Functional and Neuropsychological Assessment in Adults With Fetal Alcohol Spectrum Disorder

PURPOSE AND RATIONALE: The estimate of fetal alcohol spectrum disorder (FASD) in the United States and internationally is imprecise but conservatively 2% to 5% of the school-age population (May et al., 2014). These children grow up, and many end up with connections to the justice and social security systems. Streissguth and O’Malley (2000) are credited with identifying psychosocial issues’ impact on FASD. Remaining in the community and being productive are a challenge for these individuals due to brain-based disability and behavioral problems like impaired inhibition and attention (Brintnell et al., 2012; Manning & Hoyme, 2007).

Little guidance exists for occupational therapists in planning intervention strategies and service delivery models as there is a paucity of research on these adults. A holistic understanding of the complex interaction of their cognitive, affective, psychosocial, and functional abilities is urgently needed. The present study investigated both functional and neuropsychological abilities in adults with mild to moderate FASD based on diagnostic criteria. The two objectives were (1) to compare neuropsychological and functional performance between participants with brain scores 2 and 3 (mild and moderate impairment, respectively) and (2) to explore factors (cognitive, psychosocial, and functional) that could predict brain scores 2 and 3.

DESIGN: This study used a cross-sectional design and was a secondary analysis of data from research on adults who are in contact with the justice system and suspected of having FASD. Participants were clients referred to a Canadian university-based occupational therapy service unit from a community organization in the FASD provincial network. Data were extracted manually for accuracy and conceptual integrity by a psychologist and an occupational therapist. Participants gave written consent and agreed to their data’s use for future further analysis. The study was approved by the human ethics board of the host university and the FASD organization.

METHOD: Sixty-eight adults with FASD were included in the study. All participants had a diagnosis of FASD and a brain score of 2 or 3. All of them were tested on neuropsychological assessments, including the Trail Making Test Parts A and B (TMTA/B), California Verbal Learning Test–2nd edition (CVLT–2), Stroop Color and Word Test (Stroop), Grooved Pegboard Test (GPT), and Finger Tapping Test (FTT), and on functional assessments, including the Allen Cognitive Level Screen (ACLS) and Independent Living Scales (ILS). Details of the tests can be found in Lezak, Howieson, and Loring (2004). For Objective 1, independent-samples t tests were computed to compare performance between brain scores 2 and 3. For Objective 2, hierarchical logistic regression was used to identify predictors of brain scores.

RESULTS: Results showed that adults with a brain score of 3 performed significantly worse than those with a brain score of 2 on the TMTB, CVLT–2, Stroop, ACLS, and ILS (money management subscale and managing home and transportation subscale; ps < .001). Brain scores were significantly predicted by the ACLS, CVLT–2 (long-delay cued recall), and ILS (money management subscale; Nagelkerke R ² = 68.6%). Psychosocial ability and emotional regulation were low in all participants, regardless of brain score.

CONCLUSION: This study showed that individuals with brain score 3 performed significantly worse compared with those with brain score 2 on nearly all functional and neuropsychological tests except for basic cognitive processing (i.e., TMTA for measuring attention) and psychomotor tasks (i.e., FFT and GPT for measuring psychomotor speed). This suggests that basic cognitive processing tasks could be used as remedial training to strengthen functional skills in occupational therapy programming. Furthermore, the money management subscale of the ILS, ACLS, and CVLT–2 test scores predicted the brain score, suggesting the potential use of these assessment tools for occupational therapists to identify problems and plan effective treatments in adults suspected of FASD when prenatal alcohol exposure is not confirmed. This study shows that psychosocial abilities were not adequate to predict brain scores, nor did they differentiate between mild and moderate FASD in adults. Their presence was documented in the occupational performance assessment through challenges in interpersonal relations and emotional control. Hence, the results further support the inclusion of a psychosocial element in the new diagnostic criteria for FASD.

IMPACT STATEMENT: This study impacts both occupational therapy practice and policy development. Specifically, the valuable contributions of the ILS and ACLS to the challenges of intervention planning and determining FASD diagnosis (adaptive behavior and emotional regulation) using the new Canadian FASD diagnostic guidelines are highlighted.

References

Brintnell, S. E., Sawhney, A., Palmer, T., Morgovsky, S., Nelson, M., Heard, N., et al. (2012). Report on Corrections to Community Connections Project. Edmonton, Alberta, Canada: Government of Alberta Tri-Ministries.

Lezak, M. D., Howieson, D. B., & Loring, D. W. (2004). Neuropsychological assessment (4th ed.). Boston: Oxford University Press.

Manning, M. A., & Hoyme, H. E. (2007). Fetal alcohol spectrum disorders: A practical clinical approach to diagnosis. Neuroscience and Biobehavioral Review, 31, 230–238. https://doi.org/10.1016/j.neubiorev.2006.06.016

May, P. A., Baete, A., Russo, J., Elliott, A. J., Blankenship, J., Kalberg, W. O., . . . Hoyme, H. E. (2014). Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics, 134, 855–866. https://doi.org/10.1542/peds.2013-3319

Streissguth, A. P., & O’Malley, K. (2000). Neuropsychiatric implications and long-term consequences of fetal alcohol spectrum disorders. Seminars in Clinical Neuropsychiatry, 5, 177–190. https://doi.org/10.1053/scnp.2000.6729