Screening and identification of fetal alcohol spectrum disorder in criminal legal settings: A realist review.

BACKGROUND: Screening for fetal alcohol spectrum disorder (FASD) has been identified as a promising approach to improve recognition, understanding and effective response to the unique needs of those with FASD in criminal legal settings. However, to date, there has been limited synthesis of relevant screening tools, indicators, or implementation considerations in this context. AIMS: The present review aimed to synthesise evidence and develop a conceptual framework for understanding how, when, why, for whom and by whom FASD screening tools, items and/or indicators and characteristics serve to accurately identify people with FASD in criminal legal contexts, with consideration of individual and system needs relevant to effective implementation and response. METHODS: A preregistered search was conducted using a modified realist review framework for both peer-reviewed articles and grey literature. Included sources were available in English, which focused on individuals with prenatal alcohol exposure and/or FASD with criminal legal involvement and offered new empirical evidence. Sources were reviewed using the Quality Control Tool for Screening Titles and Abstracts by Second Reviewer framework, extracted using a structured coding form and narratively synthesised. RESULTS: The search yielded 52 sources, 11 FASD screening tools designed for or applied in criminal legal settings and 38 potential FASD indicators or characteristics relevant to identifying people who may have FASD in criminal legal settings, organised into six conceptually related domains. There was limited evidence supporting the psychometric properties of screening tools across populations or settings, though growing evidence highlights the promise of some instruments. Although few studies characterised potential considerations to be made when implementing a screening tool or approach, both system and individual level needs related to recognising and effectively responding to FASD in criminal legal contexts were identified, and findings revealed strong support among legal and clinical professionals regarding the need for FASD screening in these settings. CONCLUSIONS: Findings of this review can be used to inform the development, selection, implementation and evaluation of FASD screening tools in criminal legal settings and underscore a continued need for enhanced resources, policy and cross-sectoral response to better support the needs of people with FASD in the criminal legal contexts.

Screening approaches for identifying fetal alcohol spectrum disorder in children, adolescents, and adults: A systematic review.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is a prevalent neurodevelopmental disorder that is caused by prenatal alcohol exposure (PAE) and associated with a range of cognitive, affective, and health concerns. Although the identification of FASD can facilitate the provision of interventions and support, and plays a protective role against adverse outcomes, there are high rates of missed detection. The identification of FASD via screening may improve its recognition across settings. The current systematic review examined the available evidence on FASD screening tools and approaches across age groups and settings. METHODS: A systematic search was carried out for both peer-reviewed studies and gray literature sources published between January 1990 and May 2020 and was preregistered with PROSPERO (#CRD42019122077). Studies included in the review focused on human applications of FASD screening in children, adolescents, and adults. The quality of the studies was assessed using the QUADAS-2 and GRADE frameworks. RESULTS: The search yielded 20 screening tools and approaches across 45 studies, broadly characterized in 2 groups. The first group included approaches currently in use that aim to identify individuals at risk of FASD using a range of markers (n = 19) or associated sentinel dysmorphic facial features (n = 6). Another group of studies, characterized as emerging, focused on identifying promising biomarkers of PAE/FASD (n = 20). Overall, we identified limited research supporting the psychometric properties of most screening approaches. The quality review provided evidence of bias due to the common use of case-control designs and lack of adequate reference standards. CONCLUSIONS: Although several FASD screening tools and approaches are available for use across a range of age groups and settings, the overall evidence base supporting their psychometric properties is weak, with most studies demonstrating significant risk of bias. Service providers should exercise caution in selecting and implementing FASD screening tools given these limitations. It is critically important to accurately identify individuals with FASD across ages and settings to support healthy outcomes. Thus, there is a pressing need for additional research in this area, particularly validation studies in large and representative samples using robust methodological approaches.

Balancing the story of fetal alcohol spectrum disorder: A narrative review of the literature on strengths.

For many years, researchers have explored the complex challenges experienced by individuals with fetal alcohol spectrum disorder (FASD). This research has been important for documenting the brain- and body-based impacts of prenatal alcohol exposure and the psychosocial vulnerabilities and environmental adversities frequently associated with FASD. It has also supported advocacy efforts and highlighted the necessity of providing FASD services and supports. However, with the focus on deficits and needs, there is a considerable gap in the literature on the strengths and successes of individuals with FASD. The lack of strengths-based FASD research has likely perpetuated the stress and stigma experienced by individuals with FASD and their families. Thus, there is a critical need to shift the direction of the field. Here we provide a narrative review of the literature on strengths in FASD. Our goals are to: (1) understand the state of strengths-based research related to individuals with FASD across the lifespan, and (2) describe positive characteristics, talents, and abilities of individuals with FASD that may be cultivated to promote their fulfillment and well-being. We identified a total of 19 studies, most of which were conducted to explore the lived experiences of adults with FASD. This preliminary but critical body of evidence highlights the intrinsic strengths of individuals with FASD, including strong self-awareness, receptiveness to support, capacity for human connection, perseverance through challenges, and hope for the future. Despite the importance of this emerging evidence, appraisal of the literature indicates a need for more intentional, methodologically rigorous, participatory, and theory-driven research in this area. Findings from this study, including the identified gaps in the literature, can be used to inform research, practice, and policy to meaningfully advance the field of FASD and promote positive outcomes in this population.

Difficulties in Daily Living Experienced by Adolescents, Transition-Aged Youth, and Adults With Fetal Alcohol Spectrum Disorder.

BACKGROUND: Individuals with fetal alcohol spectrum disorder (FASD) experience a range of problems in their cognitive, affective, and physical functioning following prenatal alcohol exposure (PAE), in addition to multiple complex difficulties in daily living that impact well-being. Using the Canadian National FASD Database, we sought to profile a range of difficulties in daily living, along with risk factors, in a large cross-sectional cohort of adolescents, transition-aged youth, and adults with PAE, of which a subset was ultimately diagnosed with FASD. METHODS: We summarized data for 9 current difficulties in daily living reported at the time of diagnostic assessment for 726 individuals with PAE assessed at 26 FASD diagnostic clinics across Canada, including 443 adolescents (12 to 17 years), 135 transition-aged youth (18 to 24 years), and 148 adults (25 to 60 years). Difficulties included problems related to school disruption, employment, independent living needs, supportive or sheltered housing, legal problems with victimization, legal problems with offending, incarceration, alcohol misuse, and other substance misuse. Risk factors included age, gender, living placement, postnatal trauma, and neurodevelopmental impairment. RESULTS: Across the full PAE sample, adolescents, transition-aged youth, and adults presented with high rates of difficulties in daily living, including independent living support needs (63%), alcohol misuse (38%), other substance misuse (46%), employment problems (37%), legal problems with offending (30%), assisted or sheltered housing (21%), school disruption (18%), legal problems with victimization (4%), and incarceration (3%). Difficulty rates were similar for those with FASD irrespective of diagnosis (e.g., with or without sentinel facial features), but rates greater for adults, and those with low overall intellectual functioning (IQ < 70). Controlling for age and IQ, cumulative difficulty was independently associated with gender, living placement, and neurodevelopmental impairment. CONCLUSIONS: Adolescents, transition-aged youth, and adults with FASD experienced a range of substantial and complex difficulties at the time of their diagnostic assessment, signaling a high level of service needs. These findings underscore the importance of developmentally informed assessment continued through childhood, as well as ongoing functional and needs-based service provision as youth with FASD transition to adulthood and beyond.

Performance Validity Testing in Justice-Involved Adults with Fetal Alcohol Spectrum Disorder.

OBJECTIVES: A number of commonly used performance validity tests (PVTs) may be prone to high failure rates when used for individuals with severe neurocognitive deficits. This study investigated the validity of 10 PVT scores in justice-involved adults with fetal alcohol spectrum disorder (FASD), a neurodevelopmental disability stemming from prenatal alcohol exposure and linked with severe neurocognitive deficits. METHOD: The sample comprised 80 justice-involved adults (ages 19-40) including 25 with confirmed or possible FASD and 55 where FASD was ruled out. Ten PVT scores were calculated, derived from Word Memory Test, Genuine Memory Impairment Profile, Advanced Clinical Solutions (Word Choice), the Wechsler Adult Intelligence Scale - Fourth Edition (Reliable Digit Span and age-corrected scaled scores (ACSS) from Digit Span, Coding, Symbol Search, Coding - Symbol Search, Vocabulary - Digit Span), and the Wechsler Memory Scale - Fourth Edition (Logical Memory II Recognition). RESULTS: Participants with diagnosed/possible FASD were more likely to fail any single PVT, and failed a greater number of PVTs overall, compared to those without FASD. They were also more likely to fail based on Word Memory Test, Digit Span ACSS, Coding ACSS, Symbol Search ACSS, and Logical Memory II Recognition, compared to controls (35-76%). Across both groups, substantially more participants with IQ <70 failed two or more PVTs (90%), compared to those with an IQ ≥70 (44%). CONCLUSIONS: Results highlight the need for additional research examining the use of PVTs in justice-involved populations with FASD.

Myelin Water Fraction Imaging of the Brain in Children with Prenatal Alcohol Exposure.

BACKGROUND: Prenatal alcohol exposure (PAE) is linked to alterations of cerebral white matter, including volume and nonspecific diffusion magnetic resonance imaging (MRI) indices of microstructure in humans. Some animal models of PAE have demonstrated myelination deficiencies, but myelin levels have not yet been evaluated in individuals with PAE. Multiecho T2 MRI offers a quantitative method to estimate myelin water fraction (MWF; related to myelin content) noninvasively, which was used here to evaluate brain myelination in children with PAE. METHODS: Participants with PAE (n = 10, 6 females, mean age 13.9 years, range 7 to 18 years) and controls (n = 14, 11 females, mean age 13.2 years, range 9 to 16 years) underwent 3T MRI of the brain. T2 images (15 minutes acquisition for 32 echoes) were used to create MWF maps from which mean MWF was measured in 12 regions of interest (ROIs) including 8 in white matter and 4 in deep gray matter. RESULTS: As expected, across the combined sample, MWF was highest for major white matter tracts such as the internal capsule and genu/splenium of the corpus callosum (10 to 18%) while the caudate and putamen had MWF less than 5%. Mean MWF was similar across 11/12 brain white and gray matter regions for the PAE and control groups (L/R internal capsule, major forceps, putamen, caudate nucleus, L minor forceps, genu and splenium of corpus callosum). In the PAE group, MWF was positively correlated with age in the genu of corpus callosum and right minor forceps, notably 2 frontal tracts. CONCLUSIONS: Given comparable MRI-derived myelination fraction measures in PAE relative to controls, white matter alterations shown in other imaging studies, such as diffusion tensor imaging, may reflect microstructural anomalies related to axon caliber and density.

Technological advances in the assessment of impulse control in offenders: A systematic review.

Deficits in impulse control have been linked to criminal offending, risk of recidivism, and other maladaptive behaviours relevant to the criminal justice system (e.g. substance use). Impulse control can be conceptualized as encompassing the broad domains of response inhibition and impulsive/risky decision-making. Advancements in technology have led to the development of computerized behavioural measures to assess performance in these domains, such as go/no-go and delay discounting tasks. Despite a relatively large literature examining these tasks in offenders, findings are not universally consistent. This systematic review aims to synthesize the literature using computerized neurocognitive tasks to assess two domains of impulse control in offenders: response inhibition and impulsive/risky decision-making. The review included 28 studies from diverse geographic locations, settings, and offender populations. The results largely support the general conclusion that offenders exhibit deficits in impulse control compared with non-offenders, with studies of response inhibition more consistently reporting differences than studies using impulsive and risky decision-making tasks. Findings are discussed in the context of contemporary neuroimaging research emphasizing dysfunction in prefrontal cortex as a key contributor to impulse control deficits in offenders.

Afternoon cortisol provides a link between self-regulated anger and peer-reported aggression in typically developing children in the school context.

Aggression jeopardizes positive development in children and predicts social and academic maladjustment in school. The present study determined the relationships among anger dysregulation (a marker of emotion regulation), cortisol activity (a biomarker of stress), and peer-nominated aggression in typically developing children in their everyday classroom setting (N = 151, Mean age = 10.86, SD =.74). Salivary cortisol was collected at 09:15, 11:45, and 14:45 hr across 4 consecutive days. Children provided self-reports of anger regulation; peers reported proactive and reactive aggressive behaviors. Hierarchical linear regression analyses, followed by a bootstrapping analysis identified basal afternoon cortisol as a significant mediator between anger regulation and peer-reported aggression. More dysregulated anger significantly predicted lower afternoon cortisol, which in turn predicted increased peer-reported aggression. These results align with previous research on links among hypocortisolism, emotional regulation, and behavior, and suggest a possible meditational pathway between emotion and behavior regulation via decreased afternoon cortisol levels.

Evaluating the psycholegal abilities of young offenders with fetal alcohol spectrum disorder.

Individuals with a diagnosis of fetal alcohol spectrum disorder (FASD) experience a range of physical, cognitive, and behavioral deficits thought to interfere with their ability to competently navigate the arrest, interrogation, and trial process. This study examined the psycholegal abilities of young offenders with FASD, including their understanding and appreciation of Miranda rights, and adjudication capacities (factual knowledge of criminal procedure, appreciation of the nature and object of the proceedings, ability to participate in a defense and communicate with counsel). Two groups of young offenders (50 with FASD and 50 without prenatal alcohol exposure) completed Grisso's Instruments for Assessing Understanding and Appreciation of Miranda rights and the Fitness Interview Test-Revised to assess overall rates of impairment in youth with FASD, as well as differences between the groups. Potentially important predictors of psycholegal abilities were also evaluated. Results indicated the majority of young offenders with FASD (90%) showed impairment in at least one psycholegal ability, and rates of impairment were significantly higher than the comparison group. However, considerable within-group variability was observed. IQ and reading comprehension emerged as robust predictors of participants' psycholegal abilities, while the FASD diagnosis differentiated participants' scores on the FIT-R. These findings underscore the importance of individualized and comprehensive forensic assessments of psycholegal abilities in this population when warranted. Additional system level strains for this population are discussed, including problems in approaching competency remediation, and the potentially growing need for accommodation and forensic assessments in the face of limited financial and professional resources in legal settings.

An examination of executive functioning in adolescents with FASD in a self-regulation intervention.

Adolescents with Fetal Alcohol Spectrum Disorder (FASD) often have challenges with executive functioning (EF), which impacts their ability to self-regulate. In this study, 23 adolescents with FASD completed a self-regulation intervention. The intervention was a manualized Teen Adaptation of the Alert Program®. A nonrandomized waitlist control design was used, and participants completed pre- and post-testing using performance-based measures of EF, and rating scales of EF were completed by caregivers. Results were analyzed three ways; 1) intervention and waitlist control group comparison, 2) whole sample pre-and post- test comparison, and 3) using Reliable Change Indexes to examine individual-level clinically relevant changes. No significant intervention effects were found when comparing the intervention and waitlist control groups. A significant difference was found on a measure of verbal inhibition when total sample pre-and post-test scores were compared. Using Reliable Change Index analysis, 30% participants showed reliable change in the direction of improvement on direct measures of EF, and 57% demonstrated reliable change in the direction of improvement on rating scales. This research study underscores the importance of investigating both individual and group level changes when analyzing data, as well as using reliable change to understand clinically meaningful effects that may be otherwise masked. These findings highlight the potential of the SR intervention to positively impact EF in adolescents with FASD. This study contributes to the growing literature that demonstrates the potential of individuals with FASD to benefit from direct intervention.

Latent classes of neurodevelopmental profiles and needs in children and adolescents with prenatal alcohol exposure.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) resulting from prenatal alcohol exposure (PAE) is a common neurodevelopmental disorder, but substantial interindividual heterogeneity complicates timely and accurate assessment, diagnosis, and intervention. The current study aimed to identify classes of children and adolescents with PAE assessed for FASD according to their pattern of significant neurodevelopmental functioning across 10 domains using latent class analysis (LCA), and to characterize these subgroups across clinical features. METHODS: Data from the Canadian National FASD Database, a large ongoing repository of anonymized clinical data received from diagnostic clinics across Canada, was analyzed using a retrospective cross-sectional cohort design. The sample included 1440 children and adolescents ages 6 to 17 years (M = 11.0, SD = 3.5, 41.7% female) with confirmed PAE assessed for FASD between 2016 and 2020. RESULTS: Results revealed an optimal four-class solution. The Global needs group was characterized by high overall neurodevelopmental impairment considered severe in nature. The Regulation and Cognitive needs groups presented with moderate but substantively distinguishable patterns of significant neurodevelopmental impairment. The Attention needs group was characterized by relatively low probabilities of significant neurodevelopmental impairment. Both the Global and Regulation needs groups also presented with the highest probabilities of clinical needs, further signifying potential substantive differences in assessment and intervention needs across classes. CONCLUSIONS: Four relatively distinct subgroups were present in a large heterogeneous sample of children and adolescents with PAE assessed for FASD in Canada. These findings may inform clinical services by guiding clinicians to identify distinct service pathways for these subgroups, potentially increasing access to a more personalized treatment approach and improving outcomes.

Behavior regulation skills are associated with adaptive functioning in children and adolescents with prenatal alcohol exposure.

Children with prenatal alcohol exposure (PAE) experience a range of adverse outcomes that impact multiple domains of functioning, including cognitive, physical, mental health, behavioral, social-emotional, communication, and learning. To inform tailored clinical intervention, the current study examined the relation between caregiver-reported cognitive skills (executive function; EF) and adaptive functioning. The study conducted a secondary analyses of data provided by caregivers of 87 children and adolescents (aged 5-18 years, M = 11.7; 52% male) with confirmed PAE, including a subset (n = 70) with Fetal Alcohol Spectrum Disorder (FASD), who reported on their child's EF (Behavior Rating Inventory of Executive Function) and adaptive function (Adaptive Behavior Assessment System, 2nd Edition) skills. Findings from the current study showed that caregivers reported significantly poorer EF and adaptive functioning skills for children with PAE as compared to normative samples. Poorer behavior regulation skills were associated with all aspects of adaptive functioning (i.e., practical, conceptual, and social skills). Specifically, shifting skills emerged as the best predictor of adaptive functioning among children with PAE. These results highlight the possibility that targeting particular EF domains among individuals with PAE may benefit behavior regulation, which may also extend to adaptive skills. This highlights the need to develop EF interventions for children and adolescents who have been prenatally exposed to alcohol.

Examining the role of interrogative suggestibility in Miranda rights comprehension in adolescents.

This study aimed to further clarify the association between interrogative suggestibility and Miranda rights comprehension in adolescents; in particular, we examined whether intellectual ability (IQ) serves as a mediator of this relationship. Participants completed Grisso's Miranda Instruments, the Wechsler Abbreviated Scale of Intelligence, and the Gudjonsson Suggestibility Scale. Many youth demonstrated poor comprehension of their rights, particularly younger and less intellectually capable adolescents. Both yield and shift components of interrogative suggestibility were inversely related to rights comprehension; however, IQ fully mediated these relationships. Neither demographic variables (gender, ethnicity, socio-economic status after controlling for IQ, and English as a second language (ESL) status) nor previous police experience were significantly associated with rights comprehension in the present sample. The implications of these findings are discussed.

Responding to the Unique Complexities of Fetal Alcohol Spectrum Disorder.

Fetal alcohol spectrum disorder (FASD) is a multifaceted disability, characterized not only by brain- and body-based challenges, but also high rates of environmental adversity, lifelong difficulties with daily living, and distinct sociocultural considerations. FASD is one of the most common neurodevelopmental disabilities in the Western world and associated with significant social and economic costs. It is important to understand the complexities of FASD and the ways in which FASD requires unique consideration in research, practice, and policy. In this article, we discuss our perspectives on factors that distinguish FASD from other disabilities in terms of complexity, co-occurrence, and magnitude. We provide an overview of select literature related to FASD as a socially rooted disability with intergenerational impacts and multiple layers of stigma. These social issues are intertwined with notable experiences of adversity across the lifespan and high rates of co-occurring health concerns for individuals with FASD, all of which present unique challenges for individuals, caregivers, families, service providers, and policy makers. Understanding these factors is the first step in developing and implementing specialized initiatives in support of positive outcomes for individuals with FASD and their families. Future directions are proposed for advancing research, practice, and policy, and responding to the unique complexities of FASD.

Defense attorneys' concerns about the competence of adolescent defendants.

Research indicates that a sizable proportion of adolescent defendants have difficulty understanding and participating in legal proceedings against them, and may be incompetent to stand trial. To examine attorneys' experience in defending adolescents with competence-related difficulties, 214 juvenile attorneys were surveyed. Findings indicated that attorneys have doubts about the competence of approximately 10% of adolescent defendants, and that they find these cases particularly challenging to defend. Most attorneys appear to recognize that developmental factors may contribute to adolescents' competence-related difficulties, and believe that the law should accept developmental immaturity as a basis for incompetence findings. In approximately half of the cases in which attorneys had doubts about competence, attorneys did not request a competence evaluation but instead made other efforts to address competence issues, such as by teaching adolescents about legal proceedings and further involving their parents. The implications of these findings are discussed.

Current Socioeconomic Status Correlates With Brain Volumes in Healthy Children and Adolescents but Not in Children With Prenatal Alcohol Exposure.

Individuals with prenatal alcohol exposure (PAE) exhibit neurological deficits associated with brain injury including smaller brain volumes. Additional risk factors such as lower socioeconomic status (SES) may also have an impact on brain development for this population. This study examined how brain volumes are related to SES in both neurotypically developing children and adolescents, and those with PAE. 3D T1-weighted MPRAGE images were acquired from 69 participants with PAE (13.0 ± 3.2 years, range 7.1-18.8 years, 49% female) and 70 neurotypical controls (12.4 ± 2.9 years, range 7.0-18.5 years, 60% female) from four scanning sites in Canada. SES scores calculated using Hollingshead's Four-Factor Index of Social Status from current caregiver placement were not significantly different between groups, though more children with PAE had lower SES scores compared to controls. Psychometric data comprised 14 cognitive measures, including executive functioning, attention and working memory, memory, math/numerical ability, and word reading. All cognitive scores were significantly worse in children with PAE compared to controls, though SES was not correlated with cognitive scores in either group after correction for multiple comparisons. All 13 brain volumes were smaller in children with PAE compared to children in the control group. Higher SES was associated with larger hippocampus and amygdala volumes in controls, but there were no such associations in children with PAE. Direct evaluation of the interaction between SES and diagnostic group did not show a significant differential impact of SES on these structures. These findings support previous links between SES and brain volumes in neurotypically developing children, but the lack of such a relationship with SES in children with PAE may be due to the markedly smaller brain volumes resulting from the initial brain injury and postpartum brain development, regardless of later SES.

An evaluation of the predictive validity of the SAVRY and YLS/CMI in justice-involved youth with fetal alcohol spectrum disorder.

Despite the high prevalence of fetal alcohol spectrum disorder (FASD) in youth criminal justice settings, there is currently no research supporting the use of violence risk assessment tools in this population. This study examined the predictive validity of the Structured Assessment of Violence Risk in Youth (SAVRY) and the Youth Level of Service/Case Management Inventory (YLS/CMI) in justice-involved youth with FASD. Participants were 100 justice-involved youth (ages 12-23; 81% male), including 50 diagnosed with FASD and 50 without FASD or prenatal alcohol exposure. The SAVRY and YLS/CMI were prospectively coded based on interview and file review, with recidivism (both any and violent specifically) coded 1-year post-baseline assessment. Results provide preliminary support for the validity of the SAVRY and YLS/CMI in predicting recidivism in justice-involved youth with FASD. Higher ratings across SAVRY and YLS/CMI domains were found in youth with FASD, underscoring a critical need for assessments and interventions to buffer recidivism risk and address clinical needs. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Dysregulation of the cortisol diurnal rhythm following prenatal alcohol exposure and early life adversity.

The hypothalamic-pituitary-adrenal (HPA) axis is impacted by a multitude of pre- and postnatal factors. Developmental programming of HPA axis function by prenatal alcohol exposure (PAE) has been demonstrated in animal models and in human infants, but remains understudied in older children and adolescents. Moreover, early life adversity (ELA), which occurs at higher rates in children with PAE than in non-exposed children, may also play a role in programming the stress response system. In a cohort of children and adolescents with PAE and ELA (PAE + ELA), we evaluated HPA function through assessment of diurnal cortisol activity compared to that in typically developing controls, as well as the associations among specific ELAs, adverse outcomes, protective factors, and diurnal cortisol. Morning and evening saliva samples were taken under basal conditions from 42 children and adolescents (5-18 years) with PAE + ELA and 43 typically developing controls. High rates of ELA were shown among children with PAE, and significantly higher evening cortisol levels and a flatter diurnal slope were observed in children with PAE + ELA, compared to controls. Medication use in the PAE + ELA group was associated with lower morning cortisol levels, which were comparable to controls. Complex associations were found among diurnal cortisol patterns in the PAE + ELA group and a number of ELAs and later adverse outcomes, whereas protective factors were associated with more typical diurnal rhythms. These results complement findings from research on human infants and animal models showing dysregulated HPA function following PAE, lending weight to the suggestion that PAE and ELA may interact to sensitize the developing HPA axis. The presence of protective factors may buffer altered cortisol regulation, underscoring the importance of early assessment and interventions for children with FASD, and in particular, for the many children with FASD who also have ELA.

Evaluation of the neurobehavioral screening tool in children with fetal alcohol spectrum disorders (FASD).

BACKGROUND: There is a growing need for validated tools to screen children at risk of fetal alcohol spectrum disorders (FASD). The Neurobehavioral Screening Tool (NST) is one of several promising screening measures for FASD, though further evidence is needed to establish the tool's psychometric utility. OBJECTIVE: To assess the predictive accuracy of the NST among children with an FASD diagnosis, with prenatal alcohol exposure (PAE) but no FASD diagnosis, and typically developing controls. METHOD: The NST was completed by caregivers of children ages 6 to 17, including 48 with FASD, 22 with PAE, and 32 typically developing non-exposed controls. Predictive accuracy coefficients were calculated using Nash et al. (2006) criteria, and compared against controls. An alternative scoring scheme was also investigated to determine optimum referral thresholds using item-level total scores. RESULTS: The NST yielded 62.5% sensitivity for participants with FASD and 50% for PAE. Specificity values were 100% with no typically developing control scoring positive. Within the FASD group there was a trend for higher sensitivity among adolescents aged 12 to17 (70.8%) compared with children aged 6 to 11 years (54.2%), p = 0.23. CONCLUSION: The findings support a growing body of literature evidencing psychometric promise for the clinical utility of the NST as an FASD screening tool, though further research on possible age-effects is warranted. The availability of a validated clinical screening tool for FASD, such as the NST, would aid in accurately screening a large number of children and lead to a timelier diagnostic referral.