Global DNA Methylation and Histone Posttranslational Modifications in Human and Nonhuman Primate Brain in Association with Prenatal Alcohol Exposure.

BACKGROUND: Based upon experimental animal studies, the neurodevelopmental abnormalities associated with prenatal alcohol exposure (PNAE)/fetal alcohol spectrum disorder (FASD) have been attributed, at least in part, to epigenetic modifications. However, there are no direct analyses of human brain tissue. METHODS: Immunohistochemical detection of global epigenetic markers was performed on temporal lobe samples of autopsied fetuses and infants with documented PNAE. They were compared to age-, sex-, and postmortem delay-matched control cases (18 pairs; 20 to 70.5 weeks postconception). Temporal lobe tissue from a macaque monkey model of PNAE was also studied (5.7 to 6 months of age). We used antibodies targeting 4 DNA cytosine, 4 histone methylation, and 6 histone acetylation modifications and assigned scores based upon the semiquantitatively graded intensity and proportion of positively labeled nuclei in the ventricular and subventricular zones, ependyma, temporal cortex, temporal white matter, dentate gyrus (DG), and CA1 pyramidal layer. RESULTS: Temporal changes were identified for almost all marks according to the state of maturation in the human brain. In the DG (and 3 other brain regions), a statistically significant increase in H3K9ac was associated with PNAE. Statistically significant decreases were seen among 5mC, H3K4me3, H3K9ac, H3K27ac, H4K12ac, and H4K16ac in select regions. In the macaques, H3K36me3 decreased in the DG, and the ependyma showed decreases in 5fC and H3K36me3. CONCLUSIONS: In human brain, global intranuclear epigenetic modifications are brain region and maturation state-specific. These exploratory results support the general hypothesis that PNAE is associated with a global decrease in DNA methylation, a global decrease in histone methylation, and a global increase in histone acetylation. Although the human and monkey subjects are not directly comparable in terms of brain maturation, considering the rapid temporal changes in global epigenetic modifications during brain development, interspecies comparisons may be extremely difficult.

FAST Club: The Impact of a Physical Activity Intervention on Executive Function in Children With Fetal Alcohol Spectrum Disorder.

Physical activity (PA) has been demonstrated to have positive effects on cognitive function, particularly executive function (EF) skills. Animal models suggest PA may be effective in ameliorating some of the neuropsychological effects of fetal alcohol spectrum disorder (FASD), but this approach has not been extended to humans. The purpose of this study was to develop a PA program, FAST Club, for children with FASD and to evaluate its effect on a measure of EF. Using a wait-list control design, 30 children age 7-14 yr participated in FAST Club for 2 × 1.5-hr sessions/week for 8 weeks. EF was assessed using the Children's Color Trails Test. Significant improvements in T scores on the Children's Color Trails Test were seen immediately postprogram, and this improvement was sustained at 3 months postprogram. These findings provide evidence to support the use of PA as a means to improve EF in children with FASD.

Using a Common Form for Consistent Collection and Reporting of FASD Data from Across Canada: A Feasibility Study.

BACKGROUND: This study was undertaken to determine the feasibility of collecting information on individuals newly diagnosed with Fetal Alcohol Spectrum Disorder (FASD) in multi-disciplinary diagnostic programs across Canada. OBJECTIVE: To determine the frequencies of specific diagnoses within the spectrum, the frequencies and patterns of specific functional deficits, and the range of recommendations made for intervention and management for children and adults. METHODS: All qualifying clinics in Canada were invited to join this project and complete questionnaires on the patients that were seen during the research period. RESULTS: Over half of all clinics participated (25/45) and submitted the information requested on 307 individuals, ranging in age from 1 to 42 years. Two hundred and eighty-nine individuals had a diagnosis of FASD and were analysed further. The percent of individuals with Fetal Alcohol Syndrome was 2.1% of those with FASD diagnoses, which was lower than expected based on the literature. The level of disability among the entire FASD was always significant with at least 3 domains measured as severely impaired via the criteria for diagnosis but almost one-quarter were extremely disabled with 6 of a possible 9 brain domains measured significantly impaired. No specific patterns of functional disability were found to represent any significant subgroup of the patients. An average of 13 new recommendations for intervention and management were made for each patient in health, mental health, social services, and education. CONCLUSION: Although this was a pilot study with a relatively small sample, it is the largest collection of cases of FASD from multiple sites in one country ever published to our knowledge. It illustrates that important patient information can be collected across clinical programs considering the diagnosis of FASD but only with financial support for time and personnel. Using the methodology of a common data form, consistent data collection can be achieved and patterns and trends can be identified that can help with assuring consistency in diagnosis and with planning for improved patient outcomes.

Salivary cortisol levels are elevated in the afternoon and at bedtime in children with prenatal alcohol exposure.

Prenatal alcohol exposure can cause dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which may underlie some of the behavioral and adaptive problems seen in individuals with Fetal Alcohol Spectrum Disorders (FASD). Infants prenatally exposed to alcohol show altered basal and post-stress cortisol levels, but it is unknown if this persists beyond 2 years of age. It is also unknown if cortisol levels can be normalized through intervention programs. In this study, we investigated the effects of a physical activity program for children with FASD to determine: 1) if HPA dysregulation persists in school-age children with FASD, and 2) the effect of our program on cortisol levels. Twenty six children (ages 6-14 years) with FASD participated in an 8 week motor skill development program. Salivary cortisol levels were measured in 24 children and compared at 4 time points: before, immediately after, 3 months, and 1 year after program completion. Cortisol levels were also compared to 32 control children to evaluate the long-term effects of prenatal alcohol exposure on HPA regulation. For each time point, saliva was collected on each of 2 days at 3 times in the diurnal cycle: awakening, after school, and just before bedtime. Cortisol levels were significantly higher in the afternoon and at bedtime in children with FASD with confirmed prenatal exposure to high levels of alcohol (alcohol exposure rank 4), compared with Control children or children with FASD with exposure to low or unknown levels of alcohol (alcohol exposure rank 3). The program did not significantly affect cortisol levels in children with FASD as a group. These results provide support for long-term effects of prenatal alcohol exposure on the HPA system in humans, which could increase vulnerability to mental health issues and diseases later in life.

Cost of fetal alcohol spectrum disorder diagnosis in Canada.

BACKGROUND: Fetal Alcohol Spectrum Disorder (FASD) is underdiagnosed in Canada. The diagnosis of FASD is not simple and currently, the recommendation is that a comprehensive, multidisciplinary assessment of the individual be done. The purpose of this study was to estimate the annual cost of FASD diagnosis on Canadian society. METHODS: The diagnostic process breakdown was based on recommendations from the Fetal Alcohol Spectrum Disorder Canadian Guidelines for Diagnosis. The per person cost of diagnosis was calculated based on the number of hours (estimated based on expert opinion) required by each specialist involved in the diagnostic process. The average rate per hour for each respective specialist was estimated based on hourly costs across Canada. Based on the existing clinical capacity of all FASD multidisciplinary clinics in Canada, obtained from the 2005 and 2011 surveys conducted by the Canada Northwest FASD Research Network, the number of FASD cases diagnosed per year in Canada was estimated. The per person cost of FASD diagnosis was then applied to the number of cases diagnosed per year in Canada in order to calculated the overall annual cost. RESULTS: Using the most conservative approach, it was estimated that an FASD evaluation requires 32 to 47 hours for one individual to be screened, referred, admitted, and diagnosed with an FASD diagnosis, which results in a total cost of $3,110 to $4,570 per person. The total cost of FASD diagnostic services in Canada ranges from $3.6 to $5.2 million (lower estimate), up to $5.0 to $7.3 million (upper estimate) per year. DISCUSSION: As a result of using the most conservative approach, the cost of FASD diagnostic services presented in the current study is most likely underestimated. The reasons for this likelihood and the limitations of the study are discussed.

The Canadian guidelines and the interdisciplinary clinical capacity of Canada to diagnose fetal alcohol spectrum disorder.

BACKGROUND: In 2005, the CMAJ published the Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. The intent of this publication was to encourage a more consistent interdisciplinary team approach and diagnostic procedure for FASD diagnoses. That same year, the Canada Northwest FASD Research Network (CanFASD Northwest) determined the locations and capacity for interdisciplinary FASD diagnosis across Canada. Six years later, we wondered how successfully these Guidelines had been in bringing consistency to FASD clinical work. METHOD: All clinical programs in Canada that routinely performed FASD evaluations were identified through membership in either our Network Action Team on FASD Diagnosis, professional meetings, organizational memberships, websites, programs lists available from Provincial or Federal offices or by word of mouth. Surveys were sent to all of the programs identified. RESULTS: A total of 55 clinics had been identified in seven provinces and one territory in 2005 that did FASD multidisciplinary diagnostics. In 2011 only 44 clinics were identified in six provinces and one territory using the same methodology. Survey responses were completed by 89% of these 44 clinics identified in 2011. The Guidelines were well known to all programs and actively referred to by most. Only 46% of respondents had a full staff of professionals on site for diagnosis, however 90% did use the team approach in determining final FASD diagnosis, while 79% used the team to help in developing a treatment plan. Among the clinics reporting, 74% of them used the new diagnostic schema proposed in the Guidelines and another 12% report using both the Guidelines and another system for diagnosis. INTERPRETATION: The Guidelines have become well known to the medical community. They have contributed to increased consistency in approach and in diagnosis. The variations in clinical ability to fully staff themselves, and the 20% decline in clinic numbers suggest important funding gaps. Many provinces and territories still have no local interdisciplinary programs for FASD diagnosis, and the need across Canada is still many times greater than what is currently available.

Developing effective, culturally appropriate avenues to FASD diagnosis and prevention in northern Canada.

This article describes 2 research initiatives that are being undertaken by members of the Canada Northwest FASD Research Network, involving collaborations between researchers, clinicians, service providers and community members in the Canadian North. Improving both the diagnosis and prevention of FASD requires evidence-based approaches to clinical and social service delivery that are capable of accounting for the unique contours of the geographic, regional and cultural diversities in which women become pregnant and in which families live. Although FASD has been a priority for communities and governments in northern Canada, research capacity has not been available to support the development of the context-specific knowledge needed to inform policy and practice in this region. Moreover, there have not been adequate mechanisms for transferring practice-based knowledge from the Canadian North to researchers and service providers in the South, who might make use of this knowledge to inform their own practice. Herein, we highlight the ways in which reciprocal knowledge exchange involving CanFASD Northwest researchers at academic health science centres and diverse stakeholder groups is supporting multi-directional capacity building in FASD diagnosis and prevention.

Fetal alcohol spectrum disorders: gene-environment interactions, predictive biomarkers, and the relationship between structural alterations in the brain and functional outcomes.

Prenatal alcohol exposure is a major, preventable cause of behavioral and cognitive deficits in children. Despite extensive research, a unique neurobehavioral profile for children affected by prenatal alcohol exposure remains elusive. A fundamental question that must be addressed is how genetic and environmental factors interact with gestational alcohol exposure to produce neurobehavioral and neurobiological deficits in children. The core objectives of the NeuroDevNet team in fetal alcohol spectrum disorders is to create an integrated research program of basic and clinical investigations that will (1) identify genetic and epigenetic modifications that may be predictive of the neurobehavioral and neurobiological dysfunctions in offspring induced by gestational alcohol exposure and (2) determine the relationship between structural alterations in the brain induced by gestational alcohol exposure and functional outcomes in offspring. The overarching hypothesis to be tested is that neurobehavioral and neurobiological dysfunctions induced by gestational alcohol exposure are correlated with the genetic background of the affected child and/or epigenetic modifications in gene expression. The identification of genetic and/or epigenetic markers that are predictive of the severity of behavioral and cognitive deficits in children affected by gestational alcohol exposure will have a profound impact on our ability to identify children at risk.

Normal distribution of palpebral fissure lengths in Canadian school age children.

BACKGROUND: Fetal alcohol syndrome (FAS) includes the facial dysmorphic feature of short palpebral fissures (PFs) and short PFs are a key physical marker for identifying children with FAS and some other rarer conditions. There is concern that normative data on PFs now available may not reflect all racial/ethnic groups and might be inaccurate in general. OBJECTIVES: To accomplish a large population based study that would accurately determine normative PF values across the full diversity of the Canadian school age population. METHODS: A normative sample of school age children was identified in Vancouver, British Columbia and Winnipeg, Manitoba to reflect the diversity of racial and national groups in Canada. The sample included students in grades 2, 4, 6, 8, and 10 from 17 schools in Vancouver and 31 schools in Winnipeg. Schools were selected based on racial diversity obtained from data from the 2001 Statistics Canada census. 1064 students in Vancouver and 1033 students in Winnipeg were photographed in a standardized way. Photographs were analyzed using a computerized method. RESULTS: Analysis demonstrated that PFs do grow with age and there is a slight but meaningful difference between boys and girls in each age group. It is possible to define Canadian standards without reference to racial or ethnic origin. CONCLUSION: Mean results with norms and standard deviations are presented in figures for clinical use and are clinically smaller than those found in the most commonly used reference book.

Development of Canadian screening tools for fetal alcohol spectrum disorder.

BACKGROUND: Fetal alcohol spectrum disorder (FASD) is the most common cause of neurobehavioural handicap in North America. Screening for FASD may facilitate diagnosis and hence management of these children. We present a variety of screening tools for the identification of children at risk for FASD. METHODS: We critically reviewed and evaluated published and practiced methods for their potential of screening suspected cases, their epidemiological characteristics (sensitivity, specificity, positive and negative predictive values) [Phase I], as well as their feasibility [Phase II]. RESULTS: The following five tools were selected for the FASD screening toolkit: screening fatty acid ethyl esters in neonatal meconium, the modified Child Behaviour Checklist, Medicine Wheel tool, Asante Centre Probation Officer Tool, and maternal history of drinking and drug use. CONCLUSIONS: The toolkit for FASD screening aims at screening different populations, from the newborns to youth and at-risk mothers. It is anticipated that the toolkit will facilitate diagnosis of FASD.

Building clinical capacity for fetal alcohol spectrum disorder diagnoses in western and northern Canada.

BACKGROUND: Fetal alcohol syndrome and fetal alcohol spectrum disorder are common problems. In response to this problem the Canada Northwest FASD Research Network was established in 2005 by the Canada Northwest FASD Ministerial Partnership. This study was conducted to determine the FASD clinical activity in Canada Northwest. METHODS: The Network identified all clinical programs via Internet sites, provincial postings and professional word of mouth references that purported to do FASD assessments regularly using a multidisciplinary assessment team. Each of these programs was sent a questionnaire asking about clinical capacity, aggregate diagnostic results, team composition, time of clinical assessment and cost of assessment. RESULTS: Of the 27 programs identified to receive the questionnaire 15 programs responded. These programs were determined to have evaluated about 85% of the patients evaluated by all the programs. The total 7 jurisdictional capacity for FASD diagnosis was 816 evaluations in 2005 and projected to be 975 in 2006. Selection methods for appointing patients for assessment seemed excellent as 23% of those assessed were found to have FAS or pFAS and another 44% had other forms of FASD. The most common professionals to participate in the team evaluations were Paediatricians, Clinical Psychologists, Speech and Language Pathologists and Occupational Therapists. INTERPRETATION: Clinics are developing in western and northern Canada to diagnose patients with FASD. Comparing the experiences of these clinics can help to determine the continued need to increase diagnostic capacity, standardize diagnostic approaches to assure consistency of approach and diagnosis across the sites and appropriately staff and fund the programs. Key words: FASD; diagnosis; Canada; clinics.

Preventing fetal alcohol spectrum disorders. Preconception counseling and diagnosis help.

QUESTION: By the time women find out they are pregnant and see a family physician, they might have already consumed alcohol during the pregnancy and affected the development of their fetuses. How can family physicians better prevent exposure to alcohol during pregnancy? ANSWER: Women of childbearing age should be counseled about the risks associated with alcohol consumption during pregnancy before they become pregnant. Diagnosing children who have fetal alcohol spectrum disorders can help identify birth mothers who are at risk of other alcohol-exposed pregnancies and who need support to change their behaviour.

Variation in health care provider definitions of moderate consumption of alcohol as related to recommendations regarding alcohol consumption during pregnancy: results from a Canadian survey.

Women rely on health care providers for general health care and preconception counseling, including advice on alcohol consumption. Definitions of moderate consumption may differ by individual provider, resulting in inconsistency in advice and lack of clarity for patients both before and during pregnancy. The objective of this study was to determine if health care providers' definition of moderate alcohol consumption was associated with advice to pregnant women regarding alcohol use during pregnancy and to describe health care providers' communication regarding alcohol consumption. Between October 2001 and October 2002, a survey was mailed to a national random sample of 3114 Canadian obstetricians and gynecologists, midwives, and family physicians. The main outcome measure was questionnaire responses regarding knowledge and prevention issues related to alcohol and pregnancy as well as provider characteristics. Response rates ranged from 31.1% among family physicians to 63.5% among midwives. Moderate alcohol consumption among nonpregnant women was defined as 1 to 2 drinks per occasion by about 89% of providers and did not relate to recommendations during pregnancy. Those who recommended abstinence during pregnancy were more likely to define moderation as 4 or more occasions per week as compared with those who did not recommend abstinence (P=0.022). Fewer than 50% of providers frequently defined "moderation" for their patients. More family physicians (90.0%) than obstetricians (83.9%) or midwives (81.1%) recommended alcohol abstinence during pregnancy (overall 87.8%, P=0.005). Thus, there is opportunity for providers to appropriately counsel their patients by advising alcohol abstinence during pregnancy and more frequently defining "moderation" for all clients.

Clinical practice characteristics and preconception counseling strategies of health care providers who recommend alcohol abstinence during pregnancy.

OBJECTIVE: National initiatives on fetal alcohol syndrome in Canada and the United States aimed at prevention, identification, and treatment of individuals who are affected by alcohol exposure in utero recommend that women abstain from consuming alcohol during pregnancy. Health care providers are key educators regarding appropriate alcohol use. The objective of this study was to describe characteristics of physicians who recommend alcohol abstinence during pregnancy with regard to knowledge of fetal alcohol syndrome and preconception counseling strategies. METHODS: A survey was mailed to Canadian physicians and midwives between 2001 and 2002. Participants consisted of a national random sample of 1090 Canadian obstetricians and gynecologists, midwives, and family physicians who were current members of provincial and national professional organizations. The main outcome measure was questionnaire responses to knowledge, prevention, and diagnosis of issues related to alcohol use during pregnancy. RESULTS: Response rates ranged from 31.1% among family physicians to 63.5% among midwives. Overall, 91.2% of providers recommended abstinence from alcohol during pregnancy. These providers were significantly more likely to believe that there is sufficient information about alcohol use and that clients were interested in discussing alcohol (p < 0.05). They were also significantly more likely to discuss depression, personal alcohol use, partner's use of alcohol, and family history of alcohol misuse with women of childbearing age (p < 0.05). Once a patient became pregnant, fewer practice differences were noted, although those who recommended alcohol abstinence were significantly more likely to take clinical action when pregnant patients were consuming moderate amounts of alcohol (p < 0.05). CONCLUSIONS: It is encouraging that almost 90% of Canadian health care providers recommend abstinence from alcohol during pregnancy. However, differences in clinical practice exist between providers who recommend alcohol abstinence during pregnancy as compared with those who recommend a "glass in moderation."

Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population.

We determined the prevalence of fetal alcohol syndrome (FAS) in a foster care population and evaluated the performance of the FAS Facial Photographic Screening Tool. All children enrolled in a Washington State Foster Care Passport Program were screened for three conditions: (1) the FAS facial phenotype from a photograph, (2) evidence of brain damage with prenatal alcohol exposure from their Health and Education passport, and/or (3) other syndromes identifiable from a facial photograph. Screen-positives received diagnostic evaluations at a FAS Diagnostic and Prevention Network clinic. The prevalence of FAS in this foster care population was 10 to 15/1000, or 10 to 15 times greater than in the general population. The screening tool performed with 100% sensitivity, 99.8% specificity, 85.7% predictive value positive, and 100% predictive value negative. We conclude that the foster care population is a high-risk population for FAS. The screening tool performed with very high accuracy and could be used to track FAS prevalence over time in foster care to accurately assess the effectiveness of primary prevention efforts.