In this systematic review, we found limited evidence for specific interventions for children with FASD. There is evidence from RCT that a language and literacy intervention improves reading spelling and pre-literacy skills (n = 65); a mathematics intervention increases mathematics knowledge (n = 61); Attention Process Training may improve attention and non-verbal reasoning (n = 20); stimulant medication may decrease hyperactivity and impulsivity but not does improve attention (n = 16); Virtual Reality Training may facilitate learning (n = 16); and Cognitive Control Therapy in the classroom may improve behaviour (n = 10). There is evidence from a quasi-RCT of effectiveness of social skills training in improving social skills and behaviour at home but not at school (n = 100).
A strength of this systematic review is that it provides a comprehensive overview of the evidence for specific interventions for children with FASD. We searched six databases and the search was not limited by language. However, the databases included have a bias towards English language publications. A potential limitation is that we did not hand search journals. During the latter stages of our review process, a systematic review on a similar topic was published, however it differs from ours, having restricted studies to RCTs thus only including three studies.[27
] By including a broader range of study types, we have been able to provide a useful summary for clinicians of the current evidence for a variety of interventions. We have also clearly identified the urgent need for more high quality intervention research. This is a rapidly evolving area with six studies published between 2006 and 2008.
The greatest limitation of our review lies in the quality of the studies available for inclusion. Significant methodological problems limit the extent to which conclusions can be drawn. Study design is often inadequate. Pre- and post-assessments and retrospective reviews are frequently used rather than RCT and in the RCT we identified, the method of randomization, allocation concealment, and blinding are rarely described. Very small sample sizes are common. Studies by O'Connor et al,[22
] Adnams et al[16
] and Kable et al[18
] are exceptions, with sample sizes of 100, 65 and 61 respectively. The remainder of the studies have samples sizes between one and thirty-two. Small sample size may reflect challenges in recruitment and the expense of conducting intervention studies. However, a small sample size may render studies insufficiently powered to detect a true effect of treatment. In addition, the diagnostic criteria used for FASD vary between studies and sometimes are not stated. Several diagnostic criteria are described in the literature and, although similar, these have important differences.[3
] Use of different criteria makes it difficult to compare studies outcomes because study populations may differ. It also limits the applicability of study findings to patients in other clinical settings. Another problem in the studies we identified is the short term follow-up. Disabilities associated with FASD persist into adulthood[1
] so children with FASD need interventions with long term efficacy. A strength of most of the studies is the use of standardised outcome measures.
Interventions for FASD should target the specific clinical and neuropsychological deficits seen most commonly in these conditions. The neurobehavioural profile of children with FASD may include low IQ[29
], however, IQ scores in individuals with FAS range from 20 to 120, and only 25% have IQ scores less than 70.[30
] Children exposed to alcohol in utero
but without the physical features of FAS may also have cognitive impairment, although this is usually less severe than in children with FAS.[31
] Other common difficulties are activity and attention;[29
] learning and memory;[29
] language development;[29
] motor abilities including balance;[29
] visuo-spatial abilities;[29
] non-verbal problem solving;[29
] planning ability;[29
] reaction time;[30
] executive function;[32
] adaptive and social skills;[5
] and academic function, particularly in mathematics.[5
] Many of these deficits are more severe than can be explained by IQ alone and may occur in children with IQ scores in the normal range who were exposed to alcohol in utero
The pattern of hyperactivity/inattention in children with a FASD diagnosis may differ from that seen in children with familial ADHD, as may their response to stimulant medications.[6
] The lack of response of inattention symptoms to medication identified in this review may relate to the underlying aetiology.
One of the barriers to health professionals making a diagnosis of a FASD is their perception of a lack of effective interventions.[35
] Nevertheless, early diagnosis of a FASD reduces the risk of developing secondary disabilities.[5
] The reason for this is not clear and it may simply reflect early referral for general educational and medical support. Some studies included in our review address specific deficits of children with a FASD, including attention and social skills. Although there is currently a lack of good studies, there are seven intervention studies in progress or recently completed (Table )[15
], A number of these are funded by the CDC[38
] and appear to be high quality RCTs with adequate sample size. The forthcoming studies evaluate targeted interventions addressing specific strengths and needs of children with a FASD such as attention, behaviour and social communication and will significantly enhance the evidence base available to inform management of FASD.