The impact of traumatic childhood experiences on cognitive and behavioural functioning in children with foetal alcohol spectrum disorders

Abstract

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.