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Systematic review of interventions for children with Fetal Alcohol Spectrum Disorders

  • Elizabeth Peadon1, 2, 3Email author,
  • Biarta Rhys-Jones1,
  • Carol Bower4 and
  • Elizabeth J Elliott1, 2, 3
BMC PediatricsBMC series ¿ open, inclusive and trusted20099:35

DOI: 10.1186/1471-2431-9-35

Received: 23 November 2008

Accepted: 25 May 2009

Published: 25 May 2009

Abstract

Background

Children with Fetal Alcohol Spectrum Disorders (FASD) may have significant neurobehavioural problems persisting into adulthood. Early diagnosis may decrease the risk of adverse life outcomes. However, little is known about effective interventions for children with FASD. Our aim is to conduct a systematic review of the literature to identify and evaluate the evidence for pharmacological and non-pharmacological interventions for children with FASD.

Methods

We did an electronic search of the Cochrane Library, MEDLINE, EMBASE, PsychINFO, CINAHL and ERIC for clinical studies (Randomized controlled trials (RCT), quasi RCT, controlled trials and pre- and post-intervention studies) which evaluated pharmacological, behavioural, speech therapy, occupational therapy, physiotherapy, psychosocial and educational interventions and early intervention programs. Participants were aged under 18 years with a diagnosis of a FASD. Selection of studies for inclusion and assessment of study quality was undertaken independently by two reviewers. Meta-analysis was not possible due to diversity in the interventions and outcome measures.

Results

Twelve studies met the inclusion criteria. Methodological weaknesses were common, including small sample sizes; inadequate study design and short term follow up. Pharmacological interventions, evaluated in two studies (both RCT) showed some benefit from stimulant medications. Educational and learning strategies (three RCT) were evaluated in seven studies. There was some evidence to suggest that virtual reality training, cognitive control therapy, language and literacy therapy, mathematics intervention and rehearsal training for memory may be beneficial strategies. Three studies evaluating social communication and behavioural strategies (two RCT) suggested that social skills training may improve social skills and behaviour at home and Attention Process Training may improve attention.

Conclusion

There is limited good quality evidence for specific interventions for managing FASD, however seven randomized controlled trials that address specific functional deficits of children with FASD are underway or recently completed.

Background

Alcohol exposure in utero may impair growth, central nervous system structure and/or function and cause birth defects. Children exposed to alcohol in utero may have significant neurobehavioural problems persisting into adulthood [1] and/or develop one of the Fetal Alcohol Spectrum Disorders [2, 3]. This spectrum includes: FAS, the most severe outcome of alcohol exposure in utero; Partial FAS; and Alcohol Related Neurodevelopmental Disorder (ARND), the diagnosis of which requires confirmation of maternal alcohol exposure and neurodevelopmental problems not otherwise explained. Also included are Alcohol Related Birth Defects (ARBD), the diagnosis of which require confirmation of maternal alcohol exposure and specific birth defects attributable to alcohol.[3] The term Fetal Alcohol Effects (FAE) was previously used to describe children with some, but not all of the features of FAS.[4] Adverse life outcomes for individuals with FAS or FAE include inappropriate sexual behaviours, disrupted school education, trouble with the law, confinement, and mental health, alcohol and drug problems.[5]

Early diagnosis of FAS and FAE is associated with decreased risk of adverse outcomes,[5] perhaps because it enables carers and health professionals to advocate for and deliver appropriate interventions in childhood. Interventions that have been recommended for children with FASD include pharmacological interventions (psychotropic and stimulant medications) [6, 7] and educational, behavioural, social skills and communication interventions.[8, 9] Carers of children with FASD report that conventional behavioural and learning approaches often fail to assist their children.[10, 11]

Our aim was to systematically review the medical literature to identify and evaluate the evidence for efficacy of pharmacological and non-pharmacological interventions for children with FASD.

Methods

Inclusion and Exclusion Criteria, participants and outcome measures

We sought RCTs evaluating pharmacological and non-pharmacological interventions for children with FASD aged under 18 years. Non-pharmacological interventions of interest included behavioural, speech, occupational and physio therapies, early intervention programmes, and psychosocial and educational interventions. Because published reviews indicated that there were unlikely to be many RCT, we also included other study types that included a control group (quasi RCT, non-randomized controlled trials) and cohort studies with pre- and post-intervention measurements. Control interventions could include no treatment, waiting list, usual therapy or placebo.

Outcomes of interest included measures of physical and mental health, developmental status, cognitive status, quality of life, educational attainment, employment, contact with the law and substance abuse, whether measured during and immediately after the intervention and/or in adolescence and adulthood.

Identification of studies

We searched MEDLINE (1950 – January 2009), EMBASE (1980 – January 2009), CINAHL (1982 – January 2009), PsycINFO (1865 – January 2009), Cochrane Central Register Controlled Trials (Cochrane Library Issue 1, 2009) and ERIC (1966 – January 2009), with no language restrictions, using terms for Fetal Alcohol Spectrum Disorders and therapies including: Fetal Alcohol Syndrome; Early Intervention; Drug Therapy; Allied Health Occupations; Occupational Therapy; Physical Therapy Modalities; Exercise Therapy; Behavior Therapy; and Social Support. Search terms were adapted for individual databases. Additional studies were sought by contacting individuals undertaking research on FASD and from bibliographies of identified papers, review articles and FASD conference proceedings.

Data management and quality assessment

Two reviewers independently screened the titles and abstracts of articles identified in the search and reviewed the full text of articles that appeared to fulfill the inclusion criteria. We developed a form to standardize extraction of data regarding study design, participants, study setting, interventions and outcomes. Two independent reviewers extracted the data and assessed study quality including blinding of outcome assessment, use of standardized measures, follow-up and, for RCT, method of randomization, allocation concealment and intention-to-treat analysis (ITT). Disagreements were resolved by a third reviewer.

Statistical Analysis

We intended to undertake meta-analyses but the data were unsuitable due to the small number of studies and the disparate interventions and outcome measures.

Results

Search results

We identified 6263 studies using our search strategy (Figure 1). After exclusion of ineligible studies (animal studies, people with FASD aged over eighteen years and studies which did not evaluate an intervention), only twelve studies fulfilled our inclusion criteria. These included six RCT; one quasi-RCT; one controlled trial; and four pre- and post- intervention studies. Of these, two studies evaluated pharmacological interventions (total n participants = 16), seven studies evaluated educational and learning strategies (n = 167), two evaluated social skills and communication (n = 101), and one evaluated a behavioural intervention (n = 20).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2431-9-35/MediaObjects/12887_2008_Article_266_Fig1_HTML.jpg
Figure 1

Flow chart of the study selection process. *Studies were excluded if they were animal studies; did not include children aged 0 to 18 years with FASD; or did not evaluate an intervention.

Pharmacological Interventions (Table 1)

Table 1

Pharmacological Interventions

Study quality

Participants (n), age, inclusion criteria and setting

Interventions and follow-up

Outcome measures

Oesterheld et al, 1998[12]

Cross-over RCT

Randomized (method unclear); allocation concealment unclear; blinding (researchers, outcome assessors); follow-up 100%; ITT analysis unclear; study power not provided.

n = 4

5 to 12 years

FAS or partial FAS[4] & ADHD (DSM-IV)

Native American residential school

0.6 mg/kg methylphenidate per dose to nearest 2.5 mg or lactose placebo or Vitamin C placebo

Interventions were given 3 times per day for 5 days with a 2 day washout period prior to each intervention.

Follow-up: Day 5 of each intervention

Hyperactivity-Impulsivity score on CPRS-48: significant improvement in methylphenidate group (F = 4.34, df = 2, p < 0.05)

Hyperactivity-Impulsivity score on CTRS-39: significant improvement in methylphenidate group (F = 6.42, df2, p < 0.02)

Daydreaming-Attention score on Conners Teacher Rating Scale-39: no significant difference (F = 1.429, df2, p = 0.289)

Adverse events: three children experienced decreased appetite; two, mild stomach aches; and two, headaches.

Snyder et al, 1997[13]

Cross-over RCT

Randomized (method unclear); allocation concealment unclear; blinding (researchers, outcome assessors); follow-up 92%; ITT analysis unclear; study power not provided.

n = 12

6 to 16 years

FAS[4] & ADHD (DSM-IV) & reported positive response to stimulant medication

Selected from a child development unit database, Canada

Usual dose of medication (methylphenidate: 8 children; pemoline: 2 children; dexedrine: 1 child) or colour matched capsule (placebo)

Interventions were given for 3 days with a 1 day washout prior to each intervention. Usual medication was given for 3 days between the 2 interventions.

Follow-up: Day 3 of each intervention

Attention: No significant difference between groups on vigilance task and no significant difference on Underlining Test.

Hyperactivity: scores on the Abbreviated Symptoms Questionnaire – Parents were significantly improved for stimulant medication (68.36, SD 17.4) compared to placebo (84.4, SD 14.0) (F = 8.66; p = 0.016)

Adverse events: not reported

Oesterheld et al[12] randomly allocated four children to a sequence of methylphenidate and two placebos. Conner's Parent Rating Scale-48 (CPRS-48) and Conner's Teacher Rating Scale-39 (CTRS-39) were completed at the end of each day, and the Barkley Side Effects Questionnaire was completed and weight, orthostatic blood pressure and pulse rate recorded on day five of each medication. Compared to placebo, methylphenidate significantly improved hyperactivity and impulsivity but not attention. Most children receiving methylphenidate experienced adverse effects.

Snyder et al[13] randomly allocated twelve children to a sequence of usual stimulant medication and placebo. Selection bias may have occurred as the method of selection was unclear. The authors report randomization by the Pharmacy department and use of a colour matched placebo capsule which suggest possible allocation concealment and blinding of researchers and outcome assessors, but this is not clearly stated. One child was excluded from the study due to inability to complete the required tasks. Usual stimulant medication had no significant effect on performance on attention compared with placebo. Hyperactivity scores were improved significantly by stimulant medication compared to placebo.

Educational and learning strategies (Table 2)

Table 2

Educational and Learning Strategies

Study quality

Participants (n), age, inclusion criteria and setting

Interventions and follow-up

Outcome measures

Adnams et al, 2003 In: Riley et al, 2003[14]

RCT: randomization method, allocation concealment, blinding, ITT analysis unclear; follow-up 100%; study power not given.

n = 10, Mean age: 8.5 years

FAS[3]

Selected from previous study of 64 South African children

CCT or usual classroom, 1 hour per week, 10 school months.

Follow-up: 10 months

Behaviour: Personal Behaviours Checklist score: improvement in CCT group compared to controls (mean pre-intervention scores 21.4 vs 14.8 and mean post-intervention scores 7.6 vs 15.4).

Neuropsychological profile: no significant difference.

CCT battery: qualitative improvements in function but no significant difference

Adnams et al, 2005 In: Stromland et al, 2005[15]& Adnams et al, 2007[16]

RCT: randomization method, allocation concealment, ITT analysis unclear; outcome assessors blinded; follow-up 94%; study power not given.

n = 65, 9 to 10 years

FAS or partial FAS[3] and "deferred diagnosis category"

Exposed children selected from study of 105 South African children,

Language and literacy intervention, 1 hour per week for 38 weeks over 9 months

Follow-up: 9 months

Pre-literacy, reading and spelling: FASD children in intervention group had significantly improved scores on Phonological Awareness and Early Literacy Test: Manipulating Syllables (t = 2.23, p = 0.034), Letter Sounds (t = 3.7, p = 0.001), Written Letters (t = 3.14, p = 0.004), Reading (t = 3.72, p = 0.001), Reading Non-Words (t = 3.65, p = 0.001) and Spelling Non-Words (t = 3.44, p = 0.002).

General scholastic tests: No significant difference between FASD intervention and control group.

Coles et al, 2007[17]

RCT: randomization method, allocation concealment, ITT analysis unclear; outcome assessor blinded; follow-up 100%; study power not given.

n = 32

4 to 10 years

FAS or partial FAS[28], excluded if IQ < 50.

Recruited from a Fetal Alcohol Clinic, USA

Virtual reality game of fire safety or virtual reality game of street safety

Follow-up: immediately 1-week post-intervention

Post-intervention: children exposed to the computer game had significantly greater knowledge gain of fire safety (F(1, 31) = 18.94, p < 0.000) or street safety (F(1, 31) = 16.3 p < 0.000).

One week: children exposed to the computer game had significantly greater knowledge gain of fire safety (F(1, 31) = 15.56, p < 0.000) but not street safety (F(1, 31) = 3.13, p = 0.096).

Kable et al, 2007[18]

RCT: randomization method, allocation concealment, ITT analysis unclear; blinding (outcome assessors); follow-up 92%; sample size calculation provided.

n = 61, 3 to 10 years

FAS, partial FAS, or alcohol related dysmorphology[28]

Excluded if IQ < 50 or mental health problems prevented participation.

Recruited: USA Fetal Alcohol Clinic and community.

Mathematics intervention (6 weeks tutoring) or a standard psycho-educational group.

Follow-up: 6 weeks.

Mathematics: The mathematics intervention group had a significantly higher gain in mathematical knowledge (F(3, 43) = 2.97, p < 0.04) and were significantly more likely to demonstrate a clinical gain compared to the psychoeducational group (58.6 vs 23.1%, χ(1, 55) = 7.1, p < 0.008)

Loomes et al, 2008[19]

Controlled trial

Allocation method unclear; unblinded; follow up 97%; ITT analysis unclear; study power not provided.

n = 33, 4.2 to 11.8 years

ARND, Alcohol Exposed Neuro-behavioural Disorder or Static Encephalopathy (criteria not stated)

From hospital/FASD clinics, schools, community, Canada

Rehearsal training following pretest

Follow-up: at average 10.6 days (range 6–21)

Post-intervention: there was no significant difference between intervention and control groups (t = -0.49, p > 0.05)

Follow-up: the intervention group had significantly increased digit span compared to the control group (t = -1.96, p < 0.05)

Meyer, 1998[20]

Pre-post intervention, No blinding.

n = 4, primary school age, USA. FAE & learning disabled (criteria not stated)

Four minute videotape of building task

Learning: No child could imitate the building block task

Padgett et al, 2006[21]

Pre- and post-intervention; No blinding; follow-up 100%.

n = 5, 4 to 7 years

FAS, partial FAS (criteria not stated); USA Fetal Alcohol Clinic

Virtual reality game of home fire safety

Follow-up:1 week

Post-intervention: 4 children correctly sequenced cards and 3 demonstrated all steps in response to an imaginary fire. One week: 3 children correctly sequenced the cards and 5 showed all steps in response to an imaginary fire

Adnams et al reported two pilot studies evaluating educational interventions. [1416] In the 2003 study,[14] ten children selected from a previous cohort of 64 children with FAS were randomly allocated to Cognitive Control Therapy (CCT) in an intervention classroom at one school or a control classroom at another school. The randomization method used to allocate children to the intervention or control group was not described, which means that selection bias cannot be excluded. CCT addresses body position, movement and awareness; attention; and information processing, controlling and categorizing. At baseline, the groups were similar for age, first language, socioeconomic status, school grade and locality of school and were assessed with the Cognitive Control Battery and a neuropsychological testing battery. CCT improved behaviour of the intervention group but there was no change in the control group. As the teacher rating of behaviour at baseline was worse in the intervention group at baseline, the effect of the intervention on behaviour may have been underestimated.

The 2007 Adnams et al study[15, 16] recruited 65 children to evaluate language interventions focussing on basic literacy skills. Forty children with FASD were selected from a larger study of 105 children with FASD. The children with FASD were randomly assigned to language and literacy training intervention or control group. Intervention and control groups were similar in age, socioeconomic status and first language. Twenty-five children without exposure to alcohol in utero were randomly selected from 193 children in an epidemiologic study, and were assigned to a control group. The randomization method was not described, and selection bias cannot be excluded. Two children in the FASD control group who did not meet diagnostic criteria were excluded from analysis. Two children from the FASD intervention group and two from the alcohol unexposed control group were lost to follow up. The language and literacy intervention focussed on phonological awareness and other pre- and early literacy skills needed for reading and spelling. It was administered for half an hour, twice a week, by a speech therapist over a 9 month period for a total of 38 hours of intervention. Children were evaluated with a range of measures prior to the intervention and immediately post-intervention. The intervention led to improvements in reading, spelling and some pre-literacy domains in the FASD intervention group compared to the FASD control group. Both FASD groups continued to score lower than the alcohol unexposed control group.

Coles et al[17] randomly allocated sixteen children to exposure to a fire safety virtual reality game or a street safety virtual reality game. The randomization method was not described and selection bias cannot be excluded. Post intervention, children were tested verbally on the safety steps and were asked to act out the safety steps. The training increased the children's knowledge of fire safety and street safety.

Kable et al[18] randomly assigned 61 children to a mathematics intervention (adapted to address the neurodevelopmental difficulties seen in children with FASD) or a standard psychoeducational intervention (control). The randomization method was not described and selection bias cannot be excluded. Children were evaluated with a range of measures before the intervention and within four weeks of completing the programme. Groups were similar at baseline apart from birth weight. Two children from the intervention group and three children from the control group were lost to follow-up. The intervention group had a significantly greater improvement in mathematics knowledge.

Loomes et al[19] evaluated rehearsal training for improving memory for numbers in 33 children with FASD who were assigned to a rehearsal training group or a control group. The method of assignment to the intervention or control group was not described and selection bias cannot be excluded. The groups were similar in age at baseline. One child in the control group was lost to follow up. Both groups completed a digit span memory task at baseline, immediately post-intervention and at an average of 10.6 days following the intervention. The intervention group was given instructions on the use of rehearsal to remember information following baseline assessment and were reminded of this strategy at follow up. The intervention group had an increased score on the digit span memory task at the follow up session.

Meyer[20] evaluated modelling of perceptual tasks as a teaching strategy in four boys. Each boy was shown a video of a boy of similar age building a balanced and symmetrical structure with wooden blocks and was then given ten minutes to build the same structure with the same blocks. None of the boys was able to imitate the building project.

Padgett et al [21] evaluated the effectiveness a virtual reality game to teach home fire safety in five children. The game was tailored specifically to accommodate the usual verbal strengths and visual-spatial and fine motor weaknesses of children with FAS. Post-intervention, children were asked to sequence a set of three picture cards outlining the fire safety steps and respond to an imaginary fire in the building. The training increased the children's knowledge of home fire safety.

Social skills and social communication interventions (Table 3)

Table 3

Social Communication and Behavioural Strategies

Study quality

Participants (n), age, inclusion criteria and setting

Interventions and follow-up

Outcome measures

O'Connor et al, 2006[22]

Quasi – RCT

Alternate allocation; blinding unclear; follow-up 93%; ITT analysis unclear; sample size calculation provided.

n = 100, 6 to 12 years

FAS, Partial FAS or ARND[23] & social skills deficit & verbal IQ ≥ 70

Children with major sensory or motor deficits or a past diagnosis of mental retardation or pervasive developmental disorder were excluded

Recruited from community, USA

CFT or delayed treatment

Twelve 90-minute sessions over twelve weeks

Parents attended concurrent information sessions on FASD and social skills

Follow-up: 3 months

Test of Social Skills Knowledge: The CFT group showed significant improvement in knowledge compared to the control group (F(1, 90) = 56.52, p = 0.0001). At three months, social skills knowledge was maintained (t(48) = 1.07, p < 0.29).

Social Skills Rating System Parent : social skills (F(1, 93) = 5.03, p < 0.03) and problem behaviours (F(1, 93) = 4.05, p < 0.05) significantly improved in the CFT group compared to the control group. At three months, parent reported social skills continued to improve (t(48) = 3.35, p < 0.002) and the decrease in problem behaviours was maintained (t(48) = 1.48, p < 0.15).

Social Skills Rating System Teacher : no significant difference in social skills or problem behaviours between the groups immediately post-intervention or at three months.

Timler, 2005[25]

Pre- and post-intervention

Blinding unclear

n = 1, 9 years

FASD[23]

Recruited from a Fetal Alcohol Clinic, USA

Social communication intervention

Two one-hour individual sessions per week, then four two-hour group sessions

Follow-up: 6 weeks

More strategies on how to behave in a variety of social situations.

Increased number of mental state verbs used.

Vernescu, 2007[26]

RCT

Randomized (method unclear); allocation concealment unclear; blinding unclear; follow up 100%; ITT analysis unclear; study power not provided.

n = 20, 6 to 12 years

FASD Inuit children, Canada

Attention Process Training or contact sessions

Follow-up: 3 weeks

Measures of sustained attention: children in the intervention group showed significant improvement.

Measures of non-verbal reasoning ability: children in the intervention group showed significant improvement.

Measures of executive function: no significant difference.

O'Connor et al[22] recruited 100 children to evaluate parent assisted child friendship training (CFT). A diagnosis of FASD was assigned by a paediatrician, blinded to group assignment.[23] FAS was diagnosed in 11% of the children, partial FAS in 43% and ARND in 46%. Selection bias is a potential issue as the children were allocated alternately to the intervention or delayed treatment group. The groups were similar at baseline. Four children from the intervention group and three from the delayed treatment group did not complete all the assessments. The children were assessed immediately post-intervention and at 3 months follow-up. CFT significantly improved knowledge of appropriate social behaviour. Parents reported improved social skills and fewer problem behaviours, however, teachers did not report any significant improvement. The knowledge of appropriate social behaviour, parent reported gains in social skills, and reductions in problem behaviours were maintained at three months follow-up. Children receiving neuroleptic medications alone showed significantly greater improvement on parent report of Self-control and teacher-reported Problem Behaviours.[24] Children on both stimulant and neuroleptic medication had a significantly worse outcome on teacher reported Problem Behaviours but not on parent report.

Timler[25] undertook a pre and post assessment of a social communication in one child. The intervention improved the child's social communication skills.

Behavioural interventions (Table 3)

Vernescu[26] randomly allocated 20 children to receive Attention Process Training or control contact sessions with games and academic support. The randomization process was not described and selection bias cannot be excluded. The groups were similar at baseline. Children were assessed using measures of attention, nonverbal reasoning ability measures and behavioural measures of attention and executive function at baseline and at the end of the intervention. Teachers who completed the behavioural measures of attention and executive function were blinded to group assignment. The blinding status of the researchers and assessors of other outcome measures were not described. Children in the intervention group showed significant improvement on measures of sustained attention and non-verbal reasoning ability but there was no improvement on measures of executive function.

Discussion and Conclusion

In this systematic review, we found limited evidence for specific interventions for children with FASD. There is evidence from RCT that a language and literacy intervention improves reading spelling and pre-literacy skills (n = 65); a mathematics intervention increases mathematics knowledge (n = 61); Attention Process Training may improve attention and non-verbal reasoning (n = 20); stimulant medication may decrease hyperactivity and impulsivity but not does improve attention (n = 16); Virtual Reality Training may facilitate learning (n = 16); and Cognitive Control Therapy in the classroom may improve behaviour (n = 10). There is evidence from a quasi-RCT of effectiveness of social skills training in improving social skills and behaviour at home but not at school (n = 100).

A strength of this systematic review is that it provides a comprehensive overview of the evidence for specific interventions for children with FASD. We searched six databases and the search was not limited by language. However, the databases included have a bias towards English language publications. A potential limitation is that we did not hand search journals. During the latter stages of our review process, a systematic review on a similar topic was published, however it differs from ours, having restricted studies to RCTs thus only including three studies.[27] By including a broader range of study types, we have been able to provide a useful summary for clinicians of the current evidence for a variety of interventions. We have also clearly identified the urgent need for more high quality intervention research. This is a rapidly evolving area with six studies published between 2006 and 2008.

The greatest limitation of our review lies in the quality of the studies available for inclusion. Significant methodological problems limit the extent to which conclusions can be drawn. Study design is often inadequate. Pre- and post-assessments and retrospective reviews are frequently used rather than RCT and in the RCT we identified, the method of randomization, allocation concealment, and blinding are rarely described. Very small sample sizes are common. Studies by O'Connor et al,[22] Adnams et al[16] and Kable et al[18] are exceptions, with sample sizes of 100, 65 and 61 respectively. The remainder of the studies have samples sizes between one and thirty-two. Small sample size may reflect challenges in recruitment and the expense of conducting intervention studies. However, a small sample size may render studies insufficiently powered to detect a true effect of treatment. In addition, the diagnostic criteria used for FASD vary between studies and sometimes are not stated. Several diagnostic criteria are described in the literature and, although similar, these have important differences.[3, 4, 23, 28] Use of different criteria makes it difficult to compare studies outcomes because study populations may differ. It also limits the applicability of study findings to patients in other clinical settings. Another problem in the studies we identified is the short term follow-up. Disabilities associated with FASD persist into adulthood[1] so children with FASD need interventions with long term efficacy. A strength of most of the studies is the use of standardised outcome measures.

Interventions for FASD should target the specific clinical and neuropsychological deficits seen most commonly in these conditions. The neurobehavioural profile of children with FASD may include low IQ[29], however, IQ scores in individuals with FAS range from 20 to 120, and only 25% have IQ scores less than 70.[30] Children exposed to alcohol in utero but without the physical features of FAS may also have cognitive impairment, although this is usually less severe than in children with FAS.[31] Other common difficulties are activity and attention;[29] learning and memory;[29] language development;[29] motor abilities including balance;[29, 30] visuo-spatial abilities;[29] non-verbal problem solving;[29] planning ability;[29] reaction time;[30] executive function;[32] adaptive and social skills;[5, 33, 34] and academic function, particularly in mathematics.[5] Many of these deficits are more severe than can be explained by IQ alone and may occur in children with IQ scores in the normal range who were exposed to alcohol in utero.[31]

The pattern of hyperactivity/inattention in children with a FASD diagnosis may differ from that seen in children with familial ADHD, as may their response to stimulant medications.[6] The lack of response of inattention symptoms to medication identified in this review may relate to the underlying aetiology.

One of the barriers to health professionals making a diagnosis of a FASD is their perception of a lack of effective interventions.[35, 36] Nevertheless, early diagnosis of a FASD reduces the risk of developing secondary disabilities.[5] The reason for this is not clear and it may simply reflect early referral for general educational and medical support. Some studies included in our review address specific deficits of children with a FASD, including attention and social skills. Although there is currently a lack of good studies, there are seven intervention studies in progress or recently completed (Table 4)[15, 3739], A number of these are funded by the CDC[38] and appear to be high quality RCTs with adequate sample size. The forthcoming studies evaluate targeted interventions addressing specific strengths and needs of children with a FASD such as attention, behaviour and social communication and will significantly enhance the evidence base available to inform management of FASD.
Table 4

Studies in Progress

Principal Investigator

Title

Study Type

Sample Size

Thomas Lock[37]

Assess the Effectiveness of Atomoxetine in Children with Fetal Alcohol Syndrome and ADD/ADHD (2006 ongoing)

RCT

60

Thomas Lock[37]

Open-Label Study of the long Tern Tolerability and Safety of Atomoxetine in Children with FASD and ADD/ADHD (2006 ongoing)

Open label, uncontrolled

60

Ira Chasnoff[37, 38]

Neurocognitive Habilitation for Children with Fetal Alcohol Syndrome/Alcohol Related Neurodevelopmental Disorder (2002 ongoing)

RCT

100

John Mulvihill[37, 38]

Fetal Alcohol Syndrome/ARND Research Consortium: Parent Child Interaction Therapy (2001 to 2005)

RCT

100

Colleen Adnams[15]

Language and Literacy therapy, Cognitive Control Therapy and Parent Group Intervention

RCT

100

Susan Astley [3739]

Intervening with Children/Adolescents with FAS/ARND: Positive Behaviour Support (2001 to 2005)

RCT

52

Susan Astley[38, 39]

School-based social communication intervention provided directly to children with FAS/ARND

RCT

NA

NA, not available

Declarations

Acknowledgements

Paula Cronin assisted in the original review design and Ruth Mitchell assisted with the search strategy. Drug and Alcohol Services, South Australia supported this review financially. We acknowledge the National Health and Medical Research Council (NH&MRC) Program Grants 003209 and 353514; NH&MRC Fellowships (CB) 172303 and 353625 and (EE) 457084; and NH&MRC Postgraduate Scholarship (EP) 457230 for financial support. The Australian Paediatric Surveillance Unit is a Unit of the Division of Paediatrics and Child Health, Royal Australasian College of Physicians and is funded by the Department of Health and Ageing, the Faculty of Medicine at the University of Sydney, and an NH&MRC Enabling Grant, 402784.

Authors’ Affiliations

(1)
Discipline of Paediatrics and Child Health, University of Sydney
(2)
Australian Paediatric Surveillance Unit
(3)
The Children's Hospital at Westmead
(4)
Telethon Institute for Child Health Research, Centre for Child Health Research, University of Western Australia

References

  1. Spohr HL, Willms J, Steinhausen HC: Fetal alcohol spectrum disorders in young adulthood. J Pediatr. 2007, 150: 175-9. 10.1016/j.jpeds.2006.11.044. 179.View ArticlePubMed
  2. Bertrand J, Floyd RL, Weber MK, O'Connor ML, Riley EP, Johnson KA, et al: Fetal Alcohol Syndrome: guidelines for referral and diagnosis. 2004, Atlanta: Centers for Disease Control and Prevention
  3. Hoyme HE, May PA, Kalberg WO, Kodituwakku P, Gossage JP, Trujillo PM, et al: A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 institute of medicine criteria. 48. Pediatrics. 2005, 115: 39-47. 10.1542/peds.2005-0702.View ArticlePubMed
  4. Sokol RJ, Clarren SK: Guidelines for use of terminology describing the impact of prenatal alcohol on the offspring. Alcohol Clin Exp Res. 1989, 13: 597-598. 10.1111/j.1530-0277.1989.tb00384.x.View ArticlePubMed
  5. Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O'Malley K, Young JK: Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr. 2004, 25: 228-238. 10.1097/00004703-200408000-00002.View ArticlePubMed
  6. O'Malley KD, Koplin B, Dohner VA: Psychostimulant clinical response in fetal alcohol syndrome. Can J Psychiatry. 2000, 45: 90-91.PubMed
  7. Coe J, Sidders J, Riley K, Waltermire J, Hagerman R: A survey of medication responses in children and adolescents with fetal alcohol syndrome. Mental Health Aspects of Developmental Disabilities. 2001, 4: 148-155.
  8. Kalberg WO, Buckley D: Educational planning for children with fetal alcohol syndrome. Ann Ist Super Sanita. 2006, 42: 58-66.PubMed
  9. Kalberg WO, Buckley D: FASD: what types of intervention and rehabilitation are useful?. Neurosci Biobehav Rev. 2007, 31: 278-285. 10.1016/j.neubiorev.2006.06.014.View ArticlePubMed
  10. Devries J, Waller A: Fetal alcohol syndrome through the eyes of parents. Addict Biol. 2004, 9: 119-126. 10.1080/13556210410001716971.View ArticlePubMed
  11. Malbin D: FASD and Standard Interventions: Poor Fits?. British Columbia Alternate Education Association Newsletter, Accessed on: 3/9/2007., [http://bctf.ca/bcaea/newsletter/2005_Summer.pdf]
  12. Oesterheld JR, Kofoed L, Tervo R, Fogas B, Wilson A, Fiechtner H: Effectiveness of methylphenidate in Native American children with fetal alcohol syndrome and attention deficit/hyperactivity disorder: a controlled pilot study. J Child Adolesc Psychopharmacol. 1998, 8: 39-48. 10.1089/cap.1998.8.39.View ArticlePubMed
  13. Snyder J, Nanson J, Snyder R, Block G: A study of stimulant medication in children with FAS. Overcoming and Preventing Secondary Disabilities in Fetal Alcohol Syndrome and Fetal Alcohol Effects. Edited by: Streissguth A, Kanter J. 1997, Seattle, WA: University of Washington Press, 64-77.
  14. Riley EP, Mattson SN, Li TK, Jacobson SW, Coles CD, Kodituwakku PW, et al: Neurobehavioral consequences of prenatal alcohol exposure: an international perspective. Alcohol Clin Exp Res. 2003, 27: 362-373. 10.1097/01.ALC.0000052703.38558.B2.View ArticlePubMed
  15. Stromland K, Mattson SN, Adnams CM, Autti-Ramo I, Riley EP, Warren KR: Fetal Alcohol Spectrum Disorders: An International Perspective. Alcohol Clin Exp Res. 2005, 29: 1121-1126. 10.1097/01.ALC.0000168172.62481.07.View Article
  16. Adnams CM, Sorour P, Kalberg WO, Kodituwakku P, Perold MD, Kotze A, et al: Language and literacy outcomes from a pilot intervention study for children with fetal alcohol spectrum disorders in South Africa. Alcohol. 2007, 41: 403-414. 10.1016/j.alcohol.2007.07.005.PubMed CentralView ArticlePubMed
  17. Coles CD, Strickland DC, Padgett L, Bellmoff L: Games that "work": using computer games to teach alcohol-affected children about fire and street safety. Res Dev Disabil. 2007, 28: 518-530. 10.1016/j.ridd.2006.07.001.View ArticlePubMed
  18. Kable JA, Coles CD, Taddeo E: Socio-cognitive habilitation using the math interactive learning experience program for alcohol-affected children. Alcohol Clin Exp Res. 2007, 31: 1425-1434. 10.1111/j.1530-0277.2007.00431.x.View ArticlePubMed
  19. Loomes C, Rasmussen C, Pei J, Manji S, Andrew G: The effect of rehearsal training on working memory span of children with fetal alcohol spectrum disorder. Res Dev Disabil. 2008, 29: 113-124. 10.1016/j.ridd.2007.01.001.View ArticlePubMed
  20. Meyer MJ: Perceptual differences in fetal alcohol effect boys performing a modeling task. Percept Mot Skills. 1998, 87: 784-786.View ArticlePubMed
  21. Padgett LS, Strickland D, Coles CD: Case study: using a virtual reality computer game to teach fire safety skills to children diagnosed with fetal alcohol syndrome. J Pediatr Psychol. 2006, 31: 65-70. 10.1093/jpepsy/jsj030.View ArticlePubMed
  22. O'Connor MJ, Frankel F, Paley B, Schonfeld AM, Carpenter E, Laugeson EA, et al: A controlled social skills training for children with fetal alcohol spectrum disorders. J Consult Clin Psychol. 2006, 74: 639-648. 10.1037/0022-006X.74.4.639.View ArticlePubMed
  23. Astley SJ, Clarren SK: Diagnosing the full spectrum of fetal alcohol-exposed individuals: introducing the 4-digit diagnostic code 54. Alcohol Alcohol. 2000, 35: 400-410.View ArticlePubMed
  24. Frankel F, Paley B, Marquardt R, O'Connor M: Stimulants, Neuroleptics, and Children's Friendship Training for Children with Fetal Alcohol Spectrum Disorders. J Child Adolesc Psychopharmacol. 2006, 16: 777-789. 10.1089/cap.2006.16.777.View ArticlePubMed
  25. Timler GR, Olswang LB, Coggins TE: "Do I know what I need to do?" A social communication intervention for children with complex clinical profiles. Lang Speech Hear Serv Sch. 2005, 36: 73-85. 10.1044/0161-1461(2005/007).View ArticlePubMed
  26. Vernescu R: Attention Process Training in Young Children with Fetal Alcohol Spectrum Disorders. 2007, Victoria, Canada
  27. Premji S, Benzies K, Serrett K, Hayden KA: Research-based interventions for children and youth with a Fetal Alcohol Spectrum Disorder: revealing the gap. Child Care Health Dev. 2007, 33: 389-397. 10.1111/j.1365-2214.2006.00692.x.View ArticlePubMed
  28. Stratton KR, Howe CJ, Battaglia FC: Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment. 1996, Washington, D.C.: National Academy Press
  29. Mattson SN, Riley EP: A review of the neurobehavioral deficits in children with fetal alcohol syndrome or prenatal exposure to alcohol. Alcohol Clin Exp Res. 1998, 22: 279-294. 10.1111/j.1530-0277.1998.tb03651.x.View ArticlePubMed
  30. Riley EP, McGee CL: Fetal alcohol spectrum disorders: an overview with emphasis on changes in brain and behavior. Exp Biol Med. 2005, 230: 357-365.
  31. Mattson SN, Riley EP, Gramling L, Delis DC, Jones KL: Heavy prenatal alcohol exposure with or without physical features of fetal alcohol syndrome leads to IQ deficits. J Pediatr. 1997, 131: 718-721. 10.1016/S0022-3476(97)70099-4.View ArticlePubMed
  32. Mattson SN, Goodman AM, Caine C, Delis DC, Riley EP: Executive functioning in children with heavy prenatal alcohol exposure. Alcohol Clin Exp Res. 1999, 23: 1808-1815.View ArticlePubMed
  33. Mattson SN, Riley EP: Parent ratings of behavior in children with heavy prenatal alcohol exposure and IQ-matched controls. Alcohol Clin Exp Res. 2000, 24: 226-231. 10.1111/j.1530-0277.2000.tb04595.x.View ArticlePubMed
  34. Thomas SE, Kelly SJ, Mattson SN, Riley EP: Comparison of social abilities of children with fetal alcohol syndrome to those of children with similar IQ scores and normal controls. Alcohol Clin Exp Res. 1998, 22: 528-533.View ArticlePubMed
  35. Payne J, Elliott E, D'Antoine H, O'Leary C, Mahony A, Haan E, Bower C: Health professionals' knowledge, practice and opinions about fetal alcohol syndrome and alcohol consumption in pregnancy. Aust N Z J Public Health. 2005, 29: 558-564. 10.1111/j.1467-842X.2005.tb00251.x.View ArticlePubMed
  36. Elliott EJ, Payne J, Haan E, Bower C: Diagnosis of foetal alcohol syndrome and alcohol use in pregnancy: A survey of paediatricians' knowledge, attitudes and practice. J Paediatr Child Health. 2006, 42: 698-703. 10.1111/j.1440-1754.2006.00954.x.View ArticlePubMed
  37. National Institutes of Health: ClinicalTrials.gov. National Institutes of Health, Accessed on: 6/9/2008, [http://www.clinicaltrials.gov/]
  38. Centers for Disease Control and Prevention: Fetal Alcohol Spectrum Disorders: Developing Intervention Strategies for Children. Centers for Disease Control and Prevention, Accessed on: 6/9/2008., [http://www.cdc.gov/ncbddd/fas/intervening.htm]
  39. FAS Diagnostic and Prevention Network: FAS Diagnostic and Prevention Network: Intervention Research. FAS Diagnostic and Prevention Network, Accessed on: 6/9/2008., [http://depts.washington.edu/fasdpn/htmls/interv-research.htm]
  40. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2431/9/35/prepub

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