Published online June 22, 2007
PEDIATRICS Vol. 119 No. 3 March 2007, pp. e733-e741 (doi:10.1542/peds.2006-1606)
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ARTICLE

Evaluation of Psychopathological Conditions in Children With Heavy Prenatal Alcohol Exposure

Susanna L. Fryer, MSa, Christie L. McGee, MSa, Georg E. Matt, PhDb, Edward P. Riley, PhDb,c and Sarah N. Mattson, PhDb,c

a San Diego State University/University of California San Diego Joint Doctoral Program in Clinical Psychology
b Department of Psychology
c Center for Behavioral Teratology, San Diego State University, San Diego, California


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVE. This study compared the prevalence of psychopathological conditions in children with heavy prenatal alcohol exposure (N = 39) and nonexposed, typically developing peers (N = 30), matched with respect to age, gender, and socioeconomic status.

METHODS. Caregivers were interviewed with either the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version, or the Computerized Diagnostic Interview Schedule for Children, Version IV. Statistical resampling methods were used to create 95% confidence intervals for the difference between the proportions of children with psychopathological conditions in the exposed and control groups.

RESULTS. Group differences were seen in the attention-deficit/hyperactivity disorder, depressive disorders, oppositional defiant disorder, conduct disorder, and specific phobia outcome categories. The group difference in the attention-deficit/hyperactivity disorder category was by far the largest effect observed.

CONCLUSIONS. These results suggest that fetal alcohol exposure should be considered a possible factor in the pathogenesis of childhood psychiatric disorders. These data provide clinically relevant information about the mental health problems that children with fetal alcohol exposure are likely to face.

Key Words: fetal alcohol syndrome • teratogens • psychopathological conditions • attention-deficit/hyperactivity disorder

Abbreviations: FAS—fetal alcohol syndrome • FASD—fetal alcohol spectrum disorders • DSM-IV—Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • SCID—Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition • SUD—substance use disorder • K-SADS-PL—Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version • C-DISC-IV—Computerized Diagnostic Interview Schedule for Children, Version IV • ADHD—attention-deficit/hyperactivity disorder • SES—socioeconomic status

The pattern of birth defects resulting from prenatal alcohol exposure has been studied extensively since the first descriptions of fetal alcohol syndrome (FAS) appeared in the scientific literature.1–3 FAS is associated with a specific clinical presentation, with (1) prenatal and/or postnatal growth deficiency, (2) characteristic facial features (eg, short palpebral fissures, indistinct philtrum, and thin vermillion), and (3) central nervous system dysfunction. Although all 3 indicators must be present to meet the formal diagnostic criteria for FAS, central nervous system dysfunction may occur after prenatal alcohol exposure in the absence of other FAS characteristics.4 In recognition of the wide range of effects after gestational alcohol exposure, the term fetal alcohol spectrum disorders (FASD) is now used as a nondiagnostic umbrella term.5 This new term acknowledges that individuals who fail to meet FAS diagnostic criteria may still show negative effects related to their gestational alcohol exposure. Refining the diagnostic criteria that characterize FASD remains a major research priority.6 The cognitive and behavioral problems associated with fetal alcohol exposure include deficits in learning, language, motor, visuospatial, and executive functioning abilities.4 Deficits in attention and arithmetic skills seem to be especially marked and persistent.7,8 Despite significant cognitive disabilities and lowered IQ, the majority of individuals with prenatal alcohol exposure are not mentally retarded (eg, see ref 9). This fact has important implications, because alcohol-exposed individuals with IQ scores of >70 (ie, those not defined as mentally retarded according to current standards) may not qualify for supportive services, despite evidence that these individuals perform poorly on tests of complex attention, verbal learning, and executive function.10 Adaptive functioning is also affected in this population,9,11,12 and many individuals identified as having FASD are unable to live or work independently.13 Therefore, general cognitive ability alone may not be an effective indicator of special service needs in the FASD population.

Compared with extensive research on cognitive abilities in FASD, mental health outcomes after prenatal alcohol exposure are less well studied. A study of secondary disabilities in FASD revealed that mental health problems had the highest prevalence, compared with other negative outcomes studied (such as disrupted school experience and legal trouble).13 More than 400 individuals with prenatal alcohol exposure were studied, and 94% of the sample experienced mental health problems, according to caretaker reports. Another longitudinal investigation evaluated psychopathological behavior in young children with FAS and observed increased rates of many maladaptive behaviors.14–16 A follow-up report from the same study demonstrated the persistence of psychopathological symptoms through late childhood, including maintained levels of the leading diagnosis of hyperkinetic disorder.17 Although other maternal lifestyle variables, such as smoking, may be important risk factors associated with attention deficits,18 the association between prenatal alcohol exposure and attention deficits is well established in the FASD literature.

There is also evidence that prenatal alcohol exposure is a risk factor for developing depressive features, although alcohol-exposed girls may be more affected than boys.19 Several studies have used Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)-based criteria to evaluate psychopathological conditions in FASD. The Structured Clinical Interview for DSM-IV (SCID) was used to examine psychiatric illness directly in 25 non–mentally retarded, clinically referred, young adults with a history of alcohol exposure.20 Strikingly, 23 (92%) of the 25 participants met SCID criteria for an axis I disorder. Alcohol or drug dependence was the most common diagnosis, followed by major depressive disorder. Similar total rates of psychopathological conditions were found in a mixed sample of nonretarded, 5- to 13-year-old, inpatient and outpatient children with histories of heavy prenatal alcohol exposure.21 Twenty (87%) of 23 children met the criteria for ≥1 of the psychiatric disorders examined, with mood disorders being the most common (including both major depressive and bipolar disorders). More recently, 400 young adults with or without prenatal alcohol exposure were interviewed with the SCID (axis I and axis II versions).22 The study examined whether the high rates of psychiatric illness observed in clinical samples of individuals with FASD would be replicated in a nonclinical, prospectively identified, community sample. The odds of developing substance use disorders (SUDs) and axis II passive-aggressive and antisocial personality traits were twofold greater for alcohol-exposed individuals, after controlling for a multitude of potentially confounding factors, including prenatal nicotine or marijuana exposure, gender, family placement, low socioeconomic status (SES), poor maternal nutrition, and family history of psychiatric problems and alcoholism.

The purpose of the current study was to examine broad-spectrum psychopathological conditions, as defined by the DSM-IV, in a sample of children with heavy prenatal alcohol exposure, compared with nonexposed peers. Increasing awareness among pediatric primary care and mental health providers regarding the psychiatric sequelae associated with fetal alcohol exposure might facilitate the detection of affected children. Such information is especially warranted in this population because early identification and treatment of children affected by prenatal alcohol exposure are associated with improved outcomes.9


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Sample and Procedure
Interviews were conducted with caretakers of 39 children with heavy prenatal alcohol exposure and 30 control children. Alcohol-exposed subjects were drawn from a retrospectively ascertained cohort of >100 children with documented histories of heavy prenatal alcohol exposure (see ref 23 for ascertainment methods). All alcohol-exposed children were evaluated by a dysmorphologist with expertise in the effects of prenatal alcohol exposure (Dr Kenneth Lyons Jones of the University of California, San Diego). The alcohol-exposed group contained children with and without FAS; 15 children (38.5%) had FAS, and 24 children (61.5%) were nondysmorphic alcohol-exposed children. Children in the alcohol-exposed group were all born to mothers who abused alcohol during pregnancy. Although the specific timing and amounts of alcohol exposure are typically unknown under retrospective assessment conditions, histories were determined through a combination of caregiver reports, medical charts, and, if appropriate, social services records. The exposure levels of children studied by our research group were usually in the range associated with DSM-IV-defined criteria for alcohol abuse or dependence. Children with alcohol exposure were referred by Dr Jones, were referred by other medical, social service, or mental health providers, or were self-referred. Children in the comparison groups were self-referred or were recruited through community outreach. The comparison group was matched with the alcohol-exposed group with respect to age, SES, race, and gender (Table 1). Because we were interested in comparing the alcohol-exposed group with a typically developing control group, children were excluded from the comparison group if the following factors were apparent at the time of initial recruitment into the larger research study: exposure to known teratogens, preexisting psychiatric disorders, or parental complaints of notable behavioral problems. With respect to alcohol consumption, mothers of the control children reported no intake or <1 ounce of absolute alcohol intake per day, before pregnancy recognition. Full-scale IQ estimates for children from both groups were based on assessments with the Wechsler Intelligence Scale for Children-III.24


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  		TABLE 1 Sample Demographic Features for Children in the Alcohol-Exposed and Nonexposed Control Groups

 
Interviews with the primary caregivers (most frequently the biological or adoptive mother) of the children in the sample were conducted at our research center. All procedures were approved by the San Diego State University institutional review board, and informed consent was obtained from all interviewees before the interview session. Interviewees were compensated for their time with a small monetary reward.

Psychiatric Interviews
Psychopathological conditions were assessed through standard psychiatric interview measures based on DSM-IV criteria. Two different interviews were used, namely, the Computerized Diagnostic Interview Schedule for Children, Version IV (C-DISC-IV), and the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children, Present and Lifetime Version (K-SADS-PL). The C-DISC-IV is a computer-assisted structured interview developed by the National Institute of Mental Health.25 The interview version used in this study uses the parent or caregiver as the interview subject. The C-DISC-IV covers axis I DSM-IV disorders, and diagnoses are generated by using an algorithm provided in the software administration package. The K-SADS-PL is a semi-structured psychiatric interview involving separate interviews with the parent or caregiver and child. Diagnoses and impairment ratings based on Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and DSM-IV criteria are generated from answers provided by the interviewee concerning the child’s present and lifetime symptoms.26,27

Interviews performed between 1999 and 2001 (37 interviews) were conducted with the K-SADS-PL by a child psychiatrist who had received specific training on the measure and underwent reliability assessment. Subsequent interviews (32 interviews) were conducted with the C-DISC-IV by psychology graduate students. C-DISC-IV assessments were supervised by a licensed clinical psychologist (Dr Mattson). The measures are equated across groups, such that in the alcohol-exposed sample 17 interviews (43.6%) were conducted with the C-DISC-IV and 22 interviews (56.4%) were conducted with the K-SADS-PL, whereas in the comparison group 15 interviews (50.0%) were conducted with the C-DISC-IV and 15 interviews (50.0%) were conducted with the K-SADS-PL. A previous study comparing clinician-administered K-SADS-P with lay interviewer-administered DISC interviews in an epidemiologic sample demonstrated moderate agreement between the 2 measures.28

Statistical Methods
Eleven psychopathological outcome categories were examined, namely, depressive disorders, attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, tic disorders, conduct disorder, generalized anxiety disorder, specific phobia, social phobia, separation anxiety disorder, panic disorder, and obsessive-compulsive disorder. Subjects were coded as positive for a particular outcome category on the basis of meeting full criteria on the C-DISC-IV or meeting criteria for a definite past and/or definite present diagnosis on the K-SADS-PL. Between-group analyses were not conducted for the following outcomes because, although assessed, there were no instances of these diagnoses among the study sample: psychotic disorders (eg, schizophrenia or schizoaffective disorder), bipolar spectrum disorders, post-traumatic stress disorder, eating disorders, agoraphobia, and SUDs. Specific criteria according to psychopathological outcome and psychiatric interview measure are presented in Table 2.


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  		TABLE 2 Criteria for Positive Psychopathological Outcomes According to Psychiatric Interview Measure

 
Because of 0-frequency counts in many observational cells, standard, parametric, inferential statistics were not appropriate and logistic regression analysis was not feasible. Instead, data were analyzed by using nonparametric resampling methods (Resampling Stats software; Resampling Stats, Arlington, VA). These computation-intensive methods draw replication samples from observed data to construct confidence intervals based on empirical sampling distributions. Common statistical paradigms that rely on resampling logic include Monte Carlo simulation and bootstrapping techniques. The {chi}2 test, with Fisher’s exact test to address comparisons with low cell counts, also could have been used to evaluate between-group comparisons. However, the {chi}2 reference distribution is a theoretical probability distribution that is based on parametric assumptions and therefore is less appropriate than the resampling technique, given the small sample size of this study and the nonnormal distribution of the psychopathological outcomes. By using resampling methods, we created 95% confidence intervals for the difference between the proportions of children with psychopathological conditions in the alcohol-exposed group and the matched control group; 95% confidence intervals that contain 0 rule out significant group effects and correspond to a nonsignificant null hypothesis significance test with {alpha} set to .05. Alternatively, 95% confidence intervals that do not contain 0 indicate a significant group effect and correspond to a significant null hypothesis significance test at an {alpha} level of .05.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
In our initial analyses, group differences in factors that may account for variance in mental health outcomes were examined. Specifically, between-group statistical comparisons (alcohol-exposed group versus control group) were conducted for age, SES, and full-scale IQ (independent-sample t test) and for gender, ethnicity, and interview measure ({chi}2 analysis). As expected, there was a significant group difference in full-scale IQ (t67 = 7.04; P < .001); all other matching-variable analyses yielded nonsignificant results. In addition, the groups differed with respect to family placement, with higher rates of nonbiological parent placement in the alcohol-exposed group ({chi}21 = 31.40; P < .001). This was expected, because a large proportion of alcohol-exposed children in our sample do not live with biological relatives (26 of 39 nonbiological placements) and the groups were not matched with respect to family placement.

In terms of overall psychiatric diagnoses, 38 (97.44%) of the 39 alcohol-exposed children and 12 (40.00%) of the 30 control children met the criteria for ≥1 axis I disorder. Significant group differences were observed in the following psychopathological outcome categories: ADHD, depressive disorders, oppositional defiant disorder, conduct disorder, and specific phobia. Differences were not seen in tic disorders, generalized anxiety disorder, social phobia, separation anxiety disorder, panic disorder, or obsessive-compulsive disorder (Table 3). Also, there were substantially more observations of comorbid diagnoses in the alcohol-exposed group (27 of 38 cases; 71.05%) than in the control group (6 of 12 cases; 50%). The most common comorbidities occurred among the disruptive disorders (Table 4).


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  		TABLE 3 Psychopathological Outcomes and 95% Confidence Intervals for Proportional Group Differences

 

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  		TABLE 4 Numbers of Children With 0 to 7 Diagnoses in the Alcohol-Exposed and Control Groups

 
For the alcohol-exposed group, diagnostic differences according to the presence of a FAS diagnosis and family placement were examined qualitatively (because of small sample size) for psychological outcome categories in which significant differences were observed. The presence of a FAS diagnosis was defined as a binary variable (yes or no). Family placement was also defined as a binary variable, as either biological (living with ≥1 biological parent or biological relative, such as a grandparent or aunt) or nonbiological (foster or adoptive care) placement. In the alcohol-exposed group, 15 children (38.46%) were diagnosed as having FAS, and 26 (66.67%) were living in nonbiological family settings. Qualitatively, slightly higher rates of psychopathological conditions were associated with nonbiological family placement and not having a diagnosis of FAS, although these differences are not likely to be statistically significant, given the small sample size (Table 5).


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  		TABLE 5 Qualitative Distributions of Family Placement Status and FAS Diagnosis Among Psychopathological Outcomes in the Alcohol-Exposed Group

 
Lastly, measurement equivalence was examined by looking at the pattern of diagnoses generated with the K-SADS-PL versus the C-DISC-IV within our sample. More specifically, an index score was generated by summing the outcomes (positive diagnosis versus negative diagnosis) for the 5 psychopathological categories in which group differences were observed. Although this type of analysis is less ideal for establishing measurement equivalence than is examination of overlapping data points derived from the 2 types of interviews, the latter type of data was not available for our sample. Therefore, the strategy described above was used to examine measurement comparability, given feasibility constraints. In total, 50 positive and 110 negative diagnoses were generated with the C-DISC-IV, whereas 41 positive and 144 negative diagnoses were generated with the K-SADS-PL. The 95% confidence interval for the proportional difference between the measure-generated outcomes contained 0, providing some evidence that, for the psychopathological outcomes examined, the 2 measures performed with reasonable equivalence in this sample.


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
Children with heavy prenatal alcohol exposure experienced higher rates of many common DSM-IV axis I psychiatric disorders, compared with matched comparison children. High rates of axis I disorders were documented previously in samples of children21 and young adults20,22 with prenatal alcohol exposure. These data support those findings and extend them by comparing alcohol-exposed children directly with their typically developing peers.

The largest group effect observed in our sample was in the ADHD category, which is not surprising, given the well-documented association between FASD and attention deficits. This finding is consistent with previous research focused on fetal alcohol exposure and psychopathological outcomes in children.15,17 Evidence from both anecdotal description3 and empirical studies23,29 corroborates the widespread presence of attention problems in the FASD population. In particular, studies have shown that the attention deficits associated with prenatal alcohol exposure occur independently of general intelligence deficits and are persistent and stable over time.7,30 A study from our laboratory suggested that children with heavy prenatal alcohol exposure could be distinguished from nonexposed peers on the basis of scores for frequently used measures of attention; alcohol-exposed and comparison subjects were classified with 91.7% accuracy.31 Therefore, attention deficits, as indicated for the current sample, are well described in the scientific literature on fetal alcohol effects. Although these deficits obviously are not pathognomonic for FASD, data suggest that their presence can be of diagnostic utility. Notably, our control group exhibited an unexpectedly high rate of ADHD (30%). One explanation for this phenomenon is ascertainment bias. Although children were excluded from the comparison group on the basis of premorbid psychiatric conditions or noted behavioral problems, it is possible that the recruited control group still possessed a higher rate of undiagnosed attention problems than found for the population at large. Because participation offered neuropsychological services to the subject at no cost, there might have been some enticement for participation. Another possibility is that our study protocol (ie, diagnosis based on psychiatric interview results, rather than an experienced clinician’s opinion) overdiagnosed the disorder. However, the ADHD between-group effect was quite large (95% vs 30%), which emphasizes that alcohol-exposed children are far more likely to present with ADHD than are their nonexposed peers.

In addition to ADHD, significant group differences were observed within the other disruptive disorder categories, that is, oppositional defiant disorder and conduct disorder. This finding too is reflected in the literature on FASD. Increased delinquent behavior has been reported for alcohol-exposed youths,13 although factors such as level of exposure32 and home placement (biological, foster, or adoptive)33 likely moderate the relationship between prenatal alcohol exposure and delinquency. A qualitative examination of these variables in our alcohol-exposed sample did not suggest different patterns of psychopathological conditions based on family placement or FAS diagnosis; however, this might be attributable to the small sample size. In any case, individuals with prenatal alcohol exposure are thought to be significantly overrepresented in the criminal justice system,34,35 although corrections staff members are largely unaware of this phenomenon.36 One of the few systematic FASD screens of a delinquent group was undertaken in a forensic psychiatric facility in British Columbia. The study revealed that 23% of juvenile detainees were exposed to significant amounts of alcohol prenatally; the majority of these exposures were undetected before the screen.37 Unlike studies of young adults, which have associated FASD with increased rates of SUDs,20,22 we did not observe any instances of SUDs in our sample, although this is likely a reflection of the relative youth of our subjects.

A greater proportion of depressive disorders was also observed in our alcohol-exposed sample, compared with control subjects, which emphasizes that the impairments associated with alcohol teratogenesis are not limited to disruptive behavior. This is an important point, because the internalizing nature of depressive disorders may be more difficult to recognize than externalizing behavior problems, which are observed commonly in the disruptive disorders. The potential link between fetal alcohol exposure and depression has been investigated less frequently than the relationship between FASD and disruptive psychopathological conditions. However, our finding is consistent with research associating prenatal alcohol exposure with the development of negative infant affect19 and, subsequently, depressive features in children.38 Also, research using a psychosocial inventory indicated that, as reported by their caregivers, alcohol-exposed children displayed higher rates of depressive features, compared with typically developing children,39 although factors such as SES may serve as important moderators of the relationship between prenatal alcohol exposure and parental reports of internalizing behaviors.40

In our sample, there were no instances of disorders on the bipolar spectrum. This finding diverges from results of a study by O’Connor et al,21 which documented high rates of bipolar disorder in children with FASD (8 of 23 children; 35% of the sample). One possible reason for this discrepancy might be the inclusion of inpatients in the study by O’Connor et al,21 whereas the present study sampled noninpatients exclusively. It is possible that more severe or different types of psychopathological conditions are associated with inpatient individuals with FASD. Such a rationale may also explain the much higher rates of ADHD in the present study, compared with the study by O’Connor et al21 (95% vs 13%). Interestingly, both studies failed to observe any instances of psychotic disorders; however, as with SUDs, it is possible that this finding is related to the typical age of onset, because there is a suggestion that increased rates of psychosis occur in alcohol-exposed young adults.20

These data indicate that children exposed to alcohol prenatally may present with significant psychopathological conditions. Moreover, certain psychiatric disorders may be more prevalent than others in FASD, because disruptive disorders were particularly common in our sample, whereas many anxiety disorders were not. Ultimately, these data underscore the need for special services, including psychological evaluations, for individuals with histories of prenatal alcohol exposure.

This study should be of interest to clinicians, because its main purpose was to ascertain the frequency and nature of mental illness in a sample of children with documented histories of heavy fetal alcohol exposure. Medically defined diagnoses are a useful step in translating behavioral symptoms of children with prenatal alcohol exposure into clinical relevance and are warranted in the interest of guiding strategies for remediation in this special-needs population. The effects observed in this study support existing literature that suggests that prenatal alcohol exposure is associated with clinically significant psychopathological conditions. Surprisingly, although 97% of alcohol-exposed children had ≥1 axis I disorder, only 40% of our alcohol-exposed sample had been evaluated for or received a psychiatric diagnosis previously. It is hoped that these data will serve to increase awareness among pediatric and mental health caregivers, because many individuals who suffer deleterious consequences from prenatal alcohol exposure remain undetected or misdiagnosed.

This study is limited by several factors. The first is the small sample size (N = 69), which limits the power to detect relationships with small effect sizes. Therefore, the negative findings presented in this study should be interpreted cautiously until they are replicated with a larger sample. Although the modest sample size is a limitation, heavy prenatal alcohol exposure has a low base rate in the population at large, and the small sample size must be weighed against the relative incidence of this condition. In addition to sample size concerns, the psychiatric diagnoses in our study were generated with protocols from psychiatric-based interview tools. Although such measures can be a useful component of an integrated psychological assessment approach, they are not intended to be diagnostically conclusive. In the context of this study, the psychopathological assessment methods used are best viewed as an approximation of an evaluation performed more properly by a trained clinician with expertise regarding the diagnosis in question, who synthesizes data from a variety of sources. However, the psychiatric interview-based assessment approach used was adequate for the study aim, and similar interview-based approaches have been used in studies of other populations.41,42 Also, this study combined interview results from a structured measure (C-DISC-IV) and a semi-structured measure (K-SADS-PL). Although this approach is not ideal, because the measurement equivalence of these 2 methods has not been researched thoroughly, threats to construct validity posed by this limitation were minimized by ensuring that the alcohol-exposed and comparison groups were equally represented by both measures and by examining statistically the patterns of diagnoses (positive versus negative) through interview measurements within our sample.

Another limitation exists because of the retrospective ascertainment of the study sample. Because most individuals from the alcohol-exposed group were clinically referred, it is possible that this study overestimates the association of prenatal alcohol exposure and psychopathological conditions. Therefore, these study results may not be generalizable to the alcohol-exposed population at large. However, this study should inform intervention efforts, and this sample reflects adequately the portion of the alcohol-exposed population that would most likely seek out and benefit from mental health treatment. In addition, previous studies indicated that our alcohol-exposed sample was similar, with respect to several important characteristics (such as IQ and attention abilities), to other samples of individuals with FASD.4 Lastly, the quasi-experimental design of this study involves the comparison of 2 groups that are not equivalent with respect to 2 important factors, namely, family placement and general intelligence, both of which are potential sources of variance in mental health outcomes.43,44 Although these factors possibly confound interpretation of these results, we do not think that the matching scheme used in this study detracts from the overall study aim, to characterize the likely psychopathological presentations of alcohol-exposed children. Future studies of psychopathological conditions and prenatal alcohol exposure should seek to replicate these results by using a comparison sample of mental age- and home placement-matched individuals, to better pinpoint the cause of the FASD-associated psychiatric problems described in this report. Despite these limitations, this study provides important information on the extent of mental health issues in the FASD population and will likely be of relevance to a wide-ranging readership, including health care providers, social service advocates, and individuals suffering negative effects of prenatal alcohol exposure.


   ACKNOWLEDGMENTS
 
This research was funded by National Institute on Alcohol Abuse and Alcoholism grants R01 AA010417, R01 AA012596, R01 AA010820, and F31 AA016051.

We acknowledge the contributions of Drs Brigitte Robertson and Jeffrey Max and the assistance and support of the Center for Behavioral Teratology.


   FOOTNOTES
 
Accepted Sep 26, 2006.

Address correspondence to Sarah N. Mattson, PhD, 6363 Alvarado Ct, Suite 200, San Diego, CA 92120. E-mail: smattson{at}sunstroke.sdsu.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.


   REFERENCES
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 METHODS
 RESULTS
 DISCUSSION
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics

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