis. Body function and structure, activity, behaviour, and sense of self outcomes were pooled. A small, positive effect favouring interventions was found (g = 0.29, 95% CI = 0.15-0.43), however the GRADE certainty was rated as low. No participation outcomes were identified.

CONCLUSIONS

Some interventions targeting body function and structure, activity and behaviour outcomes were effective. Evidence of interventions that support children's and adolescent's participation as an outcome is lacking.

Psychosocial and medication interventions to stop or reduce alcohol consumption during pregnancy

BACKGROUND

Despite the known harms, alcohol consumption is common in pregnancy. Rates vary between countries, and are estimated to be 10% globally, with up to 25% in Europe.

OBJECTIVES

To assess the efficacy of psychosocial interventions and medications to reduce or stop alcohol consumption during pregnancy.

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group Specialised Register (via CRSLive), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, and PsycINFO, from inception to 8 January 2024. We also searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). All searches included non-English language literature. We handsearched references of topic-related systematic reviews and included studies.

SELECTION CRITERIA

We included randomised controlled trials that compared medications or psychosocial interventions, or both, to placebo, no intervention, usual care, or other medications or psychosocial interventions used to reduce or stop alcohol use during pregnancy. Our primary outcomes of interest were abstinence from alcohol, reduction in alcohol consumption, retention in treatment, and women with any adverse event.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures.

MAIN RESULTS

We included eight studies (1369 participants) in which pregnant women received an intervention to stop or reduce alcohol use during pregnancy. In one study, almost half of participants had a current diagnosis of alcohol use disorder (AUD); in another study, 40% of participants had a lifetime diagnosis of AUD. Six studies took place in the USA, one in Spain, and one in the Netherlands. All included studies evaluated the efficacy of psychosocial interventions; we did not find any study that evaluated the efficacy of medications for the treatment of AUD during pregnancy. Psychosocial interventions were mainly brief interventions ranging from a single session of 10 to 60 minutes to five sessions of 10 minutes each. Pregnant women received the psychosocial intervention approximately at the end of the first trimester of pregnancy, and the outcome of alcohol use was reassessed 8 to 24 weeks after the psychosocial intervention. Women in the control group received treatment as usual (TAU) or similar treatments such as comprehensive assessment of alcohol use and advice to stop drinking during pregnancy. Globally, we found that, compared to TAU, psychosocial interventions may increase the rate of continuously abstinent participants (risk ratio (RR) 1.34, 95% confidence interval (CI) 1.14 to 1.57; I2 =0%; 3 studies; 378 women; low certainty evidence). Psychosocial interventions may have little to no effect on the number of drinks per day, but the evidence is very uncertain (mean difference -0.42, 95% CI -1.13 to 0.28; I2 = 86%; 2 studies; 157 women; very low certainty evidence). Psychosocial interventions probably have little to no effect on the number of women who completed treatment (RR 0.98, 95% CI 0.94 to 1.02; I2 = 0%; 7 studies; 1283 women; moderate certainty evidence). None of the included studies assessed adverse events of treatments. We downgraded the certainty of the evidence due to risk of bias and imprecision of the estimates.

AUTHORS' CONCLUSIONS

Brief psychosocial interventions may increase the rate of continuous abstinence among pregnant women who report alcohol use during pregnancy. Further studies should be conducted to investigate the efficacy and safety of psychosocial interventions and other treatments (e.g. medications) for women with AUD. These studies should provide detailed information on alcohol use before and during pregnancy using consistent measures such as the number of drinks per drinking day. When heterogeneous populations are recruited, more detailed information on alcohol use during pregnancy should be provided to allow future systematic reviews to be conducted. Other important information that would enhance the usefulness of these studies would be the presence of other comorbid conditions such as anxiety, mood disorders, and the use of other psychoactive substances.

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.

A pooled prevalence of fetal alcohol spectrum disorders in South Africa: a systematic review and meta-analysis protocol

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) remains a global public health problem. South Africa is estimated to have the highest recorded prevalence of FASD. However, no study has systematically evaluated the available prevalence studies to provide estimates that may facilitate effective planning and delivery of prevention and management services. Therefore, we propose to conduct a systematic review and meta-analysis to report a pooled estimate of the FASD prevalence among children, youth and adults in South Africa.

METHODS

We will include quantitative (cohort and cross-sectional) studies that reported on the prevalence of FASD in South Africa. We will search databases such as Academic Search Complete, Education Resource Information Center (ERIC), SocINDEX, Health Source: Nursing/Academic Edition, Cumulative Index of Nursing and Allied Health and PsycARTICLES), Scopus, Science Direct, Springer Link, JSTOR, SAGE journals, PubMed, Web of Science and Sabinet. The references of included studies will be searched for additional studies on the prevalence of FASD. The search will be from inception to October 2021. Screening of (titles, abstracts and full text of the potentially relevant articles) will be done by two independent authors using software. All disagreements will be resolved by discussion. A standardised data extraction form will be designed for the extraction. Two authors will independently extract the data from the selected articles and all disagreements will be resolved by discussion. We will use a tool developed by Munn and colleagues to critically appraise all the included studies. The primary outcome will be the proportion of individuals with FASD in South Africa. We will use the Freeman-Tukey double arcsine transformation to transform the raw prevalence estimates so that the data can follow an approximately normal distribution. We will use random-effects models to calculate 95% confidence intervals and prediction intervals based on multiple meta-analyses with transformed proportions. We will test heterogeneity using Cochran's Q and describe using the I2 statistic.

DISCUSSION

The pooled prevalence estimate will assist the government and other stakeholders (such as non-profit organisations and researchers) to plan and prioritise prevention and management interventions.

SYSTEMATIC REVIEW REGISTRATION

The protocol has been registered with PROSPERO (registration number: CRD42020197979 ).

Policy Requirements for the Prevention and Management of Fetal Alcohol Spectrum Disorder in South Africa: A Policy Brief

This policy brief is aimed to guide policymakers in developing a comprehensive and multi-sectoral policy for the prevention and management of fetal alcohol spectrum disorder (FASD). FASD is a leading source of non-genetic developmental and intellectual disability globally and is usually associated with primary and secondary disabilities. South Africa has been identified to have the highest reported prevalence of FASD in the world. Nevertheless, evidence shows that there is no specific policy for FASD, albeit there are clauses that could be attributed to its prevention and management in other existing policies. In this brief, we present a guideline to inform programmes and interventions to tackle the FASD problem in South Africa and other relevant contexts through developing a policy.

Fetal Alcohol Spectrum Disorder resources for educators working within primary school settings: a scoping review protocol

INTRODUCTION

Many children affected by Fetal Alcohol Spectrum Disorder (FASD) exhibit neurocognitive delays that contribute to secondary consequences, including a disrupted school experience. Educators often have limited knowledge or experience in the identification, referral, management and accommodation of students with FASD. Effective resources and tools for educators are crucial to ensure these students are supported in their ongoing learning, development and school participation. This scoping review aims to identify and evaluate resources for educators that aid in the identification, management, or accommodation of students with FASD.

METHODS AND ANALYSIS

A search will be conducted in 9 peer-reviewed and 11 grey literature databases, Google search engine, two app stores and two podcast streaming services (planned search dates: November 2020 to February 2021). Relevant experts, including researchers, health professionals and individuals with lived experience of FASD, will be contacted in February and March 2021 to identify additional (including unpublished) resources. Resources will be selected based on registered, prespecified inclusion-exclusion criteria, and the quality of included resources will be critically appraised using a composite tool based on adaptions of the National Health and Medical Research Council FORM Framework and the iCAHE Guideline Quality Checklist. Relevant experts will also be requested to provide feedback on included resources.

ETHICS AND DISSEMINATION

Ethical approval for this scoping review was obtained from the University of Sydney Human Research Ethics Committee (2020/825). Results of the review will be disseminated through a peer-reviewed publication, conference presentations, and seminars targeting audiences involved in the education sector.

TRIAL REGISTRATION

Open Science Framework: osf.io/73pjh.

[Fetal alcohol spectrum disorders in adults]

Fetal alcohol spectrum disorders (FASD) are a common cause of a congenital developmental disability acquired in the womb due to alcohol consumption by the mother during pregnancy. The physical and mental consequences persist into adulthood. The 4‑digit code is an evidence-based method for diagnosing the full spectrum of outcomes, i.e. the full picture of fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD). The four key diagnostic features are (1) growth disorder, (2) facial dysmorphia, (3) central nervous system (CNS) structural and functional abnormalities and (4) prenatal alcohol exposure. Even if the disorder cannot be cured, supportive therapeutic interventions can improve the quality of life and independence and psychiatric comorbidities can be treated.

Maternal Substance Use: Consequences, Identification, and Interventions

Alcohol, tobacco, and cannabis are the substances most frequently used during pregnancy, and opioid-exposed pregnancies have increased fourfold. The purpose of this review is to describe the prevalence and consequences of prenatal exposure to alcohol, tobacco, cannabis, and opioids. Currently available screening questionnaires for prenatal substance use are summarized and contrasted with the measures available for prenatal alcohol use. Because screening for prenatal alcohol and substance use is but the prelude to efforts to mitigate the potential adverse consequences, attempts for the modification of these consequences are briefly reviewed. In addition, areas of future research related to the criminalization of prenatal substance use, which may inhibit both inquiry and disclosure, are discussed. Indeed, the full potential of effective interventions has yet to be realized.

A guideline for the prevention and management of Fetal Alcohol Spectrum Disorder in South Africa

Background

Fetal Alcohol Spectrum Disorder (FASD) is a public health problem globally, with South Africa having the highest recorded prevalence of all countries. Government programmes to prevent and manage FASD remain limited because of the lack of a specific policy. Herein, we developed a guideline to inform policy on the prevention and management of FASD in South Africa.

Methods

We applied a modified version of the World Health Organization’s approach to guideline development in three phases. In the first phase, we designed the initial guideline prototype. To do this, we conducted an in-depth interview with policymakers and a focus group with relevant service providers on policy requirements for FASD, a document review of policies on FASD and a scoping review of various interventions for FASD. In phase 2, we refined the initially formulated guideline prototype through a discursive approach with seven local and international experts on FASD. Phase 3 involved refining the prototype using a modified Delphi approach. Forty-three and forty-one experts participated in rounds 1 and 2 of the Delphi approach, respectively. The acceptable consensus for each included policy statement was 85%.

Results

We identified three aspects of the proposed guideline, which are the approaches and guiding principles, the prevention measures and the management measures. The guideline proposes that a FASD policy should consider lifespan needs, be culturally diverse, collaborative, evidence-based, multi-sectoral and address social determinants of health contributing to FASD. The essential components of FASD prevention policy consist of awareness and education of the dangers of drinking alcohol, access to treatment for alcohol problems and training of service providers. The management components include capacity building related to diagnosis, educating parents regarding the needs and management, appropriate referral pathways, training of teachers regarding classroom management and support for parents and individuals with FASD.

Conclusion

FASD in South Africa deserves urgent attention. Developing a specific policy to guide programmes could enhance and coordinate the efforts towards preventing and managing FASD. The guideline has the potential to assist policymakers in the development of a comprehensive and multi-sectoral policy for prevention and management of FASD, considering the consensus obtained from the experts.

Fetal Alcohol Spectrum Disorders: Fixing Our Aim to Aim for the Fix

We, as editors of this special issue on Fetal Alcohol Spectrum Disorders (FASD), are proud to present eleven papers [...].