Danish studies suggesting low and moderate prenatal alcohol exposure has no adverse effects on children aged 5 years did not use appropriate or effective measures of executive functioning



I am writing in reference to the article by Skogerbø et al.,1 published online on 20 June 2012.

My husband and I are physicians who adopted two nonrelated children from Russia in 1997 and 1999. They were both prenatally exposed to alcohol, and both have had neurological sequelae.

Over the past 15 years, as their parents, we have struggled with cognitive, social, medical and emotional issues as a result of their brain damage, and have found virtually no practical help from medical professionals or neuropsychologists because the professions are not adequately trained to do anything other than diagnose the problem.

We could see the problems; we educated ourselves; we asked for executive function testing. The tests generally performed were the Behaviour Rating Inventory of Executive Function and the tests that are part of the Wechsler Intelligence Scale for Children (WISC) and the Developmental Neuropsychological Assessment. The results were either normal or only slightly below normal. At the same time as we were told that the testing was normal, we were struggling to get our daughter to remember to flush the toilet. It took her 5 years to do this reliably.

We read the literature and found that there is major disagreement as to which tests adequately measure executive functioning. Something else that is also not generally understood is that these children are prompt dependent, so that, if a tester hovers over them urging them on, they can often perform the required task. The result seems to be normal, but, in fact, it is completely invalid.

In my experience, the Delis–Kaplan system is a somewhat better measure of executive functioning, and better yet are the tests used for traumatic brain injury, such as the booklet category test and the Cognitive Assessment System. For my children, when they were aged 5 years, the only measure commonly available that would have captured some of the difficulties is the Vineland Adaptive Behavior Scale.

Another problem with the Danish studies is that it is quite difficult to estimate executive functioning in a 5-year-old child. There is such a degree of normal variability in executive functioning at that age that it really is difficult to measure competently at all, and certainly not with the poor choice of tests used in the studies.

Our daughter is now a late teenager. She is clearly disabled, and probably even the most wretchedly trained examiner could pick up some of her difficulties. At the age of 5 years, she ‘tested’ as essentially normal for executive functioning using the tests that were employed in the Danish studies, although she certainly was not.

I am very worried that these studies will lead women to relax and begin to drink moderately again during pregnancy. I would suggest that all the children in the studies be retested with a variety of instruments, and insist on the inclusion of teacher rating scales. I do not believe any responsible conclusions can be drawn until these children are older and are retested using more rigorous instruments.

It is ironic that, just as we see prenatal alcohol exposure finally being included in the Diagnostic and Statistical Manual of Mental Disorders (DSM V), we see such an irresponsible study coming from professionals and sponsors who ought to have been far more thorough in investigating the measuring devices used.