OBJECTIVES:Fetal alcohol syndrome (FAS) is frequently undiagnosed or misdiagnosed, particularly among populations at elevated risk of the condition. We examined the prevalence of FAS among children aged 0 to 5 years enrolled in Medicaid, described characteristics of affected children, and evaluated diagnostic timing between children in foster care and children not in foster care. METHODS:We conducted a retrospective analysis of Medicaid Transformed Analytic Files for children born from 2015 through 2017 with FAS diagnoses (n = 771), following each birth cohort for 5 years. We used descriptive statistics to examine prevalence rates and demographic characteristics. Multivariate linear regression models assessed differences in diagnostic timing between children in foster care and children not in foster care, controlling for demographic factors. RESULTS:The overall FAS prevalence per 100 000 children aged 0 to 5 years enrolled in Medicaid was 7.7, increasing from 5.1 in 2015 to 11.4 in 2017. Children in foster care represented 60.2% (n = 464) of the FAS cohort. Although behavioral assessments occurred at similar ages for both groups, children in foster care received FAS diagnoses 4.6 to 5.4 months later than children not in foster care (P < .001). The time between the first behavioral assessment and FAS diagnosis was 2.1 to 3.9 months longer for children in foster care than for children not in foster case. CONCLUSIONS:Children in foster care had substantial delays in diagnosis compared with children not in foster care. Initial access to behavioral assessment appears equitable; however, barriers exist in the progression from assessment to diagnosis for children in foster care. Implementing targeted screening protocols, improving cross-system information sharing, and enhancing health care provider training could reduce diagnostic delays and improve outcomes for this population.

The COVID-19 pandemic was a source of global prolonged, multilayered adversity that caused heightened levels of social, emotional, and psychological stressors. It is imperative to understand the heightened stressors and protective factors that caregivers experienced during the pandemic in order to better contextualize treatment for caregivers, their children, and families today. Research has shown that caregiver and child well-being are interconnected. Indicating that the impacts of the pandemic on caregivers as individuals likely contributed to overall child well-being in the context of changes in parental thoughts, feelings, and actions. Therefore, the primary objectives of the current study were to determine, from a qualitative perspective, positive and negative parenting behavioral changes throughout various levels of stay in place orders attributed to the pandemic and how these experiences may fit within the cognitive behavioral framework. A sample of caregivers (N = 67) across five states were identified by previous studies, social media advertisements, community events, and medical clinics. It is important to note that the caregivers in the current sample were predominantly white and highly educated. Caregivers reported perceived positive and negative parenting changes experienced during the pandemic (child age range = 6 weeks to 4 years). Fewer than one-third of participants described negative parenting changes, such as harsher parenting practices or increased irritability. In contrast, over half of caregivers described positive changes, including increased quality time, stronger feelings of attachment, greater patience, and flexibility. These findings emerged from thematic analysis and reflect the most frequently discussed patterns across interviews. This exploratory study acknowledges the difficulties of parenting during a pandemic while also identifying and emphasizing the strategies families used to adapt.

The study examined the cognitive processes involved in written sentence construction in children affected by prenatal alcohol exposure (PAE) when compared a control group of nonexposed typically developing children, and a contrast group of nonexposed children with various clinical diagnoses. Results indicated that children with PAE and those in the contrast group exhibited poorer sentence writing than the control group. Additionally, children with PAE utilized different cognitive processes to write sentences when compared to the nonexposed groups, irrespective of having a diagnosis. For children in the nonexposed groups, improved sentence writing was associated with better performance on measures of intellectual ability, verbal retrieval, verbal learning and recall, and inhibition. For children with PAE, more proficient sentence writing was associated with the same cognitive processes plus spatial working memory. This suggested that unique, altered, or inefficient cognitive functioning associated with effects of PAE impacted written sentence construction. The findings underscore the importance of considering specific cognitive processes, including spatial working memory, when assessing for writing difficulties and developing interventions for children with PAE.

OBJECTIVE:A systematic review using Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines was conducted to evaluate the potential adverse impacts on neurodevelopment associated with prenatal opiate exposure. METHOD:After applying exclusion criteria to the identified collection of studies, 86 studies were included in this review. Each article was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations system. Results were grouped into 6 neurobehavioral function domains (executive, language, general development, motor, neurosensory, and socioemotional) and 1 neuroimaging domain. RESULT:Risk difference analyses showed the neurosensory domain in children prenatally exposed to opioid had highest risk of impairment (76.9%), whereas the executive domain had lowest risk (44.8%). The meta-analysis of pooled estimates after statistical adjustments associated with the Egger's test results showed effect size (Hedge's g) was largest in the socioemotional domain (-1.14; 95% CI, -1.61 to -0.66) and smallest in the general development domain (-0.44; 95% CI, -0.70 to -0.18). Neuroimaging studies on prenatal exposure to opioid were limited and varied in the techniques and topographical focus in their approaches, resulting in a heterogenous body of literature. CONCLUSION:Maternal opioid use during pregnancy can serve as a risk indicator for an at-risk child and the potential need for monitoring the child's neurodevelopmental growth. The conclusions related to the direct teratogenic effects of maternal opioid use, however, are often limited by poor experimental and statistical controls used to address other substances and social adversity that co-occur with opioid use.

BACKGROUND:Substance use and mental health problems have been documented in individuals with prenatal alcohol exposure (PAE) in young adulthood, but little is known about how these patterns progress over time into midlife. The current study examined rates of substance use in a sample of adults with PAE in mid-life compared to a demographically similar contrast group. METHODS:Participants (n = 233) were drawn from two longitudinal cohorts of individuals recruited prenatally and followed into adulthood. Measures of cognition, substance use, and self-reported mental health functioning were obtained. RESULTS:Differences among groups (PAE no dysmorphology, PAE with dysmorphology, No PAE contrast group) were examined on demographic variables of interest and substance use outcomes. Both PAE groups experienced higher levels of Adverse Childhood Experiences (ACEs) compared to the contrast group. We also observed higher rates of current tobacco use in those with PAE; those with PAE and no dysmorphology had almost twice the rate of current tobacco use as the nonexposed contrast group. We observed similar rates of high risk drinking on the Alcohol Use Identification Test (AUDIT) in all groups. Individuals with PAE also showed high rates of cannabis use compared to national averages. Generalized linear regressions examining predictive effects of PAE on substance use outcomes did not show significant results, though female sex at birth was predictive of current cannabis use. Current alcohol use predicted depression and PTSD symptoms, and significant interactions were observed between PAE group and ACEs on depression, PTSD, anxiety, and psychotic symptoms. CONCLUSION:This is one of the only studies to examine rates of alcohol and other substance use among adults in mid-life with PAE. Results suggest that relationships between PAE, substance use, and mental health symptoms are complex, and it will be important for future studies to examine factors associated with high-risk substance use among this vulnerable population.

The detrimental effects of prenatal alcohol exposure on the development of humans are well understood and include fetal alcohol spectrum disorders (FASD), a broad set of conditions referring to the adverse physical and behavioral health impairments associated with exposure to alcohol in utero. Using a case-control study design, the purpose of this study was to better understand the complex comorbidity patterns associated with FASD (N = 3,248) and to examine how they differ with the general patient population (N = 16,240) and a cohort of behavioral health controls (N = 16,240). Employing a novel unsupervised machine learning algorithm applied to a nationally representative hospital discharge database, we found 57 distinct comorbidities that frequently occurred among FASD cases, in addition to a set of 144 complex overlapping comorbidity patterns. The identified comorbidities were generally more likely to occur in the FASD cases compared to the general patient population control group, while differences with behavioral health controls were less readily apparent. This study adds to a small but growing body of research on comorbidities experienced by individuals with FASD. We discuss the implications of the identified comorbidity patterns on the ongoing identification, treatment, and surveillance of FASD in the US.

The HEALthy Brain and Child Development (HBCD) study, a multi-site prospective longitudinal cohort study, will examine human brain, cognitive, behavioral, social, and emotional development beginning prenatally and planned through early childhood. The study plans enrolling over 7000 families across 27 sites. This manuscript presents the measures from the Neurocognition and Language Workgroup. Constructs were selected for their importance in normative development, evidence for altered trajectories associated with environmental influences, and predictive validity for child outcomes. Evaluation of measures considered psychometric properties, brevity, and developmental and cultural appropriateness. Both performance measures and caregiver report were used wherever possible. A balance of norm-referenced global measures of development (e.g., Bayley Scales of Infant Development-4) and more specific laboratory measures (e.g., deferred imitation) are included in the HBCD study battery. Domains of assessment include sensory processing, visual-spatial reasoning, expressive and receptive language, executive function, memory, numeracy, adaptive behavior, and neuromotor. Strategies for staff training and quality control procedures, as well as anticipated measures to be added as the cohort ages, are reviewed. The HBCD study presents a unique opportunity to examine early brain and neurodevelopment in young children through a lens that accounts for prenatal exposures, health and socio-economic disparities.

BACKGROUND:The neurobehavioral health impairments associated with prenatal alcohol exposure are now known to persist through adulthood. However, little is known about how these impairments affect individuals' parenting abilities and the neurobehavioral health of their offspring. This study compares parents with fetal alcohol spectrum disorder (FASD) with socioeconomically matched, nonexposed parents on measures of parenting and family support and assesses the neurobehavioral health of the children in both groups. METHODS:Forty-nine parent-child dyads were recruited from a longitudinal cohort of low socioeconomic status. Measures included the Parenting Styles and Dimensions Questionnaire, Family Support Scale, an in-depth psychosocial history, the Pediatric Symptom Checklist (PSC; parent and child reports), the Achenbach Child Behavior Checklist (CBCL), a screening psychiatric evaluation of the child, the NIH Toolbox Cognition Battery for Children, The Vineland Adaptive Behavior Scales-Third Edition caregiver rating form, and the Traumatic Events Screening Inventory (parent and child reports). RESULTS:Cognitive functioning was impaired for both offspring of parents with FASD ( x ¯  = 81.1, SD = 13.0) and control parents ( x ¯  = 79.9, SD = 16.1), but despite similar impairments, children of parents with FASD were less likely to have an Individualized Education Plan than controls. Adaptive functioning was adequate for both groups ( x ¯  = 92.1, SD = 15.4 in exposed vs. x ¯  = 94.3, SD = 12.3 in controls) and CBCL and PSC scores in both groups were within normal limits. Parents in both groups showed a predominantly authoritative parenting style. Despite a similar frequency of adverse childhood experiences in both groups, parents with FASD were less likely to recognize their child's adverse experiences. CONCLUSION:Parents with FASD display notable strengths including a predominantly authoritative parenting style. However, parents with FASD underrecognize child trauma and underutilize developmental services compared to socioeconomically matched controls, despite similar neurocognitive impairments. Impairments in adaptive functioning in parents with FASD may translate into difficulties with child-parent communication and limit both insight into neurobehavioral problems and advocacy skills. There is a need to identify and support parents with FASD to optimize their parenting abilities in the context of their individual strengths and difficulties.

This study evaluated criteria for Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). Kable et al. (2022) assessed the validity of this diagnosis in a sample with low exposure to alcohol. The current study expanded this assessment to a sample with a wider age range and heavier alcohol exposure. Data were collected from participants (5-17y) with prenatal alcohol exposure (PAE) and typically developing controls at six Collaborative Initiative on Fetal Alcohol Spectrum Disorders sites using neuropsychological assessment and caregiver reports. Impairment was tested at 1SD, 1.5SD, and 2SD below the normative average and a modification of the adaptive functioning requirement was tested. Testing impairment at 1SD resulted in the highest endorsement rates in both groups. Our findings replicated the study by Kable et al. and show that current criteria captured a high rate of those with PAE and that requiring fewer adaptive functioning criteria resulted in higher sensitivity to PAE.

Background: Choline is essential for healthy cognitive development. Single nucleotide polymorphisms (SNPs; rs3199966(G), rs2771040(G)) within the choline transporter SLC44A1 increase risk for choline deficiency. In a choline intervention trial of children who experienced prenatal alcohol exposure (PAE), these alleles are associated with improved cognition. Objective: This study aimed to determine if SNPs within SLC44A1 are differentially associated with cognition in children with PAE compared with normotypic controls (genotype x exposure). A secondary objective tested for an association of these SNPs and cognition in controls (genotype-only). Design: This is a secondary analysis of data from the Collaborative Initiative on Fetal Alcohol Spectrum Disorders. Participants (163 normotypic controls, 162 PAE) underwent psychological assessments and were genotyped within SLC44A1. Choline status was not assessed. Association analysis between genotype x exposure was performed using an additive genetic model and linear regression to identify the allelic effect. The primary outcome was the interaction between SLC44A1 genotype x exposure status with respect to cognition. The secondary outcome was the cognitive-genotype association in normotypic controls. Results: Genotype x exposure analysis identified 7 SNPs in SLC44A1, including rs3199966(G) and rs2771040(G), and in strong linkage (D' >= 0.87), that were associated (adjusted P <= 0.05) with reduced performance in measures of general cognition, nonverbal and quantitative reasoning, memory, and executive function (13, 1.92-3.91). In controls, carriers of rs3199966(GT or GG) had worsened cognitive performance than rs3199966(TT) carriers (13, 0.46-0.83; P < 0.0001), whereas cognitive performance did not differ by rs3199966 genotype in those with PAE. Conclusions: Two functional alleles that increase vulnerability to choline deficiency, rs3199966(G) (Ser644Ala) and rs2771040(G) (3' untranslated region), are associated with worsened cognition in otherwise normotypic children. These alleles were previously associated with greater cognitive improvement in children with PAE who received supplemental choline. The findings endorse that choline benefits cognitive development in normotypic children and those with PAE.

Fetal alcohol spectrum disorders (FASDs) affect at least 0.8% of the population globally. The diagnosis of FASD is uniquely complex, with a heterogeneous physical and neurobehavioral presentation that requires multidisciplinary expertise for diagnosis. Many researchers have begun to incorporate machine learning approaches into FASD research to identify children who are affected by prenatal alcohol exposure, including those with FASD. This narrative review highlights these efforts. Following an introduction to machine learning, we summarize examples from the literature of neurobehavioral screening tools and physiologic markers of exposure. We discuss individual efforts, including models that classify FASD based on parent-reported neurocognitive or behavioral questionnaires, 3D facial imaging, brain imaging, DNA methylation patterns, microRNA profiles, cardiac orienting response, and dysmorphic facial features. We highlight model performance and discuss the limitations of these approaches. We conclude by considering the scalability of these approaches and how these machine learning models, largely developed from clinical samples or highly exposed birth cohorts, may perform in the general population.

BACKGROUND:The Developmental Origins of Health and Disease Hypothesis (DOHaD) suggests prenatal alcohol exposure (PAE) should have implications for adult physical and mental health. Since the health profile of older adults with PAE and diagnoses of fetal alcohol spectrum disorder (FASD) is unknown, the current study evaluates self-reported health problems of midlife adults with and without a history of PAE to describe these outcomes. METHODS:Participants (N = 357) recruited from longitudinal cohorts in Atlanta, GA and Seattle, WA completed a health survey assessing a range of physical conditions. Initial analysis compared the frequency of conditions between alcohol-exposed and nonexposed groups. To identify patterns within groups, 10 problem areas were subjected to latent class analysis (LCA). Finally, the direct effect of PAE on health outcomes was evaluated using multilevel modeling, controlling for effects of other factors. RESULTS:Compared with unexposed controls, individuals with PAE reported significantly higher frequencies of problems with hearing, dentition, heart, cancer, gastritis, kidney stones, bladder, diabetes, thyroid, skin, and seizures. LCA found that controls yielded two classes, with 45% reporting sleep and vision problems and 55% reporting sleep, vision, cardiovascular, endocrine, immune, and dental problems. The PAE group yielded three classes, with 13% endorsing few health problems, 43% reporting sleep, vision, immune, and dental problems, and 43% reporting sleep, vision, cardiovascular, urinary, endocrine, skin, immune, dental, and gastrointestinal problems. With multivariate analysis, controlling for other influences, PAE was associated directly with hearing, urinary, dental, and gastrointestinal problems. A similar pattern was found for alcohol-exposed individuals who did and did not meet criteria for fetal alcohol syndrome (FAS). DISCUSSION:Patients affected by alcohol may report greater frequency and range of health adversity. That PAE was only uniquely associated with a limited set of problems suggests that many health outcomes in midlife result from an initial vulnerability potentiated by postnatal stress resulting from other associated factors.

Math development in children relies on several underlying cognitive functions, including executive functions (EF), working memory (WM), and visual-motor abilities, such as visual-motor integration (VMI). Understanding how these cognitive factors contribute to children’s math performance is critical to supporting math learning and long-term math success. The present quasi-experimental waitlist control study ( N = 28) aimed to (a) examine the unique contributions of EF, WM, and VMI to math abilities among children ages 5–8 years old with neurodevelopmental difficulties; (b) determine whether a math intervention (the Mathematics Interactive Learning Experience; MILE) that supports these cognitive processes was effective when modified to be delivered to small groups in a school setting, and (c) examine whether any participant characteristics, such as age or IQ, were correlated with post-intervention math score changes. At baseline, participants’ math scores were significantly below the normative mean in all math content areas ( ps < .01). EF, WM, and VMI were highly correlated with math ability; however, verbal WM was the only unique predictor of math ability in regressions analysis. Compared to a waitlist control group, children in the immediate MILE intervention group achieved significantly greater math gains overall. When all children who ultimately completed the intervention were considered together, significant improvement was observed in more than half of math content areas. Furthermore, at the individual level, 85.7% of participants showed reliable change in at least one math content area. Implications for supporting math learning in children with neurodevelopmental difficulties are discussed.