Letter  submitted  [  not  accepted  for  publication]  in  response  to  the  five  Danish  papers.      The  Editor,  British  Journal  of  Obstetrics  and  Gynaecology    Dear  Sir.  Re. The five papers by Kesmodel  U,  Bertrand  J,  Støvring  H,  Skarpness  B,  Denny  C,   Mortensen  E,  the  Lifestyle  During  Pregnancy  Study  Group.  BJOG  2012;  DOI:  10.1111/j.1471  -­‐-­‐  The  effect  of  alcohol  binge  drinking  in  early  pregnancy  on  general  intelligence  in  children    -­‐-­‐  The  effects  of  low  to  moderate  prenatal  alcohol  exposure  in  early  pregnancy  on  IQ  in  5-­‐year-­‐-­‐old  children.  -­‐-­‐  The effects of low to moderate alcohol consumption and binge drinking in early pregnancy on executive function in 5-year-old children. - - The effects of low to moderate alcohol consumption and binge drinking in early pregnancy on selective and sustained attention in 5-year-old children. -- The  effect  of  different  alcohol  drinking  patterns  in  early  to  mid  pregnancy  on  the   child’s  intelligence,  attention,  and  executive  function.       There  is  now  an  extensive  body  of  research  that  shows  the  ubiquitous  effect  of  prenatal  alcohol  on  the  developing  brain[1,2,3,5].  The  I.Q.  is  inadequate  and  misleading  as  a  tool  for  measuring  the  abilities  of  children who have been exposed to alcohol prenatally. To exclude the disruptive effect of prenatal

alcohol on brain function all domains of brain function, with subtests, need to be assessed [4,5]. The  WPPSI-­‐-­‐R  does  not  assess  all  domains  and  is  inadequate  for  totally  excluding  brain  dysfunction  in  children  exposed  to  prenatal  alcohol.    Experience  shows  that  tests  results  can  be  inconsistent  and  it  is  often  necessary  to  examine  the  domain  with  more  than  one  test.  When the test results are negative or inconclusive in preschool years they should be repeated two to four years later. FASD [FAS/ARND] should be excluded in all children who have been exposed to prenatal alcohol. To exclude the diagnosis of FASD all domains of brain function need to be assessed [4]. Those  with  FASD  have  an  I.Q.  ranging  from  extremely  low  to  superior  [5].  Yet  even  the  intelligent,  as  measured  by  the  I.Q.,  have  chaotic  lives  ;  such  is  the  variability  and  complexity  of  brain  function  following  prenatal  exposure  to  alcohol.      FASD  is  a  Complex  [Chaotic]  System  [6,  7]  that  leads  to  multiple  diagnoses  [5].   ADHD is the most common other diagnosis given to children with FASD [5]. ADHD is often diagnosed before FASD, sometimes years before. In such cases the variable brain dysfunctions of FASD are missed, with tragic consequences. No amount of Ritalin will overcome learning disabilities. Previously the diagnosis of ADHD has been based upon subjective observations. Only objective tests have been reported in the papers by Kesmodel et.al. In the end it is the subjective observations of the parent and teacher that will determine how the child is seen

regarding attention. Whatever the method of diagnosis, ADHD usually precludes further exploration of the reasons for not paying attention. For those exposed to prenatal alcohol these reasons are not understanding what they are told, or being instructed inappropriately for their individual impairments. Other common causes of inattention are sensory disabilities. Again, these need to be explored and dealt with before diagnosing ADHD. The test results reported by Kesmodel et.al. may be valid in themselves for those tests on these children at that time. However, there is no indication that they have excluded attention problems related to neurological impairments that have not been detected due to insufficient testing of all brain domains and/or the young age of the children. When we consider the complex interaction of all of the brain’s areas and the complex variability of alcohol on the developing brain it is apparent that the tools presently used for assessment need to be improved upon [6, 7, 8]. If the BRIEF [ Behavior Rating Inventory of Executive Function] has any usefulness for PAE [ Prenatal Alcohol Exposure ] it is as a screening tool for Executive Function and only relevant if it also includes the teacher’s assessment. It is my experience that those children who are less affected by prenatal alcohol, as measured by current tests, still have adaptive sociobehavioral sequelae that last a life time [9]. The resulting chaos affects all who are involved with them. For those who have average or above average I.Q.s expectations are too high, consequently they are seen as selfish, willful or criminal and treated in ways that compound their behaviour and its effects on society.

Every effort should be made at this early age to exclude FASD so that, when necessary, appropriate and supportive measures can be provided, especially the education of the parent, guardian or teacher in the intricacies of FASD. It is well known that the earlier the diagnosis, with the appropriate environment, the less the child will experience the secondary disabilities of alcohol and drug abuse, disrupted schooling, trouble with the law, confinement, inappropriate sexual behaviour and problems with employment and independent living [5]. Not with standing the caution “As alcohol is a known teratogen, it remains the most conservative advice for women to abstain from alcohol during pregnancy” many women will see these publications as reasons for continuing to consume alcohol while pregnant. I fear the conclusions of these papers make it likely that many of the families will not be prepared for the difficulties that lie ahead. An additional point needs to be made. It is time that all research into PAE took into account the epigenetic transgenerational effect of alcohol, which includes the effect of the father’s consumption of alcohol prior to conception [10]. Acknowledgements – n/a Disclosure of interests – Parent of 37 year old son diagnosed with FASD [ARND] Contribution to authorship – nil. Details of ethics approval and Funding – n/a Yours truly B. Stanley References   1 - Astley SJ, Aylward EH, Olson HC, Kerns K, Brooks A, Coggins TE, Davies J, DornS, Gendler B, Jirikowic T,

Kraegel P, Maravilla K, Richards T. Magnetic resonance imaging outcomes from a comprehensive magnetic resonance study of children with fetal alcohol spectrum disorders. Alcohol Clin Exp Res. 2009 Oct;33(10):1671-89. 2 - Lebel C, Rasmussen C, Wyper K, Walker L, Andrew G, Yager J, Beaulieu C. Brain diffusion abnormalities in children with fetal alcohol spectrum disorder. Alcohol Clin Exp Res. 2008 Oct;32(10):1732-40. 3 - Fagerlund A et.al. Brain metabolic alterations in adolescents and young adults with fetal alcohol spectrum disorders. Alcohol Clin Exp Res. 2006 Dec;30(12):2097- 104 4- Albert E. Chudley, Julianne Conry, Jocelynn L. Cook, Christine Loock, Ted Rosales, Nicole LeBlanc. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. JAMC • 1er MARS 2005; 172 5-­‐-­‐  Streissguth et.al., Fetal Alcohol and Drug Unit, University of Washington, Seattle, U.S.A. Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects [FAE]. Final Report, August 1996. 6- Wolf Singer. The Brain, a Complex Self-organizing System. European Review, Vol. 17, No. 2, 321-329. 2009. 7 – Chaos theory. Wikipedia 8 - Piyadasa W. Kodituwakku. Neurocognitive Profile In Children With Fetal Alcohol Spectrum Disorders. Dev Disabil Res Rev. 2009 ; 15(3): 218–224 9 - Katrina Kully-Martens, Kennedy Denys, Sarah Treit, Sukhpreet Tamana, and Carmen Rasmussen. A Review of Social Skills Deficits in Individuals with Fetal Alcohol Spectrum Disorders and Prenatal Alcohol Exposure:

Profiles, Mechanisms, and Interventions. Alcohol Clin Exp Res. 2012 Apr;36(4):568-76. 10 - Philip Haycock. Fetal Alcohol Spectrum Disorders: The Epigenetic Perspective The Society for the Study of Reproduction, 2009.