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Parent rating of executive function in fetal alcohol spectrum disorder: A review of the literature and new data on Aboriginal Canadian children

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Child Neuropsychology
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Aboriginal children in Canada are at high risk of fetal alcohol spectrum disorder (FASD) but there is little research on the cognitive impact of prenatal alcohol exposure (PAE) in this population. This paper reviews the literature on parent report of executive functioning in children with FASD that used the Behavior Rating Inventory of Executive Function (BRIEF). New data on the BRIEF is then reported in a sample of 52 Aboriginal Canadian children with FASD for whom a primary caregiver completed the BRIEF. The children also completed a battery of neuropsychological tests. The results reveal mean scores in the impaired range for all three BRIEF index scores and seven of the eight scales, with the greatest difficulties found on the Working Memory, Inhibit and Shift scales. The majority of the children were reported as impaired on the index scores and scales, with Working Memory being most commonly impaired scale. On the performance-based tests, Trails B and Letter Fluency are most often reported as impaired, though the prevalence of impairment is greater for parent ratings than test performance. No gender difference is noted for the parent report, but the boys had slightly slower intellectual functioning and were more perseverative than the girls on testing. The presence of psychiatric comorbidity is unrelated to either BRIEF or test scores. These findings are generally consistent with prior studies indicating that parents observe considerable executive dysfunction in children with FASD, and that children with FASD may have more difficulty with executive functions in everyday life than is detected by laboratory-based tests alone.
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Child Neuropsychology
A Journal on Normal and Abnormal Development in Childhood and
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ISSN: 0929-7049 (Print) 1744-4136 (Online) Journal homepage: http://www.tandfonline.com/loi/ncny20
Parent rating of executive function in fetal alcohol
spectrum disorder: A review of the literature and
new data on Aboriginal Canadian children
Jaspreet K. Rai, Maurissa Abecassis, Joseph E. Casey, Lloyd Flaro, Laszlo A.
Erdodi & Robert M. Roth
To cite this article: Jaspreet K. Rai, Maurissa Abecassis, Joseph E. Casey, Lloyd Flaro, Laszlo A.
Erdodi & Robert M. Roth (2016): Parent rating of executive function in fetal alcohol spectrum
disorder: A review of the literature and new data on Aboriginal Canadian children, Child
Neuropsychology, DOI: 10.1080/09297049.2016.1191628
To link to this article: http://dx.doi.org/10.1080/09297049.2016.1191628
Published online: 10 Jun 2016.
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Parent rating of executive function in fetal alcohol spectrum
disorder: A review of the literature and new data on
Aboriginal Canadian children
Jaspreet K. Rai
a
, Maurissa Abecassis
b
, Joseph E. Casey
a
, Lloyd Flaro
c
, Laszlo A. Erdodi
a
and Robert M. Roth
b
a
Department of Psychology, University of Windsor, Ontario, Canada;
b
Neuropsychology Program,
Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA;
c
Private Practice,
Edmonton, Alberta, Canada
ABSTRACT
Aboriginal children in Canada are at high risk of fetal alcohol
spectrum disorder (FASD) but there is little research on the cog-
nitive impact of prenatal alcohol exposure (PAE) in this population.
This paper reviews the literature on parent report of executive
functioning in children with FASD that used the Behavior Rating
Inventory of Executive Function (BRIEF). New data on the BRIEF is
then reported in a sample of 52 Aboriginal Canadian children with
FASD for whom a primary caregiver completed the BRIEF. The
children also completed a battery of neuropsychological tests.
The results reveal mean scores in the impaired range for all
three BRIEF index scores and seven of the eight scales, with the
greatest diculties found on the Working Memory, Inhibit and
Shift scales. The majority of the children were reported as impaired
on the index scores and scales, with Working Memory being most
commonly impaired scale. On the performance-based tests, Trails
B and Letter Fluency are most often reported as impaired, though
the prevalence of impairment is greater for parent ratings than
test performance. No gender dierence is noted for the parent
report, but the boys had slightly slower intellectual functioning
and were more perseverative than the girls on testing. The pre-
sence of psychiatric comorbidity is unrelated to either BRIEF or test
scores. These ndings are generally consistent with prior studies
indicating that parents observe considerable executive dysfunc-
tion in children with FASD, and that children with FASD may have
more diculty with executive functions in everyday life than is
detected by laboratory-based tests alone.
ARTICLE HISTORY
Received 21 December 2015
Accepted 14 May 2016
Published online
10 June 2016
KEYWORDS
Fetal alcohol spectrum
disorders; Neuropsychology;
Executive function;
Cognition;
Neurodevelopment
Fetal alcohol spectrum disorder (FASD) is a non-diagnostic umbrella term widely
adopted to refer to a variety of conditions related to prenatal alcohol exposure (PAE)
(Bertrand, Floyd, & Weber, 2005; Sokol, Delaney-Black, & Nordstrom, 2003). One such
condition is fetal alcohol syndrome (FAS), which involves craniofacial dysmorphology,
growth deciency, and central nervous system abnormality. Other conditions that do
CONTACT Laszlo A. Erdodi lerdodi@uwindsor.ca Department of Psychology, University of Windsor, Chrysler
Hall South 168 401 Sunset Avenue, Windsor, Ontario N9B 3P4, Canada
CHILD NEUROPSYCHOLOGY, 2016
http://dx.doi.org/10.1080/09297049.2016.1191628
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not meet the full criteria for FAS but are associated with PAE include partial FAS
(PFAS), alcohol-related neurodevelopmental disorder (ARND), and alcohol-related
birth defects (ARBD).
The prevalence rate of FASD has been reported to be as high as 25% in the general
population of the United States (US) and Western Europe (May et al., 2014,2009). In
Canada, prevalence rates in the general population have ranged from 0.1% (Roberts &
Hanson, 2000) to 0.9% (Public Health Agency of Canada, 2003). The rate for children
under the care of the child welfare system, however, has been reported to be consider-
ably higher (Fuchs, Burnside, Marchenski, & Murdy, 2005; Popova, Lange, Burd, &
Rehm, 2014).
The prevalence rate of FASD has generally been reported to be higher for Aboriginal
than non-Aboriginal communities, with rates as high as 1019% in Canadian samples
(Tough & Jack, 2011). Some have attributed the higher rates of FASD to risk factors
such as poor education, physical and sexual abuse, untreated mental illness, and
poverty, which are often more common in Aboriginal communities (Schröter, 2010).
Others have argued that methodological problems in the epidemiological literature
preclude any rm conclusions with respect to prevalence rates among Aboriginal
Canadians (Pacey, 2009).
FASD and Executive Function
FASD is associated with a variety of cognitive decits, including in general intellectual
ability, executive function, attention, language, visuospatial skills, verbal and visual
learning and memory, motor function, and social cognition (Davis, Gagnier, Moore,
& Todorow, 2013; Kodituwakku, 2009; Mattson, Crocker, & Nguyen, 2011). Such
decits are common in relation to PAE, irrespective of whether or not full diagnostic
criteria for FAS are met.
Executive function in particular has been the focus of considerable research in FASD.
This is due in part to the vital role that executive functions play in the self-regulation of
behavior, cognition and emotion (Roth, Isquith, & Gioia, 2005), all of which are com-
monly disrupted in FASD. Furthermore, the neural substrates of executive function, such
as the prefrontal cortex, are vulnerable to the eects of PAE in both animal models (Fabio,
Vivas, & Pautassi, 2015; Mihalick, Crandall, Langlois, Krienke, & Dube, 2001)andin
children with FASD, as revealed by neuroimaging studies (Donald et al., 2015).
Investigations of children with FASD using performance-based tests have reported
decits in several aspects of executive function (Connor, Sampson, Bookstein, Barr, &
Streissguth, 2000; Fuglestad et al., 2014). Recent meta-analyses examining studies that
have compared children with FASD and typically-developing (TD) children have
provided further support for the presence of executive dysfunction in the disorder.
One such analysis yielded medium eect sizes for working memory and inhibition, and
a large eect size for set shifting (Khoury, Milligan, & Girard, 2015). Another reported
the largest eect sizes for planning, uency, and set shifting, along with a moderate to
large eect for working memory and a smaller eect for inhibition (Kingdon, Cardoso,
& McGrath, 2015).
A complementary approach to investigating executive function in FASD has
involved the use of rating scales completed by parents, and to a much lesser extent
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by teachers. The use of such rating scales permits a clinician to gauge the integrity of
executive functions as manifested in the real world, allowing for a more ecologically
valid assessment of these cognitive abilities than provided by performance-based mea-
sures alone (Isquith, Roth, & Gioia, 2013).
The Behavior Rating Inventory of Executive Function (BRIEF; Gioia, Isquith, Guy, &
Kenworthy, 2000) has been employed in several studies of children with FASD. It has
been shown to have good psychometric properties and has been used extensively in the
pediatric literature with children having the study of a wide variety of disorders (Roth,
Isquith, & Gioia, 2014). The BRIEF was designed to assess executive functioning in the
everyday lives of children over the prior six months. It yields two main index scores,
each of which is composed of several scales. The Behavior Regulation Index (BRI)
reects an individuals ability to regulate his or her behavior and emotional responses,
and includes scales assessing the ability to inhibit thoughts and actions (Inhibit),
exibly shift problem-solving strategies and adjust to changes in his or her environment
(Shift), and regulate his or her emotions (Emotional Control). The Metacognition Index
(MI) reects the individuals ability to actively solve problems by evaluating the ability
to get started on tasks without external prompting (Initiate), hold and manipulate
information in mind in order to complete tasks (Working Memory), plan and organize
problem-solving approaches (Plan/Organize), monitor his or her own performance on
tasks for accuracy, monitor the eect of his or her behavior on others (Monitor), and
maintain an organized environment such as maintaining an orderly room and being
able to readily nd materials needed for schoolwork (Organization of Materials). The
BRIEF also yields an overall index score, the Global Executive Composite (GEC),
reecting overall executive functioning. Higher t-scores (mean of 50, standard deviation
[SD] of 10) indicate worse executive functioning, and a t-score of 65 or higher is
considered to be clinically signicant (Gioia et al., 2000).
Only one published study to date has evaluated executive functions on performance-
based tests in Aboriginal children with FASD, but it does not report ndings specically
for that subset of their mixed ethnicity sample (Rasmussen et al., 2010). Similarly, only
two studies of the BRIEF in FASD have included Aboriginal children in mixed ethnicity
samples, but neither have reported scores for the Aboriginal subsample (Rasmussen
et al., 2010; Rasmussen, Horne, & Witol, 2006).
In the present paper, we rst review the literature on the BRIEF in children with
FASD in order to determine whether they dier from TD children and the prevalence
of clinically signicant executive dysfunction as assessed by the BRIEF (Table 1), and
then report new data on parent report BRIEF index and scale scores for a sample of
Aboriginal Canadian children with FASD.
Literature Review
BRIEF Parent Report in FASD: Index Scores
Mean BRIEF index t-scores for children with FASD have been consistently found to be
in the clinical range relative to the standardization sample. This has been found for nine
studies that reported on the GEC (Astley et al., 2009; Gross, Deling, Wozniak, & Boys,
2015; Knuiman, Rijk, Hoksbergen, & van Baar, 2015; McGee, Fryer, Bjorkquist,
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Mattson, & Riley, 2008; Nash et al., 2015; Rasmussen et al., 2006; Rasmussen, McAuley,
& Andrew, 2007; Stevens et al., 2013; Wozniak et al., 2013), all six studies that included
the BRI (Astley et al., 2009; McGee et al., 2008; Nash et al., 2015; Rasmussen et al., 2007;
Schonfeld, Paley, Frankel, & OConnor, 2006; Stevens et al., 2013), and all ve studies
that used the MI (Astley et al., 2009; McGee et al., 2008; Rasmussen et al., 2007;
Schonfeld et al., 2006; Stevens et al., 2013). One study reported higher GEC in children
with FASD than TD children, but did not provide scores (Gautam et al., 2015). Studies
that have compared children with FASD and TD children recruited for the same study
have also found poorer executive functions in the FASD group on the GEC (McGee
et al., 2008; Wozniak et al., 2013), the BRI (McGee et al., 2008), and the MI (McGee
et al., 2008).
It is also informative to know the prevalence of everyday executive dysfunction in
FASD given the heterogeneity of cognitive functioning among these children (Davis
et al., 2013; Mattson et al., 2013). To date, only three studies have reported the
Table 1. Studies Reporting Parent Report BRIEF t-scores in Children with FASD.
Age (years)
Study Participants (% female) MSD BRIEF Indices and Scales
Astley et al. (2009) FAS/PFAS, n= 20 (50.0) 12.7 2.4 GEC, BRI, MI
SE/AE, n= 24 (33.3) 12.2 2.0
ND/AE, n= 21 (47.6) 12.4 2.3
TD, n= 16 (50.0) 12.4 2.7
Gautam et al. (2015) PAE, n= 75 (38.6) 12.3 2.6 GEC
TD, n= 64 (51.6) 12.3 2.5
Gross et al. (2015) FASD, n= 551 (42.5) 10.0 N/A GEC, Shift, Initiate, WM
Knuiman et al. (2015) FASD, n= 37 (46.0) 11.0 2.9 GEC, Inhibit, Shift, EC,
Initiate, WM, P/O, Monitor,
OM
Suspected FASD, n= 25 (56.0) 11.4 2.4
TD, n= 59 (46.0) 10.5 2.7
McGee et al. (2008) PAE, n= 28 (54.2) 15.2 1.5 GEC, BRI, MI, Inhibit, Shift, EC,
Initiate, WM, P/O, Monitor,
OM
TD, n= 15 (46.7) 15.4 1.6
Nash et al. (2015) FASD, n= 25 (48.0) 10.3 N/A GEC, BRI, Inhibit, Shift, EC
Nguyen et al. (2014)
*
FASD with ADHD, n= 73 (36.7) 12.6 2.6 Inhibit,Shift, EC, Initiate, WM,
P/O, Monitor, OMFASD without ADHD, n= 35 (55.6) 12.9 2.8
ADHD, n= 87 (25.6) 11.5 2.7
TD, n= 151 (44.6) 12.4 2.5
Rasmussen et al. (2006) FASD, n= 31 (N/A) 10.0 N/A GEC, Inhibit, Shift, EC,
Initiate, WM, P/O, Monitor,
OM
Rasmussen et al. (2007) FASD, n= 64 (42.2) 8.0 N/A GEC, BRI, MI, Inhibit, Shift, EC,
Initiate, WM, P/O, Monitor,
OM
Schonfeld et al. (2006) FASD, n= 98 (48.0)* 8.6 1.5 GEC, BRI, MI, Inhibit, Shift, EC,
Initiate, WM, P/O, Monitor,
OM
FAS, n= 10 (N/A) N/A N/A
PFAS, n= 45 (N/A) N/A N/A
ARND, n= 43 (N/A) N/A N/A
Stevens et al. (2013) FASD, n= 110 (N/A) N/A N/A GEC, BRI, MI
PAE, n= 49 (N/A) N/A N/A
Wozniak et al. (2013) FASD, n= 24 (46.0) 14.3 2.2 GEC
TD, n= 31 (45.0) 13.7 2.3
Note. *Gender distribution and mean age was reported only for the overall sample of children with FASD. Sample sizes
are also reported for the three subgroups. ADHD = attention-decit/hyperactivity disorder; ARND = alcohol-related
neurodevelopmental disorder; BRI = Behavioral Regulation Index; EC = Emotional Control; FAS = fetal alcohol
syndrome; GEC = General Executive Composite; MI = Metacognition Index; N/A = not available; ND/
AE = neurobehavioral disorder/alcohol exposed; OM = Organization of Materials; PAE = prenatal alcohol exposure;
PFAS = partial fetal alcohol syndrome; P/O = Plan/Organize; SE/AE = static encephalopathy/alcohol exposed;
TD = typically-developing; WM = Working Memory.
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percentage of children within a sample with FASD who obtained BRIEF index scores in
the clinical range. Of a sample of 64 children, Rasmussen et al. (2007) reported that
86.5%, 83.9%, and 84.5% scored in the clinical range on the GEC, BRI, and MI,
respectively. Using a higher cutoof two SDs from the standardization sample mean,
Astley et al. (2009) observed impairment for 76.285.0% of the sample for the GEC,
71.480.0% for the BRI, and 76.290.0% for the MI. Most recently, Knuiman et al.
(2015) reported a lower prevalence of clinical-range GEC scores in FASD than prior
studies. They found rates of 46% for children with FASD, 24% for those with suspected
FASD, and 12% for those without FASD. These latter ndings must be interpreted with
caution, however, as classication into groups was based solely on a questionnaire
completed by parents asking whether or not their child had been diagnosed with or was
suspected of having FASD.
Three studies examined whether the subtype of FASD is related to BRIEF scores.
One reported no dierences for the BRI and the MI between children with diagnoses of
FAS, PFAS, or ARND (Schonfeld et al., 2006). Another found comparable index scores
for children classied as FAS/PFAS, static encephalopathy/alcohol-exposed or neuro-
behavioral disorder/alcohol-exposed (Astley et al., 2009). In contrast, the three BRIEF
index scores were reported to be more impaired and more likely to be in the clinical
range for a group of children with FASD than children with PAE (i.e., not meeting
criteria for FASD), although the mean t-scores for both groups were in the clinical
range, with the exception of the MI for the PAE group, which was just below the cuto
(t= 64.9; Stevens et al., 2013).
Together, these studies indicate that children with FASD typically score within the
clinical range on all three BRIEF index scores. This holds true regardless of whether the
children are compared to the published normative sample or to TD children recruited
for the same study. Furthermore, although the literature is relatively sparse and some-
what inconsistent at this time, the extent of executive dysfunction as reected by BRIEF
index scores is generally comparable across most FASD subtypes.
BRIEF Parent Report in FASD: Scale Scores
Three studies reported scores for all BRIEF scales within a sample of children with
FASD. In the rst such study, Rasmussen et al. (2006) observed that nearly all scales
were in the clinical range, with the greatest diculty experienced for Working Memory
and Plan/Organize, and the least for Organization of Materials. No ethnic dierence
was found on the BRIEF between Aboriginal and non-Aboriginal children, although
separate scores for these subgroups are not provided. In a follow-up study (with
participants of unspecied ethnicity), all scales were in the clinical range, with the
highest scores obtained for Initiate, Working Memory and Inhibit, and the lowest
scores for Plan/Organize and again for Organization of Materials (Rasmussen et al.,
2007). Impairment was most common for Initiate (79.4%), Working Memory (78.1%),
and Inhibit (75.0%), while even the scale with the lowest percentagePlan/Organize
identied almost 59.6% of the sample as impaired. McGee et al. (2008) found worse
scores on all BRIEF scales in adolescents with PAE as compared to TD children, with
the largest eects seen for Initiate, Plan/Organize and Monitor, and the smallest for
Organization of Materials. In contrast, Knuiman et al. (2015) only observed worse
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scores in their FASD group compared to their TD group for the Inhibit, Emotional
Control, and Organization of Materials scales, with Inhibit the only one in the clinical
range.
Two studies only examined a few of the BRIEF scales. Gross et al. (2015) observed
mean t-scores in the clinical range for the three scales they examined (Initiate, Shift,
and Working Memory) in their large sample of children with FASD, with Working
Memory having the highest score. In a study of a self-regulation intervention for
children with FASD, pre-treatment BRIEF scores were in the clinical range for the
three scales evaluatedInhibit, Shift, and Emotional Control (Nash et al., 2015).
Two studies have examined parent report BRIEF in children with FASD and
comorbid attention-decit/hyperactivity disorder (ADHD), with ADHD being highly
prevalent among those with FASD (Mattson et al., 2011). Rasmussen et al. (2010) found
that children with FASD with and without comorbid ADHD do not dier on an
executive function composite score that includes the BRIEF and a performance-based
test; the results for the BRIEF itself are not reported. Nguyen et al. (2014) compared
children with FASD with and without comorbid ADHD, children with ADHD only,
and TD children. Their results revealed that the FASD without ADHD group had
higher t-scores for all BRIEF scales relative to the TD group, although none of the
scores were clinically elevated. In contrast, children with FASD and comorbid ADHD
had higher scores than the other groups on almost all scales, with the highest scores
obtained for Inhibit and Working Memory.
These ndings indicate that children with FASD have diculty with multiple aspects
of executive functions, as assessed by the individual scales of the BRIEF parent report,
with comorbid ADHD being associated with an exacerbating of executive dysfunction
in at least one study. However, no clear prole of scale elevations has emerged across
studies. This may be due in part to there being relatively few investigations reporting
scores for all eight scales. Nonetheless, the available research indicates that the most
pronounced impairment tends to be seen for Working Memory, while Organization of
Materials typically has the lowest score, though in some studies is still within the clinical
range.
Relationship between BRIEF Scores and Performance-Based Tests
A small number of studies of children with FASD have investigated the relationship
between scores on the parent report BRIEF and scores on performance-based tests of
executive function. These have revealed low or non-signicant correlations (Gross et al.,
2015; Nguyen et al., 2014). Interestingly, in one study impairment was observed in
8090% of the sample for the BRIEF index scores but only 34% on the Trail Making
Test (TMT), the latter being the performance-based test with the highest percentage of
impaired scores (Astley et al., 2009).
No association to modest relationships between parent ratings on the BRIEF and
neuropsychological test performance is common in the literature on a number of
disorders (McAuley, Chen, Goos, Schachar, & Crosbie, 2010; Parrish et al., 2007;
Toplak, Bucciarelli, Jain, & Tannock, 2008). The reason for such a discrepancy is
unclear, but it has been hypothesized to be related to performance-based tests assessing
executive functions over a short time frame in a typically highly structured setting, in
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contrast to the integrated, multidimensional, and priority-based decision-making that is
frequently needed in real-world situations (Goldberg & Podell, 2000; Isquith et al.,
2013).
Summary of BRIEF Studies
Overall, the current literature on the parent report BRIEF indicates considerable
executive dysfunction in the everyday lives of children with FASD. This is reected in
both the more general measures of functioning (the GEC, BRI, and MI) and several of
the individual scales, with the Working Memory scale being the most commonly
impaired across studies. However, few studies have examined whether ratings of
executive function are impacted by factors such as gender or the presence of psychiatric
conditions that are highly comorbid with FASD, such as ADHD and depression (Fryer,
McGee, Matt, Riley, & Mattson, 2007).
The Present Investigation
In the present investigation, we sought to replicate a prior study that used the parent
report BRIEF in a sample of Aboriginal Canadian children but that does not provide
scores for the Aboriginal subset of participants and only states that there are no
ethnicity eects in the data (Rasmussen et al., 2006). We hypothesized that our
Aboriginal children with FASD would have a high prevalence of executive dysfunction
both on the BRIEF and on performance-based tests, but that rates would be higher for
the former given the ndings of Astley et al. (2009). Furthermore, since generally low to
modest correlations are seen between the BRIEF and performance-based test scores in
FASD (Gross et al., 2015) and other populations (Lovstad et al., 2012; McAuley et al.,
2010), we expected to observe a similar limited relationship in our sample. We also
evaluated whether there are gender dierences on the BRIEF in Aboriginal children
with FASD. Based on the work of Rasmussen et al. (2006), we expected that girls would
be reported to have worse executive functions than boys, especially for the BRI and the
Inhibit scale, although these authors did not report on whether there were gender
eects within their Aboriginal subsample specically. Finally, we evaluated whether the
presence of psychiatric comorbidity is associated with greater impairment on the
BRIEF.
Method
Participants
The sample included a consecutive series of Aboriginal children with FASD referred for
neuropsychological assessment. The term Aboriginalrefers to those people who are
First Nations as characterized within the constitution of Canada. All children were
referred to a child neuropsychologist in private practice in Edmonton, Alberta, Canada
by psychiatrists, pediatricians, neurologists, or social workers. The presence of FASD
was primarily established by medical specialists (pediatricians, psychiatrists, pediatric
neurologists) in clinics specializing in the evaluation of FASD prior to referral for
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neuropsychological assessment, or in some cases conrmed upon further evaluation by
a neuropsychologist. This was based on medical history and evaluation, including
information about growth factors, facial morphology, central nervous system dysfunc-
tion, and an admission of alcohol use during pregnancy. The specic subtype of FASD,
based on the four-digit coding system (Astley, 2004), was available for only a small
subset of the patients, as reports provided by the FASD clinics generally concluded this
child meets the diagnostic criteria for FASDwithout reference to a specic four-digit
code.
Seven performance validity tests (PVTs) were used to determine the credibility of the
test performance: Word Memory Test standard cuto(Green, 2003), Medical Symptom
Validity Test standard cuto(Green, 2004), Non-Verbal Medical Symptom Validity
Test standard cuto(Green, 2008), TMT B/A ratio < 1.50 (Iverson, Lange, Green, &
Franzen, 2002), Wisconsin Card Sorting Test (WCST) Failure to Maintain Set > 3
(Greve, Heinly, Bianchini, & Love, 2009), ConnersContinuous Performance Test
Second Edition (CPT-II) omissions and perseverations t-scores > 100 (Conners, 2004).
The majority of the sample (65.4%) passed all PVTs, and 34.6% failed one.
The nal sample for analyses consisted of 52 children aged 916 years (mean = 13.2,
SD = 2.7). There were 23 girls (44.2%) and 29 boys (55.8%). The presence of comorbid
diagnoses was established from clinical evaluation and collateral sources of information.
Half of the children in the sample had at least one comorbid diagnosis. These included
ADHD (n= 12), conduct disorder (n= 2), nonverbal learning disability (n= 1),
language impairment (n= 2), mood disorder (n= 1), anxiety disorder (n= 1), post-
traumatic stress disorder (n= 1), reactive attachment disorder (n= 1), personality
disorder (n= 4), and pica (n= 1).
The children were usually raised on reserves until placed with Caucasian or
Aboriginal families (equally) in homes outside the reserve. All of the children were
either adopted or placed in foster homes. The children were typically exposed to the
English language from birth, and most attended either regular or specialized school
programs. Informed consent was obtained from a parent or other legal guardian for the
use of the childs demographics, diagnostic information, and neuropsychological test
data for the purpose of research. The study was approved by the University of Windsor
Ethics Review Board.
Procedure
Behavior Rating Inventory of Executive Function (BRIEF)
A caregiver completed the BRIEF (Gioia et al., 2000), an 86-item rating scale for
children and adolescents aged 518 years. Items are rated on a three-point scale
(with the responses never,sometimes,andoften), with higher scores reecting greater
diculty with executive function. The BRIEF yields an overall score, the GEC,
composed of two index scores: the Behavioral Regulation Index (BRI) and
Metacognition Index (MI). The BRI is comprised of three clinical scales (Inhibit,
Shift, and Emotional Control) and the MI is comprised of four clinical scales
(Working Memory, Plan/Organize, Organization of Materials, and Monitor). Raw
scores are converted to t-scores relative to the large normative sample (n= 1419). A
t-score of 65 or higher is considered impaired (Gioia et al., 2000). The measure has
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good psychometric properties, including internal consistency and test-retest reliabil-
ity, and there is a wealth of evidence for its usefulness for assessing executive
functioning in a variety of populations (for a review, see Roth et al., 2014). All
BRIEF proles met the published criteria for response validity.
Performance-Based Tests
Children with FASD were administered a battery of neuropsychological tests.
Intellectual functioning was assessed using the Full Scale IQ (FSIQ) from the
Wechsler Intelligence Scale for Children Third Edition (WISC-III; Wechsler, 1991)
or WISC Fourth Edition (WISC-IV; Wechsler, 2003). Executive functions were
assessed using the following measures.
Wisconsin Card Sorting Test (WCST) Total Perseverative Errors. The WCST (Heaton,
Chelune, Talley, Kay, & Curtis, 1993) measures concept formation and set shifting. The
child is asked to match key cards from a deck, one by one, to one of four key cards. The
cards can be matched based on one or more of three principles, and the child uses
feedback from the examiner to determine which of these principles is correct at any
given time. Once the child demonstrates an understanding of the operating matching
criterion by obtaining ten consecutive correct scores, the criterion is changed without
warning to the child. The test is discontinued when the child successfully completes six
categories (ten consecutive correct matches per category) or when all 128 cards have
been sorted.
Trail Making Test (TMT) Time to Complete Part A and Part B. The TMT (Reitan &
Wolfson, 1985)is a timed paper-and-pencil test consisting of two parts. The childrens
version of the TMT is used for children aged 9 to 14 years, while the adult version is
used for individuals aged 15 years and over. In Part A (TMT-A), participants are
presented with numbered circles scattered around the page and asked to connect
them in numerical order as quickly as possible. The childrens version consists of 15
circles, while the adult version consists of 25 circles. Part B (TMT-B), which is
considered a measure of set shifting, requires participants to connect encircled numbers
and letters in alternating order as quickly as possible (i.e., 1-A-2-B-3-C. . .).
Controlled Oral Word Association Test (COWAT) Total Correct. The Controlled Oral
Word Association Test (COWAT; Spreen & Benton, 1977) is a task of phonemic verbal
uency in which children are asked to orally generate as many words as they can that
begin with a specic letter (F,A, and Sin this study) in 60-second trials. Children
are not permitted to use proper nouns (i.e., the names of people or places).
ConnersContinuous Performance Test Second Edition (CPT-II) Errors of Omission,
Errors of Commission, and Mean Hit Reaction Time. The CPT-II (Conners, 2004)i
sa
test in which letters are presented on a computer screen, one at a time, over a period of
approximately 14 minutes. Participants are instructed to respond by pressing the
spacebar when a letter appears on the screen, but to withhold their responses when
presented with the letter X (target). Errors of omission reect a failure to respond to
non-target stimuli, while errors of commission occur when the participant responds to
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an Xstimulus, reecting impulsivity. A fast mean hit reaction time can also reect
impulsivity, especially in the context of elevated errors of commission.
Statistical Analysis
To facilitate comparison with the BRIEF, neuropsychological test scores were converted
to t-scores using appropriate normative data, with higher scores reecting worse
performance. The exception is the FSIQ, for which the standardized scale score is
employed.
Descriptive statistics (mean, SD, range and skew) were computed for the variables of
interests. The percentage of children with scores in the clinical range (t65) was
computed. BRIEF scores for boys and girls, as well as subsets of participants with and
without a psychiatric comorbidity, were compared using independent sample t-tests.
Eect size was computed using Cohensd. Pearson correlation coecients were com-
puted between the BRIEF and performance-based measure scores. All analyses used
p< .05 two-tailed signicance tests to determine signicance.
Results
Outlier Analysis
While all BRIEF scores had a skew within ±1.0, while most were within ±0.50, some of
the cognitive tests had excessive skew in the impaired direction (TMT-A: 2.89; TMT-B:
1.92; CPT-II Errors of Omission: 1.26). Outliers on these scales were replaced with the
t-score corresponding to a z-score of +2.0, computed using the standard raw-to-z
transformation formula. This procedure reduces the undue inuence of extreme scores
while still preserving their relative standing within the sample (Field, 2005).
Transformed scores were used in subsequent analyses.
The BRIEF and Neuropsychological Test Performance
Table 2 presents the BRIEF and neuropsychological test results. All of the mean BRIEF
scale and index scores were in the impaired range, with the exception of Organization of
Materials. Among the scales, Working Memory and Inhibit had the highest mean t-scores.
A majority of the children were rated as being in the impaired range on the indices and
scales. Among the scales, the percentage impaired ranged from a low of 55.8% for
Organization of Materials to a high of 82.7% for Working Memory, with about 70% of
children being impaired on most scales. For both the MI and the GEC, over 80% of
children fell into the impaired range, while 73.1% were impaired on the BRI.
On the neuropsychological measures, the mean FSIQ fell into the low average range,
with scores ranging from the borderline to average range. Mean scores on letter uency
and TMT-B were in the impaired range, with the majority of children scoring in the
impaired range (66.8% and 78%, respectively). In contrast, perseverative errors on the
WCST, TMT-A and CPT-II variables were not in the impaired range, with only around
one quarter of the children obtaining scores within the impaired range on these
measures.
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Many BRIEF and neuropsychological test scores had a bimodal distribution
(Table 2). For most BRIEF scales, a rst peak was observed around the cutofor
impairment, while a second peak reected more severe impairment. A similar trend was
observed for FSIQ and TMT-B. For FAS, TMT-A and CPT-II a rst peak was well
within the normal range, while a second peak was in the impaired range.
Eect of Psychiatric Comorbidity and Gender
Table 3 presents the BRIEF and performance-based test scores for children with and
without psychiatric comorbidities. No eect of comorbidity was observed for either the
BRIEF or the performance-based tests. Gender dierences on mean BRIEF t-scores
were also examined. No gender eect is observed for the BRIEF. On performance-based
tests, a lower FSIQ was found for boys (M= 79.9, SD = 7.7) than girls (M= 84.6,
SD = 9.3), t(50) = 2.0, p= .05, d= .55. Similarly, boys (M= 55.3, SD = 10.2) were more
perseverative than girls (M= 48.3, SD = 9.2) on the WCST, t(50) = 2.51, p< .05, d= .72.
No other signicant gender dierences are observed.
Correlation between the BRIEF and Neuropsychological Test Performance
Table 4 presents the correlations between the BRIEF and the neuropsychological test
scores. Few signicant correlations are observed. A greater number of perseverative
errors on the WCST is associated with better scores on the MI and Organization of
Materials. Slower reaction time on the CPT-II is associated with better Organization of
Table 2. Descriptive Statistics for BRIEF Parent Report and Performance-Based Tests in Aboriginal
Canadian Children with FASD.
Test MSDRange Skew % Impaired Peaks
BRIEF: Inhibit 73.6 14.8 41103 0.26 73.1 75 & 85
BRIEF: Shift 72.4 12.7 4094 0.34 75.0 65 & 85
BRIEF: Emotional Control 70.3 15.6 38123 0.30 69.2 -
BRIEF: Initiate 68.8 12.3 4393 0.25 69.2 55 & 70
BRIEF: Working Memory 74.0 11.1 4593 0.28 82.7 70 & 80
BRIEF: Plan/Organize 72.1 10.7 53103 0.50 75.0 -
BRIEF: Monitor 70.2 8.4 4786 0.56 76.9 65 & 75
BRIEF: Organization of Materials 63.6 10.1 3498 0.14 55.8 -
BRIEF: BRI 74.4 13.6 44109 0.27 73.1 -
BRIEF: MI 73.6 9.4 5492 0.23 80.8 75 & 85
BRIEF: GEC 75.0 11.4 38101 0.53 86.5 75 & 90
FSIQ 82.0 8.7 70102 0.35 38.5 72 & 90
WCST Perseverative Errors 52.2 10.3 2772 0.37 12.2 -
TMT-A* 59.4 15.1 36107 1.04 26.9 50 & 65
TMT-B* 78.0 28.8 35160 1.09 63.3 -
COWAT 66.8 13.8 3797 0.15 58.3 55 & 75
CPT-II Errors of Omission* 55.3 12.4 4183 1.13 20.0 45 & 80
CPT-II Errors of Commission 52.0 10.9 2372 0.50 8.0 40 & 65
CPT-II Mean Hit Reaction Time 47.5 10.3 2080 0.25 8.0 -
Note. *Outliers transformed by converting original value to raw score corresponding to z= 2.0.
BRI = Behavioral Regulation Index; COWAT = Controlled Oral Word Association Test; CPT-II = ConnersContinuous
Performance Test Second Edition; FSIQ = Full Scale IQ (standard score); GEC = Global Executive Composite; MI =
Metacognition Index; TMT-A = Trail Making Test, Part A; TMT-B = Trail Making Test, Part B; WCST = Wisconsin Card
Sorting Test. The Peaks column represents peaks in score distribution. Except for FSIQ, all scores on performance
measures are converted to t-scores, with higher scores reecting more severe impairment. The cutofor impairment
is t65.
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Materials. None of the other neuropsychological measures correlate with any BRIEF
index or scale score.
Discussion
In the present study, the parent report BRIEF results indicate signicant executive
dysfunction in the everyday lives of Aboriginal children with FASD. All three index
scores (the GEC, BRI and MI) are in the clinical range at the group level in this FASD
sample, with 7386% of the children having scores in the clinical range (t65). All
Table 3. Independent t-tests Comparing Parent Report BRIEF t-scores in Children with FASD with and
without Psychiatric Comorbidity.
Present (n= 28) Absent (n= 24)
Test M SD M SD p
BRIEF: Inhibit 73.0 14.2 74.3 15.7 .76
BRIEF: Shift 70.9 13.5 74.2 11.8 .35
BRIEF: Emotional Control 68.4 15.6 72.6 15.7 .34
BRIEF: Initiate 67.1 11.6 70.8 12.9 .28
BRIEF: Working Memory 72.4 10.1 76.0 12.2 .25
BRIEF: Plan/Organize 70.8 10.4 73.7 11.1 .34
BRIEF: Monitor 69.3 9.4 71.3 7.2 .38
BRIEF: Organization/Materials 62.6 8.2 64.8 11.9 .46
BRIEF: BRI 72.4 13.7 76.7 13.4 .26
BRIEF: MI 72.7 9.6 74.6 9.4 .47
BRIEF: GEC 74.3 10.3 75.8 12.7 .63
FSIQ 81.1 8.1 83.0 9.3 .43
WCST Perseverative errors 53.0 10.7 51.1 9.9 .51
TMT-A 59.8 14.8 59.0 15.8 .86
TMT-B 76.6 24.6 79.7 33.3 .71
COWAT 66.5 12.3 67.2 15.6 .87
CPT-II Omissions 56.7 13.4 53.7 11.3 .40
CPT-II Commissions 53.0 11.4 50.8 10.5 .48
CPT-II Hit Reaction Time 46.1 12.4 49.0 7.4 .33
Note. BRI = Behavioral Regulation Index; COWAT = Controlled Oral Word Association Test; CPT-II = ConnersContinuous
Performance Test Second Edition; FSIQ = Full Scale IQ (standard score); GEC = Global Executive Composite; MI =
Metacognition Index; TMT-A = Trail Making Test, Part A; TMT-B = Trail Making Test, Part B; WCST = Wisconsin Card
Sorting Test.
Table 4. Correlations between BRIEF Parent Report and Performance-Based Test Scores.
BRIEF Scale FSIQ WCST TMT-A TMT-B FAS OMI COM HRT
Inhibit .08 .22 .05 .03 .18 .07 .19 .16
Shift .27 .10 .25 .15 .13 .00 .06 .11
Emotional Control .12 .17 .09 .05 .04 .21 .05 .02
Initiate .17 .06 .27 .26 .19 .06 .28 .19
Working Memory .24 .11 .21 .26 .20 .03 .05 .16
Plan/Organize .02 .17 .09 .20 .11 .17 .00 .08
Monitor .14 .19 .25 .01 .09 .19 .03 .11
Organization of Materials .00 .31* .19 .00 .04 .06 .02 .35*
BRI .12 .15 .17 .10 .00 .11 .09 .10
MI .20 .34* .23 .05 .17 .11 .06 .24
GEC .21 .26 .24 .09 .12 .12 .04 .15
Note.*p <.05. BRI = Behavioral Regulation Index; COM = CPT-II errors of commission; COWAT = Controlled Oral Word
Association Test; CPT-II = ConnersContinuous Performance Test Second Edition; FAS = letter uency FSIQ = Full
Scale IQ (standard score); GEC = Global Executive Composite; HRT = CPT-II mean hit reaction time; MI =
Metacognition Index; OMI = CPT-II errors of omission; TMT-A = Trail Making Test, Part A; TMT-B = Trail Making
Test, Part B; WCST = Wisconsin Card Sorting Test. Except for FSIQ, all scores on performance measures are converted
to t-scores, with higher scores reecting more severe impairment. The cutofor impairment is t65.
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prior studies reporting BRIEF index scores have found that they are signicantly worse
in children with FASD relative to either the measures standardization sample or a
study-specic sample of TD children. Only three studies to date have reported the
percentage of children with FASD in their samples who are in the clinical range on the
BRIEF (Knuiman et al., 2015), two of which also observed very high rates, ranging from
71.4% to 90% (Astley et al., 2009; Rasmussen et al., 2007), and one reporting a rate of
46% for the GEC, though diagnostic grouping in that study was solely based on a
questionnaire completed by parents (Knuiman et al., 2015). The present ndings are
consistent with the few studies that have reported impairment, as reected by both the
BRI and MI t-scores (Astley et al., 2009; McGee et al., 2008; Rasmussen et al., 2007;
Stevens et al., 2013).
Mean scores for seven of the eight BRIEF scales were also in the clinical range in our
sample. The greatest diculty was endorsed for Working Memory, followed by Inhibit,
Shift and Plan/Organize, with all but Organization of Materials within a range of about
ve t-scores. Prior studies of non-Aboriginal samples have most commonly found the
greatest impairment on Working Memory, typically followed closely by Initiate, Inhibit
or Plan/Organize. Both in the present sample and in prior research, Organization of
Materials generally shows the least impairment, with studies diering with respect to
whether the score is in the clinical range or not. Together, these ndings indicate
widespread disruption of executive functions in children with FASD, at least as reported
by their parents. This is largely consistent with recent meta-analyses of performance-
based tests indicating that children with FASD are impaired in several aspects of their
executive function, including working memory, inhibition, planning, set shifting and
uency (Khoury et al., 2015; Kingdon et al., 2015).
This study has found that the presence of psychiatric comorbidity in children with
FASD did not have an impact on the BRIEF results. This contrasts with some prior
work which found that comorbidities such as ADHD are associated with worse execu-
tive function on the parent report BRIEF (Nguyen et al., 2014), although not on
performance-based executive function measures (Glass et al., 2013; Nguyen et al.,
2014). The reason for the present results is unclear, and there is not a suciently
large subset of children with a specic comorbidity such as ADHD to permit subgroup
analyses. Thus, the possibility that the present ndings are due, at least in part, to the
presence or lack thereof of specic comorbid diagnoses among this FASD sample
cannot be ruled out. Additional studies evaluating the impact of prevalent comorbid-
ities in FASD on ratings of executive functioning, in both Aboriginal and non-
Aboriginal samples, are needed to clarify this issue.
A sizeable subset of this sample of Aboriginal children with FASD was impaired on
performance-based tests of executive function, most prominently on Trails B (63.3%)
and letter uency (58.3%). Rates of impairment on the other cognitive measures
(excluding FSIQ) range from a low of 8.0% (CPT-II errors of commission and mean
hit reaction time) to a high of 26.9% (Trails A). Overall, the children have much higher
rates of executive dysfunction as assessed by the BRIEF than by performance-based
tests. Not surprisingly, almost no signicant relationships are observed between parent
report of executive functioning and test performance. This is consistent with prior
research on children with FASD (Gross et al., 2015), as well as a broader literature
showing generally none to at best modest correlations in a variety of pediatric patient
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samples (Lovstad et al., 2012; McAuley et al., 2010). This discrepancy may indicate that
rating scales and performance-based tests tap dierent aspects of executive functions, or
that children with FASD may be unable to adequately engage their execute abilities in
their everyday lives. The possibility that elevated parental ratings may at least partly
reect a negative bias, such as due to parental frustration with respect to behavior,
cannot be completely ruled out. However, while there is inherent subjectivity in parent
report of cognitive functioning, recent neuroimaging studies showing associations
between the GEC and brain integrity on magnetic resonance imaging scans in children
with FASD lends support to the validity of the BRIEF as tapping into cognitive
dysfunction in this population (Gautam et al., 2015; Wozniak et al., 2013). It is also
possible that the ability to identify a signicant relationship between the BRIEF and
performance-based tests in this study has been impacted by the selection of measures.
In particular, tests designed to place great demands on working memory were not
included, though prior studies have not observed a relationship between the BRIEF
Working Memory and tests of working memory (e.g., the WISC-IV Working Memory
Index and Digit Span Backwards) in children with FASD (Gross et al., 2015; Nguyen
et al., 2014). Nevertheless, given that few studies have examined this relationship, future
studies should therefore consider including tests of working memory.
Poorer parent rated executive function is not associated with lower intellectual
functioning in the present sample of Aboriginal children with FASD, restricted to
those with an FSIQ of at least 70. This is consistent with research indicating that the
level of intellectual functioning is associated with executive functioning but does not
fully account for impairment on either the BRIEF (Nguyen et al., 2014) or performance-
based tests of executive functioning (Burden, Jacobson, Sokol, & Jacobson, 2005;
Rasmussen, 2005) in FASD. Nonetheless, the presence of both lower intellectual
functioning and impaired executive functions on the BRIEF has been associated with
more behavioral problems, as rated by teachers in children with FASD (Schonfeld et al.,
2006). Thus, children with FASD with both a low IQ and executive dysfunction may be
at risk for worse outcomes than children with the disorder who have only one or
neither of these diculties.
No gender dierences are observed on the BRIEF in the present sample, in contrast
with a prior study where girls had worse overall scores than boys (Rasmussen et al.,
2006). The reason for this discrepancy is unclear, but may be a sample-speciceect.
The present nding of minimal sex dierences on the BRIEF is, however, consistent
with results of a recent meta-analysis indicating that gender is not consistently related
to executive functioning in FASD (Kingdon et al., 2015).
Interestingly,whileBRIEFscoresinthepresentFASDsamplearetypicallyinthe
impaired range, a bimodal distribution is observed for most scores, with one peak
close to the clinical cutoof t65 and another 1.0 to 2.0 SDs higher. This suggests
the presence of subsets of children with FASD with milder and more severe execu-
tive dysfunction, at least as reected by parent ratings. The present ndings suggest
that gender and the presence of psychiatric comorbidity in general cannot account
for these subsets, although intellectual functioning might play a role. It is possible
that the present sample is composed of a mix of FASD subtypes, with subtype
dierences on the BRIEF having been reported in one study (Stevens et al., 2013)
but not in others (Astley et al., 2009;Schonfeldetal.,2006). Unfortunately,
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information on the specic subtype of FASD was not available for the participants in
this study. Further research is needed to determine whether there are characteristics
(e.g., FASD subtype, biological, psychosocial, specic comorbidities) which dier-
entiate these subsets of children and which could help inform interventions to
ameliorate their diculties with executive functions.
The present study should be interpreted in the context of its limitations. It is possible
that BRIEF scores in this sample are articially elevated, since central nervous system
dysfunction is one of the criteria employed to identify the presence of FASD. However,
this is unlikely to account for these ndings, given that the mean scores are comparable
to those reported in other studies of parent report BRIEF. Although a minimal eect is
observed on the BRIEF scores for having a comorbid psychiatric diagnosis, there is not
asucient subset of any given diagnosis to identify potentially more speciceects. In
particular, previous research has found that children with PAE and comorbid ADHD
are reported has having worse executive functions on the BRIEF than children with
PAE but without ADHD in some studies (Nguyen et al., 2014), but not in others
(Rasmussen et al., 2010). As symptoms of ADHD are highly prevalent in Aboriginal
Canadian children (Baydala, Sherman, Rasmussen, Wikman, & Janzen, 2006), further
evaluation of BRIEF scores in subsamples of these children with FASD both with and
without ADHD is important.
This study focuses on parent report of executive functioning. At least one study has
found that problems on the BRIEF in children with FASD are reported to be more
severe by teachers than parents (Rasmussen et al., 2006). It is unclear whether this
discrepancy is due to such factors as dierent contextual demands placed on the
childrens executive functions (school versus home), rater expectations (e.g., greater
self-regulation expected in the classroom), some combination of these and/or other
factors. Thus, studies comparing parent and teacher reports on the BRIEF in Aboriginal
children with FASD are needed.
The BRIEF scores in this study are examined relative to the standardization sample
(Gioia et al., 2000), consistent with many other studies using the measure in FASD. No
eect of ethnicity on BRIEF scores was observed in a study that included a small
subsample of Aboriginal Canadians (Rasmussen et al., 2006), and there is evidence that
BRIEF parent report scores are unrelated to geographic location in TD children (Roth,
Erdodi, McCulloch, & Isquith, 2015). Nonetheless, the lack of Aboriginal TD and non-
Aboriginal FASD control groups precludes the determination of whether ethnic back-
ground and/or environmental factors impact on executive functions in Aboriginals with
FASD (e.g., cohort eects, sociocultural dierences).
All of the children in the present study were either adopted or in foster care.
Problems with executive function have been reported in adopted children on perfor-
mance-based tests (Colvert et al., 2008; Hostinar, Stellern, Schaefer, Carlson, & Gunnar,
2012) and parent ratings on the BRIEF (Merz & McCall, 2011; Merz, McCall, & Groza,
2013). Although the precise reason for these ndings remains unclear, early psychoso-
cial deprivation, lower quality of physical/social care in institutions, and genetic inu-
ences have all been suggested as playing a role (Hostinar et al., 2012; Leve et al., 2013;
Merz & McCall, 2011). Further research evaluating the extent to which such factors
may contribute to executive dysfunction in adopted/foster care children with FASD will
therefore be helpful not only with respect to informing our understanding of the
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etiology and maintenance of executive dysfunction in this population but also in terms
of identifying possible preventative and intervention strategies.
In summary, the present study indicates that Aboriginal Canadian children with
FASD show signicant executive dysfunction, as reected by both parent report and
performance-based tests. Such dysfunction may contribute to the problems that chil-
dren with the disorder experience in school, home life, and interpersonal relations.
Thus, interventions targeted at ameliorating executive dysfunction in these children
appears warranted, and may yield broad benets for their functioning.
Disclosure statement
No potential conict of interest was reported by the authors.
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... En el caso concerniente, existen tres estudios anteriores que aplican la prueba BRIEF-2 para la evaluación de todas las funciones ejecutivas en población afectada por TEAF en Reino Unido y Canadá, manifestándose alteraciones significativas en la mayoría de los dominios que evalúa la prueba, excepto en el dominio "organización de materiales" (Rai et al., 2017;Rasmussen et al., 2006;Zameer et al., 2020). Los resultados de este estudio discurren siguiendo un patrón similar a los obtenidos en los trabajos de Rai et al. (2017), McLachlan et al. (2017, Zameer et al. (2020) entre otros, esto es, los participantes afectados por TEAF muestran diferencias significativas en los dominios de funcionamiento ejecutivo evaluados (inhibición, supervisión de sí mismo, flexibilidad, control emocional, iniciativa, memoria de trabajo, planificación y organización, supervisión de la tarea y organización de materiales). ...
... En el caso concerniente, existen tres estudios anteriores que aplican la prueba BRIEF-2 para la evaluación de todas las funciones ejecutivas en población afectada por TEAF en Reino Unido y Canadá, manifestándose alteraciones significativas en la mayoría de los dominios que evalúa la prueba, excepto en el dominio "organización de materiales" (Rai et al., 2017;Rasmussen et al., 2006;Zameer et al., 2020). Los resultados de este estudio discurren siguiendo un patrón similar a los obtenidos en los trabajos de Rai et al. (2017), McLachlan et al. (2017, Zameer et al. (2020) entre otros, esto es, los participantes afectados por TEAF muestran diferencias significativas en los dominios de funcionamiento ejecutivo evaluados (inhibición, supervisión de sí mismo, flexibilidad, control emocional, iniciativa, memoria de trabajo, planificación y organización, supervisión de la tarea y organización de materiales). ...
... Confirmándose de este modo una de las hipótesis de partida de este estudio, es decir, las diferencias encontradas en el funcionamiento ejecutivo en función del sexo son de escasa relevancia estadística en este grupo de edad. Estos resultados son confirmados por los obtenidos en los trabajos de Herman et al. (2008) o Rai et al. (2017), en los que no se detectan diferencias estadísticamente significativas entre las mediciones del deterioro del funcionamiento ejecutivo entre niños y niñas mediante la prueba BRIEF-2. ...
Chapter
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El Trastorno del Espectro Alcohólico Fetal reúne una heterogeneidad de condiciones relacionadas con la exposición prenatal al alcohol, asociadas a anomalías faciales, de crecimiento y de peso inusual considerando los parámetros establecidos por edad, a irregularidades en las estructuras cerebrales y dificultades neurocognitivas, entre las que se incluye el deterioro en la capacidad intelectual, dificultades para el aprendizaje, alteraciones en la memoria y déficits en la capacidad visoespacial, en el funcionamiento ejecutivo y en la capacidad de autorregulación (Hoyme et al., 2016). Más allá de estas inherentes particularidades del TEAF, existen otras que suponen un obstáculo adicional que afecta a la calidad de vida como, por ejemplo, dificultades en el funcionamiento autónomo y en las actividades de la vida diaria, afecciones en la salud mental, problemas con la justicia y barreras para el aprendizaje y en la participación en la comunidad (Petrenko et al. 2019). Para hacer frente a estas barreras, es preciso un proceso de cambio. En el contexto de la educación inclusiva, este proceso no solo involucra a las escuelas y a los miembros que la conforman, sino también a las Administraciones Públicas y a los agentes externos que abogan por una enseñanza equitativa para toda la diversidad del alumnado (Sandoval et al., 2002). Tomando en consideración la dimensión cultural del Index for Inclusion, la labor de las familias es esencial para trabajar en sintonía con el centro educativo y los agentes implicados hacia una filosofía de inclusión. Así, el entorno familiar juega un papel fundamental a la hora de determinar el grado de desarrollo de sus hijos, y más concretamente, del niño, niña y adolescente con un diagnóstico de Trastorno del Espectro Alcohólico Fetal (Olson et al., 2009). Sin embargo, la mayoría de las familias se encuentran con multitud de obstáculos como, por ejemplo, las necesidades individuales del niño junto a las implicaciones subyacentes del diagnóstico, las interpretaciones erróneas por parte la sociedad sobre las condiciones conductuales del TEAF, la falta de conocimiento sobre este trastorno por parte de la comunidad educativa y la ausencia de un diagnóstico temprano (Petrenko et al. 2019). La investigación actual sobre TEAF debe progresar en pro de la evaluación de los dominios afectados por el TEAF (fisionómicos, neurocognitivos, etc.), considerando no solo la perspectiva clínica, sino también la de los cuidadores de la persona afectada con este trastorno (Zameer et al., 2020). De manera específica, es preciso un abordaje de los dominios cognitivos afectados por el TEAF, que incluyen trastornos del neurodesarrollo, discapacidad intelectual, déficit de atención, hiperactividad, dificultades para el aprendizaje, velocidad de procesamiento disminuida, problemas en la memoria de trabajo, problemas en el lenguaje receptivo, comprensión deficiente del contexto social, alteraciones del comportamiento y de la función ejecutiva, a lo largo del ciclo vital, es decir, se necesita una recopilación de información en población infantil, adolescente, adulta y anciana para discernir cómo
... Likewise, the influence of gender on the expression of difficulties in executive and behavioral functioning in cases of comorbidity with ADHD should be considered [17]. In this sense, gender plays an important role in the profile of cognitive and behavioral functioning, with a greater deterioration in males [18]. ...
... In the first instance, the BRIEF-2 neuropsychological test provides a measure of executive function assessment based on an ecological perspective [14]. There are three previous studies that apply the BRIEF-2 test for the assessment of all executive functions in the population affected by FASD in the United Kingdom and Canada, showing significant alterations in most of the domains assessed by the test, except in the domain "organization of materials" [12,18,22]. The results of this study follow a similar pattern to those obtained in different works [12,18,23]. ...
... There are three previous studies that apply the BRIEF-2 test for the assessment of all executive functions in the population affected by FASD in the United Kingdom and Canada, showing significant alterations in most of the domains assessed by the test, except in the domain "organization of materials" [12,18,22]. The results of this study follow a similar pattern to those obtained in different works [12,18,23]. That is, participants affected by FASD show significant differences in the executive functioning domains assessed (inhibition, self-monitoring, flexibility, emotional control, initiative, working memory, planning and organization, task monitoring, and organization of materials), with working memory being the most impaired variable and organization of materials the least impaired, although in some cases they continue to belong to the clinical population. ...
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Associations and families demand the need to raise awareness of the implications in the cognitive and behavioral development of children with Fetal Alcohol Spectrum Disorder (FASD) that affect their learning and school participation. This study aims to generate a profile of executive and behavioral functioning in children and adolescents diagnosed with FASD. A probabilistic sampling by clusters (associations for individuals with FASD) is applied. The sample is composed of 66 families from three associations. The BRIEF-2 and SENA tests were administered to assess executive and behavioral functioning domains. Data analysis found that the executive and behavioral functioning profile of individuals with FASD varies with age, with greater impairment in middle and late adolescence. Likewise, the domain of executive functioning most affected in any of the developmental stages is working memory. Finally, cognitive impairment in the executive functioning domains has a direct impact on the social and adaptive functioning of people with FASD.
... The Behavior Rating Inventory of Executive Function (BRIEF; Gioia et al., 2000) is one of the most frequently used forms of indirect assessment of executive functioning across research and clinical contexts (e.g., Khoury & Milligan, 2019) and is the only executive functioning rating scale listed in the Canadian guidelines (Cook et al., 2016). Studies using the BRIEF have consistently demonstrated that caregivers of children with PAE often report significant concerns around applying executive functioning skills, with most mean ratings falling near or above the clinically elevated range (e.g., Astley et al., 2009;Gross et al., 2015;Mohamed et al., 2019;Nguyen et al., 2014;Rai et al., 2017;Taylor & Enns, 2019). ...
... The first Canadian study to examine this relationship among children with FASD used all of the BRIEF clinical scales, index, and composite scores and several tests that were not included in previous studies (Rai et al., 2017). Scores on a measure of cognitive flexibility, the Wisconsin Card Sorting Test, were found to be significantly correlated with the Organization of Materials scale (r = -.31) and the MI (r = -.34). ...
... Examining this association among additional clinical populations is also important from a research standpoint given that executive functioning skills may vary across clinical groups. For example, Mohamed et al. (2019) found higher mean caregiver ratings across the BRIEF scales among a sample of children diagnosed with FASD at The FASD National Behavior Clinic in the United Kingdom (UK) than a sample of children with FASD who were assessed through private practice in Alberta, Canada (Rai et al., 2017). ...
Article
Full-text available
Research to date has found discrepancies between performance-based measures and caregiver ratings of executive functioning among children with fetal alcohol spectrum disorder (FASD). These studies are limited by the participant sample, the assessment measures available, and the type of analyses used to examine this relationship. The main objective of the current study was to extend the literature on the association between tests and caregiver ratings of executive functioning by addressing limitations of past research and examining this association among children with prenatal alcohol exposure (PAE) with and without a diagnosis of FASD. Participants were 212 children with PAE, including 99 children with and 113 without FASD. Caregiver ratings and most of the scores on tests of executive functioning were above and below the normative mean range, respectively. None of the correlations between tests and caregiver ratings of executive functioning were significant across the groups. The results of this study suggest that tests and caregiver ratings of executive functioning may not measure the same construct or other factors may be impacting the strength and significance of the relationship. Directions for future research and clinical implications are provided.
... Psychosocial impacts associated with PAE can include cognitive impairment; impaired executive function skills such as behavior regulation, decision-making, and planning; a greater likelihood of having mental health challenges such as depression and anxiety; and higher rates of contact with juvenile justice and child welfare systems. These can occur in the absence of distinguishable facial characteristics (Bagheri et al., 1998;Beckett, 2011;Brownell et al., 2019;Kaemingk & Halverson, 2000;Rai et al., 2017). These impacts can rise to the level of diagnosable conditions (e.g., fetal alcohol syndrome (FAS), alcohol-related neurodevelopmental disorder, neurobehavioral disorder associated with PAE) that collectively are referred to as fetal alcohol spectrum disorders (FASDs). ...
Article
Full-text available
Tribal communities face critical challenges in identifying and addressing substance use by pregnant women. These challenges are often exacerbated by limited resources for services and limited research on effective interventions. To address these challenges, tribal communities are developing innovative and culturally resonant approaches to address prenatal alcohol exposure (PAE) and prenatal substance exposure (PSE). This article describes an environmental scan that was completed to understand and support the important work of these communities. It concludes with a discussion of the implications for tribal practitioners, specifically those in child welfare as well as policymakers and funders in child welfare and allied service provision systems, and provides potential directions for future research.
... This supported previous recommendations that BRIEF should be considered alongside current diagnostic assessments when establishing the presence of FASD [40], as clinically elevated scores appear widely among FASD populations. This finding is also consistent with international reports of elevated BRIEF scores among children with FASD [41,42], suggesting the phenomenon persists cross-culturally. There was variation in the ASD responses to the BRIEF. ...
Article
Full-text available
Background The term Fetal Alcohol Spectrum Disorders (FASD) describes a range of neurodevelopmental conditions, the direct result of prenatal alcohol exposure. FASD encompasses a range of behavioural, cognitive and sleep patterns that are sometimes indiscernible from other neurodevelopmental conditions, one in particular being Autism Spectrum Disorders (ASD). This study aimed to provide a comparison of behavioural, cognitive, affect-related and sleep profiles in children aged between 6 and 15 years with diagnoses of FASD or ASD, in contrast to typically developing (TD) children. Methods We compared 29 children with FASD, 21 children with ASD and 45 typically developing (TD) children on parental-reported questionnaires measuring behaviour and executive functioning: the Child Behaviour Checklist (CBCL), the Spence Children’s Anxiety Scale (SCAS) and the Behaviour Rating Inventory for Executive Function (BRIEF). Additionally, parents completed the Children’s Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches while sleeping to objectively capture their sleep habits. The three groups were compared using ANCOVA, controlling for age effects. Results Children with FASD scored significantly higher than the other two groups on the CBCL subscales of attention problems, somatic complaints, social problems, delinquency, and aggressive behaviour, as well as the panic subscale of the SCAS. Children with FASD also scored higher on all measures of the BRIEF than the ASD and TD groups, indicating greater problems with working memory and more difficulty shifting between tasks, planning, organising, inhibiting their behaviour and exercising emotional control. Nocturnal sleep duration in children with FASD was reported as one hour less than TD children and 46 minutes less than children with ASD per night. Conclusions The findings in this study highlight several syndrome specific features (shorter sleep duration, executive functioning difficulties, and higher levels of social and behavioural problems and panic) that potentially contribute to the unique phenotype of FASD. Whilst this research highlights the need for further work in this area, initial clinical screening for FASD should take such data on discernible characteristics, particularly the syndrome specificity of the BRIEF, into consideration.
... It is sensitive to deficits in language and pragmatic communication. As parent-reported and directly measured abilities often do not align among this population (e.g., Gross, Deling, Wozniak & Boys, 2015;Nguyen et al., 2014;Glass et al., 2014;Rai et al., 2017;Mohamed et al., 2019), inclusion of parent-reported general language abilities provides a comprehensive profile of overall language abilities and allows for examination of direct versus subjective measures. The General Communication Composite standard score (M = 100, SD = 15) was used in analyses as a measure of general language abilities. ...
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Objective Language and communication are largely understudied among youth with fetal alcohol spectrum disorders (FASD). Findings have been mixed, and have generally focused on more severely affected (i.e., children with FAS alone) or younger children. This study aimed to elucidate the profiles of language (i.e., receptive, expressive, general language) and communication (i.e., functional, social) abilities in adolescents with FASD. Method Participants aged 12–17 years with (AE = 31) and without (CON = 29) prenatal alcohol exposure were included. Receptive and expressive language were measured by the Clinical Evaluation of Language Fundamentals – Fifth Edition (CELF-5). Parents or caregivers completed the Children’s Communication Checklist – Second Edition as a subjective measure of general language skills. Functional communication was measured by the Student Functional Assessment of Verbal Reasoning and Executive Strategies and parents or caregivers completed the Social Skills Improvement System Rating Scales as a measure of social communication. Multivariate analysis of variance determined the overall profiles of language and communication and whether they differed between groups. Results The AE group performed significantly lower than the CON group on receptive language and parent report of general language while groups did not significantly differ on expressive language. Groups did not significantly differ on functional communication while social communication was significantly lower in the AE group. Conclusions Results of this study provide important information regarding the overall profile of basic language abilities and higher-level communication skills of adolescents with FASD. Ultimately, improving communication skills of youth with FASD may translate to better overall functioning.
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Children with prenatal alcohol exposure (PAE) and Fetal Alcohol Spectrum Disorder (FASD) have high rates of sleep disturbance and marked difficulties with executive functioning (EF). Sleep disturbance has been associated with poorer EF across development in typically developing children. The contribution of insomnia symptoms and nightmares to EF difficulties in children with PAE and FASD is unclear. The current study examined whether caregiver-reported insomnia symptoms and nightmares predicted difficulties with EF in children with PAE who were assessed at FASD diagnostic clinics. Archival data on 116 children with PAE assessed at FASD diagnostic clinics were extracted from databases. Children were assigned to a preschool-age group (3.1 to 5.9 years, n = 40) and a school-age group (5.9 to 10.9 years, n = 76). Insomnia symptoms and nightmares were measured using items extracted from the Child Behavior Checklist (CBCL) while EF was measured using the caregiver and teacher Behavior Rating Inventory of Executive Function (BRIEF) rating forms. Bootstrapped regression models were used examine the effects of insomnia symptoms and nightmares on domains of EF in each group while adjusting for potential confounds. For preschool children, insomnia symptoms were associated with greater daytime tiredness while nightmares were associated with greater difficulties with Emergent Metacognition according to their teachers. For school-age children, insomnia symptoms predicted greater EF difficulties across most domains according to their caregivers but not teachers. Sleep disturbance may compound EF impairments in children with PAE and should be screened for as part of FASD diagnostic assessment.
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Background Executive dysfunction, especially impaired inhibitory control, is a common finding in individuals with fetal alcohol syndrome (FAS). Previous research has mostly focused on neural correlates of inhibitory deficits in children and adolescents. We investigated inhibitory functions and underlying cerebral activation patterns in young adult women with FAS. Methods Task performance and functional magnetic resonance imaging (fMRI) data were acquired during a Go/NoGo (GNG) inhibition task in 19 young adult women with FAS and 19 healthy female control subjects. Whole‐brain activation and task performance analyses were supplemented by region of interest (ROI) analyses of fMRI data within a predefined cognitive control network (CCN). Results Task performance did not differ significantly between groups on errors of commission, associated with inhibitory control. Similarly, overall activation within the preselected ROIs did not differ significantly between groups for the main inhibitory contrast NoGo > Go. However, whole‐brain analyses revealed activation differences in the FAS group when compared to controls under inhibitory conditions. This included hyperactivations in the left inferior frontal, superior temporal, and supramarginal gyri in the FAS group. Likewise, lateralization tendencies toward right‐hemispheric ROIs were weaker in FAS subjects. In contrast to comparable inhibitory performance, attention‐related errors of omission were significantly higher in the FAS group. Correspondingly, FAS subjects had lower activity in attention‐related temporal and parietal areas. Conclusions The known alterations of inhibitory functions associated with prenatal alcohol exposure in children and adolescents were not seen in this adult sample. However, differential brain activity was observed, reflecting potential compensatory mechanisms. Secondary results suggest that there is impaired attentional control in young adult women with FAS.
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This chapter provides a review of common chronic childhood illnesses that may either directly or indirectly impact cognitive functioning. Children with a history of central nervous system infection or compromise, chronic medical illnesses, acquired or congenital brain damage, and neurodevelopmental risk factors are included. The chapter also provides a “snapshot” overview of neurocognitive sequelae associated with chronic medical conditions. Factors that may impact the brain during critical early developmental periods include premature birth, low birth weight, and exposure to substances such as drugs and alcohol in utero. These conditions can result in permanent change in neurocognitive functioning with varying degrees of severity. These issues, along with mitigating factors, are discussed. The chapter also provides further detail regarding the neuropsychological sequelae associated with endocrinological conditions.
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Children with fetal alcohol spectrum disorders (FASD) are known to experience cognitive and neurobehavioral difficulties, including in areas of executive function and social skills development. Interventions for these challenges have focused on a number of areas, including parent-based training. Despite the general consensus that specific parenting styles consistent with an “authoritative” – warm but firm – parenting approach may influence behavioral self-regulation, it is not known what specific parental interaction styles are associated with child engagement and emerging executive function in this population. The current study used an observation-based behavioral coding scheme during parent–child play interactions and associated parent report-based executive function measures in children with FASD. Here, we demonstrate that parental interaction styles with increased responsive/child-oriented behavior and parental affect are associated with higher levels of child play engagement, while parental interaction that has increased achievement-orientation is associated with higher levels of emerging executive function in children with FASD. These findings help inform future studies on behavioral targets in parent-based training programs and highlight the importance of considering certain parental interaction styles during parent–child play.
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The Behavior Rating Inventory of Executive Function (BRIEF) was one of the first attempts to measure executive function via self- and informant reports of everyday functioning in the real-world environment and was the first published measure of these self-regulatory capabilities in children and adolescents (Gioia, Isquith, Guy & Kenworthy, 2000a). The impetus for the BRIEF arose among the authors in 1994 while trying to reconcile the often discrepant parent and teacher reports of children’s everyday functioning at home and in school with their performance on putative performance measures (i.e., “tests”) of executive function. At that time, there were few such performance measures of executive function developed for children and adolescents, no rating scales or structured observational methods for evaluating executive functions, and very few published articles on executive function in children (Bernstein & Waber, 2007).
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This paper reviews the magnetic resonance imaging (MRI) literature on the effects of prenatal alcohol exposure on the developing human brain. A literature search was conducted through the following databases: PubMed, PsycINFO and Google Scholar. Combinations of the following search terms and keywords were used to identify relevant studies: 'alcohol', 'fetal alcohol spectrum disorders', 'fetal alcohol syndrome', 'FAS', 'FASD', 'MRI', 'DTI', 'MRS', 'neuroimaging', 'children' and 'infants'. A total of 64 relevant articles were identified across all modalities. Overall, studies reported smaller total brain volume as well as smaller volume of both the white and grey matter in specific cortical regions. The most consistently reported structural MRI findings were alterations in the shape and volume of the corpus callosum, as well as smaller volume in the basal ganglia and hippocampi. The most consistent finding from diffusion tensor imaging studies was lower fractional anisotropy in the corpus callosum. Proton magnetic resonance spectroscopy studies are few to date, but showed altered neurometabolic profiles in the frontal and parietal cortex, thalamus and dentate nuclei. Resting-state functional MRI studies reported reduced functional connectivity between cortical and deep grey matter structures. Discussion There is a critical gap in the literature of MRI studies in alcohol-exposed children under 5 years of age across all MRI modalities. The dynamic nature of brain maturation and appreciation of the effects of alcohol exposure on the developing trajectory of the structural and functional network argue for the prioritisation of studies that include a longitudinal approach to understanding this spectrum of effects and potential therapeutic time points.
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Background: ADHD-like symptoms are common in FASD. FASD and ADHD groups both display executive function impairments, however, there is ongoing debate whether the pattern and magnitude of executive function deficits differs between these two types of disorders. Methods: An electronic literature search was conducted (PubMed, PsychInfo; 1972-2013) to identify studies comparing the executive functioning of children with FASD with ADHD or control groups. FASD groups included those with and without dysmorphy (i.e., FAS, pFAS, ARND, and other FASD diagnoses). Effect sizes (Hedges’ g, standardized mean difference) were calculated. Random effects meta-analytic models were performed using the metafor package for R. Results: Fifty-one studies met inclusion criteria (FASD N=2,115; ADHD N=453; controls N=1,990). Children with FASD showed the strongest and most consistent deficits in planning, fluency, and set-shifting compared to controls (Hedges’ g=-0.94, -0.78) and children with ADHD (Hedges’ g=-0.72, -0.32). FASD was associated with moderate to large impairments in working memory, compared to controls (Hedges’ g= -.84, -.58) and small impairments relative to groups with ADHD (Hedges’ g= -.26). Smaller and less consistent deficits were found on measures of inhibition and vigilance relative to controls (Hedges’ g=-0.52, -0.31); FASD and ADHD were not differentiated on these measures. Moderator analyses indicated executive dysfunction was associated with older age, dysmorphy, and larger group differences in IQ. Sex and diagnostic system were not consistently related to effect size. Conclusions: While FASD is associated with global executive impairments, executive function weaknesses are most consistent for measures of planning, fluency, and set-shifting. Neuropsychological measures assessing these executive function domains may improve differential diagnosis and treatment of FASD.
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Prenatal ethanol exposure (PEE) promotes alcohol intake during adolescence, as shown in clinical and pre-clinical animal models. The mechanisms underlying this effect of prenatal ethanol exposure on postnatal ethanol intake remain, however, mostly unknown. Few studies assessed the effects of moderate doses of prenatal ethanol on spontaneous and ethanol induced brain activity on adolescence. This study measured, in adolescent (female) Wistar rats prenatally exposed to ethanol (0.0 or 2.0 g/kg/day, gestational days 17-20) or non-manipulated (NM group) throughout pregnancy, baseline and ethanol-induced cathecolaminergic activity (i.e., colocalization of c-Fos and tyrosine hydroxylase) in ventral tegmental area (VTA), and baseline and ethanol-induced Fos inmunoreactivity (ir) in nucleus accumbens shell and core (AcbSh and AcbC, respectively) and prelimbic (PrL) and infralimbic (IL) prefrontal cortex. The rats were challenged with ethanol (dose: 0.0, 1.25, 2.5 or 3.25 g/kg, i.p.) at postnatal day 37. Rats exposed to vehicle prenatally (VE group) exhibited reduced baseline dopaminergic tone in VTA; an effect that was inhibited by prenatal ethanol exposure (PEE group). Dopaminergic activity in VTA after the postnatal ethanol challenge was greater in PEE than in VE or NM animals. Ethanol-induced Fos-ir at AcbSh was found after 1.25 g/kg and 2.5 g/kg ethanol, in VE and PEE rats, respectively. PEE did not alter ethanol-induced Fos-ir at IL but reduced ethanol-induced Fos-ir at PrL. These results suggest that prenatal ethanol exposure heightens dopaminergic activity in the VTA and alters the response of the mesocorticolimbic pathway to postnatal ethanol exposure. These effects may underlie the enhanced vulnerability to develop alcohol use disorders of adolescents with a history of in-utero ethanol exposure. Copyright © 2015. Published by Elsevier Ltd.
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Prenatal alcohol exposure is associated with a constellation of adverse physical, neurocognitive and behavior outcomes, which comprise a continuum of disorders labeled Fetal Alcohol Spectrum Disorders (FASD). Extant research has consistently identified executive functions (EF) as a central impairment associated with FASD. Despite this, heterogeneity exists regarding the strength of the association between FASD and different EF, and this association has not yet been quantitatively synthesized. The current meta-analysis reviews 46 studies that compare children and adolescents with FASD to participants without FASD, on a variety of EF measures. In accordance with Miyake et al. Cognitive Psychology, 41, 49– 100 (2000) three-factor model of EF, findings for the primary EF domains of working memory, inhibition, and set shifting are reviewed. Results indicate that children and adolescents with FASD demonstrate significant deficits across these EF, although the magnitude of effects diverged between EF, with working memory and inhibition yielding medium effects and set shifting yielding large effects. These results were moderated by sample characteristics, type of FASD diagnosis, and EF methodology. This quantitative synthesis offers novel future research directions.
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Children with prenatal alcohol exposure (PAE) may have cognitive, behavioral and brain abnormalities. Here, we compare rates of white matter and subcortical gray matter volume change in PAE and control children, and examine relationships between annual volume change and arithmetic ability, behavior, and executive function. Participants (n = 75 PAE/64 control; age: 7.1-15.9 years) each received two structural magnetic resonance scans, ∼2 years apart. Assessments included Wechsler Intelligence Scale for Children (WISC-IV), the Child Behavior Checklist and the Behavior Rating Inventory of Executive Function. Subcortical white and gray volumes were extracted for each hemisphere. Group volume differences were tested using false discovery rate (q < 0.05). Analyses examined group-by-age interactions and group-score interactions for correlations between change in volume and raw behavioral scores. Results showed that subjects with PAE had smaller volumes than control subjects across the brain. Significant group-score interactions were found in temporal and parietal regions for WISC arithmetic scores and in frontal and parietal regions for behavioral measures. Poorer cognitive/ behavioral outcomes were associated with larger volume increases in PAE, while control subjects generally showed no significant correlations. In contrast with previous results demonstrating different trajectories of cortical volume change in PAE, our results show similar rates of subcortical volume growth in subjects with PAE and control subjects. We also demonstrate abnormal brain-behavior relationships in subjects with PAE, suggesting different use of brain resources. Our results are encouraging in that, due to the stable volume differences, there may be an extended window of opportunity for intervention in children with PAE. Hum Brain Mapp, 2015. © 2015 The Authors Human Brain Mapping Published by Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.