This research proposed to quantify and link the neuroanatomic and neuropsychological abnormalities in people with brain damage caused by prenatal alcohol exposure. Prior to this study, there were few methods for quantifying the brain damage caused by alcohol and its relation to dysfunctional behavior in the individual patient, and none that used modern morphometric methods measuring neuroanatomic shape variation as discernible from MRI scans. Traditionally the only "quantification" of this brain damage was indirect, and lies in the diagnostic category called Fetal Alcohol Syndrome (FAS). Unfortunately, FAS is a very insensitive guide to the extent of underlying brain pathology, even though it is specific for alcohol. People with FAS vary widely in many channels of behavior, and many other heavily exposed people who do not meet criteria for an FAS diagnosis show neurobehavioral deficits that may be as severe as FAS. Such patients are often referred to as having Fetal Alcohol Effects (FAE) or Alcohol Related Neurodevelopmental Disorders (ARND).

Although we hypothesized that our image analysis methods would reveal significant mean differences in brain form between FAS/FAE and Controls, we were surprised to find that the most significant finding was a hypervariation of form of the Corpus Callosum (CC: a white matter pathway connecting the two hemispheres of the brain). Subjects with FAS and FAE had callosa that were generally thicker or thinner than control counterparts. In addition 3, of the subjects with FAS/FAE showed frank dysgenesis (incomplete development) of the corpus callosum. This study also found that there was a complete intermingling of (lack of discrimination between) the alcohol exposed subjects with and without the facial features of FAS in terms of representations of the shape of the CC. There was no difference in CC neuroanatomy between subjects with FAS and those with FAE or ARND.

When the shape measurement of the Corpus Callosum was combined with results of neuropsychological testing, we found further surprising results. The variation in the shape of the corpus callosum was related to two specific patterns of neuropsychological performance. Those subjects with FAS/FAE whose callosa were thinner than controls demonstrated deficits in motor coordination but had relatively normal executive function abilities. Conversely, those subjects with FAS/FAE whose callosa were thicker than controls demonstrated relatively normal motor coordination but had deficits in executive function abilities. Utilizing neuroanatomy and neuropsychology together, we could discriminate between FAS/FAE subjects and control subjects; with 100% sensitivity and 93% specificity. Again the two exposed groups were completely intermingled demonstrating that there is no difference in neuroanatomy and neuropsychology between subjects diagnosed FAS and those with FAE or ARND. Future research will use the same methodology to study other brain regions thought to be associated with the damaging effects of prenatal alcohol exposure.

The potential role of these findings suggests that MRI screening of extent of damage in FAS/FAE would be of great benefit. For those without the full stigmata of the disorder, but with characteristic dysfunctional behaviors, the detection of neuroanatomic anomalies may permit proper identification and service delivery prior to the development of debilitating secondary consequences. Also, it will become possible to draw much finer distinctions among the clinical samples currently diagnosed as "FAS" or "FAE". Prognoses would thereby become more accurate, and the provision of therapeutic intervention or special education would become both more effective and more humane. Further work is appropriate in order to extend these correlated dimensions of structural-functional deficit downward into childhood or even infancy.

The Center on Human Development and Disability's summary of Ann Streissguth's brain study.

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Building on the work of our neuroanatomy and neuropsychology study, we have recently begun work on a study of functional MRI (fMRI) in individuals with FAS/FAE. This study proposes to demonstrate abnormalities in the functional activity of the brain due to prenatal alcohol exposure. Subjects with FAS, FAE, and matched controls will be administered a series of neuropsychological tests spanning the functions of mathematics, attention, motor coordination, and executive function while a special type of MRI is being conducted. Functional MRI (fMRI) measures local variations in the ratio between oxygenated and deoxygenated blood. When a region of the brain is more active, there is a localized imbalance in this ratio. Therefore, by performing neuropsychological tasks while images are being acquired, we can establish the locations within the brain and the amount of activation that each subject requires in order to complete the task. These activation maps can then be compared between patients with FAS/FAE and their control counterparts in order to elucidate differences in activation.

We hypothesize that there will be a difference between exposed patients and controls on the pattern and extent of activation of brain regions during these neuropsychological tasks. We also hypothesize that, like much of our previous work, there will be no significant differences between FAS and FAE subjects in their patterns of activation.

With the development of fMRI techniques, we now have the opportunity to assess directly the metabolic activity in the brains of subjects who have been exposed to alcohol prenatally and to determine the differences in that activity from healthy controls. Through the use of these techniques, we will be able to add to our understanding of the pathways of prenatal alcohol effects on the brain. In the future, the techniques utilized in this study could aid in early identification and diagnosis, quantification of the level or subtype of deficit, and suggestions for appropriate treatment approaches that could be attempted for patients with prenatal alcohol exposure.

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The Parent-Child Assistance Program (PCAP), originally known as the Seattle Birth to 3 Project, began in 1991 as a 5-year federally funded research demonstration project designed to test the efficacy of a model of intensive, long-term paraprofessional advocacy with high-risk mothers who abuse alcohol or drugs heavily during pregnancy and are estranged from community service providers. The primary goal of the program is a straightforward one -- to prevent alcohol and drug exposure among the future children of these mothers. In 1996, on the basis of demonstrated positive outcomes, the Washington State Legislature appropriated funds for continuation of the Seattle program and expansion to a Tacoma site; in 1999 sites in Yakima and Spokane (including Grant County) were funded, creating a capacity to serve 360 families. In 2005 and 2006, sites in Cowlitz and Skagit Counties were funded, increasing that capacity to 540. The program has been recognized by SAMHSA's National Registry of Effective Programs and Practices, and has been commended by Drug Strategies, a Washington D.C.-based policy research institute. The model has been replicated at over a dozen sites in the United States and Canada.

PCAP paraprofessional advocate case managers work with a caseload of approximately 15 families each, for 3 years beginning at enrollment during pregnancy or in the postpartum period. PCAP does not provide direct treatment services. Instead, advocates help substance-abusing mothers address a wide range of environmental problems, connect mothers and their families with existing community services, coordinate services among this multidisciplinary network, assist mothers in following through with provider recommendations (including obtaining substance abuse treatment and staying in recovery), and assure that the children are in safe home environments and receiving appropriate health care. A unique feature of the model is that women are never asked to leave the program because of relapse or setbacks.

The lives of mothers enrolled in PCAP are characterized by poverty, upbringing by substance-abusing parents, childhood abuse, abusive adult relationships, trouble with the law, and chaotic and unstable living conditions. As products of this background they are often distrustful of community service agencies. PCAP paraprofessional advocates have themselves overcome many difficult life circumstances prior to achieving successes in school, jobs, and parenting. Because of this, the advocates are able to inspire trust and hope, and act as realistic role models and guides toward meaningful change.

Notably, there has been relatively low staff turnover in a field known for high rates of burnout. Three administrative components contribute to job satisfaction and retention: weekly group staffing, individual weekly supervision by a master's level supervisor, and a dynamic evaluation process allowing advocates to see that they are indeed helping clients make gains, as well as to observe areas for improvement.

The effectiveness of PCAP has been demonstrated. Among 156 PCAP mothers recently exiting the program: 88% completed alcohol/drug treatment; 47% had been abstinent from alcohol/drugs for more than 6 months at program exit, and 89% had more than 6 months abstinence from alcohol/drugs while in the program; 73% were using a contraceptive method on a regular basis, and 51% were using a more reliable method; 25% delivered a subsequent child, and of these 41% were clean and sober throughout the pregnancy, and another 37% quit using alcohol and drugs after pregnancy recognition.

A study of 45 original PCAP clients followed-up an average of 2.5 years after graduation indicated that benefits of the program were sustained. The proportion of clients abstinent from alcohol and drugs for at least 6 months at the time of interview increased significantly from 31% at graduation to 51% at follow-up. Those abstinent for at least one year increased from 38% to 48%. Subsequent births decreased from 27% during the program to 9% during the follow-up period.

Click here for a brochure (in pdf format) describing PCAP services, eligibility, and referral information.

For information regarding PCAP evaluation forms, please contact our office at (206) 543-7155.

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Two University of Washington programs-the evidence-based Parent-Child Assistance Program (PCAP) and the Center on Infant Mental Health and Development (CIMHD)- have partnered to pilot an innovative infant/mother mental health intervention.

PCAP is a home visitation intervention that has worked since 1991 with high-risk mothers who abuse alcohol or drugs during pregnancy, and their children. The model has been designated by the National Registry of Evidence-based Programs and Practices (NREPP) as a Promising Practice. For many years we have seen the need to introduce a more child-focused intervention component to our PCAP model. At the same time we have seen a dramatic increase in the number of mothers in the Washington State PCAP who use amphetamine/methamphetamines during pregnancy (from 0% in 1991 to 55% currently). We have an exciting opportunity to address both of these concerns now. CIMHD is the only university-affiliated center of its kind in the country combining education, research, clinical services and policy leadership. Together we are conducting a pilot project in which we supplement the standard 3-year PCAP intervention with a nested 12-month infant/mother mental health intervention delivered in the home by CIMHD-supervised infant mental health therapists. We will evaluate the pilot by comparing outcomes from the enhanced infant/mother intervention group (N=40 infant/mother pairs) with data from a matched comparison group (N=40 infant/mother pairs) that receives standard PCAP intervention alone.

We hypothesize that compared to standard PCAP, mothers in the intervention group will demonstrate improved responsiveness to the child and greater improvement in quality of infant/mother interaction, and that improved relationships will yield reduced rates of maternal drug/alcohol use, higher rates of permanent maternal child custody placement, improved rates of safe, stable housing, and fewer additional methamphetamine and other substance-exposed pregnancies. For infants in the intervention group, we hypothesize increased reciprocity in interaction with the mother, decreased indicators of disordered relationship, and improved age-specific mental and motor development and functional social-emotional competence. This project will maximize prevention efforts by targeting limited resources to methamphetamine-affected mothers and children at highest risk for compromised outcomes.

A collaboration between the School of Law and the School of Medicine has been formed with the awarding of a Robert Wood Johnson Foundation Public Policy Grant to establish an FAS/FAE Legal Issues Resource Center. The Center will operate out of the Fetal Alcohol and Drug Unit in the Department of Psychiatry and Behavioral Sciences.

The one year grant began January 15, 2003 and is designed to identify and seek to improve public policies that affect individuals with Fetal Alcohol Syndrome or Fetal Alcohol Effects. The Center will provide to those individuals, their families, their advocates, and their communities information regarding legal rights that have an important impact on individuals with FAS/FAE, including educational, disability, criminal and juvenile justice issues. This information will be publicly available through the website of the Fetal Alcohol and Drug Unit.

We will respond by telephone, website referral and email to requests for assistance from families of those with FAS/FAE, as well as from advocates, attorneys, law enforcement, judges, corrections and probation officers. We are dedicated to providing assistance to those who have Civil Justice and Resource Issues such as rights under the Individuals With Disabilities Education Act (IDEA), benefits under the Social Security Act (SSI and Title II) and eligibility for state programs for the developmentally disabled. We will also address Criminal and Juvenile Justice Issues such as FAS/FAE and sentencing, juvenile court and correctional facilities practices.

Since this disability is largely unknown to the court family, we plan to organize peer training about FAS/FAE for Judges, Defense Attorneys, Prosecutors, Probation and Correctional Officers. Police Officers play a vital role as the initial point of contact for those with FAS/FAE and the criminal and juvenile justice systems. Sensitizing police officers to the disability is critical. We also want to publish articles on FAS/FAE in professional journals (for judges as well as attorneys specializing in education, disability or Social Security law) focusing on the relevance of FAS/FAE to each particular specialty.

The website will include a basic overview of each FAS/FAE issue, a list of relevant cases, documents that we think will be helpful to families, advocates and professionals and a list of books that address the several problems we have outlined. We want to identify the best practices and strategies for dealing with the legal issues and then disseminate this through the website. Of course, the website material will expand over the years time.

In order to identify the public policies which have the greatest impact on those with FAS/FAE, we hope to hear from individuals with the disability, their families and advocates as well as the various professionals regarding specific problems with which the FAS/FAE Legal Issues Resource Center can be helpful.

Click here for a list of selected publications.