title: The impact of traumatic childhood experiences on cognitive and behavioural functioning in children with foetal alcohol spectrum disorders
Creators: name: Price, Alan
Publisher: name: University of Salford
Year: 2019

description: Prenatal alcohol exposure (PAE) can cause lasting physical damage to the developing foetus including the brain. This brain damage can manifest as cognitive dysfunction and behavioural difficulties, which can be diagnosed as foetal alcohol spectrum disorders (FASD). FASD is thought to be common in the UK, with estimates ranging from 3.24% up to 17% of the population affected, although rates of diagnosis are much lower than this. Children with FASD are at increased risk of a range of traumatic or adverse childhood experiences, such as neglect or abuse. Studies into the longterm effects of neglect or abuse show a similar range of cognitive dysfunction and behavioural difficulties as those seen in FASD, but there is a lack of evidence on the impact of a dual exposure of PAE and trauma. This is especially necessary for clinicians, who may need to use the presence of trauma to inform and potentially exclude a diagnosis on the foetal alcohol spectrum. This aim of this thesis was to investigate the impact of childhood trauma on the cognitive and behavioural functioning of children with FASD. A wide-ranging overview of the literature on the effects of PAE and trauma as separate exposures was conducted and was followed by a systematic literature review of studies into the dual exposure of PAE and trauma. The reviews showed that only five studies had investigated the impact of both exposures, although one further study was published more recently. The literature reviews, including the one new study showed that, although there had only been a small number of studies conducted, a pattern was emerging that children with both FASD and trauma were more similar to children with just FASD than they were to children with just trauma, in terms of their cognitive and behavioural functioning. The findings of the reviews were used to develop four original studies, which advanced the evidence in this area. The studies were designed to assess the damage caused by dual exposure at four levels: neurological, cognitive, behavioural, and finally the effect of behavioural problems on other people. A neuroimaging study measured task-related blood oxygenation in the prefrontal cortex in 15 children aged 8-14 years with FASD with and without a history of trauma. A series of cognitive tasks assessed verbal, non-verbal and overall intelligence, working memory and inhibitory control in 25 children aged 8-14 years with FASD with and without a history of trauma. An informant-report survey that assessed Adverse Childhood experiences, cognitive, affective and overall empathy, behavioural strengths and difficulties, and comorbid diagnoses was completed by the carers of children aged 4-16 years with FASD. A series of semi-structured interviews was conducted with caregivers of children aged 8-14 years with FASD, with and without a history of trauma. Children with FASD had high levels of adverse childhood experiences including neglect and abuse, poor empathy, high levels of behavioural difficulties, and high levels of comorbid diagnoses, particularly attention deficit hyperactivity disorder (ADHD). They also had verbal, non-verbal and overall intelligence in the average range, and working memory and inhibitory control scores that were similar to the scores of typically developing children of the same age. Children with both FASD and a history of trauma were found not to be significantly different from children with FASD without trauma in terms of their task-related prefrontal activity, verbal, non-verbal and overall intelligence, working memory, inhibitory control, and empathy. There was a slight tendency for children with higher numbers of adverse childhood experiences to exhibit more severe behavioural difficulties, particularly conduct problems. Caregivers of children with both exposures described experiences with the same themes as those whose children had FASD without trauma. Caregivers described their children as difficult to manage, but also described many strengths and rewarding moments. Caregivers were critical of service providers including medical and educational services, social services, adoption agencies and local authorities, who lacked knowledge and understanding of FASD. This led to their children being misunderstood and offered insufficient or inappropriate services. The findings of this thesis support previous research showing that children with FASD have high levels of behavioural difficulties, poor empathy, and high levels of comorbid diagnoses. It provides the first data on levels of adverse childhood experiences in children with FASD, which are also high. The main finding of the thesis is that the impact of traumatic childhood experiences on the cognitive and behavioural functioning of children with FASD may be very subtle, especially in terms of cognitive functioning. Clinicians and other professionals should be aware that a history of neglect or abuse does not appear to be a better explanation for cognitive dysfunction or behavioural difficulties than prenatal alcohol exposure. Where children have a history of both exposures, they should primarily be treated as children with FASD, and provided appropriate support and interventions specifically designed for FASD.