Twelve-year follow-up of children exposed to alcohol in utero

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1 Twelve-year follow-up of children exposed to alcohol in utero Ilona Autti-Rämö* MD PhD, Hospital for Children and Adolescents, University of Helsinki, PL 280, HYKS, Finland. *Correspondence to author at address above. Eighty-two women who were consuming alcohol while pregnant attended a special clinic at the University Central Hospital, Helsinki with the aim of reducing heavy drinking during pregnancy. The children born to these women were followed up regularly. During their preschool years the children were assessed to have fetal alcohol syndrome, fetal alcohol effects, alcohol-related neurodevelopmental disorder, pre- and/or postnatal growth retardation, or they were assessed to have normal cognitive and somatic growth. Of the original children, 70 of 82 could be traced at the age of 12 years. Through semistructured interview and contact with the health and social care authorities, information was gathered about schooling, family structure, whether help had been sought for behavioural difficulties and major adverse events in the family. The longer the intrauterine alcohol exposure and the more severe the diagnosis related to prenatal alcohol exposure, the more often the children required special education, were temporarily or permanently taken into care, and had behavioural problems. There is a considerable need for prolonged multidisciplinary follow-up and support of all children whose mothers have not been able to reduce drinking in early pregnancy, whether or not cognitive disturbances are evident in early childhood. During development, the fetus is exposed to various external factors, some of which can interfere with normal development resulting in abnormal tissue formation and/or function. It was first recognised in 1973 (Jones et al.) that heavy, continual prenatal exposure to alcohol is associated with a characteristic but not pathognomonic fetal alcohol syndrome (FAS). This consists of (1) pre- and/or postnatal growth retardation, (2) CNS dysfunction, and (3) at least two of the following craniofacial features: (a) microcephaly, (b) short palpebral fissures, (c) hypoplastic philtrum, thin upper lip, and/or hypoplastic maxillary area (Rosett 1980). The existence of FAS has since become well established. Partial expression of the syndrome is often referred to as fetal alcohol effects (FAE) (Olegård et al. 1979, Rosett 1980, Conry 1990, Nanson and Hiscock 1990, Streissguth et al. 1991), although no generally accepted definition for this diagnosis exists. Follow-up data from several prospective studies have shown that prenatal exposure to alcohol is associated with a wide range of developmental disorders of varying severity and complexity: major organ malformation without other symptoms, growth retardation without other symptoms, and cognitive disorders without other symptoms (Stratton et al. 1996). Studies of the long-term effects of prenatal exposure to alcohol have led to consistent reports of dose-dependent deficits in attention, memory, language, and mathematical skills (Streissguth et al. 1986; 1990; 1994a, b; 1996). Studies of children born to alcoholic mothers have revealed a wide variety of symptoms, ranging from learning disabilities* to specific learning difficulties (e.g. dyscalculia, dyslexia) (Jones et al. 1974, Olegård et al. 1979). It has become evident that only some alcoholic mothers give birth to children with full-blown FAS (Abel 1995). Prospective studies involving intervention during pregnancy have shown that the longer the exposure to prenatal alcohol the poorer the outcome in terms of cognitive function and growth (Rosett et al. 1980, 1983; Aronson et al. 1984; Larsson et al. 1985). Aronson and Hagberg (1998) reported follow-up between the ages of and 14 years of 24 children exposed prenatally to high levels of alcohol for various periods of time. Eight of the 24 children who were exposed to alcohol throughout pregnancy attended special education classes, had been taken into care, and were living with foster parents. Two longitudinal follow-up studies on children with FAS or FAE have been conducted. Streissguth and coworkers (1991) have followed individuals with FAS or FAE to the ages of 12 to 40 years in the USA. Spohr and colleagues (1993) have followed individuals with FAS or FAE for a 10-year period between the ages of 10 and 20 years in Germany. In the study by Streissguth et al. (1991), a particularly striking finding was that 80% of the individuals in the study had been taken into care during childhood and none of the adolescents/adults was able to live independently. Only a few of the adolescents had not been placed in special education programmes. The individuals exhibiting moderate to severe behavioural disorders tended not to improve with age. The present study was undertaken to explore the psychosocial well-being at 12 years of age of children exposed prenatally to heavy alcohol for varying periods of time. *US usage mental retardation. 406 Developmental Medicine & Child Neurology 2000, 42:

2 Method SUBJECTS Eighty-two pregnant women with drinking problems attended a special outpatient clinic for alcohol-consuming pregnant women at the Department of Gynaecology and Obstetrics, Helsinki University Central Hospital, Finland during their first trimester or early during their second trimester. They were subsequently seen at 2- to 4-week intervals by an obstetrician and a social worker (Halmesmäki 1987). The mothers were informed about the harmful nature of fetal exposure to alcohol, and efforts to reduce alcohol consumption or to stop drinking were supported. Amounts of alcohol consumed were calculated for each trimester separately. One drink (33 cl strong beer [mean concentration of alcohol, 5%], 12 cl light wine [<15% alcohol], 8 cl strong wine [15 to 21% alcohol], 4 cl spirits [>30% alcohol]) was taken to contain approximately 14 g of absolute alcohol. Fetal alcohol exposure was categorised as heavy if it exceeded 140 g/week or 630 g/month. The children born were placed in one of three groups depending on the duration of exposure to heavy alcohol consumption. Group I contained children who had been exposed to heavy alcohol consumption during the first trimester only (n=29), Group II contained children who had been exposed to heavy alcohol consumption during the first and second trimesters (n=27), and Group III contained children who had been exposed throughout pregnancy (n=26). With the consent of the mothers, the children were followed up at the former Children s Castle Hospital, now the Hospital for Children and Adolescents, University of Helsinki. The children were examined at ages 4 months, 6 months, 12 months, and 18 months by the author (Autti- Rämö et al. 1991a, b). At the age of 2 to years the children were examined by a psychologist and speech therapist (Autti- Rämö et al. 1992b, Korkman et al. 1994), and by a paediatric neurologist who assessed dysmorphology status without knowledge of possible fetal alcohol exposure (Autti-Rämö et al. 1992a). By the age of 6 to 7 years the parents had been offered detailed neuropsychological assessments of their children (Korkman et al. 1998). After starting school at an average age of 7 years in Finland children start school during the year in which they reach 7 years of age the children were referred to and followed up by their local health and social care units in accordance with individual needs. During the original study one of the following diagnoses associated with prenatal exposure had been assigned to each child. Fetal alcohol syndrome (FAS) This syndrome was diagnosed if the children met the following criteria: (1) prenatal growth retardation in relation to length, weight, or head circumference (< 2 SD according to Finnish normative values, Pihkala et al. 1989), and/or postnatal growth retardation in relation to length, head circumference (< 2 SD) or relative weight (< 10%) (Sorva et al. 1990a, b). (2) CNS dysfunction indicating persistent difficulties in relation to cognitive abilities ranging from learning disabilities to cognitive delay suggestive of subsequent specific learning difficulties. (3) Fulfilment of at least two of the following craniofacial criteria: (a) head circumference < 2 SD, (b) short palpebral fissure, and/or (c) thin upper lip and hypoplastic philtrum. Fetal alcohol effects (FAE) This is defined as fulfilment of two of the FAS criteria listed above. In this study all children with FAE fulfilled criteria 1 and 2 but not the craniofacial criterion. Alcohol-related neurodevelopmental disorder (ARND) Signs of persistent cognitive difficulties indicating subsequent specific learning difficulties without pre- or postnatal growth retardation or typical facies. Growth retardation Pre- and/or postnatal growth retardation fulfilling the first FAS criterion but no developmental abnormality below school age and normal facial appearance. PROCEDURE Once the children were between the ages of 11 and 12 years the author of this study contacted the parents by telephone. The following information was obtained by semistructured interview: age at starting school; type of schooling; type of upbringing (biological family, orphanage, foster parents); and behavioural difficulties that had caused the family to seek professional support. The regional health care services and referral hospitals were contacted and the necessary information concerning paediatric, psychological, and psychiatric evaluations was obtained from the medical records. The Minister for Social and Health Welfare approved release of the information. Children who are delayed in their psychosocial development may stay an extra year in kindergarten and start primary school during their 8th year. Children with specific learning disabilities may start school at a special preparatory class, a small class consisting of a maximum of 10 children with a teacher who has special training in specific learning disabilities. Within the primary school, children with specific learning disabilities can either enter a mainstream class or one of the existing three special education classes depending on the local facilities. In a mainstream class, the child with specific learning disabilities can have a personal assistant or have adjusted requirements in one to two subjects (usually mathematics). A special education class has a maximum of 10 children, a specially trained teacher, and follows exactly the same requirements as the mainstream classes and children are given the necessary extra support so that they can attain the same levels as their unaffected counterparts. The special education classes can be focused on children with specific learning disabilities, on children with severe behavioural disorders usually combined with specific learning disabilities, or on children with dysphasia. Children with low intelligence ( IQ 65 to 80) and children with learning disabilities (IQ <65) have their own special education classes in which the learning requirements are individually adjusted. Numbers of children in each group for whom the information required could be obtained are shown in Table I. Results Of the 11 children diagnosed as exhibiting FAS all could be traced except one child in Group III who had died at age 18 months in an accident. The relevant data cannot be given for this child. Of the children diagnosed as having FAE, 16 of 17 could be followed up. Of these 16 children, one in Group III had died at age 7 years because of spontaneous subarachnoid Follow-up of Children Exposed to Alcohol in Utero Ilona Autti-Rämö 407

3 bleeding. Data can be given for this girl because she had been taken permanently into care and had started school without any learning or behavioural difficulties. Of the 18 children with signs of ARND, 15 could be followed up; 10 of the 13 with only growth retardation, and 18 of the 23 assessed as developing normally before school age could also be followed up. PERFORMANCE AT SCHOOL Details of schooling are shown in Table II according to duration of alcohol exposure in utero, and in Table III according to assigned diagnosis before school age. All children in Group I had started school by age 7 years. In Group II one child with FAE spent an extra year in kindergarten, two children (one with FAE, one with behavioural difficulties) spent a year in a preparatory class. In Group III, three children exhibiting FAS had spent an extra year in kindergarten and four children (one with ARND, two with FAE, and one with FAS) had started school in a preparatory class. In Group I four children (two with ARND, two with normal preschool development) had started school in a mainstream class but had been transferred to a special education class early on. In Group II, three children (one with FAE, one with ARND, one with growth retardation) and in Group III one child exhibiting FAS had been transferred from a mainstream to a special education class. TYPE OF FAMILY In Group I, two of 22 children had been taken temporarily into care, three of 22 permanently. In Group II, three of 24 children were given for adoption at birth, four of 24 had been taken temporarily into care and were now living with their biological parents, and seven of 24 had been taken permanently into care, six of whom were living with foster parents, one in an orphanage. In Group III, only two of 24 children had not been taken into care; one was at the time of this study living temporarily in an orphanage but was taken permanently into care soon after without returning home in between and 20 of 24 had been taken permanently into care (19 lived with foster parents, one was living for a trial period with his father). The one child who had died due to an accident by the age of 18 months would have been taken permanently into care had she survived. Of those children who could not be found, one child in Group III had been taken temporarily into care three times but returned to her biological mother at age 3 years 1 month. Subsequently she could not be traced. Five of the six children taken temporarily into care had once or twice stayed briefly in orphanages or with foster families but one boy had lived in eight different orphanages or with foster families at the request of the mother because of her difficulties in coping with life. Of the children taken permanently into care, one of three children in Group I, two of seven in Group II, and 12 of 21 in Group III had temporarily been taken into care up to five times before any decision about permanent care was reached. Of the children taken permanently into care 11 had been taken into care before 1 year of age, four between 1 and 2 years of age, two between 2 and 3 years of age, four between 5 and 6 years of age, one between 6 and 7 years of age, two between 7 and 8 years of age, and one between 8 and 9 years of age. Types of family according to diagnosis are shown in Table IV. CONSULTATIONS FOR BEHAVIOURAL PROBLEMS By the time of the semistructured interview seven of 22 families in Group I, 11 of 24 families in Group II, and 15 of 23 families in Group III had sought or were seeking help due to the behavioural problems of their children. Continual psychotherapy had been instituted for one child in Group I, three children in Group II, and six children in Group III. The number of parents who had sought help because of behavioural problems of their children is shown in Table IV according to the diagnosis of the child s condition. Seven of 10 children exhibiting FAS, nine of 16 of the children with FAE, eight of 15 children with ARND, four of 10 children with Table I: Numbers of children in the original study and at the 12-year follow-up according to the diagnosis made before school age Original study Follow-up at Autti-Rämö (1993) 12 years (%) Group I Total (76) Normal Pure growth retardation 6 4 Pure CNS dysfunction 4 3 FAE 1 1 FAS Group II Total (89) Normal 5 4 Pure growth retardation 4 4 Pure CNS dysfunction 11 9 FAE 5 5 FAS 2 2 Group III Total (92) Normal Pure growth retardation 3 2 Pure CNS dysfunction 3 3 FAE FAS 9 9 Group I, heavy alcohol exposure during first trimester only; Group II, heavy alcohol exposure during first and second trimester; Group III, heavy alcohol exposure throughout pregnancy. Table II: Schooling during primary school according to the duration of heavy prenatal alcohol exposure School form Group I Group II Group III n=22 n=24 n=23 Mainstream class With personal assistant 2 5 Adjusted requirements in 1 to 2 1 subjects Class for children with Specific learning difficulties 1 1 Psychosocial difficulties Dysphasia 1 Low intelligence (IQ 65 80) Learning disabilities (IQ<65) Developmental Medicine & Child Neurology 2000, 42:

4 pre- or postnatal growth retardation, and five of 18 developmentally normal children had had behavioural problems causing their families to seek help. Foster parents had sought help more often than biological parents. Reasons for behavioural difficulties varied and were multiple but, according to the examining psychologist/child psychiatrist, they were associated with at least one of the following: (1) poor quality of early attachment and daily care; (2) repeated experience of neglect; (3) experience of abuse (physical or sexual); (4) frightening experience they had observed (abuse of mother or sibling); (5) not being liked by peers loneliness and poor understanding of social codes; (6) difficulties in learning capacity, attention, and impulse inhibition. ADDITIONAL ADVERSE EVENTS IN THE FAMILY Eight biological parents (one mother and one father in Group II, five mothers and one father in Group III) had died as a result of an accident while still looking after or in regular contact with their child. Three other biological parents (two mothers, one father) in Group III died when their child had already been taken permanently into care. The deaths were associated with alcohol abuse and/or psychological problems. Only one child received psychological support after his mother s accidental death. Eight biological parents (one father in Group II, four mothers and three fathers in Group III) had been in prison. One child had been in prison with his mother as an infant for a 3-month period. Discussion The children in this study have been followed from infancy by the author who maintained close contact with most of the families despite the children being referred at school age to local health and social care authorities. This is why the information used in this study could reliably be obtained by telephone interviews. In addition, the approval of the Minister for Social and Health Welfare permitted access to each child s medical records for verifying the information concerning transfers to special education classes, child psychiatric consultations, and contacts with social care authorities. The children in the study showed a fairly uniform neuropsychological profile at the age of 7 years (Korkman et al. 1998), exhibiting deficits in attention, naming, receptive language, and visuomotor function. None of the existing special education classes was, however, appropriate for all the children exhibiting specific learning disorders, but each child needed individual support. Unexpectedly, the children with ARND often required more special education than the chil- Table III: Schooling during primary school according to the diagnosis made before school age School form FAS FAE ARND Growth Normal n=10 n=16 n=15 retardation development n=10 n=18 Mainstream class With personal assistant Adjusted requirements in 1 to 2 subjects 1 Class for children with Specific learning difficulties 1 1 Psychosocial difficulties Dysphasia 1 Low intelligence (IQ 65 80) Learning disabilities (IQ<65) 1 Table IV: Family structure by age of 12 years according to diagnosis made before school age and numbers of families in each diagnostic group who had sought help due to behavioural problems of their child Family structure Number FAS FAE ARND Growth Normal n=10 n=16 n=15 retardation development n=10 n=18 Only living with biological parent Counselled for behavioural problems Adopted from birth Counselled for behavioural problems 2 2 Temporarily in care, living with biological parent Counselled for behavioural problems 3 3 Permanently in care, living with foster parents Counselled for behavioural problems Permanently in care, living in an orphanage Counselled for behavioural problems Follow-up of Children Exposed to Alcohol in Utero Ilona Autti-Rämö 409

5 dren with FAE. This finding is of clinical importance as it stresses the necessity to consider fetal alcohol exposure as an aetiologic factor of specific learning difficulties even if a child is normal in appearance and growth, as also suggested by Schaywitz and colleagues (1980). On the basis of earlier studies (Streissguth et al. 1991, Spohr et al. 1993, Steinhausen and Spohr 1998) it was expected that the children with FAS/FAE would have behavioural problems. However, in our study, it seemed that most children taken into care exhibited behavioural difficulties, independent of the diagnosis assigned to them. These findings suggest that the behavioural problems are mainly secondary, but the organic brain damage caused by fetal alcohol exposure may make these children more susceptible to any behavioural disorders. If this assumption is valid, it suggests that the behavioural problems could be prevented if the well-being of an infant born to a mother with an alcohol abuse problem is attended to on an ongoing basis. According to Finnish legislation, however, the development and well-being of the child has to be severely threatened before any decision considering temporary or permanent care can be made. As a consequence of this, a newborn infant with FAS is cared for by his/her biological parents even though the parents are known alcoholics. Since the beginning of this study, two mother-and-child homes for 12 pregnant women and new mothers with alcohol or drug problems have been founded in Finland by the Federation of Mother and Child Homes and Shelters. These units enable some mothers to receive treatment for their alcoholism and support in their parenting, but this does not solve the entire problem. The high rate at which children were repeatedly taken into temporary care reflects how difficult it is for the social workers to defend the rights of a child to have a secure and supportive childhood against the rights of the biological parents to care for their child. In this study, children were taken into care because of parental alcohol abuse and inability to provide adequate daily care for their child, often combined with psychosocial problems. Twenty-two out of 24 children born to mothers who were unable to reduce drinking during pregnancy, 10 out of 10 children with FAS, and 13 out of 16 children with FAE had been taken into care by the age of 10 years. This raises the question of whether these children should have been taken into care at birth and returned to their biological parents only after the mother had undertaken a commitment to seek treatment. This study shows the continuum of fetal alcohol effects ranging from ARND to full-blown FAS. Compared with other studies on FAS (Iosub et al. 1981, Streissguth et al 1991, Steinhausen and Spohr 1998) the children with FAS or FAE in this study have a slightly higher cognitive capacity (Autti- Rämö et al. 1992b, Korkman et al 1994, Korkman et al. 1998). The same finding can also be seen in clinical work, as very few children with FAS in Finland have learning disabilities but they mostly perform at a low to average level. Although the rate at which children taken into care due to parental alcoholism was at least as high as in all other studies (Streissguth et al 1991, Aronson and Hagberg 1998, Spohr and Steinhausen 1998), the amounts of alcohol consumed during pregnancy in Finland may not be as high as in the earlier studies but yet high enough to cause typical FAS. The results of this study further stress the important clinical aspect that it is not only the children with FAS but also the children with no typical facial features children with FAE or ARND who have specific learning difficulties, moderate to severe behavioural difficulties, and are prone to be neglected in daily care. These children are often not diagnosed if information concerning prenatal alcohol exposure is not available. The results of this prospective, long-term follow-up study show that the longer the intrauterine exposure to high levels of alcohol the poorer the long-term outcome in both academic and psychosocial respects. The group of children whose mothers had discontinued drinking after the first trimester of their pregnancy (after being informed they were pregnant and told about the detrimental effects of fetal alcohol exposure) is the most heterogeneous one. Close control of these families can be disadvantageous, constantly reminding the mothers that they had drunk too much alcohol while not yet aware that they were pregnant. Children whose mothers could not reduce their drinking during pregnancy or did so only after mid-pregnancy should, however, be carefully monitored throughout childhood. These families both biological and foster parents need wellorganised, multidisciplinary follow-up regardless of whether or not cognitive disturbances are evident in early childhood. The follow-up should be focused not only on cognitive development but on ways of supporting and improving parenthood and preventing secondary behavioural problems. Special attention should be paid to providing adequate and realistic information to foster parents on the long-term effects of exposure to alcohol on the fetus before a child enters a foster family, and to providing continual support to foster families. These children should be offered the help of a child psychiatrist to assist in coping with their histories before they enter adolescence. Accepted for publication 2nd December Acknowledgements This study was supported by the Finnish Foundation for Alcohol Studies. I am grateful to Professor Lennart von Wendt for valuable advice on the manuscript. References Abel EL. (1995) An update on incidence of FAS. FAS is not an equal opportunity birth defect. Neurotoxicology and Teratology 17: Aronson M, Hagberg B. (1998) Neuropsychological disorders in children exposed to alcohol during pregnancy: a follow-up study of 24 children of alcoholic mothers in Göthenburg, Sweden. Alcoholism: Clinical and Experimental Research 22: Olegård R, Sabel K-G. (1984) Dynamics of Infant Growth and Development from Birth to 18 Months of Age in Relation to Maternal Alcohol Consumption During Pregnancy. Reports from the Department of Applied Psychology, University of Göthenburg. Vol 9, No 3. Goteborg, Sweden: University of Goteborg. Autti-Rämö I. (1993) The outcome of children exposed to alcohol in utero: a prospective follow-up study during the first three years. Thesis, University of Helsinki. Gummerus Kirjapaino, Jyväskylä. Granström M-L. (1991a) The psychomotor development during the first year of life of infants exposed to alcohol in various durations. Neuropediatrics 22: (1991b) The effect of early intrauterine alcohol exposition in various durations on early cognitive development. Neuropediatrics 22: Gaily E, Granström M-L. (1992a) Dysmorphic features in offspring of alcoholic mothers. Archives of Disease in Childhood 67: Korkman M, Hilkakivi-Clarke L, Lehtonen M, Halmesmäki E, Granström M-L. (1992b) Mental development of 2-year-old children exposed to alcohol in utero. Journal of Pediatrics 1120: Developmental Medicine & Child Neurology 2000, 42:

6 Conry J. (1990) Neuropsychological deficits in fetal alcohol syndrome and fetal alcohol effects. Alcoholism: Clinical and Experimental Research 14: Halmesmäki E. (1987) Alcohol counselling of 85 pregnant problem drinkers; effect on drinking and foetal outcome. British Journal of Obstetrics and Gynecology 61: Iosub S, Fuchs M, Bingol N, Gromisch DS. (1981) Fetal alcohol syndrome revisited. Pediatrics 8: Jones KL, Smith DW, Ulleland CN, Streissguth AP. (1973) Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1: Streissguth AP, Myrianthopoulos NC. (1974) Outcome in offspring of chronic alcoholic mothers. Lancet 1: Korkman M, Hilkakivi-Clarke LA, Autti-Rämö I, Fellman V, Granström M-L. (1994) Cognitive impairments at two years of age after prenatal exposure to alcohol or perinatal asphyxia. Neuropediatrics 25: Autti-Rämö I, Koivulehto H, Granström M-L. (1998) Neuropsychological effects at early school age of foetal alcohol exposure of varying duration. Child Neuropsychology 4: Larsson G, Bohlin A-B, Tunell R. (1985) Prospective study of children exposed to variable amounts of alcohol in utero. Archives of Disease in Childhood 60: Nanson JL, Hiscock M. (1990) Attention deficit in children exposed to alcohol prenatally. Alcoholism: Clinical and Experimental Research 14: Olegård R, Sabel K-G, Aronson M, Sandin B, Johansson PR, Carlsson C, Kyllerman M, Iversen K, Hrbek A. (1979) Effects on the child of alcohol abuse during pregnancy: retrospective and prospective studies. Acta Paediatrica Scandinavia 275: (Suppl.) Pihkala J, Hakala T, Voutilainen P, Raivio K. (1989) Uudet suomalaiset sikiön kasvukäyrät. Duodecim 195: Rosett HL. (1980) A clinical perspective of the fetal alcohol syndrome. Alcoholism: Clinical and Experimental Research 4: Weiner L, Lee A, Zuckerman B, McKinlay S, Edelin KC. (1980) Reduction of alcohol consumption during pregnancy with benefits to the newborn. Alcoholism: Clinical and Experimental Research 4: Dooling E, Oppenheim E. (1983) Patterns of alcohol consumption and foetal development. Obstetrics and Gynecology 61: Shaywitz SE, Cohen DJ, Shaywitz BA. (1980) Behavior and learning difficulties in children of normal intelligence born to alcoholic mothers. Journal of Pediatrics 98: Sorva R, Tolppanen EM, Perheentupa J. (1990a) Variation of growth in length and weight of children. I. Years 1 and 2. Acta Paediatrica Scandinavia 79: Lankinen S, Tolppanen EM, Perheentupa J. (1990b) Variation of growth in heights and weight of children. II. After infancy. Acta Paediatrica Scandinavia 79: Spohr H-L, Willms J, Steinhausen H-Ch. (1993) Prenatal exposure to alcohol and long-term developmental consequences. Lancet 341: Steinhausen H-Ch, Spohr H-L. (1998) Long-term outcome of children with fetal alcohol syndrome: psychopathology, behavior and intelligence. Alcoholism: Clinical and Experimental Research 22: Stratton K, Howe C, Battaglia F, editors. (1996) Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention and Treatment. Washington DC: National Academy Press. Streissguth AP, Barr HM, Sampson PD, Parrish-Johnson JC, Kirchner GL, Martin DC. (1986) Attention, distraction and reaction time at age 7 years and prenatal exposure to alcohol. Neurobehavioral Toxicology and Teratology 8: (1990) Moderate prenatal exposure to alcohol: effects on child IQ and learning problems at age 7.5 years. Alcoholism: Clinical and Experimental Research 14: Aase JM, Clarren SK, Randels SP, LaDue RA, Smith DF. (1991) Fetal alcohol syndrome in adolescents and adults. JAMA 265: Sampson PD, Carmichael Olson H, Bookstein FL, Barr HM, Scott M, Mirsky AF. (1994a) Maternal drinking during pregnancy: attention and short-term memory in 14-year-old offspring a longitudinal prospective study. Alcohol Clinical Experimental Research 18: Barr HM, Carmichael Olson H, Sampson PD, Bookstein FL, Burgess DM. (1994b) Drinking during pregnancy decreases word attack and arithmetic scores on standardized tests: adolescent data from a population-based prospective study. Alcoholism: Clinical and Experimental Research 18: Booksteins FL, Barr HM. (1996) A dose-response study of the enduring effects of prenatal exposure to alcohol: birth to 14 years. In: Spohr H-L, Steinhausen H-Ch, editors. Alcohol, Pregnancy and the Developing Child. Cambridge, UK: Cambridge University Press. p Follow-up of Children Exposed to Alcohol in Utero Ilona Autti-Rämö 411

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