Infant Assessment in FASD: Ukraine Exposure Sample Claire D. Coles, Ph.D CIFASD Joint Meeting February 1, 2011

Assessment of Alcohol Exposed Infants for Research Exposure Samples Maternal Alcohol Use information obtained via self report Confounding factors identified and measured Provides information on the full range of developmental outcomes in exposed infants Allows appropriate control groups to aid interpretation of outcome data. Established methods for assessment of infants available.

Goals of Infant Assessment in Ukraine Exposure Sample Evaluate alcohol quantity, frequency, timing in relation to growth, structure and neurodevelopment. Assess infants using global measures of development (BSID-II) and early infant measures of processing speed and attentional regulation skills. Evaluate the contribution of baseline nutritional status, measured during pregnancy. Evaluate the impact of micronutrient supplementation with and without choline. Examine the relationship between indicators of oxidative stress and developmental outcomes.

Infant Testing is not Easy! Infants are not socialized yet to cooperate with the tester. Must be in the right “state” to achieve optimal performance. Cannot be hungry, tired, sick…..

Developmental Tests (DQ) (0 to 3) Developmental tests are used to measure infant development. At risk children Suspect developmental delays specific questions about a child placement tracking effects of treatment research

Developmental Assessment in Infancy: Limitations What you can measure, 0 to 3, versus what you want to know, long term. Facets of development affected by alcohol may not be measurable early in development (e.g., Executive functioning; language) The more severe the impact, the more likely to be observed. “Subtle” information may be missed. Development is “in process” so that early measures of outcome may not be predictive. Neuronal plasticity (recovery) Postnatal environmental effects Requires specialized skills both to administer and interpret. Various experimental biases

Specific Assessments of Infant Functioning that have been used to assess effects of prenatal alcohol exposure Newborn assessments (e.g., BNBAS) Specific motor tests Prelinguistic and Early Language Development Numerosity (“is it two or three items?”) Early “executive functioning” tasks (e.g., “A not B”) Temperament and Behavior (e.g., CBCL) Measures of memory and attention (Methods) Habituation Visual preference Speed of processing

Assessment of the Newborn Neonatal Behavioral Assessment Scale, 3rd Edition (NBAS) Conceptualizes Neonate as Complexly Organized individual Defends self from negative stimuli Control motor and autonomic responses to attend to environment Elicit stimulation from the environment

No “Newborn IQ” There is no summary score created. It is a description of the infant A controlled observation Observations are grouped into 7 categories with summary scores Habituation Orientation Motor Performance Range of State Regulation of State Autonomic Regulation Reflexes

Bayley Scales of Infant Development (2nd Edition) Provides a “global” measure of child’s status relative to other children of the same age on an ordinal scale of development. Individually administered measure of Infant Development. Tester must be familiar with infants, testing and be trained to reliability. Ages 2 months to 42 months Standardized scores (Developmental Quotient) Mental Development Index (MDI) (M=100, SD=15) Psychomotor Development Index (PDI) (M=100, SD=15) Behavior Rating Scale (BRS) (Percentiles)

Validity and Reliability in Testing Two Sites: Rivne and Khmelnytsky Testers experienced in evaluation and infancy but not Bayley Testing Have to be trained to do tests and to score properly. Reliability in test Administration/Scoring maintained through training, observation and checking scoring.

Results: 6 Months In December, 2010, 93 6-month-olds (30+ currently being entered) with 4 in “questionable” category and not used in the analysis. 2 Factor Analysis included: Alcohol (2 levels: Exposed/Unexposed) and Micronutrients (2 levels: none/supplements, collapsed over choline). Potential covariates examined: SES, maternal smoking, maternal nutritional status.

BSID-II Outcomes at 6 months M(SD)(N=89). Multivariate Analysis Alcohol Exposure None Exposed Micronutrients None (n=24) Supplement (n=19) (n=20) Supplement (n=24) Mental (MDI) 94.46 (10.81) 97.89 (5.55) 89.60 (14.04) 96.50 (6.28) Motor (PDI) 98.83 (9.68) 99.21 (10.78) 88.65 (18.31) 96.71 (10.40) Alcohol, MDI (F1,83)=2.21,p<.14; NS; PDI (F1,83)=5.48,p<.02 Supplement, MDI (F1,83)=6.04,p<.02; ; PDI (F1,83)=2.0,p<.16,NS No significant interactions.

Mental Development Index-6 months

Psychomotor Development Index-6 months

Exploratory Analyses: Factors to be Controlled in larger analyses SES as a covariate-attenuated effects of alcohol use on motor performance; did not change micronutrient effects. Cigarette use by mother-had a significant effect on MDI (p<.05) with trend for PDI (p<.07). When cigarettes controlled, effects of alcohol on motor development were attenuated, while effects of micronutrients were increased on both mental and motor development. Maternal use of prenatal vitamin prestudy was significantly related to MDI. Folic acid was not.

BSID-II Outcomes at 12 months M(SD)(N=55). Multivariate Analysis Alcohol Exposure None Exposed Micronutrients None (n=15) Supplement (n=12) (n=13) Supplement (n=15) Mental (MDI) 101 (14.87) 97.42 (10.13) 92.38 (13.69) 103.0 (9.73) Motor (PDI) 106.73 (8.15) 102.42 (11.12) 96.86 (18.94) 99.93 (11.91) Alcohol, MDI (F1,51)<.1,NS; PDI (F1,51)=3.10,p<.084,NS Supplement, MDI (F1,51)=1.04,p=.3,NS; PDI (F1,51)<1,NS Interaction: Alcohol Use and Supplements: MDI (F1,51)=4.61,p<.04,; PDI (F1,51)=1.11,p<.29,NS .

Mental Development Index-12 months

Motor Development Index-12 months

Exploratory Analysis: BSID and Micronutrients Analysis of micronutrients and BSID outcomes done in the No Intervention group (n=43) . A second analysis was done with the whole group with similar results. No significant relationships between PDI and individual micronutrients. Significant correlations with PDI found when interactions terms used. That is Alc*Zinc (Zn): r=-.32, p<.04; Alc*Ca:r=-.299, p<.05; ALC* Copper (Cu): r=-.37, p<.02; Alc*Cp activity: r=-.34, p<.04; Alc*Magnesium (Mg);r=-.32,p<.04; Alc*C-Reactive: r=-.32, p<.03. No significant correlations with MDI

Comments These preliminary data suggest that Alcohol exposure affects global development, particularly motor development at 6 months. Supplements with vitamin and other micronutrients may compensate for these effects on BSID-II scores. There are a number of other factors that must be considered in the final analysis including maternal baseline nutritional status, SES, other drug use. When a larger “N” is obtained, it will be possible to evaluate effects of individual micronutrients in relation to outcomes (and we have some data to support this now) and to evaluate effects at different levels of alcohol exposure.