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Fetal Alcohol Syndrome
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Presents theory, methods, results, & conclusions of studies, & follow-up studies, performed on subjects with fetal alcohol syndrome (FAS).... More...
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Paper Abstract:
Presents theory, methods, results, & conclusions of studies, & follow-up studies, performed on subjects with fetal alcohol syndrome (FAS).

Paper Introduction:
FETAL ALCOHOL SYNDROME Theory The subject of the articles in question is fetal alcohol syndrome (FAS) and its relationship to the development of the fetus and the child. Spohr, Willms, and Steinhausen (1993) call FAS a leading cause of congenital mental retardation. They investigate the long-term sequelae of intrauterine alcohol exposure. The authors postulate that it is possible to ascertain long-term effects of FAS with a follow-up study to compare two studies of the same population taken ten years apart. The authors based their hypothesis on earlier research, which they studied to see what questions had been asked and what questions required further investigation. The authors had themselves conducted the earlier study of the

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This also was comprehensive and to the point.Results In the study by Spohr, Willms, and Steinhausen, it was found thatmany of the features and minor physical abnormalities noted in the firstexamination had disappeared with time so that ten years after initialdiagnosis, more than 7 percent of the affected children were diagnosedwith only mild FAS. The tribal affiliation of the children was not available, butthat would probably have been important only if the children were stillliving within that tribal group. Using multiple regressionanalysis, it was found that only duration of alcohol exposure and socialclass of family at the time of the assessment had sufficiently large Fvalues to remain in the model, and when social class at the time of theassessment was removed, no other background variable had sufficiently largeexplanatory power to remain in the model. Results of intelligence tests were found to be stable with time, but therewas a subtle deterioration in recent school status. The sample chosen by the authors was chosen in 1987--this was afollow-up study and required the use of that same sample in order tocompare the results over a period of time. Informalinterviews suggested that 15 controls were of the Cree Indian Nation and 2were of the Dene Indian Nation. Highly significant differenceswere found among the groups for children seen by the speech therapist. Sixty of the original children wereexamined by psychologists and 53 were seen by the speech therapist. TheReynell score (Verbal Comprehension Test) was significantly lower for group3 than for group 1, and binge drinking again was not seen as significant.The number of children with a delay in active speech of poor articulationincreased with the increasing duration of intrauterine alcohol exposure.Only social class as a confounding variable was found to have a significanteffect on the scores within the exposed group, while within the nonexposedgroup there was no significant effect found. In the study, the researchers gathered information on maternal alcoholabuse and subsequent developmental outcome in the offspring of alcoholicwomen. However, there were limitations imposed by the passage of time.The original sample consisted of 72 children, of which only 6 could now befound--3 had died, 4 were of unknown residence and 5 refused to cooperate.Still, the sample size was large enough in comparison to the original groupas to provide sufficient data for comparison. The language tests used provided data regarding phonologic, semantic, andsyntactic aspects of both expressive and receptive language skills. (1992). A nonexposed group was also available as acontrol, with these children born to abstinent mothers who also came to thechildren's hospital over this period of time and who would compare wellwith the primary group. The authors had themselves conducted the earlier study of the subjects forthis study and reported their findings in 1987, the subjects being childrenborn to alcoholic mothers and diagnosed in childhood as having FAS ofvarying severity. The intentwas to investigate the long-term sequelae of intrauterine alcohol exposure. What was neededwas information on mothers identified during pregnancy as heavy consumersof alcohol. Autti-Ramo et al. D. The women wereenrolled in the special outpatient clinic for alcohol-consuming pregnantwomen, and this is a good sample from which to gather data regardingalcohol consumption prior to the birth of the children as well as forinfluencing to change drinking patterns prior to that birth. All FAS children had been identified early and had beenplaced in infant stimulation and preschool programs. The sampleconsisted of 36 boys and 24 girls, with an age range from 6 to 137 months,at a mean of 37 months, at first assessment and from 113 to 234 months, ata mean of 167 months, for follow-up. The authors basedtheir hypothesis on earlier research, which they studied to see whatquestions had been asked and what questions required further investigation. The subjects were 1 AmericanIndian children with diagnosed FAS and 17 normal American Indian controls.All the children had been placed in English-speaking adoptive or fosterhomes between birth and age 3 years and who resided in the vicinity ofSaskatoon, Saskatchewan, Canada. found that on the Bayley Mental scale,the scores of the children in group 3 (exposed to heavy alcohol consumptionthrough pregnancy) were significantly lower than those of the children ingroup 1 (children exposed during the first trimester only). Binge drinkinghad no significant effect on this score. Spohr, Willms, and Steinhausen concluded that their most importantfinding was that the deleterious effect of intrauterine alcohol exposure onthe mental development of children persists for many years, and they foundthat there was little improvement in intelligence even when domesticcircumstances changed for the better. The scales used were standard--the Bayley Scales of InfantDevelopment and the Reynall Developmental Language Scales--which make thedata comparable on a number of points with data from other studies andother groups. All composite scores were depressed for the FAS group. Theoutcomes supported earlier research showing delayed semantic developmentand disordered syntactic development among FAS children. Each subject was testedtwice within a two-week period. However, in severely affected children, thefeatures of FAS tended to persist so that these children could berecognized as having FAS even in adolescence. Seven of the FAS children were of theCree Indian Nation, and 3 were of the Dene Indian Nation. The one difference noted was thatperhaps five of the children who were diagnosed as FAS would have beendiagnosed FAE under the new diagnostic criteria, and this could be allowedfor in the analysis. An important consideration was what effect the discontinuationof drinking at a later stage of pregnancy would have on the developmentaloutcome of the offspring. utilized a sample of 82 mothers whose offspring hadbeen followed at a children's hospital in Helsinki. A pediatric score hadoriginally been used to establish the diagnosis of FAS in the sample, andthis diagnosis was found in all cases to comply with the research Societyon Alcoholism diagnostic criteria. The Wechsler primary and preschool scales are standarddevices and would allow for comparisons with other data acquired throughthe use of the same mechanisms. Statistical analysis wasused with a one-way analysis of variance to analyze the difference betweenthe exposed groups. It is not clear from the data whetherthey were or not--they were adopted into English-speaking foster homes, butit does not say the nature of those homes, whether they were Indian homesor not, and whether the adoptive parents were of the same tribalaffiliation as the children or not. This informationshould have been explained more fully. After that they were seen at2- to 4-week intervals by an obstetrician and a social worker.Examinations of the children were conducted at the age of 24 to 3 monthsexcept for one child first seen by the speech therapist at 4 months. They proposed to investigate specifically language and auditoryfunction as affected by FAS, and there has been some indication of aneffect in these areas, though the data is sparse. Clearly, it was necessary thatthis group be the sample, so the selection of subjects was proper for thestudy. Therewas also concern for the effect of the variability in adoptive placements:"Cultural and language experiences may have differed markedly as a functionof age of placement in foster or adoptive English-speaking homes,placements that occurred over the children's critical first three years oflife" (p. They note that the causalitybetween continuous heavy alcohol consumption in utero and FAS has been wellrecognized in the literature. The FAS children presented physical andbehavioral characteristics associated with the syndrome, including shortpalpebral fissures, hypoplastic philtrum, thinned upper vermilion border,anomalies of the maxilla or mandible, growth retardation, and hyperactivityor irritability. The methodology was thus also proper for making this sort ofassessment. It was further indicated that more boys were affected by intrauterineethanol exposure than were girls, and the most striking sexual differencewas in terms of weight. This conclusion needs to be tested further before it isaccepted, and the authors do not account for all the variables that mightcause the results they ascertained. Results for Carney and Chermak were examined through statisticalanalysis. FAS appears with adisproportionately high frequency among American Indian groups, and so thestudy addressed the issue within this population. Of those not available, three had died, 5 would notcooperate (or authorities or institutions associated with them refused),and 4 patients could not be found. Performance of American Indian children with fetal alcohol syndrome on the test of language development. The authors note,however, that the cross-sectional design of their study does not providemore than a preliminary look at specific linguistic deficits across age,and they state that longitudinal studies should be conducted to examinefurther the semantic and syntactic development in FAS children. The procedure was to assess these subjects utilizing the scalesmentioned and using tests and examinations to ascertain changes over time.The procedure was valid and ascertained comparable data utilizing specificdefinitions and methods of analysis under the headings of pediatric,neurological, and psychiatric examinations. The overall pattern of results was found to be consistent withprevious reports of expressive and receptive language deficits among FASchildren. The authors postulate that it is possibleto ascertain long-term effects of FAS with a follow-up study to compare twostudies of the same population taken ten years apart. The speech therapist assessed thedevelopment of active speech and articulation. Also noted werechanges in the domestic arrangements for these children with time as thenumber of children living with their biological parents or in institutionsdecreased and greater proportions were living with parental surrogates, infoster homes, and so on. J., & Chermak, G. Since such data was lacking, the authorsdetermined to ascertain it and then conduct a follow-up study to see howthe syndrome developed over time in the children born under theseconditions. Most studies in the past identified childrenwith FAS postnatally, and any information about maternal alcoholconsumption during pregnancy was gathered retrospectively. Allof the studies should be more diligent in ascertaining the importantvariable of the amount of alcohol consumption and the time-frame of thatconsumption for the mothers in order to see to what extent amount ofdrinking or drinking during certain times in the pregnancy have an effectand what that effect might be. Autti-Ramo et al. Carney and Chermak therefore provided much information on theAmerican Indian population they were addressing as to language deficitsassociated with FAS, though their conclusions cannot be regarded as final.What they did achieve was to provide data to be tested further and to pointto some of the possible factors involved in limitations on languageacquisition for this group. They also conclude thatefforts should be made to identify and find proper treatment for women whodrink early in their pregnancies, and what is now needed is a study toascertain what would be the proper treatment method to overcome thisproblem and reduce the deleterious effects on the children. ReferencesAutti-Ramo, I., Korkman, L., Hilakivi-Clarke, M., Lehtonen, E., Halmesmaki M., & Granstrom, L. Weight increased for many of the girls at puberty. The selection of the American Indian population was based both on thelack of data for that group and on the perception that FAS has beenreported with disproportionately high frequency for that population, aproblem perceived for the Indian populations in both the American Southwestand Canada. Clinical data was also examined, and comparison of the groups'performance with normative data showed that FAS performance fell below 1 SD(3) of the mean (1 ) on all TOLD-P subtests except generations. Also, no standardized intelligence measures were availableto confirm the impressions of teachers of the normally developing children,so observed language differences between groups might reflect differencesin cognitive abilities. Their most important findingwas that the deleterious effects continued for many years, and a furtherfollow-up could be needed to ascertain precisely how long these effectswill continue to be manifested in this population. Measurements were made of various physical features. 131). L., Willms, J., & Steinhausen, H. FETAL ALCOHOL SYNDROMETheory The subject of the articles in question is fetal alcohol syndrome(FAS) and its relationship to the development of the fetus and the child.Spohr, Willms, and Steinhausen (1993) call FAS a leading cause ofcongenital mental retardation. 74 ). The purpose of the authors in this instance as well is not to test ahypothesis but to provide missing data. Autti-Ramo, Korkman, Hilakivi-Clarke, Lehtonen, Halmesmaki, andGranstrom (1992) also conducted a follow-up study specifically to providesomething missing in the literature--data on maternal alcohol consumptionduring pregnancy and the developmental outcome of children exposed toalcohol in utero, with reference to degrees of mental retardation comparedto normal performance in cognitive function: "The main aim of this studywas to assess the effect of discontinuation of heavy drinking at a laterstage of pregnancy on the developmental outcome of the offspring" (p. Therewas a nonexposed group that consisted of 32 children born to abstinentwomen of low social class and 16 children born to abstinent mothers who hadbeen followed during pregnancy at the outpatient clinic. One problem with the explanation of themethodology is that the Majewski scheme is not included so the reader canassess its structure and value, nor are the modifications made by thisresearch group noted in detail for the same purpose. Carney and Chermak find thatthe results of their study are consistent with earlier studies ofexpressive and receptive language deficits among FAS children, and theauthors concluded that greater control of environmental, cultural, andcognitive variables is required to clarify the relationship between FAS andlanguage deficits. The tests were such as tofacilitate comparisons of the two groups of children, necessary for thissort of analysis. They found that it is important to expend effort toidentify mothers who drink heavily in their early pregnancy and to findproper treatment for their alcohol problem. The authors make a good case that there isa need for this data and provide a good argument that their investigationwill help fill this lack. All the children had been placed in English-speakingadoptive or foster homes between birth and 3 years of age, so data on bothgroups would be comparable as each had the same language-learningopportunity. Measurements ofsuch things as head circumference were taken. The authors of this study were filling in gaps in the recorded datafor alcohol-consumption by pregnant mothers, and they accomplished thistask. Carney andChermak did not indicate the degree of alcohol use by the mothers in theirstudy, so it is difficult to assess whether this conclusion would fit withtheirs. Speech development wasdeemed delayed if the child used single words but no sentences and as poorif it was understandable only with the help of pictures. The present study was conducted ten years after thefirst and consisted of 6 children and adolescents from the original samplefor reassessment. Further studies will have to refinetheir original research to accomplish this. Autti-Ramo et al. These things could be important andcould have an effect on learning and so should be indicated. The sample for this study was properly chosen, though small--1 American Indian children with diagnosed FAS and 17 normal AmericanIndian controls. The Lancet, 341, 9 7-91 . The authors stated that thesefindings suggested that compensatory environmental and educationalinfluences are less important to intellectual outcome of FAS patients inadolescence than expected.Evaluation/Improvement These studies tend to point out their own shortcomings to a greatdegree and to assure that future research will address certain issues or tocall for such further research to test aspects of their own research. The hypothesis is logical and can be tested with the datafrom the three sets of analyses of the same children, and a comparison ofthe condition of these individuals over a long period of time shouldprovide data that can be used to predict the course of FAS in a similarpopulation over the same period of time. The design of Spohr, Willms, and Steinhausen also made use ofpredesigned tests and general physical examinations, but Carney and Chermakaddressed specific auditory and visual tasks to relate them to FAS. The study by Autti-Ramo et al. (1991). It was not at all difficult to diagnose FAS in asubstantial proportion with mild expression of the syndrome. Prenatal alcohol exposure and long-term developmental consequences. The Journal of Pediatrics, 12 , 74 -746.Carney, L. Specifically, althoughit is known that this population suffers from a high degree of alcoholism,the literature does not report on language skills of this group. The follow-upstudy was based on such a population for which previous data existed.Methods Spohr, Willms, and Steinhausen conducted a 1 -year follow-up study of6 patients diagnosed as having FAS in infancy and childhood. One-way analysis of variance was used to analyze the differences between theexposed groups in test scores, and other statistical methods were used totest specific dimensions. (1993). The childrencan then be follow over a period of time with regular examinations as thewomen return to the hospital for follow-up care, making it relatively easyto keep track of this population of children over the period of time forthis study (27 months or so). C. They had assumed in their research that women who stopped drinkingat a later stage of pregnancy would have children who showed fewer illeffects after birth, and this was confirmed.Conclusion The conclusions reached in these studies are not reallycontradictory, but some of the studies address different variables whichmight serve well if adopted by other studies. The use of a pediatric score system madethe data all the more valuable by classifying each child as having mild,moderate, or severe FAS, with the scores being assessed based on a schemedeveloped by Majewski and used in other research, though that scheme wasmodified for this trial. Microcephaly persisted in 65 percent ofthe children at follow-up. Journal of Communications Disorders, 24, 123-134.Spohr, H. The authors used the recommendation of the Research Society onAlcoholism that the diagnosis of FAS requires confirmation of a history ofmaternal alcohol abuse and that the following criteria be used onexamination of the child: 1) prenatal or postnatal growth retardation (height and weight belowthe tenth percentile for age or gestational period); 2) CNS dysfunction (any neurological abnormality, developmentaldelay, or intellectual impairment); and 3) characteristic craniofacial abnormalities, including at least twoof microcephaly (head circumference below the third percentile),microphthalmia or short palpebral fissures, and poorly developed filtrum,and flattening of the maxillary area.The assessment procedure of the follow-up included pediatric, neurological,and psychiatric examinations as well as standard intelligence tests(Wechsler primary and preschool scales of intelligence) and the Wechslerintelligence scales for children. also foundthat their study supports conclusions reached by earlier research,especially that fetal alcohol exposure causes a continuum of developmentaldefects ranging from mental retardation to slight difficulties in someareas of development. The authors also state thatdifferences in cultural and environmental experiences and even cognitiveabilities make definitive interpretation of the results difficult.Individual differences in language could have affected the results. These same children were examined four years later by ateam of pediatricians. Only 34 still lived in West Berlin,while 26 were scattered throughout Germany because they had been adopted orwere living with foster parents or in special institutions. They were receivingspecial education services in the public schools at the time of theassessment. Language deficitssecondary to central nervous system dysfunction have been identified assequelae of FAS, but this had not been explored previously to any greatdegree, especially for the specific population to be used in this study,the American Indian population. The data collected was comprehensive and the tests usedprovided needed assessment on a variety of scales. In additionto improvement in morphological abnormalities, there was significantimprovement in internal organ malformations, skeletal abnormalities, andneurological dysfunction. For 14 of the children, thesocial class of the family had been improved once the child was takenpermanently into custody, and by 8 others by the better employment of theirbiologic parents. They investigate the long-term sequelae ofintrauterine alcohol exposure. had as subjects 82 mothers whose offspring were followed at theChildren's Castle Hospital in Helsinki, Finland, from the age of 4 months.The mothers had entered the special outpatient clinic for alcohol-consumingpregnant women during their second trimester. Carneyand Chermak do not propose a specific hypothesis so much as they simplydetermine where there is a lack of data in the literature and determinethat their methodology will ascertain the needed data. All the children showed somecatch-up growth in height and weight, but much less catch-up growth wasrecorded for head circumference. Mental development of 2-year-old children exposed to alcohol in utero. There is evidence that the persistence ofcome of the problems of FAS depend on the amount of drinking undertaken bythe mother. The procedures for testing appear to be correct and make use ofaccepted instruments for ascertaining language level and the relatedquestions of auditory and visual acuity (whose impairment might explain amore limited language-learning in the children). The authors had hypothesized that it would be possible to ascertainthe long-term sequelae of intrauterine alcohol exposure, and they didindeed ascertain this data from this study. Depressed performance was found for the FAS children relative totheir normally developing peers on all subtests of the TOLD-P, with theexception of the word articulation subtest, and on three of the fivesubtests of the TOLD-I: sentence combining, word ordering, and grammaticalcomprehension. Among the examinationsconducted were pediatric, neurological, psychiatric, and psychologicaltests and assessments. All the researchers conclude that treating the alcoholism evenafter pregnancy begins will be beneficial and will lessen the symptoms orreduce their persistence. Still,younger FAS subjects exhibited less global syntactic difficulty whencompared with the standardization sample. Themean age at follow-up was 27 months. the amount of alcoholconsumed per trimester could be ascertained with some accuracy in thisstudy, unlike earlier studies. The original sample consisted of 72 children diagnosed as havingFAS during a three-year period from 1977 to 1979 at pediatric clinics,foster homes, and institutions in West Berlin. The procedure utilized maico audiometers and a Teledyne ImpedanceMeter calibrated to manufacturer's specifications. Auditory and visual acuity were assessedin the first session, and language testing was conducted during the second. This study now considers further data from a 1 -year follow-up. Carney and Chermak (1991) saw a need for a study of the effects onAmerican Indian children and noted that such data is lacking at the presenttime. The scales selected were recommended by the research Society onAlcoholism, whose diagnostic criteria were also used. This was a sound proposition and one that could be tested witha maternal population of heavy consumers of alcohol that could then beinduced to stop drinking prior to the birth of their babies. These criteriaindicate that a child who shows two of the three criteria is to beclassified by the term FAE--fetal alcohol effects. Carney and Chermak approached the issue with a specific population,that of American Indian children, based on the fact that there is limitedinformation available about this population. The children were examined by two psychologists using the manual forthe Bayley Scales of Infant Development.

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