Adverse childhood experiences, associated stressors and comorbidities in children and youth with fetal alcohol spectrum disorder across the justice and child protection settings in Western Australia

Background

Individuals with Fetal Alcohol Spectrum Disorder (FASD) are at risk of having adverse childhood experiences (ACEs), especially those with child protection and/or justice system involvement. The complex relationship between FASD and psychosocial vulnerabilities in the affected individual is an important clinical risk factor for comorbidity. This study (1) explored the ACEs and associated stressors in individuals with FASD; (2) investigated the association between ACEs and negative outcomes, i.e., justice/child protection system involvement; and (3) examined the relationship between ACEs and comorbid conditions such as mood and neurodevelopmental disorders.

Methods

Data were collected retrospectively via file review from diagnostic clinics in Western Australia. Life adversity was coded using a standardised ACEs questionnaire. A total of 211 participants (72% males) with FASD with a mean age of 11 years (range = 2–21) were included in the final sample. 70% of the total sample had been involved with the child protection system and 40% had trouble with the law.

Results

Exposure to drinking/substance misuse at home (70%) and domestic violence (52%) were the two most common ACEs across the total sample. In the entire cohort, 39% had four or more ACEs, indicating higher risks of poor health outcomes. Additional stressors recorded were disengagement from school (43%), transiency (19%), victims of bullying (12%), traumatic brain injury (9%) and homelessness (5%). ACEs such as drinking/substance misuse at home, emotional neglect and physical neglect were positively associated with child protection system involvement. Additionally, exposure to domestic violence was positively correlated with justice system involvement. Higher rates of life adversity in this clinical population were associated with an increased number of comorbidities. Specifically, those with FASD who had comorbidities such as attachment disorder, substance use disorder, and PTSD also reported higher ACEs scores.

Conclusion

ACEs were common in this clinical population. Increased ACEs in this sample were associated with increased comorbidities and involvement with the child protection and/or justice system. This highlights that prevention, intervention and early diagnosis of FASD are important for at risk children to reduce the negative effects of ACEs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03654-y.

Correction: Gilmore et al. Association between Nightlife Goers' Likelihood of an Alcohol Use Disorder and Their Preferred Bar's Closing Time: A Cross-Sectional Observational Study in Perth, Australia. Int. J. Environ. Res. Public Health 2021, 18, 13040

In the original publication [...].

Exploring offending characteristics of young people with foetal alcohol spectrum disorder in Western Australia

Neurodevelopmental impairments resulting from Foetal Alcohol Spectrum Disorder (FASD) can increase the likelihood of justice system involvement. This study compared offence characteristics in young people with FASD to demographically matched controls (n = 500) in Western Australia. A novel approach (i.e. association rule mining) was adopted to uncover relationships between personal attributes and offence characteristics. For FASD participants (n = 100), file records were reviewed retrospectively. Mean age of the total sample was 15.60 years (range = 10-24), with 82% males and 88% Australian Aboriginal. After controlling for demographic factors, regression analyses showed FASD participants were more likely than controls to be charged with reckless driving (odds ratio, OR = 4.20), breach of bail/community orders (OR = 3.19), property damage (OR = 1.84), and disorderly behaviour (OR = 1.54). Overall, our findings suggest justice-involved individuals with FASD have unique offending profiles. These results have implications for sentencing, diversionary/crime prevention programs and interventions.

It takes a village: Influencing policy and practice to prevent alcohol use in pregnancy and promote better outcomes for individuals living with Fetal Alcohol Spectrum Disorder

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by exposure to alcohol in utero. It has pervasive, lifelong impacts and is recognised as a major public health concern in many countries where alcohol is used. The FASD Research Australia Centre of Research Excellence (CRE) was funded by the National Health and Medical Research Council to generate and translate evidence to address prevention, diagnosis, and management of FASD in Australia. The current paper describes the approach to policy and practice impact taken by our CRE, including our stakeholder engagement processes and the key principles that underlie our approach. We provide examples of policy and practice influence in FASD prevention, diagnosis and management that have been achieved over the past five years and discuss challenges that are routinely faced in the translation of our work.

It takes a village: Influencing policy and practice to prevent alcohol use in pregnancy and promote better outcomes for individuals living with Fetal Alcohol Spectrum Disorder

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by exposure to alcohol in utero. It has pervasive, lifelong impacts and is recognised as a major public health concern in many countries where alcohol is used. The FASD Research Australia Centre of Research Excellence (CRE) was funded by the National Health and Medical Research Council to generate and translate evidence to address prevention, diagnosis, and management of FASD in Australia. The current paper describes the approach to policy and practice impact taken by our CRE, including our stakeholder engagement processes and the key principles that underlie our approach. We provide examples of policy and practice influence in FASD prevention, diagnosis and management that have been achieved over the past five years and discuss challenges that are routinely faced in the translation of our work.

Nurturing families: One year pilot outcomes for a modified Parent Child Assistance Program in Australia

Alcohol and Other Drug (AOD) exposure during pregnancy is linked to serious adverse child outcomes, including Fetal Alcohol Spectrum Disorder (FASD). The Parent-Child Assistance Program (PCAP) supports women with problematic AOD use, who are pregnant or have young children, and are not effectively engaging with services. PCAP has been shown to reduce alcohol exposed pregnancies, promote AOD abstinence, increase employment and family planning and improve child outcomes. This manuscript reports the first pilot evaluation of the PCAP program delivered in Australia. A pre-post-intervention repeated measures design was used. Eleven women receiving PCAP from a not-for-profit organisation were invited to take part in the study, with eight providing complete pre-post data. Home visitation case management was provided by trained and experienced case-managers. Clients were assisted to engage with existing services effectively to meet their own goals via a combination of relational theory, motivational interviewing and harm reduction concepts. The PCAP Modified Addiction Severity Index 5th Edition was adapted for use in Australia and was used to measure domains of addiction severity related problems as the primary outcome. Secondary outcomes included client satisfaction and program fidelity. There were significant changes in composite addiction severity scores from baseline to one year. 80% of participants had periods of abstinence of longer than four months. All clients had better connection to services, no subsequent AOD exposed pregnancies, and were highly satisfied with the program. Four had children returned to their care. Implementation was similar to the original PCAP program with major differences including case-managers relying on training manuals only without undertaking in-person training; being more experienced; providing more direct AOD counselling; and having less supervision. The findings will inform future program delivery and methodology for a larger longitudinal study assessing outcomes at program exit.

A systematic review of the biological, social, and environmental determinants of intellectual disability in children and adolescents

AIM

This systematic review aimed to identify the most important social, environmental, biological, and/or genetic risk factors for intellectual disability (ID).

METHODS

Eligible were published prospective or retrospective comparative studies investigating risk factors for ID in children 4-18 years. Exclusions were single group studies with no comparator without ID and a sample size <100. Electronic databases (Medline, Cochrane Library, EMBASE, PsycInfo, Campbell Collaboration, and CINAHL) were searched for eligible publications from 1980 to 2020. Joanna Briggs Institute critical appraisal instruments, appropriate for study type, were used to assess study quality and risk of bias. Descriptive characteristics and individual study results were presented followed by the synthesis for individual risk factors, also assessed using GRADE.

RESULTS

Fifty-eight individual eligible studies were grouped into six exposure topics: sociodemographic; antenatal and perinatal; maternal physical health; maternal mental health; environmental; genetic or biological studies. There were few eligible genetic studies. For half the topics, the certainty of evidence (GRADE) was moderate or high.

CONCLUSION

Multiple studies have examined individual potential determinants of ID, but few have investigated holistically to identify those populations most at risk. Our review would indicate that there are vulnerable groups where risk factors we identified, such as low socioeconomic status, minority ethnicity, teenage motherhood, maternal mental illness, and alcohol abuse, may cluster, highlighting a target for preventive strategies. At-risk populations need to be identified and monitored so that interventions can be implemented when appropriate, at preconception, during pregnancy, or after birth. This could reduce the likelihood of ID and provide optimal opportunities for vulnerable infants.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=120032], identifier [CRD42019120032].

Identifying how the principles of self-determination could be applied to create effective alcohol policy for First Nations Australians: Synthesising the lessons from the development of general public policy

BACKGROUND

Harmful alcohol consumption contributes to poorer health for all people. For Indigenous Peoples of Australia, Canada, and New Zealand alcohol impacts their wellbeing significantly, this is partially explained by both their experiences of colonisation and the resulting impact on structural and social determinants of health. Indigenous Peoples have a recognised right to self-determination, which includes their right to contribute to policy decisions that affect them. This right is based on international recognition and principles, and acknowledgement of historical culture and law. The aim of this narrative review is to examine the processes of inclusion of Indigenous Peoples in policy development processes for evidence of self-determination to inform alcohol policy development.

METHODS

Ninety-eight peer-reviewed journal articles were identified through four databases. Twenty papers describing the inclusion of Indigenous Peoples in policy development processes were included; one focusing on alcohol. Two authors reviewed and coded the papers by four domains of Indigenous inclusion in policy processes: Indigenous representation; method of inclusion; reasons for inclusion; and stage of inclusion.

RESULTS

There is no single model for the integration of self-determination into policy. However, the nature of participation is key in ensuring that Indigenous Peoples' self-determination is recognised. While all the papers reported Indigenous Peoples being included in processes, there was little evidence of self-determination.

CONCLUSIONS

Self-determination is a right, and critical to effective policy and action. The inclusion of Indigenous Peoples in policy development alone is not self-determination; however, creating the conditions that ensures Indigenous Peoples have influence throughout policy processes is one integral component of self-determination.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

Introduction

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcohol exposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensure research is relevant and meaningful for people living with FASD, their families, and the broader public there is a need to engage community members in setting priorities for research.

Objectives

Our primary objective was to formally identify the views of people living with FASD, their parents/caregivers, service providers, and the general community on the research priorities for FASD and alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview of current research in the highest priority areas identified.

Methods

The approach for this study involved two community surveys and a consensus workshop, followed by a rapid literature review. Survey responses (n = 146) were collected and grouped using qualitative thematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22 highest ranked themes were considered in a workshop with 21 community members, and consensus on the top ten priority areas was sought. The priority areas were grouped into conceptually similar topics and rapid literature reviews were undertaken on each.

Results

A diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. On request from participants, separate priority lists were developed by Aboriginal and non-Aboriginal participants.

Conclusion

There is need for a national network of researchers to take forward the research commenced by the Centre of Research Excellence, FASD Research Australia, in addressing community priorities.

Key Words

Community, priorities, FASD, rapid review, Australia.

Predicting alcohol dependence treatment outcomes: a prospective comparative study of clinical psychologists versus 'trained' machine learning models

BACKGROUND AND AIMS

Clinical staff are typically poor at predicting alcohol dependence treatment outcomes. Machine learning (ML) offers the potential to model complex clinical data more effectively. This study tested the predictive accuracy of ML algorithms demonstrated to be effective in predicting alcohol dependence outcomes, compared with clinical judgement and traditional linear regression.

DESIGN

Prospective study. ML models were trained on 1016 previously treated patients (training-set) who attended a hospital-based alcohol and drug clinic. ML models (n = 27), clinical psychologists (n = 10) and a 'traditional' logistic regression model (n = 1) predicted treatment outcome during the initial treatment session of an alcohol dependence programme.

SETTING

A 12-week cognitive behavioural therapy (CBT)-based abstinence programme for alcohol dependence in a hospital-based alcohol and drug clinic in Australia.

PARTICIPANTS

Prospective predictions were made for 220 new patients (test-set; 70.91% male, mean age = 35.78 years, standard deviation = 9.19). Sixty-nine (31.36%) patients successfully completed treatment.

MEASUREMENTS

Treatment success was the primary outcome variable. The cross-validated training-set accuracy of ML models was used to determine optimal parameters for selecting models for prospective prediction. Accuracy, sensitivity, specificity, area under the receiver operator curve (AUC), Brier score and calibration curves were calculated and compared across predictions.

FINDINGS

The mean aggregate accuracy of the ML models (63.06%) was higher than the mean accuracy of psychologist predictions (56.36%). The most accurate ML model achieved 70% accuracy, as did logistic regression. Both were more accurate than psychologists (P < 0.05) and had superior calibration. The high specificity for the selected ML (79%) and logistic regression (90%) meant they were significantly (P < 0.001) more effective than psychologists (50%) at correctly identifying patients whose treatment was unsuccessful. For ML and logistic regression, high specificity came at the expense of sensitivity (26 and 31%, respectively), resulting in poor prediction of successful patients.

CONCLUSIONS

Machine learning models and logistic regression appear to be more accurate than psychologists at predicting treatment outcomes in an abstinence programme for alcohol dependence, but sensitivity is low.

Community Priority setting for Fetal Alcohol Spectrum Disorder Research in Australia

IntroductionFetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by prenatal alcoholexposure (PAE). FASD research is a rapidly growing field that crosses multiple disciplines. To ensureresearch is relevant and meaningful for people living with FASD, their families, and the broader publicthere is a need to engage community members in setting priorities for research. ObjectivesOur primary objective was to formally identify the views of people living with FASD, their par-ents/caregivers, service providers, and the general community on the research priorities for FASDand alcohol use in pregnancy in Australia. Our secondary objective was to provide an overview ofcurrent research in the highest priority areas identified. MethodsThe approach for this study involved two community surveys and a consensus workshop, followed bya rapid literature review. Survey responses (n = 146) were collected and grouped using qualitativethematic analysis. The themes identified were then ranked in a second survey (n = 45). The 22highest ranked themes were considered in a workshop with 21 community members, and consensuson the top ten priority areas was sought. The priority areas were grouped into conceptually similartopics and rapid literature reviews were undertaken on each. ResultsA diverse range of priorities was identified within key areas of prevention, diagnosis, and therapy. Onrequest from participants, separate priority lists were developed by Aboriginal and non-Aboriginalparticipants. ConclusionsThere is need for a national network of researchers to take forward the research commenced by theCentre of Research Excellence, FASD Research Australia, in addressing community priorities.

A preliminary investigation of the effects of prenatal alcohol exposure on facial morphology in children with Autism Spectrum Disorder

Alcohol exposure during pregnancy has been associated with altered brain development and facial dysmorphology. While Autism Spectrum Disorder (ASD) is not specifically related to distinct facial phenotypes, recent studies have suggested certain facial characteristics such as increased facial masculinity and asymmetry may be associated with ASD and its clinical presentations. In the present study, we conducted a preliminary investigation to examine facial morphology in autistic children with (n = 37; mean age = 8.21 years, SD = 2.72) and without (n = 100; mean age = 8.37 years, SD = 2.47) prenatal alcohol exposure. Using three-dimensional facial scans and principal component analysis, we identified a facial shape associated with prenatal alcohol exposure in autistic children. However, variations in the alcohol-related facial shape were generally not associated with behavioral and cognitive outcomes. These findings suggest that while early exposure to alcohol may influence the development of facial structures, it does not appear to be associated with ASD phenotypic variability. Importantly, although these findings do not implicate a role for prenatal alcohol exposure in the etiology of ASD, further research is warranted to investigate the link between prenatal alcohol exposure and facial morphology differences among neurodevelopmental conditions.

A reduction in reported alcohol use in pregnancy in Australian Aboriginal communities: a prevention campaign showing promise

OBJECTIVE

Aboriginal leaders in remote Western Australian communities with high rates of prenatal alcohol exposure invited researchers to evaluate the community-led Marulu foetal alcohol spectrum disorder (FASD) Prevention Strategy initiated in 2010.

METHODS

The proportion of women reporting alcohol use during pregnancy to midwives was compared between 2008, 2010 and 2015. Initial midwife appointments were calculated by weeks of gestation. The proportions of women reporting alcohol use by age at birth were compared.

RESULTS

Alcohol use reduced significantly from 2010 (61.0%) to 2015 (31.9%) with first-trimester use reducing significantly from 2008 (45.1%) to 2015 (21.6%). Across all years, 40.8% reported alcohol use during pregnancy and 14.8% reported use in both first and third trimesters. Most women attended the midwife in the first trimester. There was a significant relationship between increased maternal age and third-trimester alcohol use.

CONCLUSIONS

The reduction in reported prenatal alcohol exposure in an Aboriginal community setting during a period of prevention activities provides initial evidence for a community-led strategy that might be applicable to similar communities. Implications for public health: The reductions in alcohol use reduce the risk of children being born with FASD in an area with high prevalence, with possible resultant reductions in associated health, economic and societal costs.

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.

Machine learning vs addiction therapists: A pilot study predicting alcohol dependence treatment outcome from patient data in behavior therapy with adjunctive medication

BACKGROUND AND OBJECTIVES

Clinical staff providing addiction treatment predict patient outcome poorly. Prognoses based on linear statistics are rarely replicated. Addiction is a complex non-linear behavior. Incorporating non-linear models, Machine Learning (ML) has successfully predicted treatment outcome when applied in other areas of medicine. Using identical assessment data across the two groups, this study compares the accuracy of ML models versus clinical staff to predict alcohol dependence treatment outcome in behavior therapy using patient data only.

METHODS

Machine learning models (n = 28) were constructed ('trained') using demographic and psychometric assessment data from 780 previously treated patients who had undertaken a 12 week, abstinence-based Cognitive Behavioral Therapy program for alcohol dependence. Independent predictions applying assessment data for an additional 50 consecutive patients were obtained from 10 experienced addiction therapists and the 28 trained ML models. The predictive accuracy of the ML models and the addiction therapists was then compared with further investigation of the 10 best models selected by cross-validated accuracy on the training-set. Variables selected as important for prediction by staff and the most accurate ML model were examined.

RESULTS

The most accurate ML model (Fuzzy Unordered Rule Induction Algorithm, 74%) was significantly more accurate than the four least accurate clinical staff (51%-40%). However, the robustness of this finding may be limited by the moderate area under the receiver operator curve (AUC = 0.49). There was no significant difference in mean aggregate predictive accuracy between 10 clinical staff (56.1%) and the 28 best models (58.57%). Addiction therapists favoured demographic and consumption variables compared with the ML model using more questionnaire subscales.

CONCLUSIONS

The majority of staff and ML models were not more accurate than suggested by chance. However, the best performing prediction models may provide useful adjunctive information to standard clinically available prognostic data to more effectively target treatment approaches in clinical settings.

A systematic review of prevention interventions to reduce prenatal alcohol exposure and fetal alcohol spectrum disorder in indigenous communities

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is a preventable, lifelong neurodevelopmental disorder caused by prenatal alcohol exposure. FASD negatively impacts individual Indigenous communities around the world. Although many prevention interventions have been developed and implemented, they have not been adequately evaluated. This systematic review updates the evidence for the effectiveness of FASD prevention interventions in Indigenous/Aboriginal populations internationally, and in specific populations in North America and New Zealand, and offers recommendations for future work.

METHOD

The MEDLINE, Embase, CINAHL Plus, Web of Science, PsycINFO, SocINDEX, and Informit databases were searched from inception to 22/08/2017 for all prevention and intervention papers published in peer-reviewed scientific journals, with results, targeting prenatal alcohol exposure and FASD in Indigenous populations. This review was limited to studies published in English and excluded interventions focusing on the workforce. All steps were completed independently by two reviewers with discrepancies resolved via consensus with the senior author.

RESULTS

There was significant heterogeneity in the ten included studies. Populations targeted included non-pregnant women of child-bearing age, pregnant women, school children and the general public. Study designs included one randomised controlled trial, five cohort studies with pre-post design, one cross-sectional study with different pre- and post-intervention groups, and four studies collected post-intervention data. Studies assessed changes in knowledge, and/or changes in risk for prenatal alcohol exposure including self-reported alcohol consumption, use of birth control or a combination of both. One study was conducted in Australia and nine in the US. The methodological quality of all studies was rated as 'Poor' using the systematic review assessment tools developed by The National Heart, Lung and Blood Institute. Studies were subject to substantial bias due to issues such as high loss to follow-up, lack of control groups and the reliance on self-report measures to assess the main outcome.

CONCLUSION

Overall, there is little evidence that previous interventions aiming to reduce the risk of prenatal alcohol exposure or FASD in Indigenous populations have been effective. Future intervention studies should address the cultural factors and historical context that are fundamental to successful work with Indigenous populations, and be designed, implemented and evaluated using rigorous methods. This systematic review was registered with PROSPERO, CRD42018086212.

Predicting Language Difficulties in Middle Childhood From Early Developmental Milestones: A Comparison of Traditional Regression and Machine Learning Techniques

PURPOSE

The current study aimed to compare traditional logistic regression models with machine learning algorithms to investigate the predictive ability of (a) communication performance at 3 years old on language outcomes at 10 years old and (b) broader developmental skills (motor, social, and adaptive) at 3 years old on language outcomes at 10 years old.

METHOD

Participants (N = 1,322) were drawn from the Western Australian Pregnancy Cohort (Raine) Study (Straker et al., 2017). A general developmental screener, the Infant Monitoring Questionnaire (Squires, Bricker, & Potter, 1990), was completed by caregivers at the 3-year follow-up. Language ability at 10 years old was assessed using the Clinical Evaluation of Language Fundamentals-Third Edition (Semel, Wiig, & Secord, 1995). Logistic regression models and interpretable machine learning algorithms were used to assess predictive abilities of early developmental milestones for later language outcomes.

RESULTS

Overall, the findings showed that prediction accuracies were comparable between logistic regression and machine learning models using communication-only performance as well as performance on communication and broader developmental domains to predict language performance at 10 years old. Decision trees are incorporated to visually present these findings but must be interpreted with caution because of the poor accuracy of the models overall.

CONCLUSIONS

The current study provides preliminary evidence that machine learning algorithms provide equivalent predictive accuracy to traditional methods. Furthermore, the inclusion of broader developmental skills did not improve predictive capability. Assessment of language at more than 1 time point is necessary to ensure children whose language delays emerge later are identified and supported.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.6879719.

The provision of alcohol and breastfeeding information by maternal health practitioners in the Australian setting

BACKGROUND

In the 2009 National Health and Medical Research Council (NHMRC) Australian Guidelines to Reduce Health Risks from Drinking, a guideline specific to lactating women was included. For the first time the effect of alcohol at this important developmental stage was nationally and internationally acknowledged.

AIMS

To determine the degree to which maternal health practitioners adopted an Australian national policy guideline (Guideline 4B) on alcohol and breastfeeding into their everyday health practice and the factors associated with adoption.

MATERIALS AND METHODS

A convenience sample of participants completed an online survey based on the Nursing Practice Questionnaire (NPQ) to elicit measures of knowledge, awareness and practice implementation.

RESULTS

In total, 240 maternal health practitioners completed the online survey. All statistical analyses clearly indicated a higher adoption of Guideline 4B by the child health nurses, midwives and general practitioners (GPs) than was the case for paediatricians and obstetricians. A mean adoption score (range 0-4) indicative of 'some' practice implementation of 3.13, 3.04 and 2.73 was obtained by child health nurses, midwives and GPs, respectively. Obstetricians and paediatricians scored a mean of 2.0, indicating they remain to be 'persuaded about the practice' of incorporating discussions around alcohol and breastfeeding into their practice.

CONCLUSION

Despite the existence of a national alcohol guideline for breastfeeding women, maternal health practitioners are not incorporating this advice into their everyday practice with lactating women. Opportunities exist for all maternal practitioners along the reproductive continuum to protect long-term breastfeeding duration using an evidence-based harm minimisation approach to alcohol consumption.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

ACTRN12615000733572; Pre-results.

The development of a culturally appropriate school based intervention for Australian Aboriginal children living in remote communities: A formative evaluation of the Alert Program® intervention

BACKGROUND/AIM

Although previous research has demonstrated the benefits of targeting self-regulation in non-Aboriginal children, it is unclear whether such programs would be effective for Aboriginal children attending school in remote communities. Some of these children have been diagnosed with a fetal alcohol spectrum disorder (FASD) impairing their ability to self-regulate. The aim of this article is to describe a three phase formative process to develop and pilot a curriculum version of the Alert Program^® , a promising intervention for improving self-regulation that could be used in remote community schools. This modified version of the program will be subsequently tested in a cluster randomised controlled trial.

METHODS

A mixed methods approach was used.

RESULTS

Modifications to the Alert Program^® , its delivery and evaluation were made after community and stakeholder consultation facilitated by a senior Aboriginal community researcher. Changes to lesson plans and program resources were made to reflect the remote community context, classroom environment and the challenging behaviours of children. Standardised study outcome measures were modified by removing several questions that had little relevance to the lives of children in remote communities. Program training for school staff was reduced in length to reduce staff burden.

CONCLUSIONS

This study identified aspects of the Alert Program^® training, delivery and measures for evaluation that need modification before their use in assessing the efficacy of the Alert Program^® in remote Aboriginal community primary schools.

Guanine nucleotide exchange factor Dock7 mediates HGF-induced glioblastoma cell invasion via Rac activation

Background:

Glioblastoma multiforme (GBM), a highly invasive primary brain tumour, remains an incurable disease. Rho GTPases and their activators, guanine nucleotide exchange factors (GEFs), have central roles in GBM invasion. Anti-angiogenic therapies may stimulate GBM invasion via HGF/c-Met signalling. We aim to identify mediators of HGF-induced GBM invasion that may represent targets in a combination anti-angiogenic/anti-invasion therapeutic paradigm.

Methods:

Guanine nucleotide exchange factor expression was measured by microarray analysis and western blotting. Specific depletion of proteins was accomplished using siRNA. Cell invasion was determined using matrigel and brain slice assays. Cell proliferation and survival were monitored using sulforhodamine B and colony formation assays. Guanine nucleotide exchange factor and GTPase activities were determined using specific affinity precipitation assays.

Results:

We found that expression of Dock7, a GEF, is elevated in human GBM tissue in comparison with non-neoplastic brain. We showed that Dock7 mediates serum- and HGF-induced glioblastoma cell invasion. We also showed that Dock7 co-immunoprecipitates with c-Met and that this interaction is enhanced upon HGF stimulation in a manner that is dependent on the adaptor protein Gab1. Dock7 and Gab1 also co-immunoprecipitate in an HGF-dependent manner. Furthermore, Gab1 is required for HGF-induced Dock7 and Rac1 activation and glioblastoma cell invasion.

Conclusions:

Dock7 mediates HGF-induced GBM invasion. Targeting Dock7 in GBM may inhibit c-MET-mediated invasion in tumours treated with anti-angiogenic regimens.

Expansion of the canine A blood group system

A detailed study of the canine A blood group system was undertaken, resulting in the expansion of this system into a three-factor, four-allelic one with the recognition of an additional subtype, a3. The serological and extensive family data supported the proposed genetic theory of four alleles with dominance with the order being Aa1, Aa2, Aa3 and A-. Gene frequencies of the alleles were determined in various breeds of dogs with frequencies in the general Brisbane population being 0.244 (Aa1), 0.042 (Aa2), 0.045 (Aa3) and 0.669 (A-).

Canine blood groups: description of 20 specificities

Twenty blood typing reagents, four agglutinins and 16 operable in the antiglobulin test, were prepared from 54 antisera which were produced in 24 dogs. Two of the reagents were identified as anti-B and Nf6. Two of the antigens were shown by absorption and family studies to be linear subtypes. In most cases, detailed family studies demonstrated a Mendelian dominant inheritance for the genes controlling the canine red cell antigens. Gene frequencies were determined in various breeds of dogs and in the dingo.

Canine plasma alkaline phosphatase polymorphism and its relationship with the canine Tr blood group system

A canine blood group antigen, QN, which was detected by a naturally occurring alloantibody in the antiglobulin test, was shown to be antigenically related to the human A and cattle J antigens by absorption experiments. Family studies supported a dominant mode of inheritance with the gene controlling the production of QN being dominant to the gene responsible for its absence. Frequencies of the QN and Tr antigens and serological data strongly suggested that the two antigens are identical. Two canine plasma alkaline phosphatase variants, F and S, were detected by starch gel electrophoresis, pH 8.65. Assuming genetic control of two codominant alleles, ALPF and ALPS, the distributions of types in families differed significantly from expectation. A relationship between the ALP and Tr(QN) systems was demonstrated with Tr-positive animals having a significant deficiency of S alkaline phosphatase types.

The application of machine learning techniques as an adjunct to clinical decision making in alcohol dependence treatment

With few exceptions, research in the addictive sciences has relied on linear statistics and methodologies. Addiction involves a complex array of nonlinear behaviors. This study applies two machine learning techniques, Bayesian and decision tree classifiers, in the assessment of outcome of an alcohol dependence treatment program. These nonlinear approaches are compared to a standard linear analysis. Seventy-three alcohol-dependent subjects undertaking a 12-week cognitive-behavioral therapy (CBT) program and 66 subjects undertaking an identical program but also prescribed the relapse prevention agent Acamprosate were employed in this study. Demographic, alcohol use, dependence severity, craving, health-related quality of life, and psychological measures at baseline were used to predict abstinence at 12 weeks. Decision trees had a 77% predictive accuracy across both data sets, Bayesian networks 73%, and discriminant analysis 42%. Combined with clinical experience, machine learning approaches offer promise in understanding the complex relationships that underlie treatment outcome for abstinence-based alcohol treatment programs.

Rho family GTPases regulate mammary epithelium cell growth and metastasis through distinguishable pathways

BACKGROUND

Relatively few genes have been shown to directly affect the metastatic phenotype of breast cancer epithelial cells in vivo. The Rho family of proteins, incluing the Rho, Rac and Cdc42 subfamilies, are related to the small GTP binding protein Ras and regulated diverse biological processes including gene transcription, cytoskeletal organization, cell proliferation and transformation. The effects of Cdc42, Rac and Rho on the actin cytoskeleton suggested a possible role for Rho proteins in cellular motility and metastasis; however, a formal analysis of the role of Rho proteins in breast cancer cellular growth and metastasis in vivo had not previously been performed.

MATERIALS AND METHODS

We generated a panel of MTLn3 rat mammary adenocarcinoma cells that expressed similar levels of dominant inhibitory mutants of Cdc42-, Rac- and Rho-dependent signaling, to examine the contribution of these GTPases to cell spreading, guided chemotaxis, and metastasis in vivo. The ability of Rho proteins to regulate intravasation into the peripheral blood was determined by implanting MTLn3 cell stable dominant negative lines in nude mice and measuring the formation of breast cancer cell colonies grown from the peripheral blood. Serial sectioning of the lungs was performed to determine the presence of metastasis in mice in which mammary tumors expressing the dominant negative Rho family proteins had grown to a similar size.

RESULTS

Cell spreading of MTLn3 cells was selectively abrogated by N17Rac1. N19RhoA and N17Cdc42 reduced the number of focal contacts (FCs) and disrupted the co-localization of vinculin with phosphotyrosine at FCs. While N17Rac1 and N17Cdc42 preferentially inhibited colony formation in soft agar, all three GTPases affected cell growth in vivo. To distinguish effects on tumorigenicity from intravasation into the bloodstream, implanted tumors were grown to the same size in nude mice. Each dominant inhibitory Rho protein reduced intravasation into the peripheral blood. Lung metastasis of MTLn3 cells was also abrogated by the dominant inhibitory Rho proteins, despite the presence of residual CFU.

CONCLUSIONS

These studies demonstrate for the first time a critical role for the Rho GTPases involving independent signaling pathways to limit mammary tumor cellular growth and metastasis in vivo.

The thrombin receptor, PAR-1, causes transformation by activation of Rho-mediated signaling pathways

We utilized a cDNA expression library derived from the B6SutA(1) mouse myeloid progenitor cell line to search for novel oncogenes that promote growth transformation of NIH3T3 cells. A 2.2 kb transforming cDNA was recovered that encodes the wild type thrombin-stimulated G protein-coupled receptor PAR-1. In addition to its potent focus forming activity, constitutive overexpression of PAR-1 in NIH3T3 cells promoted the loss of anchorage- and serum-dependent growth. Although inhibitors of thrombin failed to block PAR-1 transforming activity, a PAR-1 mutant that cannot be cleaved by thrombin was nontransforming. Since the foci of transformed cells induced by PAR-1 bear a striking resemblance to those induced by activated RhoA, we determined if PAR-1 transformation was due to the aberrant activation of a specific Rho family member. Like RhoA, PAR-1 cooperated with activated Raf-1 and caused synergistic enhancement of transforming activity, induced stress fibers when microinjected into porcine aortic endothelial cells, stimulated the activity of the serum response factor and NF-kappaB transcription factors, and PAR-1 transformation was blocked by co-expression of dominant negative RhoA. Finally, PAR-1 transforming activity was blocked by pertussis toxin and by co-expression of the RGS domain of Lsc, implicating Galpha(i) and Galpha(12)/Galpha(13) subunits, respectively, as mediators of PAR-1 transformation. Taken together, these observations suggest that PAR-1 growth transformation is mediated, in part, by activation of RhoA.

Rac1 protects epithelial cells against anoikis

Rho family members play a critical role in malignant transformation. Anchorage-independent growth and the ability to avoid apoptosis caused by loss of anchorage (anoikis) are important features of transformed cells. Here we show that constitutive activation of Rac1 inhibits anoikis in Madin-Darby canine kidney (MDCK) epithelial cells. Constitutively active Rac1-V12 decreases DNA fragmentation and caspase activity by 50% in MDCK cells kept in suspension. In addition, expression of Rac1-V12 in MDCK cells in suspension conditions causes an increase in the number of surviving cells. We also investigated the signaling pathways that are activated by Rac1 to stimulate cell survival. We show that expression of Rac1-V12 in MDCK cells in suspension stimulates a number of signaling cascades that have been implicated in the control of cell survival, including the p42/44 ERK, p38, protein kinase B, and nuclear factor kappaB pathways. Using specific chemical or protein inhibitors of these respective pathways, we show that Rac1-mediated cell survival strongly depends on phosphatidylinositol 3-kinase activity and that activation of ERK, p38, and NF-kappaB are largely dispensable for Rac1 survival signaling. In conclusion, these studies demonstrate that Rac1 can suppress apoptosis in epithelial cells in anchorage-independent conditions and suggest a potential role for Rac1-mediated survival signaling in cell transformation.

The small GTPase Rac suppresses apoptosis caused by serum deprivation in fibroblasts

BACKGROUND

The small GTPase Rac1 is a key signaling protein that mediates a number of important physiologic functions including the organization of the actin cytoskeleton, lipid metabolism, and gene transcription. Rac1 has also been implicated in oncogenic transformation. Expression of constitutively active Rac1 in Rat1 fibroblasts elicits serum- and anchorage-independent growth and causes tumorigenicity in nude mice. The signaling pathways that mediate the role of Rac in cell transformation remain to be identified. Here, we study the role of Rac in cell survival in the absence of serum.

MATERIALS AND METHODS

The cell lines used in this study are Ratl fibroblasts that express constitutively active or dominant negative mutants of Rac1. We used long-term video time-lapse microscopy to analyze the effects of these Rac1 mutants on mitogenicity and apoptosis.

RESULTS

We show that the increase in viability, which is stimulated by Rac1 in the absence of serum, is predominantly caused by an inhibition of apoptosis, with a minor increase in cell division. We also show that Rac1-stimulated cell viability in serum-starved cells is inhibited by chemical inhibition of phosphatidylinositol 3-kinase.

CONCLUSIONS

Our observations indicate a role for Rac1 in survival signaling, possibly via activation of phosphatidylinositol 3-kinase. We propose that Rac1-stimulated cell survival may contribute to the role of Rac1 in serum-independent growth and cell transformation.

Ras GTPases: singing in tune

A review of the meeting "The Ras Superfamily of Small GTP-Binding Proteins," FASEB Summer Research Conference, Snowmass, Colorado, 15 through 20 July 2000 The molecular cloning of the human proto-oncogene encoding Ras was reported nearly 20 years ago. Since then, Ras has become the prototypical member of a superfamily of small guanosine triphosphatase proteins. Despite the maturity of this field of research, the discovery of new functions and interactions between the superfamily members continues unabated. Symons and Takai have written a meeting report on the latest findings on the Ras superfamily.

Synaptojanin 2, a novel Rac1 effector that regulates clathrin-mediated endocytosis

The small GTPase Rac has been implicated in a wide range of cellular processes, including the organization of the actin cytoskeleton, transcriptional control and endocytic vesicle trafficking [1-3]. The signaling components that mediate these functions downstream of Rac largely remain to be identified. In this study, we have identified synaptojanin 2, a polyphosphoinositide phosphatase as a novel Rac1 effector. Synaptojanin 2 directly and specifically interacts with Rac1 in a GTP-dependent manner. Expression of constitutively active Rac1 caused the translocation of synaptojanin 2 from the cytoplasm to the plasma membrane. Both activated Rac1 and a membrane-targeted version of synaptojanin 2 inhibited endocytosis of the epidermal growth factor (EGF) and transferrin receptors, a process that is known to be dependent on polyphosphoinositide lipids. Endocytosis of growth factor receptors is thought to play an important role in the regulation of cell proliferation. Thus, these results suggest that synaptojanin 2 may mediate the inhibitory effect of Rac1 on endocytosis and could contribute to Rac1-mediated control of cell growth.

Rho family GTPases: more than simple switches

Rho family GTPases control a large variety of biological processes. Cycling of Rho proteins between the GDP-bound and the GTP-bound state is controlled by several classes of regulatory proteins. In this review, we discuss the signal-transduction mechanisms that control these regulators. We will emphasize the subcellular localization of Rho GTPases and their regulatory proteins and the role of GTP hydrolysis in signal transmission.

Regulation of Tiam1 nucleotide exchange activity by pleckstrin domain binding ligands

Rho family GTPases play roles in cytoskeletal organization and cellular transformation. Tiam1 is a member of the Dbl family of guanine nucleotide exchange factors that activate Rho family GTPases. These exchange factors have in common a catalytic Dbl homology and adjacent pleckstrin homology domain. Previous structural studies suggest that the pleckstrin domain, a putative phosphoinositide-binding site, may serve a regulatory function. We identified ascorbyl stearate as a compound that binds to the pleckstrin domain of p120 Ras GTPase-activating protein. Furthermore, ascorbyl stearate appears to be a general pleckstrin domain ligand, perhaps by mimicking an endogenous amphiphilic ligand. Tiam1 nucleotide exchange activity was greatly stimulated by ascorbyl stearate. Certain phosphoinositides also stimulated Tiam1 activity but were less potent than ascorbyl stearate. Tiam1 contains an additional N-terminal pleckstrin domain, but only the C-terminal pleckstrin domain was required for activation. Our results suggest that the pleckstrin domains of Dbl-type proteins may not only be involved in subcellular localization but may also directly regulate the nucleotide exchange activity of an associated Dbl homology domain. In addition, this paper introduces ascorbyl stearate as a pleckstrin domain ligand that can modulate the activity of certain pleckstrin domain-containing proteins.

G2A is an oncogenic G protein-coupled receptor

G2A is a heptahelical cell surface protein that has recently been described as a potential tumor suppressor, based on its ability to counteract transformation of pre-B cells and fibroblasts by Bcr-Abl, an oncogenic tyrosine kinase. We have isolated cDNAs encoding G2A in the course of screening libraries for clones that cause oncogenic transformation of NIH3T3 fibroblasts. When expressed at high levels in NIH3T3 cells by retroviral transduction, G2A induced a full range of phenotypes characteristic of oncogenic transformation, including loss of contact inhibition, anchorage-independent survival and proliferation, reduced dependence on serum, and tumorigenicity in mice. When expressed by transfection, G2A greatly enhanced the ability of a weakly oncogenic form of Raf-1 to transform NIH3T3 cells. These results demonstrate that G2A is potently oncogenic both on its own and in cooperation with another oncogene. Expression of G2A in fibroblasts and endothelial cells resulted in changes in cell morphology and cytoskeleton structure that were equivalent to those induced by the G protein subunit Galpha13. Transformation of NIH3T3 cells via G2A expression was completely suppressed by co-expression of LscRGS, a GTPase activating protein that suppresses signaling by Galpha12 and Galpha13. Hyperactivity of Galpha12 or Galpha13 has previously been shown to result in activation of Rho GTPases. G2A expression resulted in activation of Rho, and transformation via G2A was suppressed by a dominant negative form of RhoA. These results indicate that G2A may be directly coupled to Galpha13, and that it is the activation of this Rho-activating Galpha protein which is responsible for the ability of G2A to transform fibroblasts.

Adhesion signaling: PAK meets Rac on solid ground

Interaction of cells with the extracellular matrix influences various aspects of cellular behavior. A recent study shows that cell-substrate adhesion is necessary for effective coupling of the small GTPase Rac to its effector PAK.