The fetal alcohol syndrome: a multihandicapped child

The effect of intrauterine exposure of the fetus to ethanol has been appreciated since Biblical times. An article by Lemoine (1968) describing the effects and long term prognosis was virtually ignored until 1973. At that time Jones and Smith described a constellation of anomalies in infants born to alcoholic women and labeled this condition the Fetal Alcohol Syndrome (FAS). The evolution of this syndrome over the last 15 years is reminiscent of the congenital rubella syndrome with its continuum of handicapping morbidity. Even if there is no facial dysmorphia and the child has a normal IQ, the stigma from intrauterine ethanol exposure persists. Visual-motor perception and performance IQ are lower and receptive and expressive language are delayed. Distractibility persist. The child with Fetal Alcohol Syndrome remains a multihandicapped child.     

Zinc nutrition in fetal alcohol syndrome

Because alcohol has an adverse effect on zinc homeostasis, this study was designed to study if zinc content of the diet modifies the severity of fetal alcohol syndrome in a mouse model. The effect of varying zinc intake on the progeny of pregnant mice fed a liquid diet containing 15% of the calories as ethanol was studied. Prenatal mortality was higher when the mothers consumed alcohol with inadequate zinc intake. Because of the adverse effect of alcohol on zinc homeostasis and because zinc deficiency has been shown to potentiate alcohol embryopathy, one group was given zinc supplementation to four times the Recommended Dietary Allowance. Supplemental zinc above the Recommended Dietary Allowance was not protective and appeared to have an adverse effect on fetal weight and prenatal mortality. These results suggest that zinc intake should be optimized during pregnancy but that zinc supplementation above the Recommended Dietary Allowance does not reduce the incidence or severity of fetal alcohol syndrome.     

Neurological findings in the fetal alcohol syndrome

Five children with fetal alcohol syndrome (FAS), ranging in age from 2 1/4 to 10 years, were noted to have abnormal neurological findings. These were mainly cerebellar. Others were attention deficit disorder in three, mental retardation in two, and epilepsy in one. The neuropathology seen in FAS provides a more than adequate basis for the clinical findings. Children with FAS, or a history of in utero alcohol exposure, and abnormal neurological signs, do not need investigation.     

Dendritic spine anomalies in fetal alcohol syndrome

Neuropathological findings in the brain of a 4-month-old child born to a chronic alcoholic mother were microcephaly, uncovered rostral region of the insula, disordered arrangement of nerve cells in the cerebral cortex, cerebellar abnormalities, and glial meningeal heterotopies. In addition, impregnantion of neurons by means of the Golgi method showed decreased numbers of dendritic spines and predominance of spines with long, thin pedicles on cortical pyramidal cells. A significant reduction in the number of DS (Student t test; p less than 0.001) on the apical dendrites of layer V pyramidal neurons was demonstrated in this patient when compared with similar counts performed in the brain of controls aged newborn, three months and four months. Reduced numbers of DS and abnormal geometry of spines observed in this child suggest that an abnormal maturation of nerve cells may occur in children, like it has also been demonstrated to occur in rodents, as a consequence of chronic ethanol consumption during gestation.     

Metabolic and genetic factors contributing to alcohol induced effects and fetal alcohol syndrome

Alcohol-related damages on newborns and infants include a wide variety of complications from facial anomalies to neurodevelopmental delay, known as fetal alcohol syndrome (FAS). However, only less than 10% of women drinking alcohol during pregnancy have children with FAS. Understanding the risk factors increasing the probability for newborn exposed in utero to alcohol to develop FAS is therefore a key issue. The involvement of genetics as a one risk factor in FAS has been suggested by animal models and by molecular epidemiological studies on different populations, bearing allelic variants for those enzymes, such as ADH e CYP2E1, involved in ethanol metabolism. Indeed, one of the major factors determining the peak blood alcohol exposure to the fetus is the metabolic activity of the mother, in addition to placental and fetal metabolism, explaining, at least partially, the risk of FAS. The different rates of ethanol metabolism may be the result of genetic polymorphisms, the most relevant of which have been described in the paper.     

EEG findings in fetal alcohol syndrome and Down syndrome children

Results from previous studies evaluating the electroencephalograms (EEGs) of infants bom to alcoholic mothers suggest that the neonatal EEG may be a sensitive measure of prenatal ethanol exposure. Few studies, however, have examined EEG records of adolescent children with fetal alcohol syndrome (FAS). The present study investigated the resting EEG recordings of 18 matched triads of FAS, Down syndrome, and normal control subjects. Significant reductions in mean power of the alpha frequencies (7.5–12 Hz) were seen for both clinical groups, however, each syndrome appeared to have distinct EEG spectral distributions. Down syndrome children overall had diffuse EEG slowing while the EEG records of the FAS children showed reduced power, particularly in the alpha frequencies in the absence of significant slow activity. In the Down syndrome children, significant decreases in alpha power was seen in posterior cortical regions, whereas FAS children were more affected in the left hemisphere. This study suggests that certain EEG variables may be helpful in characterizing the neurophysiology of FAS.     

Assessing client satisfaction in a psychology training clinic

Client satisfaction with services obtained at a clinical psychology training center was assessed. A modified version of the Client Satisfaction Questionnaire was developed to obtain information about levels of satisfaction in such a setting and to evaluate training clinic-specific questions of interest, such as the impact of therapists' experience on satisfaction. Results indicated that client satisfaction is multidimensional. Consistent with other studies, satisfaction was greater among clients who were in therapy for longer periods of time, who completed treatment, and who sought therapy rather than an evaluation. Reasons for dissatisfaction included a wish for more directiveness or advice in therapy and concerns over videotaping procedures. Implications of these results for clinic administrators are discussed.     

Goal‐directed arm movements in children with fetal alcohol syndrome: a kinematic approach

Background: Although many studies have documented deficits in general motor functioning in children with fetal alcohol syndrome (FAS), few have employed detailed measurements to explore the specific nature of such disabilities. This pilot study explores whether three‐dimensional (3D) kinematic analysis may generate increased knowledge of the effect of intrauterine alcohol exposure on motor control processes by detecting atypical upper‐limb movement pattern specificity in children with FAS relative to typically developing (TD) children. Methods: Left and right arm and head movements during a sequential unimanual goal‐directed precision task in a sample of children with FAS and in TD children were registered by an optoelectronic tracking system (ProReflex, Qualisys Inc.). Results: Children with FAS demonstrated evidently poorer task performance compared with TD children. Additionally, analyses of arm movement kinematics revealed atypical spatio‐temporal organization in the children with FAS. In general, they exhibited longer arm movement trajectories at both the proximal and distal level, faster velocities at the proximal level but slower at the distal level, and more segmented distal movements. Children with FAS also showed atypically augmented and fast head movements during the task performance. Conclusions: Findings indicate neuromotor deficits and developmental delay in goal‐directed arm movements because of prenatal alcohol exposure. It is suggested that 3D kinematic analysis is a valid technique for furthering the understanding of motor control processes in children with FAS/fetal alcohol spectrum disorders. A combination with relevant neuroimaging techniques in future studies would enable a more clear‐cut interpretation of how atypical movement patterns relate to underlying brain abnormalities.     

Cortical thickness in fetal alcohol syndrome and attention deficit disorder

Fetal alcohol syndrome represents the classic and most severe manifestation of epigenetic changes induced by exposure to alcohol during pregnancy. Often these patients develop attention deficit hyperactivity disorder. We analyzed cortical thickness in 20 children and adolescents with fetal alcohol syndrome and attention deficit hyperactivity disorder (group 1), in 20 patients without fetal alcohol syndrome (group 2), and in 20 control cases. The first group revealed total cortical thickness significantly superior to those of the other two groups. In per-lobe analyses of cortical thickness, group 1 demonstrated greater cortical thickness in the frontal, occipital, and right temporal and left frontal lobes compared with the second group, and in both temporal lobes and the right frontal lobe compared with the control group. This study demonstrated greater cortical thickness in patients with attention deficit hyperactivity disorder and heavy prenatal exposure to alcohol, probably as an expression of immature or abnormal brain development.     

Glutamate and GABA receptor dysfunction in the fetal alcohol syndrome

The brain damaging effects of ethanol, as the most disabling component of the fetal alcohol syndrome (FAS), have been recognized for three decades, but the mechanism underlying these effects has remained elusive. Recently, we discovered that ethanol triggers widespread apoptotic neurodegeneration throughout the developing brain when administered to infant rodents during the period of synaptogenesis, also known as the brain growth spurt period. These findings provide a more likely explanation than has heretofore been available for the reduced brain mass and lifelong neurobehavioral disturbances associated with the human FAS. We propose that a dual mechanism—blockade of NMDA glutamate receptors and hyperactivation of GABA_A receptors—mediates ethanol's apoptogenic action, based on established evidence that ethanol has both NMDA antagonist and GABAmimetic properties, and our recent finding that other drugs with either NMDA antagonist or GABAmimetic properties robustly trigger apoptotic neurodegeneration in the developing brain. The brain growth spurt occurs in different species at different times relative to birth. In rats and mice it is a postnatal event, but in humans it extends from the sixth month of gestation to several years after birth. Thus, there is a period in pre and postnatal human development, lasting for several years, during which immature CNS neurons are prone to commit suicide if exposed to intoxicating concentrations of drugs with NMDA antagonist or GABAmimetic properties. These findings are important, not only because of their relevance to the FAS, but because there are many agents in the human environment, other than ethanol, that have NMDA antagonist or GABAmimetic properties. Such agents include drugs that may be abused by pregnant mothers [ethanol, phencyclidine (angel dust), ketamine (Special K), nitrous oxide (laughing gas), barbiturates, benzodiazepines], and many medicinals used in obstetric and pediatric neurology (anticonvulsants), and anesthesiology (all general anesthetics are either NMDA antagonists or GABAmimetics).     

Psychiatry--family practice liaison: a collaborative approach to clinical training

In view of the growing need for effective liaison between psychiatry and family practice programs, some of the models for educational and clinical liaison are discussed, and a clinical training program is described in which psychiatry and family practice educators work collaboratively in the training of both family practice and psychiatry residents and medical students. The program is offered as a model for providing comprehensive clinical training to residents and students and comprehensive clinical care to patients.     

Teaching graduate trainees how to manage client anger: a comparison of three types of training

Abstract

The authors examined the effects of three types of training (supervisor-facilitated training, self-training, biblio-training) on 62 graduate student therapists’ state anxiety, self-efficacy for dealing with anger, and helping skills (i.e., reflections and immediacy) in response to videotaped vignettes of angry clients. Training overall was rated as very helpful, and trainees increased in self-efficacy for working with client anger. Supervisor-facilitated training was rated as more helpful than, and was preferred to, self-training and biblio-training; it also led to more reflection of feelings in response to clients. Results suggest that vignettes such as these might be a helpful adjunct to training once students have competency in the basic helping skills.

Zusammenfassung

Das Erlernen der Beherrschung von Klienten-Ärger bei graduierten Therapeuten in der Ausbildung: Ein Vergleich von drei Arten von Training

Die Autoren haben die Effekte von drei Arten von Therapietraining (Training mit Hilfe eines Supervisors, Selbst-Training, Training aufgrund von Lektüre) bezüglich der Zustandsangst, der Selbst-Wirksamkeit im Umgang mit Klienten-Ärger und der Fähigkeit zur Hilfe (d. h. Reflektieren oder sofortige Reaktion) bei 62 Studenten-Therapeuten in der zweiten Phase ihrer Ausbildung bei der Antwort auf Klienten-Ärger mittels auf Video festgehaltenen Vignetten untersucht. Das Training wurde insgesamt als hilfreich eingeschätzt und die Fähigkeit der Selbst-Wirksamkeit im Umgang mit Klienten-Ärger nahm bei den Auszubilden zu. Supervisionsunterstütztes Training wurde als hilfreicher eingeschätzt und wurde den beiden anderen Arten vorgezogen. Es führte auch zu mehr Reflektionen von Gefühlen bei der Reaktion auf die Klienten. Die Ergebnisse legen nahe, dass Vignetten dieser Art einen nützlichen Zusatz des Trainings bilden können, wenn die Studenten einmal die Kompetenz in den grundlegenden Fähigkeiten zur Hilfe erworben haben.

Résumé

Enseigner à des étudiants postgradués comment gérer la colère des clients?: une comparaison de trois types de formation

Les auteurs ont comparé les effets de trois types de formation (formation avec superviseur, auto-apprentissage, formation par la lecture) sur la base de l'anxiété actuelle, l'auto-efficacité pour gérer la colère, et l'habilité pour aider (réflexion et rapidité) chez 62 thérapeutes en formation postgraduée, en réponse à des vignettes vidéo de clients en colère. La formation dans sa globalité était estimée très utile, et les étudiants ont augmenté leur auto-efficacité dans la gestion de la colère du client. La formation avec superviseur était jugée plus utile que et préférée à la formation par soi-même ou la lecture?; elle aboutissait également à plus de réflexion sur les sentiments en réponse au client. Les résultats suggèrent que ce genre de vignettes pourrait être un complément utile à la formation une fois que les étudiants ont acquis les habilités d'aide de base.

Resumen

Enseñar a supervisandos cómo tratar el enojo del lciente: comparación de tres tipos de supervisión

Los autores estudiaron los efectos de tres tipos de supervisión (entrenamiento facilitado por el supervisor, auto-supervisión y biblio-supervisión) sobre el estado de ansiedad de sesenta y dos terapeutas graduados, sobre su eficiencia para tratar con el enojo y recursos para ayudar (v.g. reflexiones y rapidez) en respuesta a viñetas videograbadas de clientes enojados. La supervisión general fue evaluada como muy útil y los supervisandos mejoraron su eficiencia en el trabajo con el enojo del cliente. La supervisión facilitada fue evaluada como más útil y fue preferida a la autosupervisión y a la bibliosupervisión; también condujo a una mayor reflexión sobre los sentimientos en respuesta a los clientes. Los resultados sugieren que viñetas como estas podrían ser complementos útiles para la supervisión una vez que los estudiantes tengan competencia en los recursos básicos para ayudar.

Resumo

Ensinar estudantes graduados a lidar com a ira dos clientes: Uma comparação de três tipos de treino

Os autores analisaram os efeitos de três tipos de treino (treino facilitado pelo supervisor, auto-treino e treino bibliográfico) sobre a ansiedade-estado, auto-eficácia para lidar com a raiva e competências de ajuda (i.e., reflexões e proximidade) de 62 estudantes graduados em resposta a excertos vídeogravados de clientes irritados. No geral o treino foi avaliado como muito útil e os estudantes aumentaram a sua auto-eficácia para trabalhar com a ira dos clientes. O treino facilitado pelo supervisor foi avaliado como o mais útil e foi preferido ao auto-treino e ao treino bibliográfico; para além disso conduzia também a mais reflexões de sentimentos nas respostas aos clientes. Os resultados sugerem que excertos como estes poderão ser meios auxiliares de treino uma vez que os estudantes tenham adquirido as competências de ajuda básicas.

     

Voxelwise and skeleton‐based region of interest analysis of fetal alcohol syndrome and fetal alcohol spectrum disorders in young adults

Though fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders are among the most common developmental disorders, their understanding is incomplete. Diffusion tensor imaging (DTI), which is sensitive to microstructural organization in white matter, may provide a relevant measure in this population demonstrating incompletely characterized white matter pathology. In this study, tract‐based spatial statistics (TBSS) routine and a skeleton‐based region of interest analyses were employed to detect differences in DTI‐derived metrics between young adults who were alcohol exposed and an unexposed control group. Participants include 28 with dysmorphic features associated with FAS, 29 who were prenatally exposed but do not show physical effects, and 25 with the same low socioeconomic status but unexposed. The TBSS analysis revealed a statistically significant decrease in fractional anisotropy at the isthmus of the corpus callosum and its connected callosal fibers in dysmorphic individuals relative to controls (clusterwise P_FWE < 0.05). This finding was consistent with that of the follow‐up skeleton‐based region of interest analysis (F_(2,79) = 3.256, p = 0.044). In addition, the patterns in axial and radial diffusivity changes suggest that demyelination may be associated with the degraded white matter integrity observed in the dysmorphic group. Hum Brain Mapp, 2009. © 2009 Wiley‐Liss, Inc.