Journal of Pediatric Neuropsychology

, Volume 3, Issue 1, pp 68–78 | Cite as

Neuropsychological Aspects of Prevention and Intervention for FASD in South Africa

  • Wendy O. Kalberg
  • Anna-Susan Marais
  • Marlene M. De Vries
  • Soraya Seedat
  • Charles Parry
  • Philip A. May
Review Article

Abstract

Twenty years of collaborative epidemiology research in South Africa have revealed the highest reported rates of fetal alcohol spectrum disorders (FASD) in the world. The FASD research in South Africa has now expanded beyond prevalence research to maternal risk factor studies, longitudinal development studies, brain imaging studies, school intervention studies, and comprehensive prevention studies. The burden presented by the high numbers of affected individuals in South Africa is significant and a call to action is needed. This paper will outline the prevalence of FASD, review the South African governmental responses to the problem, report on the FASD research that has been completed, describe the prevention and intervention efforts that have been implemented, and outline how pediatric neuropsychologists and school psychologists can work with stakeholders to improve the lives of affected individuals and their families.

Keywords

Fetal alcohol spectrum disorders South Africa Fetal alcohol syndrome Review of research Neuropsychologist Prevalence 

Introduction

Fetal alcohol spectrum disorders (FASDs) have been studied in ongoing collaborations between South African and American researchers since 1997. These initiatives have included epidemiology, maternal risk factor, bio-marker, longitudinal development, school intervention, universal and primary prevention efforts, and early intervention studies. The cumulative effect of these collaborations has resulted in a better cross-cultural and population-based understanding of FASD in South Africa (ZA) and the burden that FASD carries with it for the country (Schneider et al. 2007; Riley et al. 2003). Most importantly, however, this work has increased awareness in ZA of the dangers of drinking during pregnancy and has informed policy makers and the public about the urgent need to expand screening and diagnostic programs, increase prevention initiatives, and provide targeted interventions for affected individuals. This paper will outline the prevalence of FASD, review the FASD research that has been completed, describe the prevention and intervention efforts that have been implemented, and outline how pediatric neuropsychologists and school psychologists can work with stakeholders to improve the lives of affected individuals and their families.

Epidemiology of FASD in South Africa

In 1995, Denis Viljoen, a geneticist from the Western Cape Province of ZA, traveled to the USA to speak with The National Institute on Alcohol Abuse and Alcoholism (NIAAA), and a number of FASD researchers and clinicians across the USA to discuss his concerns about the large numbers of children affected by FASD that he was seeing in his clinical practice and at clinics in rural areas (NIAAA 1998). Shortly thereafter, the NIAAA sent a delegation of American FASD researchers to ZA to meet with local stakeholders and conduct an initial FASD need assessment in ZA. Out of that collaboration, the first epidemiology study was conducted in the Western Cape Province in a community of primarily mixed ancestry population. Only fetal alcohol syndrome (FAS), not the full FASD spectrum, was assessed in that initial cohort of first graders in a community in the Western Cape Province. The prevalence published was, at the time, the highest reported rate of FAS anywhere in the world with a rate of 46 children per 1000 (4.6%) (May et al. 2000). All epidemiology studies cited here used the same active case ascertainment methods. Consented children in first grade classrooms first received dysmorphology and clinical examinations by pediatric dysmorphologists/geneticists. Secondly, the children were evaluated for neurodevelopmental abilities and finally, mothers of the children were interviewed by study staff using a structured interview to assess alcohol consumption and life ways during their pregnancy with the target child. The South African epidemiology studies pioneered the use of the active case ascertainment approach which greatly strengthened FASD epidemiological research.

Subsequently, numerous waves of epidemiology research have been conducted in a number of communities and ethnic groups in three of the nine ZA provinces (the Western Cape Province, the Northern Cape Province and Gauteng) (May et al. 2000, 2007, 2013a, 2016a, 2016b; Viljoen et al. 2005; Urban et al. 2008, 2015; Olivier et al. 2013). The range of prevalence rates from these studies of FAS and FASD collectively range from 2.9 to 29%. Most of these rates are the highest reported rates of FASD in the world. Because these studies were not completed in all areas of the country, these prevalence figures do not represent an overall prevalence for ZA but could be representative of high risk communities in ZA (See Table 1). Roozen and colleagues (2016) conducted a systematic review of worldwide FASD prevalence rates. Their analysis revealed that very high prevalence rates were seen in South Africa for FAS (55.42 per 1000), ARND (20.25 per 1000), and FASD (113.22 per 1000). However, PFAS rates for South Africa (28.29 per 1000) were lower than the rates for PFAS in Croatia (43.01 per 1000) and Italy (36.89 per 1000). Australia had the highest prevalence of alcohol-related birth defects (ARBD) at 10.82 per 1000.
Table 1

Samples and prevalence findings from in-school studies in South Africa

Study

Setting

Sample and methods

Population

FAS/PFASa

%

Total FASDb

%

May et al. (2000)

Western Cape, South Africa

1st graders in 12 schools (rural and urban) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race and Black 85% and White 15%

4.1–4.6a

NA

Viljoen et al. (2005)

Western Cape, South Africa

1st graders in 12 schools (rural and urban) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race and Black 85% and White 15%

6.5–7.4a

NA

May et al. (2007)

Western Cape, South Africa

1st graders in 12 schools (rural and urban) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race and Black 85%

and White 15%

6.8–8.9a

NA

Urban et al. (2008)

Northern Cape, South Africa

1st grade schools in 2 towns

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race 64% Black 36%

NA

14.1–24.8b

May et al. (2013a)

Western Cape, South Africa

1st grade in 13 schools (rural & urban) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race and Black 85% and White 15%

NA

13.5–20.7b

Olivier et al. (2013)

Gauteng, South Africa

0-7th graders in 1 school (rural) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview case conference

Mixed race

Black

17.5a

NA

May et al. (2016a)

Western Cape, South Africa

1st grade 13 schools (rural and urban) in one town

• Dysmorphology exam

• Neurocognitive testing

• Maternal Interview

• Case conference

Mixed race and Black 85% and White 15%

NA

17–23b

May et al. (2016b)

Western Cape, South Africa

1st grade 53 schools (rural and urban) in four towns

• Dysmorphology exam

• Neurocognitive testing

• Maternal interview

• Case conference

Mixed race 93%, Black 5.6% and White 1.5%

NA

18–26b

NA not applicable

aRate of FAS and PFAS only

bRate of full spectrum of FASD (i.e., FAS, PFAS and ARND)

Maternal Risk

Maternal risk factors for producing a child with FASD are well documented in the Western Cape Province of ZA (Viljoen et al. 2002; May et al. 2005, 2008, 2011, 2013b). The teratogenic effects of alcohol are at the base of this disorder. Quantity, frequency, and timing of alcohol exposure are key factors. South African maternal risk studies consistently show that the women who produce children with FAS drink significantly more than the control mothers. The mothers who gave birth to an affected child generally had a greater number of years of drinking history and drank 12.6 drinks per week compared with 2.4 drinks per week for the control subjects (Viljoen et al. 2002). In addition, 50% of the mothers of affected children report drinking more heavily while pregnant (May et al. 2000). These mothers also drank consistently higher amounts of alcohol during all three trimesters of pregnancy, and engaged in a binge drinking pattern (3+ drinks, 1 or more days a week) (May et al. 2008; May et al. 2011; May et al. 2013b). The multiple maternal risk studies cumulatively point to the complexities inherent in understanding the risk factors that most strongly predict producing children with FASD. Women more likely to produce an affected child come from alcohol-abusing families where heavy drinking is the norm and heavy binge drinking in small groups on the weekends is common (May et al. 2011). The complex psychosocial factors related to the alcohol use, however, include socioeconomic status (measured by maternal education, occupation, and residence), social relationships, maternal age, and number of pregnancies (May et al. 2013b). Certain maternal physical variables such as maternal height, weight, and body mass index have also been shown to be associated with producing an affected child with lighter and shorter women more at risk for producing a child more severely affected with FASD (Viljoen et al. 2002; May et al. 2005).

Dietary intake is a potential risk factor and was explored in a population in the Western Cape Province where high rates of FASD exist. May and colleagues (2014) found that mothers of children with FASD compared to control mothers reported significantly lower intake of calcium, docosapentaenoic acid (DPA), riboflavin, and choline. This lower intake correlated significantly with heavy drinking and it is postulated that poor diet lacking in nutritional adequacy along with prenatal alcohol exposure may increase the risk for, and severity of, FASD (May et al. 2014). In a second study of dietary intake in this same community, all of the mothers were again undernourished, but the mothers of children with FASD were as well-nourished as the mothers of normally functioning controls. But the teratogenic effects of alcohol were still severe and children with FASD performed worse than the controls on verbal and non-verbal IQ and behavioral assessment scales (May et al. 2016c).

A study carried out in a township on the outskirts of Cape Town investigated the predictors of alcohol use after conception but prior to pregnancy recognition among township women. Results showed that those who drank prior to pregnancy recognition were younger, single, had a greater number of sexual partners, and were at higher risk of intimate partner violence. The study also showed that alcohol users had a higher number of depressive symptoms (O’Connor et al. 2011).

Watt and colleagues (2014) used qualitative methods to explore the knowledge and attitudes about maternal alcohol use among women who acknowledged that they had used alcohol during pregnancy. The results of the study showed that women receive messages from a variety of sources about abstaining from alcohol during pregnancy. Some sources were more highly regarded than others, and some of the messages were not accurate. In general, the messages they received often went against the usual norms of drinking and social pressures in their homes and communities created internal tension and confusion. The authors of the study concluded that it is necessary to deliver accurate information from sources that are trustworthy. In addition, they concluded that it would be useful to provide individual interventions with women to help them reconcile their feelings and help them get in touch with the beneficial reasons they might decide to not drink during pregnancy.

To further the understanding of women’s perspectives of using alcohol during pregnancy, Watt et al. (2016) conducted interviews in drinking establishments to explore drinking narratives to identify factors that contributed to drinking during pregnancy. They found that (1) women used alcohol to cope with stress in their lives including negative emotions related to their pregnancy, (2) drinking was used as a way of maintaining social connections, (3) generally it was normative in these social groups to drink during pregnancy, (4) women were resistant to their pregnancy and were not attached to their pregnancy, and (5) alcohol addiction was driving them physically to drink. The authors concluded that innovative interventions outside of the health care system are needed to help decrease FASD.

Another study explored drinking patterns of South African women before and after pregnancy recognition and how early traumatic experiences moderated that drinking behavior (Choi et al. 2014). They found that women with previous traumatic experiences are more likely to engage in risky alcohol consumption when they become pregnant, pinpointing the importance of understanding this association for prevention efforts in ZA.

Finally, May and colleagues (2016d) investigated the effect of mothers’ drinking during breastfeeding on the outcomes of their children. The study found that the children of drinking mothers who were breastfeeding had lower verbal IQ scores when controlling for prenatal alcohol exposure and FASD diagnosis. The study found that mothers who drank during the period of breast feeding were 6.4 times more likely to have a child with FASD than those who did not drink, and drinking during the breastfeeding period was likely contributing to 2.5% of the physical and neurobehavioral damage to the child (May et al. 2016d).

The Context: How the Government, Schools, Mental Health Services and the Medical Community Conceptualize FASD in South Africa

Although there is not an overall prevalence rate of FASD for South Africa, the epidemiology work that has been completed has motivated the government, medical community, schools, and mental health services to respond to the issue of FASD. Shortly after the initial epidemiology study was published for the Western Cape Province, a National FAS Task Team was created and led by the Department of Health. Since 2006, the group is no longer chaired by the health department but continues do collaborative work among non-profit agencies and researchers. The goals of the National FAS Task Team are to raise awareness, work toward prevention of FASD, and share skills and information. The Team has produced a FAS training manual for health care workers, educators, school psychologists, social workers, and other professionals working with people with FASD, their families and caregivers. In 2007, they established a FASD training workshop that is made available to stake-holders on demand. The National FAS Task Team also organizes the annual awareness events for International FASD Day on September 9th of each year. Currently, there are calls to strengthen the National FAS Task Team to include representation from all nine provinces in ZA (Olivier et al. 2013).

Because of the increased awareness of FASD in South Africa which resulted from the research reported here, there has been increased focus on the cost of FASD for the country. A South African study published in 2011 examined the health care costs of caring for children with FAS or partial fetal alcohol syndrome (PFAS) in the Western Cape Province (Crede et al. 2011). This cross-sectional study used an interview-administered questionnaire with caregivers of children ages 0–12 who had a diagnosis of FAS or PFAS in the Western Cape Province. The goal was to estimate how many health services were used for children with FAS and PFAS and the cost of those services. The study revealed that the median number of visits to public health services per year per child was eight. The total average cost per child (in US dollars) was $1039.98 (95% CI = $808.68 to $1270.07). The overall average total societal cost per year was $70,960,053.68 (95% CI = $55,528,895.48 to $86,709.971.13). The study also showed that those families receiving social support grants spent significantly less on health care for their children with FAS and PFAS. This study shines a light on the immense financial burden of FASD in the Western Cape Province of South Africa and the implicit need for rigorous prevention efforts.

In 2008, the University of Pretoria, the University of Cape Town, the South African Medical Research Council, and the United Nations Children’s Fund (UNICEF) collaborated to analyze the current research on FASD in ZA and to determine what gaps existed country-wide for addressing the issue (Rendall-Mkosi et al. 2008). The gaps that were identified were (1) need for improved detection (surveillance) of FASD across the country, (2) need for service development targeted at prevention of FASD, and (3) improvement of service capacity and provision within the education system, health, and social service systems to address the complex needs of individuals with FASD and the intergenerational nature of the disorder. It was noted that the needs of the children affected by FASD are most marked in the schools where the teachers have not been equipped with knowledge and skills to support the children with FASD in the schools. Training is needed for teachers so that they can adapt their teaching and classroom environment to support the different learning abilities of affected children.

In 2001, the White Paper 6 on Special Needs Education: Building an Inclusive Education and Training System (Dept. of Education 2001) was rolled out with the expectation that the school system in ZA could meet the needs of all learners under one single system of delivery without special schools or special education settings. Although philosophically sound, an inclusive education curriculum is difficult to implement under the best of circumstances. There is a need for practical, context specific, and creative implementation processes so that children with FASD can thrive in a system driven by an inclusive education philosophy.

A FASD study group in 2008 recommended that ZA create a comprehensive public health response to FASD including the following steps: (1) establish a ZA-wide surveillance system to identify cases of FASD and improve the national health registry of affected children, (2) introduce standardized screening for substance abuse in health clinics to include a protocol for brief interventions to use with alcohol-using or abusing women of child-bearing age to motivate women to abstain from drinking during pregnancy, (3) raise awareness among religious leaders, teachers, and law enforcement entities about the dangers of drinking during pregnancy so that those stakeholders can assist in the prevention message for FASD, and (4) establish controls on the liquor industry to include warning labels, liquor sales training on strategies to prevent alcohol abuse, alcohol serving controls for women who are obviously pregnant, and integrate substance abuse prevention initiatives with the other programs that are working to decrease poverty (Rendall-Mkosi et al. 2008; Parry et al. 2012; Jacobs & Steyn 2013).

The recommendation for alcohol policy reform has resulted in some policy changes within specific ministries, but there is no stand-alone national alcohol policy. According to the 2014 International Alcohol Control Policy Evaluation Study (IAC Study 2014), ZA has the following alcohol information about alcohol policy:
  • Excise tax on beer, wine, and spirits at 33% for wine, 35% for malt beer, and 48% for spirits.

  • Legal blood alcohol concentration maximum while driving a vehicle is 0.05% for ordinary drivers and 0.02% for professional/commercial drivers.

  • Legal minimum purchase age of 18.

  • No regulation restricting marketing in print media, on radio, television; no regulation on sponsorship.

  • Advertising codes are self-regulated and often ineffectual, as the regulating body is managed by the marketing communication industry and even includes the main liquor industry social responsibility organization.

  • Mandatory warning labels required on alcohol containers (one of 7 health messages).

  • Differing policies regarding retail sale of alcohol for on- and off-premise consumption in the different provinces. Given the large number of unlicensed outlets in informal settlement areas, alcohol is freely available in a large part of the country 24 h a day, 7 days a week.

  • No sale of alcohol in plastic containers that are not self-supporting and that are non-re-sealable. They may not have a capacity in excess of 5 L.

In 2013, the Human Sciences Research Council (HSRC) published a policy brief to examine the alcohol consumption policies of the Department of Health in ZA (Jacobs et al. 2013). A previous 2001 food-based dietary guideline (FBDG) policy stated: “If you drink alcohol, drink sensibly”. In 2011, this policy was re-examined because of the high levels of alcohol consumption, the high prevalence of FASD, the social effects of alcohol abuse, and health and psychosocial concerns. The Department of Health unfortunately decided to not include alcohol guidelines in the FBDG and instead placed the emphasis on maternal health by addressing alcohol usage during pregnancy, asking for an enhanced role of the liquor industry and other media industries to provide comprehensive public education about the dangers of FASD.

More recently, there are two governmental efforts in ZA targeted at prevention and treatment of drug and alcohol dependence. A National Drug Master Plan 2013–2017 was approved by parliament and focuses on raising the quality of life of the poor and vulnerable through delivery of evidence-based practices tailored for defined needs of communities (Department of Social Development, Republic of South Africa, 2013–2017). The Western Cape Province Alcohol-Related Harms Reduction Green Paper calls for, among other topics, including a focus on individuals in the context of their families and communities (Platzky 2016). Strengthening prevention, early intervention, and providing brief motivational interventions in prenatal clinics are all portions of the proposed plan.

Review of South African Research on Neurocognitive, Academic, and Psychosocial Deficits in Children Affected with FASD

Cognitive and Behavioral Differences Between Children with FASD and Controls

In general, FASD is associated with lower overall intelligence, deficits in memory, visual-spatial skills, problem solving, executive functioning and nonverbal learning (Kodituwakku 2009; Mattson and Riley 2000). In addition, children who are heavily exposed to alcohol are at higher risk for problem behaviors (Mattson and Riley 1998; Crocker et al. 2009). The series of epidemiology studies of FAS in ZA over the past 20 years have produced information about the cognitive, motor, and behavioral abilities of children with FASD. In the Western Cape Province where numerous epidemiology studies have been conducted, the same or very similar methods were used to test children’s abilities (May et al. 2016b). In each wave of epidemiology research, a brief battery of tests was administered including the Griffiths Mental Developmental Scales (GMDS) (Griffiths 1984), the Raven Progressive Matrices (Raven 1947), Test of Reception of Grammar (Bishop 1982), WISC-IV Digit Span (Wechsler 2003) subtest, and the Achenbach Teacher Report Form (Achenbach and Rescorla 2001). These brief testing batteries were used consistently over the waves of epidemiology studies to assure comparability of data over time across communities. In the first two waves of epidemiology, only FAS was diagnosed so the research comparisons were between those diagnosed with FAS and controls. In both study waves, general intelligence and behavior scores for children diagnosed with FAS were significantly lower than scores of their control peers (May et al. 2000; Viljoen et al. 2005). In the third wave of epidemiology studies, FAS and PFAS were both diagnosed and, therefore, comparisons of those two diagnostic groups with control children were completed, showing once again significantly lower scores for the affected groups compared to the controls (May et al. 2007). The fourth and subsequent waves of epidemiology diagnosed the full spectrum of FASD (FASD, PFAS, and ARND), again showing the same pattern of significantly lower general intelligence, verbal, and behavioral abilities compared with control children (May et al. 2013a, 2016a, 2016b).

The FASD work in ZA provided opportunities to explore deficits in diagnosed children in some specific areas of functioning known by research in Western countries to be affected by prenatal alcohol exposure. Kodituwakku and colleagues (2006) looked at letter and category fluency among children who were diagnosed with FAS. Because executive functioning is affected in children with FAS (Mattson et al. 1999; Kodituwakku et al. 2001) and knowing that letter fluency is more difficult than category fluency in individuals with executive functioning deficits, the group investigated these two paradigms. As expected, this study showed that the group diagnosed with FAS had greater difficulty with letter fluency than category fluency and the FAS group generated fewer responses in both conditions.

A study conducted by Adnams et al. (2001) using a sub-sample from an early epidemiology study, compared affected children and control children on measures of cognitive motor development. The children with FAS and their age-matched controls (Mean age of 6.99 years) were evaluated using the GMDS (Griffiths 1984) to measure cognitive motor development in the following six areas: locomotor, personal-social, hearing and speech, eye and hand coordination, performance, and practical reasoning. The results showed that the children diagnosed with FAS had significant deficits in higher-order cognitive-motor skills (speech-hearing, eye-hand, performance, and practical reasoning) compared with control children. The researchers did not find significant differences in motor or personal-social domains.

Early Indicators of Later Neurocognitive Deficits

Developmental delay in infants and young children with FAS was documented in a study conducted in the Northern Cape Province of ZA. The GMDS (Griffiths 1984) was used to evaluate a group of infants and young children referred for clinical evaluation of FASD. The children were assessed at two time periods: 7–12 months and 17–21 months. The children who were diagnosed with FASD performed worse than the children who were not diagnosed with an FASD. There was a greater decline noted on the hearing and language subscales of the Griffith at time two. The authors note that the gap in scores increases if one considers low maternal education, maternal depression, high number of live births produced by the mother, and loss of siblings (Davies et al. 2011).

Shortly after the FASD work in ZA began in 1997, research collaborations between South African scholars and those in the USA evolved. A sizeable cohort was recruited through antenatal clinics and midwife obstetric units in a disadvantaged, primary mixed ancestry community in Cape Town. The resultant cohort of children recruited between 1999 and 2002 has been the subject of a number of research studies over the past 20 years on a broad variety of topics (Jacobson et al. 2008).

Eye blink conditioning among children with heavy prenatal exposure to alcohol was investigated on children at 5 years of age and again when the children were between the ages of 11 and 13. The eye blink paradigm uses an audio stimulus paired with an air puff to the eye in multiple trials to see if the child will successfully be conditioned to the stimuli and blink in anticipation of the air puff. None of the children diagnosed with FAS who participated in this study at age 5 was able to be conditioned to meet criterion for the task in contrast to 75% of the control children becoming conditioned (Jacobson et al. 2008). When the study was repeated with the older children, some subjects from the original group were included and a new sample added. In this trial, the researchers also used a trace eyeblink condition which involves introducing a stimulus-free interval between the tone and air puff. The results of this study extended the earlier findings that eyeblink conditioning is a consistent deficit seen in children heavily prenatally exposed to alcohol and, thus, may be a useful tool in the early diagnosis of FASD (Jacobson et al. 2011).

Additional research has been conducted on a number of diverse research topics including a study to determine if infant withdrawal and responsivity are early indicators of later affective disorders and cognitive deficits among heavily exposed infants (Molteno et al. 2014). The study controlled for mother-infant interaction, and child temperament, and considered maternal alcohol use and infant iron deficiency as potential confounders as well. Children diagnosed with FAS and PFAS at age 5 showed more emotional withdrawal and less responsivity. In addition, infant withdrawal, responsivity, quality of mother-infant interaction, and maternal sensitivity predicted lower intelligence scores at age 5 and 9 (Molteno et al. 2014).

A study considering growth restriction and growth trajectories in FAS was published in 2016 outlining the usefulness of growth trajectory as a biomarker for heavily exposed children who may be at greater risk for later cognitive deficits (Carter et al. 2016). Four growth trajectories were compared: small for gestational age (SGA) with long-term postnatal growth restriction, SGA children who caught up to their peers, no SGA or postnatal growth restriction and late-onset postnatal stunting. The children in the study were assessed for IQ at ages 5 and 10 and for learning, memory, and executive functioning at age 10 only. The children who were SGA with long-term postnatal growth restriction had the heaviest prenatal alcohol exposures as well as the greatest neurocognitive deficits (Carter et al. 2016).

Other aspects of FASD that have been investigated include symbolic play as an early indicator of FAS (Molteno et al. 2010), theory of mind in children with FASD (Lindinger et al. 2016), and verbal learning and memory impairments in children with FASD (O’Leary et al. 2015). In addition, numerous brain imaging studies have been conducted to look at specific brain structure and function as follows: cerebellar structure (du Plessis et al. 2014); regional differences in brain volume (Meintjes et al. 2014); and cortico-striatal-cerebellar activation during working memory (Diwadkar et al. 2013) in the brains of children affected with FASD.

Prevention Efforts in ZA: Described and Reviewed

Prevention

From the 20 years of research on FASD in ZA, there is now enough knowledge about the prevalence in ZA, the maternal risk factors, and the cultural context to guide the next step of working to prevent the birth of more affected children. Armed with this information, groups are now engaging in prevention efforts following the United States Institute of Medicine Comprehensive Prevention model (Institute of Medicine 1994). This model organizes prevention efforts by the following levels: (1) universal prevention is prevention targeted at a whole population through public service announcements and marketing strategies including brochures and billboards, (2) selective prevention targets the segment of the population that could be at risk for a certain condition (e.g., women of child bearing age), and (3) indicated prevention targets the highest risk group (women who are pregnant and drinking).

A study in the Northern Cape researched universal prevention and its association with lower prevalence of FASD. The study provided information about FASD using local media and health promotion talks at health facilities. They measured maternal knowledge of the dangers of drinking during pregnancy, drinking behaviors, and prevalence of FASD before the media presentations and promotional talks and after the interventions. They concluded that universal prevention may potentially reduce FASD prevalence and that it is advisable to increase and intensify universal prevention initiatives (Chersich et al. 2012).

Some organizations such as the South African FASD Task Force Team, Foundation for Alcohol Related Research (FARR), and FASFacts have implemented universal prevention efforts to raise awareness about the dangers of drinking during pregnancy, by observing International FASD Awareness Day on September 9th each year and by distributing brochures, providing billboards, videos, and other informational materials, and working in the schools and communities to spread the word about the dangers of drinking during pregnancy. In addition, organizations and researchers are now working in antenatal clinics to speak directly with the highest risk population, the mothers who are pregnant or who are contemplating becoming pregnant, about the importance of not drinking during pregnancy (selected prevention) (Chersich et al. 2012; De Vries et al. 2015). However, it remains difficult to assess the effectiveness of universal prevention initiatives given the difficulties in conducting large-scale random controlled trials and managing confounding factors in the broader environment.

For the women who are pregnant and still drinking, prevention initiatives are underway in the Western Cape Province as part of an NIH-funded research project. High risk pregnant women are receiving case management services on a monthly basis using both motivational interviewing and community reinforcement techniques to work with women who are pregnant and still drinking (De Vries et al. 2015). Motivational interviewing uses a reflective counseling approach to help women begin to see their use of alcohol as harmful for their unborn child through supportive and empathetic listening (Miller and Rollnick 2013). Community reinforcement involves helping the women identify what people and life circumstances act as supports for promoting a healthy pregnancy and what people and factors detract from her ability to have a healthy pregnancy (Meyers et al. 2013). Case management using these two methods has shown that the level of alcohol consumption before pregnancy drops significantly after entry into case management especially during the second and third trimesters and in the first months postpartum. In addition, case management significantly increases client happiness and is effective in helping women either decrease the amount they are drinking or stop drinking altogether (De Vries et al. 2015; May et al. 2013c).

Brief interventions targeted at drinking behavior of pregnant women in a randomized trial were carried out in the Western Cape Province as well. Brief interventions are counseling sessions that are time-limited and focus on behavior change and compliance through setting goals with the individual and reinforcing behavior change in a series of follow-up sessions. The study measured success by decreased Alcohol Use Disorders Identification Test (AUDIT) scores over the course of the pregnancies (Babor et al. 2001; Saunders et al. 1993). This study suggests that information, understanding, and a supportive relationship altogether can be the catalyst for behavior change among high risk pregnant women (Marais et al. 2011).

Intervention Efforts in ZA: Described and Reviewed

As is true in the general FASD literature, empirically proven interventions for affected children in ZA are few. In the school setting, one intervention study in ZA has been published. Adnams and colleagues (2007) reported on a classroom language and literacy intervention with children diagnosed with FASD in the Western Cape Province. These reported results were for a 9-month intervention period where children with FASD who received this intervention showed significant improvements on specific categories of language and early literacy.

School personnel in ZA where FASD research has been conducted are frustrated with the large numbers of affected children who are attending their schools. Teachers have reported that they do not generally receive pre-service training targeted at increased understanding of the learning issues that typically exist with children who are affected by FASD. Identifying a child’s individual learning style (strengths and concerns) is key to the development and implementation of potential classroom supports that might support that child. This imperative process has strong implications for an affected child’s ability to effectively traverse the educational process with productive and meaningful outcomes (Kalberg and Buckley 2007).

The first step in the process of identifying individualized learning issues for an affected child is to assess the child’s strengths and concerns. This type of evaluation should be done with tools that best elucidate the known learning issues of children with FASD. Kalberg and colleagues (2013), proposed a battery of tests that could be used in ZA that is brief and practical for use with children with FASD. The results of this type of an assessment can provide the initial foundation for understanding the supports that are needed for a given child.

Call to Action and Summary

The physical damage and neurocognitive, behavioral, and psychosocial sequelae resulting from prenatal alcohol exposure are complex and have strong implications for the lifelong success of an individual. The contextual factors in ZA such as poverty, inadequate nutrition, societal violence, norms-supporting excessive alcohol use, and deprivation add to the complexities of dealing with this devastating condition. Often, FASD is multi-generational in ZA. The mothers of children who are now being diagnosed are often women who also were physically, emotionally, and psychologically impacted from prenatal alcohol exposures because of their own mothers’ alcohol misuse. This phenomenon influences the ways in which children are parented, and often a woman’s ability to effectively parent her child is influenced by her own limitations related to prenatal alcohol exposure.

Because of the intergenerational nature of FASD, the complexities inherent in preventing FASD, and the challenges associated with child interventions, collaboration, and coordination of key role-players like governmental and nongovernmental organizations and departments are needed. A formal referral system is also needed for diagnostic services as well as prevention resources (De Vries and Green 2013). Shortages of resources (human and financial) targeted specifically at FASD prevention and interventions are identified in ZA (De Vries and Green 2013). It is recommended that governmental departments re-evaluate the need for specific funding of prevention and intervention programs for FASD (De Vries and Green 2013). In the meantime, it is important that organizations that are currently involved in the prevention and intervention of FASD work closely together to share resources, strategies, and information.

The collaborative studies that have been outlined in this paper have strengthened ZA’s understanding of the extent of the issue that the country is facing regarding FASD and have furthered the understanding of FASD in ZA in a number of domains: alcohol controls, maternal risk factors, nutritional concerns, cognitive abilities, specific neurocognitive deficits, and neuroimaging studies. Alcohol policy has been positively influenced by this work and prevention and intervention efforts have begun. With that said, there is still much work to be done in ZA within the government, schools, health systems, and mental health systems to address the societally wide implications of FASD in ZA.

Pediatric neuropsychologists are needed to help evaluate and delineate the neuropsychological profiles that are seen in affected children in ZA as well as provide recommendations to school teams and families. Because many of the deficits known to exist in children with FASD are in the neuropsychological realm (executive functioning, working memory, attention, hyperactivity, adaptive behavior, etc.), it is ideal to have pediatric neuropsychologists involved in the diagnosis and evaluation of these individuals. Pediatric neuropsychologists are also uniquely equipped to work with selected and indicated prevention efforts in ZA communities through counseling and consultation. School psychologists, similarly, are the professionals working first hand with the schools and the parents to help children receive the types of school supports and interventions that are in the best interest of a given child. School psychologists also play a pivotal role in helping to train school personnel to better understand FASD in the classroom and provide information about appropriate individual and classroom supports for these children. In ZA, there is, therefore, a strong need for more pediatric neuropsychologists and school psychologists with an understanding of FASD. It would be ideal if these specifically trained professionals could work hand-in-hand with educational, mental health, and public health entities that are also working with these individuals and their families to assist them to become productive members of society.

Notes

Acknowledgements

The authors would like to acknowledge all the South African and American researchers who have collaborated over the past 20 years to move the understanding of fetal alcohol spectrum disorders in the South African context possible. In particular, we would like to acknowledge the past and current fetal alcohol syndrome epidemiology research (FASER) study staffs from Stellenbosch University and University of Cape Town who have made long-standing and significant contributions to the research reviewed in this article.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Human Subjects

This article is a review of previously published work. There were no human subjects used directly for this publication. Informed consent was reported for each of the articles reviewed that included human subjects.

Ethical Approval

For the studies reviewed, statements of ethical standards were noted in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Copyright information

© American Academy of Pediatric Neuropsychology 2017

Authors and Affiliations

  • Wendy O. Kalberg
    • 1
  • Anna-Susan Marais
    • 2
  • Marlene M. De Vries
    • 2
  • Soraya Seedat
    • 2
  • Charles Parry
    • 2
    • 3
  • Philip A. May
    • 2
    • 4
  1. 1.The University of New Mexico, Center on Alcoholism, Substance Abuse and AddictionsAlbuquerqueUSA
  2. 2.Faculty of Medicine and Health SciencesStellenbosch UniversityCape TownSouth Africa
  3. 3.South African Medical Research CouncilCape TownSouth Africa
  4. 4.The University of North Carolina at Chapel Hill, Nutrition Research InstituteKannapolisUSA

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