Intergovernmental committee on Drugs working party on Fetal Alcohol Spectrum Disorders
Fetal Alcohol Spectrum Disorders in Australia: An Update
9.3 Interventions for children with FASD
Early intervention is recommended for children with conditions comprising Fetal Alcohol Spectrum Disorders (FASD) because longitudinal studies suggest that interventions may reduce the secondary disabilities seen in adults by 2-fold to 4-fold (Streissguth et al. 2004; Spohr et al. 2007). However, the evidence for specific interventions is often anecdotal. A systematic review of the published literature was conducted by Peadon et al. to identify and evaluate the efficacy of interventions for FASD, including pharmacological, behavioural and educational strategies (Peadon et al. 2007).
A comprehensive search strategy was used, identifying 5,899 studies about FASD. After exclusion of ineligible studies (e.g. animal studies, studies which did not evaluate an intervention, and studies with an inappropriate patient population), only eleven met the review’s inclusion criteria. The two pharmacological interventions, both small, placebo-controlled randomised controlled trials (RCTs) showed some beneficial outcomes, particularly from stimulant medication (Snyder et al. 1997; Oesterheld et al. 1998). In one trial, methylphenidate significantly improved hyperactivity and impulsivity but not attention (Oesterheld et al. 1998). In the other trial the child’s usual stimulant medication did not benefit attention but significantly improved hyperactivity. Harms reported for stimulant medications included decreased appetite, headache and insomnia (Snyder et al. 1997).
Six studies evaluating educational and learning strategies, including three small RCTs, were identified (Meyer 1998; Riley et al. 2003; Stromland et al. 2005; Padgett et al. 2006; Coles et al. 2007; Kable et al. 2007). Children with FASD were able to learn new skills through using a virtual reality computer game but not through modelling of a task (Meyer 1998; Padgett et al. 2006; Coles et al. 2007). Classroom interventions may improve language skills, classroom and adaptive behaviour and mathematical skills (Riley et al. 2003; Stromland et al. 2005). There was evidence of benefit from social skills training in one quasi-RCT and weak evidence for the value of social communication interventions (one pre- and post- intervention study) (Timler et al. 2005; O'Connor et al. 2006). Attention Process Training, evaluated in an
RCT led to a significant improvement in sustained attention (Vernescu 2007).
In summary, there is limited high quality evidence of the benefits of specific interventions for children with FASD. The strongest evidence is for social skills training, for stimulant medications (which may improve hyperactivity and impulsivity but not attention) and for Attention Process Training (Peadon et al. 2008). However, there were significant methodological weaknesses in all the intervention studies identified, including small sample sizes, inadequate study design (e.g. lack of blinding and allocation concealment) and short term follow up. These issues must be addressed in future studies to strengthen the evidence base for the management of children with FASD. We are aware of several large, welldesigned RCTs currently underway in North America to evaluate either behavioural interventions, communication strategies or use of non-stimulant medications for attention deficit/hyperactivity in children with FASD.
A protocol for a systematic review of the pharmacological interventions for ADHD symptoms in children with FASD has been published in the Cochrane Collaboration library (Peadon et al. 2012) and another protocol, under development, will review the nonpharmacological
interventions available for children with FASD. This builds on previous work by Peadon and colleagues (Peadon et al. 2008).
In the absence of good evidence of effectiveness of specific therapies, it is recommended that the management of children with FASD be co-ordinated by a developmental paediatrician and/or child development clinic with access to appropriated medical, other health professional, educational and community services and to family support and education. Optimal management required co-operation between health and education professionals and community services.
Although emphasis in this document is placed on the recognition and management of FASD in childhood, the problems associated with fetal exposure to alcohol are lifelong. It is therefore important that a wide range of professionals (including teachers, lawyers and criminal justice personnel) are aware of the adverse outcomes that may persist into adolescence and adulthood and know where to refer these people for assessment and management.
National Organisation for Fetal Alcohol Syndrome and Related Disorders Inc.The National Organisation for Fetal Alcohol Syndrome (FAS) and Related Disorders Inc (NOFASARD) is a voluntary organisation established in Adelaide in 1998 in response to a perceived need to raise awareness in Australia of the issues surrounding the damage caused by prenatal exposure to alcohol, and to provide assistance to individuals with FASD, their families, carers and other service providers. It also aims to promote good practice in the management of FAS and related disorders resulting from prenatal alcohol exposure and to support prevention efforts.
National Organisation for Fetal Alcohol Syndrome and Related Disorders Inc offers the following services;
- Workshops and keynote presentations to a range of community groups and professional organisations, both nationally and internationally (more than 200 to date).
- Provision of information and support to enquiring families, community members and professional service providers such as teachers, allied health and medical professionals.
- Advocacy services for individuals affected by FASD and their parents and caregivers across a range of sectors, including health, education, disability, social service and justice.
- Establishment and co-ordination of a network of relevant national and international agencies, community action groups and individuals.
- Early diagnosis provides an opportunity for preventing alcohol exposure in future pregnancies and enables early intervention to reduce the risk of secondary problems in adolescents and adults with FASD.
- Assessment and diagnostic guidelines developed internationally recommend the use of multidisciplinary teams; however, no sustainable diagnostic or assessment services currently exist in Australia.
- A number of diagnostic clinics operate worldwide, the majority in the USA and Canada. Variation exists between clinics in the referral processes, services offered, populations seen, staff profile, assessment protocols and funding sources. Virtually all clinics employ multidisciplinary teams.
- A number of implications for service development in Australia have been identified in an international clinic survey. Options include the establishment of teams of specially trained health professionals, or of specialised clinics, in some or all States and Territories. Other service models, including models for use in remote or Indigenous communities and telemedicine, should also be considered.
- National agreement regarding the diagnostic criteria for FASD and the protocol for assessment is required.
- Clinical teams could be trained in specially convened workshops by national or international experts and would have a responsibility for training other health professionals in diagnosis and assessment of FASD. On-line training is also available.
- Early diagnosis allows for early intervention, which is recommended for children with FASD to enable them to reach their potential and to reduce secondary problems in adult life.
- There is a paucity of good quality information about the efficacy of specific interventions for FASD. Further research, using randomised controlled trials with adequate samples sizes, as is currently underway in North America, is required to improve the evidence base for management.
- A wide range of information and support services for individuals, families, carers and services providers are provided by the National Organisation for Fetal Alcohol Syndrome and Related Disorders (NOFASARD). Resources for use by justice system personnel are planned for the future.