UK adult ADHD services in crisis.

The UK's services for adult attention-deficit hyperactivity disorder (ADHD) are in crisis, with demand outstripping capacity and waiting times reaching unprecedented lengths. Recognition of and treatments for ADHD have expanded over the past two decades, increasing clinical demand. This issue has been exacerbated by the COVID-19 pandemic. Despite an increase in specialist services, resource allocation has not kept pace, leading to extended waiting times. Underfunding has encouraged growth in independent providers, leading to fragmentation of service provision. Treatment delays carry a human and financial cost, imposing a burden on health, social care and the criminal justice system. A rethink of service procurement and delivery is needed, with multiple solutions on the table, including increasing funding, improving system efficiency, altering the service provision model and clinical prioritisation. However, the success of these solutions hinges on fiscal capacity and workforce issues.

Evaluating the Difference in Neuropsychological Profiles of Individuals with FASD Based on the Number of Sentinel Facial Features: A Service Evaluation of the FASD UK National Clinic Database.

(1) It might be implied that those with Fetal Alcohol Spectrum Disorder (FASD) with fewer sentinel facial features have a "milder" neuropsychological presentation, or present with fewer impairments than those with more sentinel facial features. The aim of this service evaluation was to compare the neuropsychological profile of people with FASD with varying numbers of sentinel facial features. (2) A clinical sample of 150 individuals with FASD, aged between 6 and 37 years, completed various standardised assessments as part of their diagnostic profiling. These included the documented level of risk of prenatal alcohol exposure (4-Digit Diagnostic Code), sensory needs (Short Sensory Profile), cognition (Wechsler Intelligence Scale for Children-4th Edition; WISC-IV), and communication and socialisation adaptive behaviours (Vineland Adaptive Behavior Scale-2nd Edition; VABS-II). As FASD has high comorbidity rates of Autism Spectrum Disorder (ASD) and Attention Deficit Hyperactivity Disorder (ADHD), these were also reviewed. The profiles of the 'FASD with 2 or 3 sentinel facial features' group (n = 41; 28 male, 13 female) were compared with the 'FASD with 0 or 1 sentinel facial features' group (n = 109; 50 male, 59 female) using Chi² tests, independent sample t-tests, and Mann-Whitney U analyses (where appropriate). (3) There were no significant differences between the two comparison groups across any measure included in this service evaluation. (4) Whilst sentinel facial features remain an important aspect in recognising FASD, our service evaluation indicates that there is no significant relationship between the number of sentinel facial features and the neuropsychological profile of people with FASD in terms of severity of presentation.

Fetal alcohol spectrum disorders.

Alcohol readily crosses the placenta and may disrupt fetal development. Harm from prenatal alcohol exposure (PAE) is determined by the dose, pattern, timing and duration of exposure, fetal and maternal genetics, maternal nutrition, concurrent substance use, and epigenetic responses. A safe dose of alcohol use during pregnancy has not been established. PAE can cause fetal alcohol spectrum disorders (FASD), which are characterized by neurodevelopmental impairment with or without facial dysmorphology, congenital anomalies and poor growth. FASD are a leading preventable cause of birth defects and developmental disability. The prevalence of FASD in 76 countries is >1% and is high in individuals living in out-of-home care or engaged in justice and mental health systems. The social and economic effects of FASD are profound, but the diagnosis is often missed or delayed and receives little public recognition. Future research should be informed by people living with FASD and be guided by cultural context, seek consensus on diagnostic criteria and evidence-based treatments, and describe the pathophysiology and lifelong effects of FASD. Imperatives include reducing stigma, equitable access to services, improved quality of life for people with FASD and FASD prevention in future generations.

Foetal alcohol spectrum disorder and Investigative interviewing: A systematic review highlighting clinical and legal implications and recommendations.

Individuals with foetal alcohol spectrum disorders (FASD) are estimated to be 19 times more likely to encounter the criminal justice system (CJS) in comparison to individuals without FASD. During encounters with the CJS, investigative interviews are employed to obtain accurate information from suspects, victims or witnesses of crime. A systematic search using PRISMA guidelines was performed to identify empirical studies published that have explored the questioning of the FASD population within the CJS and the vulnerabilities of FASD-impacted individuals during investigative interviewing. A total of 383 studies were identified from the databases searched and 7 further studies were identified from Google Scholar. After deduplication, abstract and title screening, the full text of 23 studies were assessed for inclusion and 5 were included in the narrative synthesis of results. Two papers were empirical studies focussed on the performance of FASD-impacted individuals during investigative interviewing. Whilst the first study found the FASD population susceptible to suggestions, the second (a case study), identified the ploys employed during investigative interviewing to obtain a confession. Three papers studied the wider vulnerabilities of FASD-impacted individuals and found diminished psycho-legal abilities, increased risk of recidivism and biological, psychological and social factors that render FASD-impacted individuals vulnerable to CJS encounters. Despite the greater likelihood of CJS encounters, the result of this review highlights the slim evidence base useful to establish the vulnerabilities of FASD-impacted individuals within the CJS.

Prevalence of fetal alcohol spectrum disorder in Greater Manchester, UK: An active case ascertainment study.

BACKGROUND: Despite high levels of prenatal alcohol exposure in the UK, evidence on the prevalence of fetal alcohol spectrum disorders (FASD) is lacking. This paper reports on FASD prevalence in a small sample of children in primary school. METHODS: A 2-phase active case ascertainment study was conducted in 3 mainstream primary schools in Greater Manchester, UK. Schools were located in areas that ranged from relatively deprived to relatively affluent. Initial screening of children aged 8-9 years used prespecified criteria for elevated FASD risk (small for age; special educational needs; currently/previously in care; significant social/emotional/mental health symptoms). Screen-positive children were invited for detailed ascertainment of FASD using gold standard measures that included medical history, facial dysmorphology, neurological impairment, executive function, and behavioral difficulties. RESULTS: Of 220 eligible children, 50 (23%) screened positive and 12% (26/220) proceeded to Phase 2 assessment. Twenty had a developmental disorder, of whom 4 had FASD and 4 were assessed as possible FASD. The crude prevalence rate of FASD in these schools was 1.8% (95% CI: 1.0%, 3.4%) and when including possible cases was 3.6% (2.1%, 6.3%). None of these children had previously been identified with a developmental diagnosis. CONCLUSIONS: FASD was found to be common in these schools and most of these children's needs had not previously been identified. A larger, more definitive study that uses a random sampling technique stratified by deprivation level to select schools is needed to make inferences regarding the population prevalence of FASD.

Fetal alcohol spectrum disorders: an overview of current evidence and activities in the UK.

Estimates for the UK suggest that alcohol consumption during pregnancy and prevalence of fetal alcohol spectrum disorder (FASD)-the most common neurodevelopmental condition-are high. Considering the significant health and social impacts of FASD, there is a public health imperative to prioritise prevention, interventions and support. In this article, we outline the current state of play regarding FASD knowledge and research in the UK, which is characterised by a lack of evidence, a lack of dedicated funding and services, and consequently little policy formulation and strategic direction. We highlight progress made to date, as well as current knowledge and service gaps to propose a way forward for UK research.

Comparisons of the BRIEF parental report and neuropsychological clinical tests of executive function in Fetal Alcohol Spectrum Disorders: data from the UK national specialist clinic.

Extant literature is sparse with regards to the relationship between caregiver reports and neuropsychological tests of executive functioning in Fetal Alcohol Spectrum Disorders (FASD). The goal of this paper was determining the clinical utilities of executive functioning measures used in the United Kingdom national FASD clinic. We examined relationships between outcomes on the Behavior Rating Inventory of Executive Function (BRIEF) and the Delis-Kaplan Executive Function System (D-KEFS), as part of an ongoing service evaluation. Profiles of executive functioning measures were reported in order to contribute to delineating a profile of executive dysfunction in FASD. Caregivers of 49 people with FASD completed the Parent BRIEF, and 61 people with FASD were administered the D-KEFS. Pearson's Correlations between all 11 BRIEF scales and the 18 selected D-KEFS subscales showed little relationship. The BRIEF showed a profile of clinically significant elevations in all three Index scores and seven out of the eight Scale scores. Several D-KEFS tests showed below average executive functioning. Both executive function measures have separate clinical utility in demonstrating executive function deficits in FASD. The sample population used in this study also show a similar pattern to FASD populations internationally, suggesting a similar neuropsychological profile is seen in the United Kingdom. However, caregiver reports display little relationship to neuropsychological tests. These measures likely monitor different aspects of executive functioning in different settings. Future research should focus on identifying tests that better relate findings from clinical settings to behavior in daily life.

Diagnosis and management of foetal alcohol specturm disorder.

PURPOSE OF REVIEW: Our understanding of the diagnosis and management of Foetal Alcohol Spectrum Disorders (FASD), has been increasingly refined in the last 45 years: This review highlights current understanding and identifies future areas for research. RECENT FINDINGS: Newer techniques such as three-dimensional facial recognition and advanced brain imaging, have advanced our understanding. Despite this, there remain areas, such as the relationship with other neurodevelopmental disorders, that have been insufficiently explored. Understanding the unique management approaches required is still in its infancy. However, progress is being made to treat specific aspects in FASD. SUMMARY: Foetal alcohol syndrome has progressed from identification primarily through recognition of physical stigmata, to a broad understanding of neurocognitive function in the full spectrum of alcohol exposure. Understanding of neurocognitive functioning has helped to define a specific phenotype to delineate FASD from other neurodevelopmental disorders. This review explores some of these areas and demonstrates how the field has changed since its recognition 45 years ago.

Neurodevelopmental outcomes in individuals with fetal alcohol spectrum disorder (FASD) with and without exposure to neglect: Clinical cohort data from a national FASD diagnostic clinic.

Disentangling the relative developmental impact of prenatal alcohol exposure from postnatal neglect is clinically valuable for informing future service provision. In this study, developmental outcomes across groups are compared in a 'natural experiment'. METHODS: Clinical data from 99 persons with fetal alcohol spectrum disorder (FASD) diagnoses were audited. Developmental outcomes (diagnosis of attention deficit hyperactivity disorder, ADHD; social and communication disorder, SCD; or Autistic Spectrum Disorder, ASD; Short Sensory Profile, SSP; Vineland II Adaptive Behaviour Scales) were compared across two exposure groups: prenatal alcohol only; and mixed prenatal alcohol and neglect. RESULTS: ADHD (74%) and ASD/SCD (68%) were common, with no significant difference between groups (ADHD, p = 0.924; ASD, p = 0.742). Vineland age equivalence scores were lower than chronological age (11.1 years - prenatal alcohol only, and 12.7 years - neglect) across all domains, especially receptive language (3.7 years for both groups). Age equivalence did not differ between groups, with the exception of domestic daily living (neglect: 7.7 years vs. prenatal alcohol only: 5.8 years, p = 0.027). A probable/definite difference on SSP was more common in the prenatal alcohol only (96% vs. 67%, p = 0.006). For the individual subscales of SSP, there were no significant differences by neglect category. DISCUSSION: Postnatal neglect in this group did not make the developmental outcome any worse, suggesting that prenatal alcohol influences these outcomes independently. Professionals who support families looking after a child with both FASD and a history of neglect should be aware that the behavioral difficulties are likely to be related to prenatal alcohol exposure and not necessarily reflective of parenting quality.

Neurodevelopmental disorder associated with prenatal exposure to alcohol (ND-PAE): A proposed diagnostic method of capturing the neurocognitive phenotype of FASD.

Neurobehavioral Disorder associated with Prenatal Alcohol Exposure (ND-PAE) was proposed as a diagnostic formulation intended to capture the range of mental health problems occurring in alcohol-affected individuals with a history of prenatal alcohol exposure. The proposed criteria for the disorder are reviewed as well as various factors considered in the development of the disorder and its associated criteria. The taxonomic research related to the disorder is reviewed with preliminary analyses indicating that clinicians are readily able to agree when applying the diagnostic criteria but that the adaptive functioning criteria may need to be modified to expand its coverage of alcohol-affected individuals and to aid in discriminating these individuals from others not alcohol-affected. Finally, the challenges with translating the diagnosis into European medical and mental healthcare systems are discussed and recommendations for facilitating implementation are made.

Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is related to many comorbidities because of the permanent effects of prenatal alcohol exposure on the fetus. We aimed to identify the comorbid conditions that co-occur in individuals with FASD and estimate the pooled prevalence of comorbid conditions occurring in individuals with fetal alcohol syndrome (FAS). METHODS: We did a systematic literature search of studies reporting on the comorbidity and cause of death in individuals with FASD using multiple electronic bibliographic databases, searching for studies published up to July, 2012. We included original research published in a peer-reviewed journal in the English language. We used the following criteria for determining study quality: use of an established FASD diagnostic guideline, study setting, method of data collection, and sample size. All comorbid disease conditions were coded according to the International Classification of Diseases, tenth revision (ICD-10). To estimate the pooled prevalence of comorbid conditions found to co-occur in individuals with FAS, we did meta-analyses assuming a random-effects model. FINDINGS: Of 5068 studies found, 127 met eligibility criteria for data extraction. From those studies, we identified 428 comorbid conditions co-occurring in individuals with FASD, spanning across 18 of 22 chapters of the ICD-10. The most prevalent disease conditions were within the sections of congenital malformations, deformities, and chromosomal abnormalities, and mental and behavioural disorders. 33 studies reported data for frequency in a total of 1728 participants with FAS. The five comorbid conditions with the highest pooled prevalence (between 50% and 91%) included abnormal results of function studies of peripheral nervous system and special senses, conduct disorder, receptive language disorder, chronic serous otitis media, and expressive language disorder. INTERPRETATION: The high prevalence of comorbid conditions in individuals with FASD highlights the importance of assessing prenatal alcohol exposure as a substantial clinical risk factor for comorbidity. The harmful effects of alcohol on a developing fetus represent many cases of preventable disability, and thus, alcohol use during pregnancy should be recognised as a public health problem globally. FUNDING: Public Health Agency of Canada.

Alcohol consumption during pregnancy and its effects on neurodevelopment: what is known and what remains uncertain.

It has been claimed that mothers' drinking during pregnancy may affect the neurodevelopment of around 1% of all children. If this is true, then prenatal alcohol exposure represents an important risk factor for neurodevelopmental problems, giving rise to a large burden of disability which could be potentially preventable. Evidence to support this idea has come from animal experiments and human observational studies. However, such findings need to be supported by more robust research designs. Because randomized controlled trials in this area are neither feasible nor ethical, suggestions are made for further research making more use of natural experiments.