Strong Born-A First of Its Kind National FASD Prevention Campaign in Australia Led by the National Aboriginal Community Controlled Health Organisation (NACCHO) in Collaboration with the Aboriginal Community Controlled Health Organisations (ACCHOs).

The Strong Born Campaign (2022-2025) was launched by the National Aboriginal Community Controlled Health Organisation (NACCHO) in 2023. Strong Born is the first of its kind national Aboriginal and Torres Strait Islander health promotion campaign to address Fetal Alcohol Spectrum Disorder (FASD) within Australia. Strong Born was developed to address a longstanding, significant gap in health promotion and sector knowledge on FASD, a lifelong disability that can result from alcohol use during pregnancy. Utilizing a strengths-based and culturally sound approach, NACCHO worked closely with the Aboriginal Community Controlled Health Organisations (ACCHOs) to develop the campaign through co-design, as described in this paper. Since its inception, the ACCHOs have continually invested in driving change towards improvements in Aboriginal health determinants and health promotion. The Strong Born Campaign developed culturally safe health promotion tool kits designed for the community and health sector staff and also offered communities the opportunity to apply for FASD Communications and Engagement Grants to engage in local campaign promotion. The tool kits have been disseminated to 92 ACCHOs across Australia. This paper describes the development of the Strong Born Campaign and activities following its launch in February 2023 from an Indigenous context within Australia, as described by NACCHO.

Identifying fetal alcohol spectrum disorder among South African children at aged 1 and 5 years.

BACKGROUND: Fetal Alcohol Spectrum Disorders (FASD) are a global health concern. Early intervention mitigates deficits, yet early diagnosis remains challenging. We examined whether children can be screened and meet diagnoses for FASD at 1.5 years compared to 5 years post-birth. METHODS: A population cohort of pregnant women in 24 neighborhoods (N = 1258) was recruited and 84.5 %-96 % were reassessed at two weeks post-birth, 0.5 years, 1.5 years, 3 years, and 5 years later. A two-step process was followed to diagnose FASD; first, a paraprofessional screened the children and then a physician evaluated the child. We evaluated FASD symptoms at 1.5 vs. 5 years. We also examined maternal differences in children receiving a positive FASD screening (n = 160) with those who received a negative FASD screening. RESULTS: Screening positive for FASD more than doubled from 1.5 years to 5 years (from 6.8 % to 14.8 %). About one quarter of children who screened positive and were evaluated by a physician, were diagnosed as having a FASD. However, half did not complete the 2nd stage screening. Compared to mothers of children with a negative FASD screening, mothers of children with a positive FASD screening were less likely to have a high school education and more likely to have lower incomes, have experienced interpersonal partner violence, and have a depressed mood. Mothers of children who did not follow up for a 2nd stage physician evaluation were more like to live in informal housing compared to those who followed-up (81.3 % vs. 62.5 %, p = 0.014). CONCLUSIONS: We found that children can be screened and diagnosed for FASD at 1.5 and 5 years. As FASD characteristics develop over time, repeated screenings are necessary to identify all affected children and launch preventive interventions. Referrals for children to see a physician to confirm diagnosis and link children to care remains a challenge. Integration with the primary healthcare system might mitigate some of those difficulties.

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.

[Formula: see text] Cognitive and social/emotional influences on adaptive functioning in children with FASD: Clinical and cultural considerations.

Fetal Alcohol Spectrum Disorder (FASD) is one of the leading causes of intellectual disability and learning difficulties around the world. Children with FASD often have extremely low adaptive behavior due to the severity of brain impairment, however there is limited understanding as to the important predictors of adaptive behavior. In a study of 39 children with FASD and 29 comparison children, we found that social cognition (specifically recognizing emotions) was the only significant independent predictor of teacher-rated adaptive functioning even after including IQ, executive functioning, and adverse childhood experiences into the model. In this current study, Maori (Indigenous people of Aotearoa New Zealand) were overrepresented; therefore, the research was supported by a strong partnership with Te Wahanga Hauora Maori (Maori Health Service). Aotearoa New Zealand's colonized history is recognized and findings are discussed with regard to both the psychological literature and a Te Ao Maori worldview.

The Demographic and Neurocognitive Profile of Clients Diagnosed With Fetal Alcohol Spectrum Disorder in PATCHES Paediatrics Clinics Across Western Australia and the Northern Territory.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a diagnosis relating to neurocognitive impairments associated with prenatal alcohol exposure. A key aspect of improving FASD diagnostic processes and management is understanding the demographic and neurocognitive profile of those living with FASD. The aim of this study was to describe the demographic and neurocognitive profile of the first 199 individuals diagnosed with FASD in PATCHES Paediatrics clinics. METHODS: A retrospective cross-sectional descriptive study design was conducted with individuals diagnosed with FASD between 2013 and 2018 through a multidisciplinary team according to the Australian FASD Diagnostic Guidelines. RESULTS: Participants were primarily male 133 (66.8%) and Aboriginal Australian 147 (73.9%), aged 2 to 31 (mean 10.5), with 94 (47.3%) from remote or very remote parts of Western Australia. Participants came from low 119 (59.8%), medium 48 (24.1%), and high 32 (16.1%) socioeconomic (SE) backgrounds. Low SE background was found to be a predictor of number of sentinel facial features (Wald χ2 (1) = 4.03, p < 0.05). Most received a diagnosis of FASD with <3 sentinel features 165 (82.9%). Participants either had 6 or more 46 (23.1%), 5 44 (22.1%), 4 55 (27.6%), or 3 (27.1%) neurodevelopmental domains impaired. Executive functioning was the most commonly impaired neurodevelopmental domain 158 (79.4%), and 31 (61%) reported sleep disturbance. ADHD was the most observed comorbid condition (41.7%). CONCLUSIONS: This study improves our current understanding of neurocognitive and demographic profiles in individuals with FASD that have been clinically referred for diagnosis within Western Australia and the Northern Territory, and highlights the importance of prevention and early assessment/diagnosis as well as guidance regarding more targeted interventions. FASD affects individuals from all cultural and SE backgrounds. Individuals from middle to higher SE groups are at risk of FASD with prevention efforts needing to target these sectors of society. Suggestions for future research directions are also provided.

Overcoming the challenges of caring for a child with foetal alcohol spectrum disorder: a Pilbara community perspective.

Introduction Foetal alcohol spectrum disorder (FASD) is a neurodevelopmental impairment that may result in individuals experiencing poor development, cognitive issues and disruptive behaviours. In Australia, the prevalence of FASD is unknown; however, two studies have revealed the prevalence of FASD in high risk populations in Western Australia. Individuals with FASD may experience higher rates of negative outcomes including poor school performance, involvement with the justice system and incarceration, substance use and are at risk of being placed in out-of-home care. Caregivers of children with FASD can experience challenges and high levels of stress due to the disruptive behaviours displayed by many children diagnosed with FASD. Whilst experiences of caregivers raising children with FASD have been documented globally, little is known about the experiences of caregivers in a remote Australian context, particularly from an Australian Aboriginal perspective. This study aimed to investigate the experiences of caregivers in a remote Australian context. The findings will be valuable to inform programs at the family, community and broader policy levels that can help enhance children's development and wellbeing. METHODS: Participants (n=7) in this qualitative study were recruited through a FASD diagnostic clinic and family support organisation in the Port Hedland region of Western Australia. Eligible participants were previous or current caregivers of children with a FASD diagnosis or risk of FASD and provided informed consent before participating in semi-structured interviews using a phenomenological approach. The interviews were 30-60 minutes in duration and were audio-recorded and transcribed verbatim using NVivo 11 computer software, with all identifying information removed. RESULTS: The caregivers provided rich, descriptive narratives revealing the challenges and stress they experienced when they first started caring for their child with FASD. Caregivers articulated how they developed and adapted strategies through trial and error that enabled them to better manage disruptive behaviours and maintain a stable, calm environment. A thematic analysis revealed four major themes: the importance of routine and structure for the child and family, the importance of family support, the benefits of peer support groups and various social issues impacting children's development. Maintaining routine and structure had helped many caregivers mitigate stress and reduce disruptive behaviours, and family support allowed caregivers some respite whilst ensuring children remained connected to their biological families and culture. The caregivers also shared that peer support groups would be beneficial to share stories and strategies with others experiencing similar circumstances. Broader societal issues requiring attention at the community level were discussed, in addition to caregivers having awareness of the complexities impacting the children's biological families. CONCLUSION: The caregivers in this study have gained valuable knowledge and wisdom through caring for a child with FASD that can benefit health professionals and the broader community. Whilst the caregivers in this study have overcome challenges through developing and adapting their own strategies, support services providing tailored programs for caregivers when they first start caring for a child with FASD would be beneficial. Furthermore, formal respite was not utilised by the caregivers in this study due to safety issues, inconsistent parenting and interrupted routines, therefore investigation into training respite caregivers in the area of FASD would be beneficial. Furthermore, respite services should consider provisions to include extended families and kinship relationships in a formal context to enable ongoing cultural and family connection, consistent parenting strategies and routines.

Collaborative Action on Fetal Alcohol Spectrum Disorder Prevention: Principles for Enacting the Truth and Reconciliation Commission Call to Action #33.

The association between fetal alcohol spectrum disorder (FASD), residential schools and subsequent assimilatory policies in Canada is of such significance that it was included in the groundbreaking Truth and Reconciliation Commission of Canada's Final Report through Call to Action #33, which focuses on collaboratively developing FASD prevention programs in Indigenous communities. A consensus statement with eight tenets for enacting Call to Action #33 was co-developed in May 2017 using a Two-Eyed Seeing approach during and after a meeting on Indigenous approaches to FASD prevention held in Canada. The consensus statement provides guidance for creating community-based, culture-led FASD prevention programs in Indigenous communities. The eight tenets reflect the diverse perspectives of Indigenous and non-Indigenous participants, are grounded in available research evidence, and align with Indigenous worldviews and wellness models. This paper uses the consensus statement and eight exemplary FASD prevention programs from Indigenous communities and organizations across Canada to highlight identity, culture, and relationships as central elements of FASD prevention in Indigenous communities. The consensus statement provides guidance for developing community- and culture-led FASD prevention programs and highlights the importance of Indigenous knowledge systems in developing and researching FASD prevention in, and with, Indigenous communities.

"But Problems Dwell so the Urge Is Constant " Qualitative Data Analysis of the OST CHOICES Program.

BACKGROUND: Fetal alcohol spectrum disorders are a major public health concern including among American Indian (AI)/Alaska Native (AN) communities. Various studies have demonstrated higher alcohol consumption among AI/AN women during pregnancy compared with other groups. This study intends to understand the milieu within which such consumption patterns flourish. The study utilizes qualitative and quantitative data from the Oglala Sioux Tribe (OST) CHOICES Program, a tribally run public health program that aims to reduce alcohol-exposed pregnancy preconceptually in AI women. METHODS: Alcohol consumption pattern (n = 264) is analyzed using descriptive statistics. Consumption patterns included average drinks consumed daily, their choice of drinks (beer, whiskey, wine, etc.), how much money participants were spending on alcohol and amount of calories consumed from alcohol. Qualitative data analysis included open coding of data from decisional balance exercise of the CHOICES program that looked at good things and not so good things about participants' drinking. RESULTS: Women reported drinking an average of 12 drinks daily, ranging between 1 and 86. Women drinking at home spent a median of $4,320 and $12,960 if drinking at a bar. A median of 1,200 calories per day from alcohol was reported. More women reported drinking beer compared with other types of alcohol within a domestic setting. Qualitative data analysis identified positive and negative aspects of drinking among the participants of OST CHOICES Program. Positive aspects included escaping from problems, socializing, and relaxation. Negative aspects included impact on families and domestic violence. CONCLUSIONS: While understanding their milieu, our study also unraveled different struggles (such as violence, peer pressure, financial burden, and depression) encountered by Native women in their daily lives. According to the participants, positive aspects of drinking outweigh the negative aspects and they viewed their drinking as a solution and not a problem.

Internationally adopted children: not only infectious diseases!

Information on prevalence of special needs in internationally adopted children (IAC) is incomplete. We reviewed data from 422 IAC screened at a single Centre in Italy in 2015-16. Prevalence of special needs reached 17.1% (n = 72). Among these children, the most frequent conditions were fetal alcohol spectrum disorders (FASD; n = 30; 7.1%), cleft lip palate (n = 8; 1.9%) and other congenital malformations (n = 20; 4.7%). Worrisomely, 25 out of 52 (48.1%) Russian children presented with FASD.

Online scan of FASD prevention and health promotion resources for Aboriginal and Torres Strait Islander communities.

ISSUE ADDRESSED: Foetal Alcohol Spectrum Disorder (FASD) includes a range of life-long impairments caused by alcohol exposure in utero. Health professionals are vital to preventing FASD but many are hesitant to discuss FASD with clients due to their need for additional resources to aid the conversation. This scan sought to identify the scope and gaps in publicly available FASD prevention and health promotion resources, and assess their cultural appropriateness for use among five key groups of Indigenous Australian people including: (i) pregnant women, (ii) women of childbearing age, (iii) grandmothers and aunties, (iv) men, and (v) health professionals. METHODS: Relevant resources published 1995-2017 were identified through the Australian Indigenous HealthInfoNet, FASD organisation websites, grey literature, Google searches, and field experts. Results were screened by inclusion and cultural appropriateness criteria developed and piloted by the research team, and further screened by health professionals attending FASD training workshops. RESULTS: 115 of the 2146 identified resources were eligible. Relevant resources were found for all five key groups; however, no resources were specifically designed for men, grandmothers or aunties. CONCLUSIONS: A range of high-quality, culturally appropriate resources were identified, however, health professionals attending the training workshops were not aware of their availability. Further resource development is suggested for men, grandmothers and aunties. SO WHAT?: Prioritisation of active dissemination and implementation strategies is suggested to increase awareness and use of future resource developments. The inclusion of a resource trial among health professionals is a recommended strategy to increase awareness and use of newly developed resources.

Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities.

Importance: Fetal alcohol spectrum disorders are costly, life-long disabilities. Older data suggested the prevalence of the disorder in the United States was 10 per 1000 children; however, there are few current estimates based on larger, diverse US population samples. Objective: To estimate the prevalence of fetal alcohol spectrum disorders, including fetal alcohol syndrome, partial fetal alcohol syndrome, and alcohol-related neurodevelopmental disorder, in 4 regions of the United States. Design, Setting, and Participants: Active case ascertainment methods using a cross-sectional design were used to assess children for fetal alcohol spectrum disorders between 2010 and 2016. Children were systematically assessed in the 4 domains that contribute to the fetal alcohol spectrum disorder continuum: dysmorphic features, physical growth, neurobehavioral development, and prenatal alcohol exposure. The settings were 4 communities in the Rocky Mountain, Midwestern, Southeastern, and Pacific Southwestern regions of the United States. First-grade children and their parents or guardians were enrolled. Exposures: Alcohol consumption during pregnancy. Main Outcomes and Measures: Prevalence of fetal alcohol spectrum disorders in the 4 communities was the main outcome. Conservative estimates for the prevalence of the disorder and 95% CIs were calculated using the eligible first-grade population as the denominator. Weighted prevalences and 95% CIs were also estimated, accounting for the sampling schemes and using data restricted to children who received a full evaluation. Results: A total of 6639 children were selected for participation from a population of 13 146 first-graders (boys, 51.9%; mean age, 6.7 years [SD, 0.41] and white maternal race, 79.3%). A total of 222 cases of fetal alcohol spectrum disorders were identified. The conservative prevalence estimates for fetal alcohol spectrum disorders ranged from 11.3 (95% CI, 7.8-15.8) to 50.0 (95% CI, 39.9-61.7) per 1000 children. The weighted prevalence estimates for fetal alcohol spectrum disorders ranged from 31.1 (95% CI, 16.1-54.0) to 98.5 (95% CI, 57.5-139.5) per 1000 children. Conclusions and Relevance: Estimated prevalence of fetal alcohol spectrum disorders among first-graders in 4 US communities ranged from 1.1% to 5.0% using a conservative approach. These findings may represent more accurate US prevalence estimates than previous studies but may not be generalizable to all communities.

Tailoring an Alcohol Intervention for American Indian Alaska Native Women of Childbearing Age: Listening to the Community.

BACKGROUND: Reduction of risky drinking in women of childbearing age is 1 strategy that may be employed to prevent fetal alcohol spectrum disorder, a sequela of prenatal alcohol exposure. Communities differ in risk and protective factors, necessitating culturally informed interventions for maximal efficacy. This article describes the modification of an existing web-based screening, brief intervention, and referral to treatment intervention to reduce risky drinking among American Indian Alaska Native (AIAN) women of childbearing age in Southern California into a peer-to-peer-based intervention using motivational interviewing (MI). METHODS: The modification process was iterative and included various community focus groups, interviews, and a final review. RESULTS: Intervention modification was required for cultural congruence. Components of the peer-to-peer intervention designed by this project included a flip chart used to guide the motivational interviewing, charts of the financial and physical costs of alcohol consumption, revised baseline and follow-up questionnaires, and guidance regarding the application of MI techniques. CONCLUSIONS: This study may inform the modification of future interventions among AIAN communities.

The Marulu Strategy 2008-2012: overcoming Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley.

OBJECTIVE: Aboriginal leaders concerned about high rates of Fetal Alcohol Spectrum Disorder (FASD) in the Fitzroy Valley, remote north-western Australia, introduced restrictions on access to take-away full-strength alcohol. Following this, Aboriginal leaders engaged strategic partners in a broader strategy to address FASD in the region. The aim of this study was to develop and implement a community-led, researcher-supported, FASD strategy. METHODS: A review of literature focusing on community-led FASD strategies identified key components that informed the Marulu FASD strategy. These included strategy ownership, leadership, and governance by participating communities, and a research framework. RESULTS: Community meetings and workshops led to the development of The Marulu FASD Strategy (2008). Feasibility and community consent to conduct a FASD prevalence study (the Lililwan Project) was confirmed, and implementation was progressed (2010-2013). Concurrent FASD prevention activities were conducted. In 2012, the Marulu FASD Unit was established within a local Aboriginal organisation to sustain and coordinate ongoing strategy activities. CONCLUSIONS: Community control of public health initiatives can be achieved when Aboriginal communities prioritise issues of significant concern, and engage strategic partners to overcome them. Implications for public health: The Marulu Strategy forms a template for action to address FASD and other public health issues in Aboriginal communities in Australia and internationally.

Facial Curvature Detects and Explicates Ethnic Differences in Effects of Prenatal Alcohol Exposure.

BACKGROUND: Our objective is to help clinicians detect the facial effects of prenatal alcohol exposure by developing computer-based tools for screening facial form. METHODS: All 415 individuals considered were evaluated by expert dysmorphologists and categorized as (i) healthy control (HC), (ii) fetal alcohol syndrome (FAS), or (iii) heavily prenatally alcohol exposed (HE) but not clinically diagnosable as FAS; 3D facial photographs were used to build models of facial form to support discrimination studies. Surface curvature-based delineations of facial form were introduced. RESULTS: (i) Facial growth in FAS, HE, and control subgroups is similar in both cohorts. (ii) Cohort consistency of agreement between clinical diagnosis and HC-FAS facial form classification is lower for midline facial regions and higher for nonmidline regions. (iii) Specific HC-FAS differences within and between the cohorts include: for HC, a smoother philtrum in Cape Coloured individuals; for FAS, a smoother philtrum in Caucasians; for control-FAS philtrum difference, greater homogeneity in Caucasians; for control-FAS face difference, greater homogeneity in Cape Coloured individuals. (iv) Curvature changes in facial profile induced by prenatal alcohol exposure are more homogeneous and greater in Cape Coloureds than in Caucasians. (v) The Caucasian HE subset divides into clusters with control-like and FAS-like facial dysmorphism. The Cape Coloured HE subset is similarly divided for nonmidline facial regions but not clearly for midline structures. (vi) The Cape Coloured HE subset with control-like facial dysmorphism shows orbital hypertelorism. CONCLUSIONS: Facial curvature assists the recognition of the effects of prenatal alcohol exposure and helps explain why different facial regions result in inconsistent control-FAS discrimination rates in disparate ethnic groups. Heavy prenatal alcohol exposure can give rise to orbital hypertelorism, supporting a long-standing suggestion that prenatal alcohol exposure at a particular time causes increased separation of the brain hemispheres with a concomitant increase in orbital separation.

Prevalence and profile of Neurodevelopment and Fetal Alcohol Spectrum Disorder (FASD) amongst Australian Aboriginal children living in remote communities.

BACKGROUND: Despite multiple risk factors for neurodevelopmental vulnerability, few studies have assessed neurodevelopmental performance of Australian Aboriginal children. An important risk factor for neurodevelopmental vulnerability is prenatal alcohol exposure (PAE), which places children at risk for Fetal Alcohol Spectrum Disorder (FASD). AIMS: This study assesses neurodevelopment outcomes in a population of Australian Aboriginal children with and without PAE. METHODS AND PROCEDURES: Children born in 2002/2003, and living in the Fitzroy Valley, Western Australia between April 2010 and November 2011, were eligible (N=134). Sociodemographic and antenatal data, including PAE, were collected by interview with 127/134 (95%) consenting parents/caregivers. Maternal/child medical records were reviewed. Neurodevelopment was assessed by clinicians blinded to PAE in 108/134 (81%) children and diagnoses on the FASD spectrum were assigned. OUTCOMES AND RESULTS: Neurodevelopmental disorder was documented in 34/108 children (314.8 per 1000). Any diagnosis on the FASD spectrum was made in 21/108 (194.4 per 1000) children (95% CI=131.0-279.0). CONCLUSIONS AND IMPLICATIONS: Neurodevelopmental impairment with or without PAE is highly prevalent among children in the Fitzroy Valley. Rates of diagnoses on the FASD spectrum are among the highest worldwide. Early intervention services are needed to support developmentally vulnerable children in remote communities.

Impact of the CHOICES Intervention in Preventing Alcohol-Exposed Pregnancies in American Indian Women.

BACKGROUND: Fetal alcohol spectrum disorders (FASD) comprise a continuum of lifelong outcomes in those born prenatally exposed to alcohol. Although studies have shown no differences in rates by race, FASD is of particular concern for American Indian communities. One tribally run prevention program is the Oglala Sioux Tribe (OST) CHOICES Program, which is modeled after the evidence-based CHOICES program that was focused on preconceptional prevention of alcohol-exposed pregnancy (AEP) by reducing risky drinking in women at risk for pregnancy and/or preventing unintended pregnancy. METHODS: The OST CHOICES Program was made culturally appropriate for American Indian women and implemented with 3 communities, 2 on the reservation and 1 off. Data on drinking, sexual activity, and contraception use were collected at baseline and 3 and 6 months postintervention. Data were analyzed using descriptive statistics, 1-way analysis of variance, and a random intercept generalized estimating equation model. RESULTS: A total of 193 nonpregnant American Indian women enrolled in the OST CHOICES Program, and all were at risk for AEP because of binge drinking and being at risk for an unintended pregnancy. Fifty-one percent of participants completed both 3- and 6-month follow-ups. Models showed a significant decrease in AEP risk from baseline at both 3- and 6-month follow-ups, indicating the significant impact of the OST CHOICES intervention. Women in the OST CHOICES Program were more likely to reduce their risk for AEP by utilizing contraception, rather than decreasing binge drinking. CONCLUSIONS: Even with minor changes to make the CHOICES intervention culturally and linguistically appropriate and the potential threats to program validity those changes entail, we found a significant impact in reducing AEP risk. This highlights the capacity for the CHOICES intervention to be implemented in a wide variety of settings and populations.

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.

Graphomotor skills in children with prenatal alcohol exposure and fetal alcohol spectrum disorder: A population-based study in remote Australia.

BACKGROUND/AIM: Few studies have examined graphomotor skills in children with prenatal alcohol exposure (PAE) or fetal alcohol spectrum disorder (FASD). METHODS: Graphomotor skills were assessed in 108 predominantly Australian Aboriginal children aged 7.5-9.6 years in remote Western Australia using clinical observations (pencil grasp; writing pressure) and standardised assessment tools (the Evaluation Tool of Children's Handwriting; and the Miller Function and Participation Scales - The Draw-a-Kid Game). Skills were compared between children (i) without PAE, (ii) PAE but not FASD and (iii) FASD. RESULTS: Most children used a transitional pencil grasp and exerted heavy handwriting pressure (83.3% and 30.6% of the cohort). The percentage of letters (M = 62.9%) and words (M = 73.3%) written legibly was low. Children with FASD were more likely than children without PAE to use a cross-thumb grasp (P = 0.027), apply heavy writing pressure (P = 0.036), be unable to write a sentence (P = 0.041) and show poorer word legibility (P = 0.041). There were no significant differences between groups for drawing outcomes, although some children with FASD drew pictures that appeared delayed for their age. There were no significant differences between children without PAE and those with PAE but who were not diagnosed with FASD. CONCLUSIONS: Overall, graphomotor skills were poor in this cohort, but children with FASD performed significantly worse than children without PAE. Findings suggest the need for improved occupational therapy services for children in remote regions and evaluation of graphomotor skills in children with PAE.

Establishing survey validity and reliability for American Indians through "think aloud" and test-retest methods.

The purpose of this study was to use a mixed-methods approach to determine the validity and reliability of measurements used within an alcohol-exposed pregnancy prevention program for American Indian women. To develop validity, content experts provided input into the survey measures, and a "think aloud" methodology was conducted with 23 American Indian women. After revising the measurements based on this input, a test-retest was conducted with 79 American Indian women who were randomized to complete either the original measurements or the new, modified measurements. The test-retest revealed that some of the questions performed better for the modified version, whereas others appeared to be more reliable for the original version. The mixed-methods approach was a useful methodology for gathering feedback on survey measurements from American Indian participants and in indicating specific survey questions that needed to be modified for this population.