FASD Facial Features and FASD Facial Features and Neurocognitive Outcomes in the Neurocognitive Outcomes in the

Post-Institutionalized ChildPost-Institutionalized Child

Judith Eckerle KangJudith Eckerle Kang

2/12/20102/12/2010

““I have no relevant financial relationships with I have no relevant financial relationships with the manufacturer(s) of any commercial the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial product(s) and/or provider(s) of commercial services discussed in this activity.”services discussed in this activity.”

I I do notdo not intend to discuss an intend to discuss an unapproved/investigative use of a commercial unapproved/investigative use of a commercial product/device in my presentation.product/device in my presentation.

GoalsGoals FASD- is this a problem for international FASD- is this a problem for international

adoptees?adoptees? FASD- brief review of diagnosisFASD- brief review of diagnosis FASD facial features and outcomes in the FASD facial features and outcomes in the

Growth Endocrine ProjectGrowth Endocrine Project FASD facial features and CANTAB testingFASD facial features and CANTAB testing

““Of all the substances of abuse including Of all the substances of abuse including cocaine, heroin, and marijuana, alcohol cocaine, heroin, and marijuana, alcohol produces by far the most serious produces by far the most serious neurobehavioral effects in the fetus neurobehavioral effects in the fetus resulting in life-long permanent disorders resulting in life-long permanent disorders of memory function, impulse control and of memory function, impulse control and judgment”judgment”

——IOM Report to Congress, 1996IOM Report to Congress, 1996

FASD in International AdoptionFASD in International Adoption

Each year more than 23,000 children are Each year more than 23,000 children are internationally adopted (IA) into the U.S.A. There internationally adopted (IA) into the U.S.A. There has also been a shift in demographics such that 80% has also been a shift in demographics such that 80% of IA’s now come from institutional care and from of IA’s now come from institutional care and from countries with low per capita income and poor countries with low per capita income and poor nutrition with Eastern Europe as a major participating nutrition with Eastern Europe as a major participating country in international adoption. country in international adoption.

U.S. Department of State. U.S. Department of State. Immigrant Visas Issued to Orphans Coming to Immigrant Visas Issued to Orphans Coming to the U.S.: Top Countries of Origin: FY2005, 2006the U.S.: Top Countries of Origin: FY2005, 2006 . . Yearbook of Yearbook of

Immigration StatisticsImmigration Statistics..

FASD in International AdoptionFASD in International Adoption

Additionally, there was a 48.1% increase in Additionally, there was a 48.1% increase in alcoholism among women in the Former Soviet alcoholism among women in the Former Soviet Union (FSU) countries in the 10 years post Union (FSU) countries in the 10 years post dissolution of the USSR. Estimates report that eighty dissolution of the USSR. Estimates report that eighty to ninety-four percent of girls in FSU ages 15-17 to ninety-four percent of girls in FSU ages 15-17 years reportedly drink “sometimes” and 17 percent years reportedly drink “sometimes” and 17 percent drank “often” with weekly use by teens up 54%.drank “often” with weekly use by teens up 54%.

Davis, R B. "Drug and alcohol use in the former Soviet Union: selected factors and Davis, R B. "Drug and alcohol use in the former Soviet Union: selected factors and future considerations." Substance use & misuse 29.3 (1994):303.future considerations." Substance use & misuse 29.3 (1994):303.

United Nations Office for Drug Control and Crime Prevention Statistics. Vienna, United Nations Office for Drug Control and Crime Prevention Statistics. Vienna, Austria: United Nations Publication; 2002Austria: United Nations Publication; 2002

Facts about Fetal Alcohol Facts about Fetal Alcohol Spectrum Disorders (FASD)Spectrum Disorders (FASD)

Most people with FASD have average Most people with FASD have average IQsIQs

Rate of FAS (Syndrome) is 1:500 birthsRate of FAS (Syndrome) is 1:500 births

Rate of FASD (spectrum) is 1:100 birthsRate of FASD (spectrum) is 1:100 births

FASD: An Underdiagnosed SpectrumFASD: An Underdiagnosed Spectrum

Data from more than 400 FASD patients in the Data from more than 400 FASD patients in the University of Minnesota’s Fetal Alcohol University of Minnesota’s Fetal Alcohol Clinic database show that the majority of Clinic database show that the majority of children (68%) with documented prenatal children (68%) with documented prenatal exposure to alcohol do not meet full diagnostic exposure to alcohol do not meet full diagnostic criteria for FAS (unpublished clinical data). criteria for FAS (unpublished clinical data).

Jeffrey R. Wozniak, Ph.D., Assistant Professor of Psychiatry, Jeffrey R. Wozniak, Ph.D., Assistant Professor of Psychiatry, University of MinnesotaUniversity of Minnesota

How is FASD Diagnosed? How is FASD Diagnosed? 4-Digit Diagnostic Code4-Digit Diagnostic Code

growth deficiencygrowth deficiency (height or weight (height or weight << 10th 10th percentile). (institutional care)percentile). (institutional care)

a unique cluster of minor a unique cluster of minor facial anomaliesfacial anomalies (small (small eyes, smooth philtrum, thin upper lip). eyes, smooth philtrum, thin upper lip).

central nervous system damagecentral nervous system damage (structural, (structural, neurological, and/or functional impairment). neurological, and/or functional impairment).

prenatal alcohol exposureprenatal alcohol exposure..

Lip/Philtrum GuidesLip/Philtrum Guides

(displayed (displayed with with permission, permission, Dr. Susan Dr. Susan Astley)Astley)

Face of FAS forms during the 3rd Face of FAS forms during the 3rd week of gestation, most likely days week of gestation, most likely days

19-2119-21

Rating of Lip PhiltrumRating of Lip Philtrum

http://depts.washington.edu/fasdpn/htmls/lip-http://depts.washington.edu/fasdpn/htmls/lip-philtrum-guides.htmphiltrum-guides.htm

FASD ImitatorsFASD Imitators

Cornelia de Lange Cornelia de Lange syndrome (CdLS) syndrome (CdLS) distinctive facial featuresdistinctive facial features growth retardation (<5th % growth retardation (<5th %

throughout life)throughout life) Long smooth philtrum, thin Long smooth philtrum, thin

vermillion border of upper vermillion border of upper liplip

Low-set posteriorly rotated Low-set posteriorly rotated and/or hirsute ears with and/or hirsute ears with thickened helices thickened helices

Velocardiofacial Syndrome (VCF or Velocardiofacial Syndrome (VCF or DiGeorge Syndrome)DiGeorge Syndrome)

Cleft lip and/or palate distinctive facial distinctive facial

featuresfeatures cardiac septal defectscardiac septal defects hypernasal speechhypernasal speech HypotoniaHypotonia defective thymic defective thymic

development.development.

Valproate SyndromeValproate Syndrome

Prenatal exposure to Prenatal exposure to valproic acidvalproic acid (depakene, depakote) during the (depakene, depakote) during the first trimesterfirst trimester

distinctive facial featuresdistinctive facial features Neural tube defects Congenital heart disease Cleft lip and/or palate Genitourinary malformations Tracheomalacia Arm/hand defectsArm/hand defects Arachnodactyly/overlapping digits Abdominal wall defects Intellectual impairmentIntellectual impairment

FASD is the Invisible DisabilityFASD is the Invisible Disability

Attention deficits Attention deficits Memory deficits Memory deficits Hyperactivity Hyperactivity Difficulty with abstract Difficulty with abstract

concepts concepts Inability to manage Inability to manage

money money Poor problem solving Poor problem solving

skillsskills

Difficulty learning Difficulty learning from consequences from consequences

Immature social Immature social behavior behavior

Inappropriately Inappropriately friendly to strangers friendly to strangers

Lack of control over Lack of control over emotions emotions

Poor impulse control Poor impulse control Poor judgmentPoor judgment

Protective FactorsProtective Factors A diagnosis before 6 years of ageA diagnosis before 6 years of age Living in a stable, nurturing home Living in a stable, nurturing home Not being a victim of violenceNot being a victim of violence Having received developmental disabilities Having received developmental disabilities

servicesservices Having a diagnosis of Having a diagnosis of FASFAS rather than rather than FAEFAE Lower than 70 IQLower than 70 IQ

Growth Endocrine Project: Growth Endocrine Project: FASD Facial Features and Cognitive OutcomesFASD Facial Features and Cognitive Outcomes

What is the point of the study?What is the point of the study?

1)1) Who was potentially exposed to alcohol? (Face)Who was potentially exposed to alcohol? (Face)2)2) Are there other factors that can tell us about who Are there other factors that can tell us about who

was potentially exposed or that link the children was potentially exposed or that link the children with high risk facial features? (Growth? Cognitive with high risk facial features? (Growth? Cognitive testing?)testing?)

3)3) Are there times/ages which can best predict those Are there times/ages which can best predict those that have been exposed to alcohol and may need that have been exposed to alcohol and may need extra services?extra services?

Methods:Methods:

122 Eastern European children, adopted 122 Eastern European children, adopted between 7-59 mo of age on arrival.between 7-59 mo of age on arrival.

Mean age: 20moMean age: 20mo All from institutional care (85% entire life All from institutional care (85% entire life

spent in institutional care- rest 0.87)spent in institutional care- rest 0.87)

MeasuresMeasures

Growth (Ht, wt, OFC), Neurocognitive and facial Growth (Ht, wt, OFC), Neurocognitive and facial feature information was collected at all 3 time pointsfeature information was collected at all 3 time points

Time 1 (arrival): 122 ChildrenTime 1 (arrival): 122 Children Time 2 (6 mo post): 93 childrenTime 2 (6 mo post): 93 children Time 3 (30 mo post): 58 children: 8 children in the Time 3 (30 mo post): 58 children: 8 children in the

High Risk Face group (HRF) and 50 in the Low Risk High Risk Face group (HRF) and 50 in the Low Risk Face group (LRF)Face group (LRF)

Measures: CognitiveMeasures: Cognitive

Cognitive: Time 1 and 2Cognitive: Time 1 and 2 The The Mullen Scales of Early LearningMullen Scales of Early Learning is a is a

comprehensive measure of cognitive functioning used comprehensive measure of cognitive functioning used to assess visual linguistic and motor domains while to assess visual linguistic and motor domains while also distinguishing between receptive and expressive also distinguishing between receptive and expressive processing. processing.

There are 5 Mullen Scales: Gross Motor, Visual There are 5 Mullen Scales: Gross Motor, Visual Reception, Fine Motor, Receptive Language, and Reception, Fine Motor, Receptive Language, and Expressive Language. Expressive Language.

Measures: Cognitive time 3Measures: Cognitive time 3

The The Stanford Binet intelligence scalesStanford Binet intelligence scales are are used for assessment of individual cognitive used for assessment of individual cognitive abilities. abilities.

The entire scale, called the Full Scale IQ, The entire scale, called the Full Scale IQ, consists of consists of 5 verbal and 5 nonverbal5 verbal and 5 nonverbal subscales which are compiled for assessment subscales which are compiled for assessment of general intelligence. of general intelligence.

Facial Analysis for FASDFacial Analysis for FASD Facial features were Facial features were

analyzed on arrival, 6 mo analyzed on arrival, 6 mo and 30 mo post adoption and 30 mo post adoption in person and by in person and by photographic software.photographic software.

1.0-2.0 was considered 1.0-2.0 was considered low risk facial features low risk facial features (LRF)(LRF)

2.5-4.0 were considered 2.5-4.0 were considered high risk facial features high risk facial features (HRF)(HRF)

GrowthGrowth

Time 1 and 2 were done in collaboration with Dr. Patrick Mason Time 1 and 2 were done in collaboration with Dr. Patrick Mason and Christine Narad from Inova Fairfax Hospital for Children, and Christine Narad from Inova Fairfax Hospital for Children, Fairfax Virginia. Fairfax Virginia.

For the outcomes here, we used all three times points so children For the outcomes here, we used all three times points so children are all from U of Minnesota. Time 1 and 2 outcomes are are all from U of Minnesota. Time 1 and 2 outcomes are being published Dr. Brad Miller et al; “Auxological evaluation being published Dr. Brad Miller et al; “Auxological evaluation and determinants of growth failure at the time of adoption in and determinants of growth failure at the time of adoption in Eastern European adoptees” Journal of Pediatric Eastern European adoptees” Journal of Pediatric Endocrinology and Metabolism.Endocrinology and Metabolism.

We have data on growth but will be focusing on the We have data on growth but will be focusing on the neurocognitive testing for this presentation.neurocognitive testing for this presentation.

Time of Arrival: CognitiveTime of Arrival: Cognitive

LRF and LRF and HRF HRF groups did groups did not differnot differ on the on the Mullen Mullen Scales of Scales of Early Early Learning.Learning.

Time of Arrival

0

10

20

30

40

50

60

70

80

90

100

Gross Motor t VisualReception t

Fine Motor t ExpressiveLanguage t

Low Risk Mean

High Risk Mean--------------------------------------------------------------

Time of Arrival- Head/OFCTime of Arrival- Head/OFC

Head Head circumference on circumference on arrival was arrival was significantly significantly different but different but means for both means for both groups were groups were WNL (p<0.004)WNL (p<0.004)

LRF= -0.6 SD LRF= -0.6 SD HRF= -1.6 SDHRF= -1.6 SD

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

Low Risk Mean

High Risk Mean

Low RiskMean

-1.2 -0.66 -1.1

High RiskMean

-2 -1.56 -2

Height ** OFC ** Weight

**

6 mo Post-Adoption: Cognitive6 mo Post-Adoption: Cognitive

Trend toward Trend toward significance significance in in visual visual receptionreception deficits seen deficits seen in the in the children who children who had evolving had evolving high risk high risk facial facial features. features. (p<0.072)(p<0.072)

Mullen at 6 mo post-adoption

0102030405060708090

100

Gross

Mot

or t

Visual R

eceptio

n t

Fine M

otor

t

Receptiv

e La

ngua

ge t

Expre

ssive

Lan

guag

e t

LR Mean

HR Mean**------------------------------------------------------------

Visual Reception ScaleVisual Reception Scale

This involves intrasensory tasks that focus on visual This involves intrasensory tasks that focus on visual perceptual ability. perceptual ability.

Visual information is presented in a variety of ways Visual information is presented in a variety of ways so that visual processing skills can be assessed. so that visual processing skills can be assessed. Visual discrimination is measured in all tasks, while Visual discrimination is measured in all tasks, while visual memory is assessed in only certain tasks. visual memory is assessed in only certain tasks.

Responses are given by manipulations of objects or Responses are given by manipulations of objects or by pointing to objects and pictures. No vocalization is by pointing to objects and pictures. No vocalization is involved. involved.

6 mo6 mo post adoption: OFC/Head post adoption: OFC/Head

At 6 mo post adoption there remained At 6 mo post adoption there remained significant differences between the 2 groups. significant differences between the 2 groups.

Means were still in the normal rangeMeans were still in the normal range

OFC HRF<LRF (P<0.005)OFC HRF<LRF (P<0.005)

-2.5

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

Low Risk Mean

High Risk Mean

Low RiskMean

-1.2 -0.66 -1.1

High RiskMean

-2 -1.56 -2

Height ** OFC ** Weight

6 mo follow up: OFC

-2

-1.5

-1

-0.5

0

0.5

1

1.5

2

Low Risk Mean

High Risk Mean

Low Risk Mean -0.494 -0.05 -0.54

High Risk Mean -1.496 -1.35 -1.4

Height ** OFC ** Weight

**

**

30 mo post adoption30 mo post adoption

Of these children that we saw at 30 mo Of these children that we saw at 30 mo post adoption, new facial features had post adoption, new facial features had evolved in 4 adoptees (50% of the HRF evolved in 4 adoptees (50% of the HRF group), that were not evident at earlier group), that were not evident at earlier evaluationsevaluations

30 mo post adoption: Cognitive, Verbal30 mo post adoption: Cognitive, Verbal

The HRF The HRF group had group had lower lower scores scores for for

verbal verbal working working memorymemory (p<0.05)(p<0.05)

30 mo Verbal Cognitive Testing

-113579

1113151719

Verbal FluidReasoning

VerbalKnowledge

VerbalQuantitativeReasoning

VerbalVisual-Spatial

VerbalWorking

Memory **

Low Risk Mean

High Risk Mean**

Verbal Working MemoryVerbal Working Memory

The verbal working memory subscale The verbal working memory subscale measures a child’s ability to transform, store, measures a child’s ability to transform, store, and retrieve verbal information in short-term and retrieve verbal information in short-term memory. The subscale measures the cognitive memory. The subscale measures the cognitive ability to hold and sort through verbal ability to hold and sort through verbal information. In children, the ability to repeat a information. In children, the ability to repeat a sentence measures short-term memory. sentence measures short-term memory.

30 mo post adoption: Cognitive, Nonverbal30 mo post adoption: Cognitive, Nonverbal

The HRF The HRF group had group had lower scores lower scores for for

nonverbal nonverbal fluid fluid reasoningreasoning (p<0.02)(p<0.02)

30 mo Nonverbal Cognitive Testing

-113579

1113151719

No

nve

rba

lF

luid

Re

aso

nin

g**

No

nve

rba

lK

no

wle

dg

e

No

nve

rba

lQ

ua

ntit

ativ

eR

ea

son

ing

No

nve

rba

lV

isu

al-

Sp

atia

l

No

nve

rba

lW

ork

ing

Me

mo

ry

Low Risk Mean

High Risk Mean

**

Nonverbal Fluid Reasoning:Nonverbal Fluid Reasoning:

This measures a child’s ability to solve novel This measures a child’s ability to solve novel problems without dependence on academic or cultural problems without dependence on academic or cultural information. information.

Uses visual sequences and analogical patterns to test Uses visual sequences and analogical patterns to test inductive and deductive reasoning skills. inductive and deductive reasoning skills.

In children, it measures the ability to identify shapes, In children, it measures the ability to identify shapes, colors and sizes in order to identify sequences and colors and sizes in order to identify sequences and patterns. patterns.

30 mo post adoption: IQ 30 mo post adoption: IQ No significant difference was seen in IQNo significant difference was seen in IQ and both and both

groups scored within the normal range. groups scored within the normal range.

30 mo IQ- Stanford Binet

0

20

40

60

80

100

120

Verbal IQ NonVerbal IQ Full Scale IQ

Low Risk Mean

High Risk Mean

----------------------------------------------------------------------

Take home points: #1Take home points: #1

For kids For kids >1SD below >1SD below mean for ht/wt/head at mean for ht/wt/head at 6 mo,6 mo, alcohol exposure alcohol exposure should be considered as should be considered as part of the differential part of the differential and assessment of facial and assessment of facial features and history features and history should be done.should be done.

#2: Facial features evolve over time#2: Facial features evolve over time

IA children should have repeated assessments IA children should have repeated assessments over time for facial features. Facial features over time for facial features. Facial features that are borderline at earlier ages should be that are borderline at earlier ages should be followed especially closely and consideration followed especially closely and consideration should be given for screening of FASD at should be given for screening of FASD at multiple time points. multiple time points.

Facial features evolve over timeFacial features evolve over time

Animal studies- facial features were barely Animal studies- facial features were barely prominent at 1 mo age, most detectable at 6 prominent at 1 mo age, most detectable at 6 mo and diminished progressively at 12 and 24 mo and diminished progressively at 12 and 24 months of age. months of age.

Fetal alcohol syndrome: Changes in craniofacial form with Fetal alcohol syndrome: Changes in craniofacial form with age, cognition, and timing of ethanol exposure in the macaque. age, cognition, and timing of ethanol exposure in the macaque. Susan J. Astley, Shannon I. Magnuson , Lena M. Omnell , Susan J. Astley, Shannon I. Magnuson , Lena M. Omnell , Sterling K. Clarren. Teratololgy. Sterling K. Clarren. Teratololgy. Volume 59 Issue 3Volume 59 Issue 3, Pages 163 - 172. Published Online: , Pages 163 - 172. Published Online: 18 Mar 1999.18 Mar 1999.

#3: Consider neuropsych testing#3: Consider neuropsych testing

Fluid reasoning and Working MemoryFluid reasoning and Working Memory Shown to be deficit in kids with diagnosed FASDShown to be deficit in kids with diagnosed FASD

Even children whose IQ’s are in the normal range Even children whose IQ’s are in the normal range (and thus do not qualify for school services) may (and thus do not qualify for school services) may have deficits that prevent them from effective have deficits that prevent them from effective learning. learning.

FASD- Cognitive deficitsFASD- Cognitive deficits

This has also been shown in diagnosed children with This has also been shown in diagnosed children with FASD- attentional and memory tasks, visual-spatial, FASD- attentional and memory tasks, visual-spatial, short-term auditory attention and verbal memory, short-term auditory attention and verbal memory, declarative learning, and cognitive flexibility and declarative learning, and cognitive flexibility and planning.planning.

Olson HC, Feldman JJ, Streissguth AP, Sampson PD, Bookstein FL. Neuropsychological deficits Olson HC, Feldman JJ, Streissguth AP, Sampson PD, Bookstein FL. Neuropsychological deficits in adolescents with fetal alcohol syndrome: clinical findings. in adolescents with fetal alcohol syndrome: clinical findings. Alcoholism: Clinical and Alcoholism: Clinical and Experimental ResearchExperimental Research. 1998;22(9):1998-2012. . 1998;22(9):1998-2012.

Verbal Learning and Memory in Children with Fetal Alcohol SyndromeVerbal Learning and Memory in Children with Fetal Alcohol SyndromeSarah N. Mattson, Edward P. Riley, Dean C. Delis, Catherine Stern, Kenneth Lyons JonesSarah N. Mattson, Edward P. Riley, Dean C. Delis, Catherine Stern, Kenneth Lyons JonesAlcoholism: Clinical and Experimental ResearchAlcoholism: Clinical and Experimental ResearchVolume 20, Issue 5 , Pages810 - 816Volume 20, Issue 5 , Pages810 - 8161996 The Research Society on Alcoholism1996 The Research Society on Alcoholism

Verbal Learning and Memory in Children with Fetal Alcohol SyndromeVerbal Learning and Memory in Children with Fetal Alcohol SyndromeSarah N. Mattson, Edward P. Riley, Dean C. Delis, Catherine Stern, Kenneth Lyons JonesSarah N. Mattson, Edward P. Riley, Dean C. Delis, Catherine Stern, Kenneth Lyons JonesAlcoholism: Clinical and Experimental ResearchAlcoholism: Clinical and Experimental ResearchVolume 20, Issue 5 , Pages810 - 816Volume 20, Issue 5 , Pages810 - 8161996 The Research Society on Alcoholism1996 The Research Society on Alcoholism

Specific Impairments in Self-Regulation in Children Exposed to Alcohol PrenatallySpecific Impairments in Self-Regulation in Children Exposed to Alcohol PrenatallyP. W. Kodituwakku, N. S. Handmaker, S. K. Cutler, E. K. Weathersby, S. D. HandmakerP. W. Kodituwakku, N. S. Handmaker, S. K. Cutler, E. K. Weathersby, S. D. HandmakerAlcoholism: Clinical and Experimental ResearchAlcoholism: Clinical and Experimental ResearchVolume 19, Issue 6 , Pages1558 - 1564Volume 19, Issue 6 , Pages1558 - 15641995 The Research Society on Alcoholism1995 The Research Society on Alcoholism

Effects of Prenatal Alcohol Exposure on Attention and Working Memory at 7.5 Years of Effects of Prenatal Alcohol Exposure on Attention and Working Memory at 7.5 Years of Age.Age. Alcohol Effects on the Fetus, Brain, Liver, and Other Organ SystemsAlcohol Effects on the Fetus, Brain, Liver, and Other Organ Systems

Alcoholism: Clinical & Experimental Research. 29(3):443-452, March 2005.Alcoholism: Clinical & Experimental Research. 29(3):443-452, March 2005.Burden, Matthew J.; Jacobson, Sandra W.; Sokol, Robert J.; Jacobson, Joseph L.Burden, Matthew J.; Jacobson, Sandra W.; Sokol, Robert J.; Jacobson, Joseph L.

#4: Gross motor skills are not #4: Gross motor skills are not correlated with other cognitive correlated with other cognitive

findings or facial features. findings or facial features.

Gross motor skills on this Gross motor skills on this testing were not testing were not significantly different significantly different between the 2 groups. between the 2 groups.

#5: Facial features are key#5: Facial features are key

This study supports previous work that suggests This study supports previous work that suggests facial features are enough to strongly consider or facial features are enough to strongly consider or diagnose FASD and can lead to discovery of specific diagnose FASD and can lead to discovery of specific cognitive issues. cognitive issues.

Application of the fetal alcohol syndrome facial photographic Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population.screening tool in a foster care population. Clinical and Laboratory Observations. Clinical and Laboratory Observations. Journal of Pediatrics. Journal of Pediatrics. 141(5):712-717, November 2002.141(5):712-717, November 2002.Astley, Susan J. PhD; Stachowiak, Julie RN, MN; Clarren, Sterling K. Astley, Susan J. PhD; Stachowiak, Julie RN, MN; Clarren, Sterling K.

MD; Clausen, Cherie RN, MN.MD; Clausen, Cherie RN, MN.

What’s Next? What’s Next?

Neurocognitive Functioning Neurocognitive Functioning in the Internationally in the Internationally Adopted Child with High Adopted Child with High Risk FASD Facial Features. Risk FASD Facial Features.

CANTAB testing in IA childrenCANTAB testing in IA children

In this proposal, we are taking a novel, In this proposal, we are taking a novel, collaborative approach with Psychology, using collaborative approach with Psychology, using the CANTAB (computer game testing) to the CANTAB (computer game testing) to investigate subtle brain deficits in IA’s who investigate subtle brain deficits in IA’s who are high risk for FASD. are high risk for FASD.

Specific AimSpecific Aim

Assess the brain functioning of IA children Assess the brain functioning of IA children with high risk FASD facial features using with high risk FASD facial features using computerized testing compared to matched IA computerized testing compared to matched IA children with low risk FASD facial features, children with low risk FASD facial features, half from Eastern Europe and half from half from Eastern Europe and half from Chinese institutional care. Chinese institutional care.

Compare the growth between groups.Compare the growth between groups.

HypothesisHypothesis

Our overall hypothesis is that children with Our overall hypothesis is that children with high risk facial features are at risk for specific high risk facial features are at risk for specific deficits in prefrontal lobe brain functioning, deficits in prefrontal lobe brain functioning, similar to kids with diagnosed FAS, that are similar to kids with diagnosed FAS, that are above and distinct from the baseline risk of above and distinct from the baseline risk of transitions and institutional care that is present transitions and institutional care that is present in international adoption as a whole. Children in international adoption as a whole. Children with high risk facial features will also have with high risk facial features will also have decreased growth parameters. decreased growth parameters.

MethodsMethods

20 20 IA childrenIA children from Eastern Europe between the ages of 6 and 8 years old from Eastern Europe between the ages of 6 and 8 years old with high risk facial features for FASD will be recruited from the with high risk facial features for FASD will be recruited from the International Adoption Clinic. International Adoption Clinic.

A A control groupcontrol group of children ( of children (NN=20) who do not have high risk FASD =20) who do not have high risk FASD features, who are internationally adopted from Eastern Europe will be features, who are internationally adopted from Eastern Europe will be recruited as controlsrecruited as controls

A A control groupcontrol group of children ( of children (NN=20) who do not have high risk FASD =20) who do not have high risk FASD features, who are internationally adopted from China, will also be recruited features, who are internationally adopted from China, will also be recruited as a control group who historically has a low chance of alcohol exposure. as a control group who historically has a low chance of alcohol exposure.

We will also gather parent report data on colorblindness, visual acuity, We will also gather parent report data on colorblindness, visual acuity, learning disabilities/special services and handedness on all participants. learning disabilities/special services and handedness on all participants.

Study Design and Measures:Study Design and Measures: Specific Aim 1Specific Aim 1: The Weschler Abbreviated : The Weschler Abbreviated

Scale of Intelligence (WASI), will be done as Scale of Intelligence (WASI), will be done as a brief, reliable measure of FSIQ intelligence a brief, reliable measure of FSIQ intelligence and will be used only to ensure that all and will be used only to ensure that all participants have IQ’s in the normal range and participants have IQ’s in the normal range and that comparisons are not being made about that comparisons are not being made about children in the mental retardation range.children in the mental retardation range.

Specific Aim 2:Specific Aim 2:

Cambridge Neuropsychological Cambridge Neuropsychological Test Automated Battery Test Automated Battery (CANTAB) is a computerized (CANTAB) is a computerized battery of nonverbal visually-battery of nonverbal visually-presented neuropsychological presented neuropsychological tests designed to dissociate tests designed to dissociate frontal from temporal lobe frontal from temporal lobe behavioral functions and assess behavioral functions and assess working memory and executive working memory and executive functioning. functioning.

Cambridge Neuropsychological Test Cambridge Neuropsychological Test Automated Battery (CANTAB)Automated Battery (CANTAB)

Spatial Memory Span, Spatial Working Memory, Spatial Memory Span, Spatial Working Memory, (Executive function) the Tower of London planning (Executive function) the Tower of London planning task, Visual Pattern and Spatial Recognition tasks, task, Visual Pattern and Spatial Recognition tasks, (Visual Memory), Rapid Visual Information (Visual Memory), Rapid Visual Information Processing (Attention), Stop Signal task (Decision Processing (Attention), Stop Signal task (Decision making and response control) and a Set-Shifting task. making and response control) and a Set-Shifting task.

Fine motor speed and accuracy, frontal and temporal Fine motor speed and accuracy, frontal and temporal

lobe functioning will be analyzed using mean latency lobe functioning will be analyzed using mean latency result time and accuracy/errors for each of the result time and accuracy/errors for each of the subtests. subtests.

Specific Aim 3:Specific Aim 3:

FAS Photographic Software Analysis: This FAS Photographic Software Analysis: This software gives an accurate measure of facial software gives an accurate measure of facial features in order to assess for FASD risk on a features in order to assess for FASD risk on a 4-Digit Facial Rank Score (Astley, 2003). 4-Digit Facial Rank Score (Astley, 2003).

Specific Aim 4:Specific Aim 4:

Growth data will be gathered on all Growth data will be gathered on all participants to compare catch-up and growth participants to compare catch-up and growth parameters for head circumference, height and parameters for head circumference, height and weight. Data Analysis will be done using weight. Data Analysis will be done using SPSS software to analyze catch up growth SPSS software to analyze catch up growth comparing growth at time of arrival compared comparing growth at time of arrival compared to current growth z scores. to current growth z scores.

FEASIBILITYFEASIBILITY

The proposed study is a one year project. The proposed study is a one year project. Based on previous studies by our research Based on previous studies by our research team with IA children, we expect to enroll ~6 team with IA children, we expect to enroll ~6 IA children per month and attrition to be IA children per month and attrition to be <10%, which will allow for completion within <10%, which will allow for completion within 1 year. 1 year.

Also coming up…Also coming up…

““Prenatal Choline Supplementation Prenatal Choline Supplementation in Children with Prenatal Alcohol in Children with Prenatal Alcohol Exposure”Exposure”

ThanksThanks

The Growth Endocrine TeamThe Growth Endocrine Team CNBD and Dr. Michael GeorgieffCNBD and Dr. Michael Georgieff Dr. Dana JohnsonDr. Dana Johnson Dr. Maria KroupinaDr. Maria Kroupina Anita Fuglestad, Mollika Sajady, Jamie Anita Fuglestad, Mollika Sajady, Jamie

Jenkins and Julia ChernakovJenkins and Julia Chernakov