Fetal Alcohol Spectrum Disorders: Neuropsychological and Behavioral Features

Heavy prenatal alcohol exposure can cause alterations to the developing brain. The resulting neurobehavioral deficits seen following this exposure are wide-ranging and potentially devastating and, therefore, are of significant concern to individuals, families, communities, and society. These effects occur on a continuum, and qualitatively similar neuropsychological and behavioral features are seen across the spectrum of effect. The term fetal alcohol spectrum disorders (FASD) has been used to emphasize the continuous nature of the outcomes of prenatal alcohol exposure, with fetal alcohol syndrome (FAS) representing one point on the spectrum. This paper will provide a comprehensive review of the neuropsychological and behavioral effects of heavy prenatal alcohol exposure, including a discussion of the emerging neurobehavioral profile. Supporting studies of lower levels of exposure, brain-behavior associations, and animal model systems will be included when appropriate.     

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

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

Functional Neuroimaging in the Examination of Effects of Prenatal Alcohol Exposure

Functional neuroimaging offers the opportunity to understand the effect of prenatal alcohol exposure on the activities of the brain as well as providing a window into the relationship between neural activation and the behavioral outcomes that have been described in affected individuals. Several different methodologies have been used to examine the neurophysiological signal changes associated with different brain functions in prenatally exposed individuals and those diagnosed with fetal alcohol syndrome (FAS) or other fetal alcohol spectrum disorders (FASD). These include electroencephalography (EEG), positron emission tomography (PET), single-photon emission computed tomography (SPECT), and functional magnetic resonance imaging (fMRI). These studies demonstrate that it is feasible to use these technologies with this clinical population and that the damage to the central nervous system associated with prenatal alcohol exposure has widespread functional implications; however, currently, the literature in these areas is limited and unsystematic. Functional MRI with this clinical population has just begun to explore the implications of prenatal alcohol exposure with the first paper published in 2005. Other methodologies are similarly limited in scope. Nonetheless, these functional neuroimaging studies suggest that prenatal alcohol exposure, or a diagnosis of FAS, may lead to restrictions in neural efficiency or a global decrement in processing resources.     

The Spectrum of Autism Spectrum Disorder: A Spectrum of Needs,Services, and Challenges

The dramatic rise in the diagnosis of autism spectrum disorders (ASDs) has resulted in a significant explosion in visibility and a substantial increase in the understanding of this complex group of disorders. Over the last decade, what was once defined only as “autism” has become a spectrum of neurodevelopmental disorders, with variable presentations and levels of impairment that requires an equally broad continuum of care. A wealth of research has not discovered a single “cause” for ASDs, but rather has found a range of genetic/genomic variations that likely play a significant role in the etiology of these disorders. Routine screening for autism is becoming more common, allowing for more timely diagnosis, and hopefully for earlier entry into appropriate and effective treatment. Although there remains no single ‘‘cure’’, there are treatments available that can improve overall functioning and decrease problematic or interfering symptoms across the full spectrum of this disorder. The wide spectrum of ASD presentations complicates treatment planning, with overall ASD severity a factor in determining type, intensity, and duration of interventions and services. This article presents a two-dimensional model of “ASD severity” that considers both the level of specific ASD symptoms/deficits and the level of cognitive resources/limitations as a framework for understanding needs, challenges, and potentially effective interventions for individuals across the ASD spectrum.     

Adult Asperger Syndrome and the Utility of Cognitive-Behavioral Therapy

Asperger syndrome (AS) is a developmental disorder that was first recognized in the United States in 1994 with the publication of DSM-IV (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 1994). As a relatively new concept to the United States, both within the professional community and public awareness, the diagnosis has most often applied to children, but there is a large cohort of affected adults who have never been diagnosed or properly treated. Many of these individuals are now seeking treatment for the symptoms of AS and/or comorbid mental health problems (e.g., mood and anxiety disorders). Clinicians are in need of practical and evidence-based interventions to address the problems presented by this growing patient population, but there are few such resources available. This article will present a framework for conceptualizing the mental health needs of adults with AS, using the evidence-based approaches found in the cognitive-behavior therapy (CBT) literature to inform treatment.     

Fetal Alcohol Spectrum Disorders: An Overview

When fetal alcohol syndrome (FAS) was initially described, diagnosis was based upon physical parameters including facial anomalies and growth retardation, with evidence of developmental delay or mental deficiency. Forty years of research has shown that FAS lies towards the extreme end of what are now termed fetal alcohol spectrum disorders (FASD). The most profound effects of prenatal alcohol exposure are on the developing brain and the cognitive and behavioral effects that ensue. Alcohol exposure affects brain development via numerous pathways at all stages from neurogenesis to myelination. For example, the same processes that give rise to the facial characteristics of FAS also cause abnormal brain development. Behaviors as diverse as executive functioning to motor control are affected. This special issue of Neuropsychology Review addresses these changes in brain and behavior highlighting the relationship between the two. A diagnostic goal is to recognize FAS as a disorder of brain rather than one of physical characteristics.     

Supervising Cognitive-Behavioral Psychotherapy: Pressing Needs,Impressing Possibilities

While accounts of the practice of cognitive behavioral therapy (CBT) supervision have been available over the past 15 years and have demonstrated consistency in terms of an overall model specifying the structure, process and content of supervision sessions, a number of gaps can be identified in the literature on the clinical supervision of CBT. Comprehensive consensus statements of the competencies underlying clinical supervision have been developed both in the United States (Falender et al., J Clin Psychol, 60, 771–785, 2004) and in the United Kingdom (Roth and Pilling, IAPT supervision competencies framework, University College London, 1992), but there has been a lack of attention to relevant theory and to procedural detail. As a consequence, the literature on CBT supervision has only recently begun to assimilate concepts from the wider supervision field (e.g. developmental models), and there is as yet no manual that would allow supervisors to make explicit determinations of competency. Furthermore, supervision in general continues to suffer both from the absence of compelling empirical support demonstrating its effectiveness in improving clinical outcomes, and there is a lack of explicitly-defined supervisory procedures that can be reliably observed and measured. Unfortunately, this combination of factors hampers the development of CBT supervision (e.g. it complicates efforts to provide a standardized framework for training in supervision). As an important starting point in ‘treating’ the underdeveloped state of CBT supervision, we outline a formulation of its current condition, then suggest some promising interventions.     

Social Information Processing Skills in Children with Histories of Heavy Prenatal Alcohol Exposure

Based on caregiver report, children with prenatal alcohol exposure have difficulty with social functioning, but little is known about their social cognition. The current study assessed the social information processing patterns of school-age children with heavy prenatal alcohol exposure using a paradigm based on Crick and Dodge’s reformulated six-stage model. Fifty-two children (aged 7–11) with and without heavy prenatal alcohol exposure were tested using a structured interview measure of social information processing involving 18 videotaped vignettes of children in group entry and provocation situations. Alcohol-exposed children displayed maladaptive processing patterns on the goal, response generation, and response evaluation steps in group entry situations, and encoding, attribution, response evaluation, and enactment steps during provocation situations. Children with heavy prenatal alcohol exposure also had difficulty on the Test of Problem Solving, and performance correlated with social information processing measures. Such difficulties may lead to problems in social functioning and warrant early intervention.     

Spatial memory following prenatal alcohol exposure: more than a material specific memory deficit.

Spatial memory deficits have been reported following prenatal alcohol exposure and animal studies have demonstrated hippocampal vulnerability to alcohol. This study examined spatial memory in children diagnosed with fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE) and matched controls. Spatial memory was examined with location recall measures. Since visual perceptual skills and nonspecific memory impairment could impact spatial memory, tasks assessing perception and verbal memory were administered. Analyses revealed group differences on perceptual and verbal and spatial memory tasks. There was no significant difference in spatial memory once perceptual and verbal memory task performance was taken into account, suggesting that differences in spatial memory were not solely attributable to a material specific memory deficit.     

Exploring Adoption with Clients: The Need for Adoption Education Within the Genetic Counseling Profession

Genetic counselors and other health professionals may encounter adoption during any counseling session. They must be skilled in using appropriate language and understand how to approach and discuss this topic with clients. A thorough knowledge of adoption as an option for clients facing a prenatal or postnatal diagnosis is necessary when presenting individuals with non-biased information needed for informed decision-making. However, three preliminary studies have demonstrated an absence of graduate education and lack of a professional knowledge base regarding this option (Mates 2008; Oksala 2007; Perry 2003). We discuss the impact of medical professionals’ preconceptions on client decision-making, increasing early identification of fetal anomalies, deficiency of adoption knowledge and resources, and the resulting need for genetic counselors and other health professionals to develop their skills in discussing adoption with clients.     

Social perception in children with fetal alcohol spectrum disorder

Although the profile of social cognitive difficulties is well recognized in children with certain neurodevelopmental disorders such as autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD), this profile is not as well established in other clinical pediatric populations. The objective of the present study is to examine patterns of social perception in children with fetal alcohol spectrum disorder (FASD) compared to typically-developing (TD) control children. A total of 56 children between 8 and 12 years of age—35 with FASD and 21 TD—completed the Reading the Mind in the Eyes Task – Children’s Version (RMET-C). The RMET-C accuracy scores were compared between groups and also by item difficulty and emotional valence. The relation between cognitive functioning, age, FASD severity, and RMET-C performance was also investigated. The children in the FASD group did not perform as well as the children in the TD group on the RMET-C Total score and Easy items, as well as the Positive, Negative, and Neutral emotional valence items. When age and IQ were investigated, there was a significant effect of age on the Positive items in the TD group, with scores increasing with age. With regard to FASD severity, children with alcohol-related neurodevelopmental disorder were outperformed by children with full/partial fetal alcohol syndrome on the Positive and Negative items. Overall, these results further the understanding of the social cognitive profile in children with FASD and how this profile relates to other childhood-onset neurodevelopmental disorders.     

Psychometric Validation of the Temptation and Restraint Inventory in Two Samples of College Drinkers1

Drinking restraint, commonly measured by the Temptation and Restraint Inventory (TRI; Collins & Lapp, 1992), refers to a cycle of temptation to drink alcohol and attempts to control alcohol use that results in excessive consumption. Recent research has examined college drinkers using the TRI, however, it has been validated only in adult samples. This study validated the TRI in two samples of college drinkers, designated as “hazardous” (n = 480) and “harmful” (n = 231) drinkers. Using confirmatory factor analysis, the previously reported higher order two-factor structure was identified in both samples. In addition, multiple regression analyses using derived component scores demonstrated that TRI performance was associated with degree of alcohol dependence in both samples. These data support the use of the TRI in college samples.These data were previously presented in November 2002 at the 36th annual meeting of the Association for the Advancement of Behavior Therapy, Reno, NV     

Common and Unique Factors Associated with DSM-IV-TR Internalizing Disorders in Children

With the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association. Diagnostic and statistical manual of mental disorders DSM-IV Fourth Edition-Text Revision. Author, Washington, DC. 2000) ahead, decisions will be made about the future of taxonomic conceptualizations. This study examined the factor structure of items from three internalizing disorders (Social Phobia, Generalized Anxiety Disorder, and Depression) on the Anxiety Disorders Interview Schedule for DSM-IV-Child Version (Silverman, W. K., & Albano, A. M. Anxiety disorders interview schedule for children for DSM-IV, child and parent versions. Psychological Corporation, San Antonio, 1996). Two-, three-, and four-factor models emerged in an exploratory factor analysis. Confirmatory factor analysis provided additional empirical support for the four-factor model over the two- or three-factor models. Implications for the structure of the DSM-V taxonomy in children and adolescents are discussed.     

Persistent pursuit of need-satisfying goals leads to increased happiness: A 6-month experimental longitudinal study

University-based community members (N = 181) participated in a four-wave, 6-month longitudinal experiment designed to increase treatment participants’ happiness levels. Participants were randomly assigned to set goals either to improve their life circumstances (comparison condition) or to increase their feelings of autonomy, competence, or relatedness in life (treatment conditions). We hypothesized that sustained gains in happiness would be observed only in the three treatment conditions, and that even these gains would last only when there was continuing goal engagement. Results supported these predictions and the sustainable happiness model on which they were based (Lyubomirsky et al. in Rev Gen Psychol 9:111–131, 2005). Furthermore, participants with initial positive attitudes regarding happiness change obtained larger benefits. We conclude that maintained happiness gains are possible, but that they require both “a will and a proper way” (Lyubomirsky et al. in Becoming happier takes both a will and a proper way: two experimental longitudinal interventions to boost well-being, 2009).     

Parenting Interventions for Children with Autism Spectrum and Disruptive Behavior Disorders: Opportunities for Cross-Fertilization

Empirical support exists for parent training/education (PT/PE) interventions for children with disruptive behavior disorders (DBD) and autism spectrum disorders (ASD). While the models share common roots, current approaches have largely developed independently and the research findings have been disseminated in two different literature traditions: mental health and developmental disabilities. Given that these populations often have overlapping clinical needs and are likely to receive services in similar settings, efforts to integrate the knowledge gained in the disparate literature may be beneficial. This article provides a systematic overview of the current (1995–2005) empirical research on PT/PE for children with DBD and ASD; attending to factors for cross-fertilization. Twenty-two ASD and 38 DBD studies were coded for review. Literature was compared in three main areas: (1) research methodology, (2) focus of PT/PE intervention, and (3) PT/PE procedures. There was no overlap in publication outlets between the studies for the two populations. Results indicate that there are opportunities for cross-fertilization in the areas of (1) research methodology, (2) intervention targets, and (3) format of parenting interventions. The practical implications of integrating these two highly related areas of research are identified and discussed.     

Connecting Data to Action: How the Santa Cruz County Community Assessment Project Contributes to Better Outcomes for Youth

Community indicator projects have the potential to deliver new knowledge about the quality of life in local communities and drive actions to improve them (Phillips 2003; Holden Social Indicators Research 92:429–448, 2009; Memon and Johnstone 2008). However, the connection between the information produced by community indicator projects and the actions taken to improve conditions in communities remains under-researched (Holden Social Indicators Research 92:429–448, 2009; Hezri and Dovers Ecological Economics 60:86–99, 2006). This is because community indicator projects have mainly been conceptualized as producing information for action rather than as part of an action process (Memon and Johnstone 2008). This paper provides a case study of a community indicator project with an explicit plan to move beyond the data and into action. A review of one of the oldest community indicator projects in the United States, the Santa Cruz County Community Assessment Project (CAP) demonstrates how an action oriented community improvement cycle has contributed to measurable improvements for children and youth in one California County. The paper identifies key elements that were important for turning CAP data into local actions and concludes with lessons for community indicator practitioners and questions for future research.     

Autism characteristics in children with fetal alcohol spectrum disorders

Background: Children with fetal alcohol spectrum disorders (FASD) exhibit difficulties in many cognitive and behavioral domains and also have high comorbidity with other disorders such as attention deficit/hyperactivity disorder (ADHD) and conduct disorder as well as autism. Although the FASD profile is shown to be distinct from ADHD and conduct disorder, far less is known about the commonalities with autism. The current study used a parent-rated questionnaire containing an autism subscale to explore the autistic-like features that children with FASD exhibit. Methods: Studied were 25 children with FASD (age: M = 10.3 years) and 17 normal controls (NCs; age: M = 10.2 years). As part of a larger study, all parents/caregivers completed the Social Skills Improvement System (SSIS; Gresham & Elliot, 2008), which in addition to evaluating social skills and behavior problems globally, includes an Autism subscale. Results: Between-group comparisons showed the FASD group not only scored significantly lower in social skills and significantly higher in behavior problems than the NC group but children with FASD also scored significantly higher on the Autism subscale. Item analysis revealed they showed the most difficulty in terms of social and communicative functioning and the least in repetitive and restrictive behaviors. Conclusion: Current findings signify that FASD and autism share similarities with regard to social and communicative functioning. These findings, which further our knowledge of the FASD phenotype, may be useful in specifying the particular interventions these children need.     

Autism Spectrum Symptomatology in Children: The Impact of Family and Peer Relationships

This study examines the potential impact of family conflict and cohesion, and peer support/bullying on children with autism spectrum disorder (ASD). While such impacts have been established for a range of non-ASD childhood disorders, these findings may not generalize to children with ASD because of unique problems in perspective-taking, understanding others’ emotion, cognitive rigidity, and social reasoning. A structural model-building approach was used to test the extent to which family and peer variables directly or indirectly affected ASD via child anxiety/depression. The sample (N = 322) consisted of parents of children with ASD referred to two specialist clinics. The sample contained parents of children with Autistic Disorder (n = 76), Asperger Disorder (n = 188), Pervasive Disorder Not Otherwise Specified (n = 21), and children with a non-ASD or no diagnosis (n = 37). Parents completed questionnaires on-line via a secure website. The key findings were that anxiety/depression and ASD symptomatology were significantly related, and family conflict was more predictive of ASD symptomatology than positive family/peer influences. The results point to the utility of expanding interventions to include conflict management for couples, even when conflict and family distress is low. Further research is needed on the potentially different meanings of family cohesion and conflict for children with ASD relative to children without ASD.