Ten years of evidence for the diagnostic assessment of preschoolers with prenatal alcohol exposure
Main Article Content
Keywords
Canadian, diagnostic assessment, Fetal Alcohol Spectrum Disorder (FASD), prenatal alcohol exposure, preschool child
Abstract
The assessment of preschoolers with prenatal alcohol exposure (PAE) is challenging for many diagnostic teams and clinicians. The 2016 Canadian Fetal Alcohol Spectrum Disorder (FASD) diagnostic guidelines describe the assessments recommended for individuals with PAE in various age groups. Interpretation of brain domains constituting global impairment in preschoolers is not well described in the literature, and there has been clinical reluctance to consider the interpretation of clinical assessments as definitively diagnostic in this age group. This study describes the results of 10-year retrospective clinical data of over 300 preschoolers with PAE referred to the Manitoba FASD Centre for assessment of FASD. Preschoolers who met the criteria for a diagnosis of FASD showed significantly greater global developmental impairment, compared with those with PAE alone. They also demonstrated poorer receptive and expressive language abilities when compared with preschoolers who were not diagnosed. Preschoolers with FASD were rated as having more difficulties with executive functioning skills and adaptive functioning skills, compared to their counterparts. Significant deficits were found in fine-motor, visual-motor, and components of gross-motor skills. Importantly, significant sensory processing differences are particularly evident in preschoolers and are important in understanding behavior and in intervention planning. Together, standardized assessment of motor and sensory processing skills, with a comprehensive assessment of language, are significant predictors of FASD diagnosis for preschoolers with PAE.
References
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12. Lebel CA, McMorris CA, Kar P, Ritter C, Andre Q, Tortorelli C, et al. Characterizing adverse pre¬natal and postnatal experiences in children. Birth Defects Res. 2019;111(12):848–58. https://doi. org/10.1002/bdr2.1464
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14. McLennan JD. Misattributions and potential consequences: The case of child mental health problems and Fetal Alcohol Spectrum Disorders. Can J Psychiatry. 2015;60(12):587–90. https://doi. org/10.1177/070674371506001210
15. Flannigan K, Gill K, Pei J, Andrew G, Rajani H, McFarlane A, et al. Deferred diagnosis in children assessed for fetal alcohol spectrum disorder. Appl Neuropsychol Child. 2019;8(3):213–22. https://doi. org/10.1080/21622965.2018.1427094
16. Astley S. Diagnostic guide for Fetal Alcohol Spectrum Disorders: The 4-digit diagnostic code. 3rd ed. Seattle: University of Washington; 2004.
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24. Gioia GA, Epsy KA, Isquith PK. BRIEF: Behavior rating inventory of executive function – Preschool version. Lutz, FL: Psychological Assessment Resources; 2003.
25. Harrison PL, Oakland T. Adaptive behavior assessment system. 3rd ed. San Antonio, TX: Psychological Corporation; 2015.
26. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet. 1973;302(7836):999–1001. https://doi.org/10.1016/ S0140-6736(73)91092-1
27. Lemoine P HH, Borteryu JT, Menuet JC. Les Enfants des parents alcoholiques: anomalies observees a propos de 127 cas. Ouest Medical. 1968;21:476–82.
28. Maatta S, Laakso ML, Tolvanen A, Ahonen T, Aro T. Developmental trajectories of early communication skills. J Speech Lang Hear Res. 2012;55(4):1083–96. https://doi.org/10.1044/1092-4388(2011/10-0305)
29. de Beer M, Kritzinger A, Zsilavecz U. Young children with fetal alcohol spectrum disorder – communication profiles. S Afr J Commun Disord. 2010;57:33–42. https://doi.org/10.4102/sajcd.v57i1.47
30. Kalberg WO, Buckley D. Educational planning for children with fetal alcohol syndrome. Ann Ist Super Sanita. 2006;42(1):58–66.
31. Doney R, Lucas BR, Watkins RE, Tsang TW, Sauer K, Howat P, et al. Visual-motor integration, visual perception, and fine motor coordination in a population of children with high levels of Fetal Alcohol Spectrum Disorder. Res Dev Disabil. 2016;55:346– 57. https://doi.org/10.1016/j.ridd.2016.05.009
32. Doney R, Lucas BR, Jones T, Howat P, Sauer K, Elliott EJ. Fine motor skills in children with prenatal alcohol exposure or fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2014;35(9):598–609. https://doi.org/10.1097/DBP.0000000000000107
33. Stephen JM, Kodituwakku PW, Kodituwakku EL, Romero L, Peters AM, Sharadamma NM, et al. Delays in auditory processing identified in preschool children with FASD. Alcohol Clin Exp Res. 2012;36(10):1720–7. https://doi. org/10.1111/j.1530-0277.2012.01769.x
34. Jirikowic T, Olson HC, Kartin D. Sensory processing, school performance, and adaptive behavior of young school-age children with fetal alcohol spectrum disorders. Phys Occup Ther Pediatr. 2008;28(2):117–36. https://doi. org/10.1080/01942630802031800
35. Wengel T, Hanlon-Dearman AC, Fjeldsted B. Sleep and sensory characteristics in young children with fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2011;32(5):384–92. https://doi. org/10.1097/DBP.0b013e3182199694
36. Fjeldsted B, Xue L. Sensory processing in young children with fetal alcohol spectrum disorder. Phys Occup Ther Pediatr. 2019;39(5):553–65. https://doi. org/10.1080/01942638.2019.1573775
37. Tavassoli T, Brandes-Aitken A, Chu R, Porter L, Schoen S, Miller LJ, et al. Sensory over-responsivity: Parent report, direct assessment measures, and neural architecture. Mol Autism. 2019;10(1):4. https:// doi.org/10.1186/s13229-019-0255-7
38. Brandes-Aitken A, Anguera JA, Chang YS, Demopoulos C, Owen JP, Gazzaley A, et al. White matter microstructure associations of cognitive and visuomotor control in children: A sensory processing perspective. Front Integr Neurosci. 2018;12:65. https://doi.org/10.3389/fnint.2018.00065
39. Pryweller JR, Schauder KB, Anderson AW, Heacock JL, Foss-Feig JH, Newsom CR, et al. White matter correlates of sensory processing in autism spectrum disorders. Neuroimage Clin. 2014;6:379–87. https://doi.org/10.1016/j. nicl.2014.09.018
40. Owen JP, Marco EJ, Desai S, Fourie E, Harris J, Hill SS, et al. Abnormal white matter microstructure in children with sensory processing disorders. Neuroimage Clin. 2013;2:844–53. https://doi. org/10.1016/j.nicl.2013.06.009
41. Jaegermann N, Klein PS. Enhancing mothers’ interactions with toddlers who have sensory-processing disorders. Infant Ment Health J. 2010;31(3):291– 311. https://doi.org/10.1002/imhj.20257
42. Huhdanpaa H, Klenberg L, Westerinen H, Bergman PH, Aronen ET. Impairments of exec¬utive function in young children referred to child psychiatric outpatient clinic. Clin Child Psychol Psychiatry. 2019;24(1):95–111. https://doi. org/10.1177/1359104518786537
43. McKinnon RD, Blair C, Family Life Project I. Does early executive function predict teach¬er-child relationships from kindergarten to second grade? Dev Psychol. 2018;54(11):2053–66. https:// doi.org/10.1037/dev0000584
44. Fuglestad AJ, Whitley ML, Carlson SM, Boys CJ, Eckerle JK, Fink BA, et al. Executive functioning deficits in preschool children with fetal alcohol spectrum disorders. Child Neuropsychol. 2015;21(6):716–31. https://doi.org/10.1080/0929704 9.2014.933792
45. Rasmussen C, Bisanz J. Executive functioning in children with Fetal Alcohol Spectrum Disorders: Profiles and age-related differences. Child Neuropsychol.2009;15(3):201–15. https://doi. org/10.1080/09297040802385400
46. Rasmussen C, Horne K, Witol A. Neurobehavioral functioning in children with fetal alcohol spectrum disorder. Child Neuropsychol. 2006;12(6):453–68. https://doi.org/10.1080/09297040600646854
47. Taylor NM, Enns LN. Factors predictive of a fetal alcohol spectrum disorder diagnosis: Parent and teacher ratings. Child Neuropsychol. 2018;12:1–21.
48. Greenbaum RL, Stevens SA, Nash K, Koren G, Rovet J. Social cognitive and emotion processing abilities of children with fetal alcohol spectrum disorders: A comparison with attention deficit hyperactivity disorder. Alcohol Clin Exp Res. 2009;33(10):1656–70. https://doi. org/10.1111/j.1530-0277.2009.01003.x
49. O’Connor MJ, Frankel F, Paley B, Schonfeld AM, Carpenter E, Laugeson EA, et al. A controlled social skills training for children with fetal alcohol spectrum disorders. J Consult Clin Psychol. 2006;74(4):639–48. https://doi. org/10.1037/0022-006X.74.4.639
50. Rasmussen C, Becker M, McLennan J, Urichuk L, Andrew G. An evaluation of social skills in children with and without prenatal alcohol exposure. Child Care Health Dev. 2011;37(5):711–18. https:// doi.org/10.1111/j.1365-2214.2010.01152.x
51. Molteno CD, Jacobson JL, Carter RC, Dodge NC, Jacobson SW. Infant emotional withdrawal: A precursor of affective and cognitive disturbance in fetal alcohol spectrum disorders. Alcohol Clin Exp Res. 2014;38(2):479–88. https://doi.org/10.1111/ acer.12240
52. Zoorob R, Aliyu MH, Hayes C. Fetal alcohol syndrome: Knowledge and attitudes of family medicine clerkship and residency directors. Alcohol. 2010;44(4):379–85. https://doi.org/10.1016/j. alcohol.2009.10.012
53. Zarnegar Z, Hambrick EP, Perry BD, Azen SP, Peterson C. Clinical improvements in adopted children with fetal alcohol spectrum disorders through neurodevelopmentally informed clinical intervention: A pilot study. Clin Child Psychol Psychiatry. 2016;21(4):551–67. https://doi. org/10.1177/1359104516636438
54. Rasmussen C, Kully-Martens K, Denys K, Badry D, Henneveld D, Wyper K, et al. The effectiveness of a community-based intervention program for women at-risk for giving birth to a child with Fetal Alcohol Spectrum Disorder (FASD). Community Ment Health J. 2012;48(1):12–21. https://doi. org/10.1007/s10597-010-9342-0
2. Olson HC, Jirikowic T, Kartin D, Astley S. Responding to the challenge of early intervention for fetal alcohol spectrum disorders. Infants & Young Children. 2007;20(2):172–89. https://doi.
org/10.1097/01.IYC.0000264484.73688.4a
3. Proven S, Ens C, Beaudin PG. The language profile of school-aged children with Fetal Alcohol Spectrum Disorder (FASD). Can J Speech-Lang Pathol Audiol.. 2014;37(4):268–79.
4. McLachlan K, Andrew G, Pei J, Rasmussen C. Assessing FASD in young children: Exploring clinical complexities and diagnostic challenges. J Popul Ther Clin Pharmacol. 2015;22(1):e108–e124.
5. Bakhireva LN, Garrison L, Shrestha S, Sharkis J, Miranda R, Rogers K. Challenges of diagnosing fetal alcohol spectrum disorders in foster and adopted children. Alcohol. 2018;67:37–43. https:// doi.org/10.1016/j.alcohol.2017.05.004
6. Brown TT. Individual differences in human brain development. Wiley Interdiscip Rev Cogn Sci. 2017;8(1–2):e1389. https://doi.org/10.1002/wcs.1389
7. Mills KL, Goddings AL, Herting MM, Meuwese R, Blakemore SJ, Crone EA, et al. Structural brain development between childhood and adulthood: Convergence across four longitudinal samples. Neuroimage. 2016;141:273–81. https://doi. org/10.1016/j.neuroimage.2016.07.044
8. Donald KA, Ipser JC, Howells FM, Roos A, Fouche JP, Riley EP, et al. Interhemispheric functional brain connectivity in neonates with prenatal alcohol exposure: Preliminary findings. Alcohol Clin Exp Res. 2016;40(1):113–21. https://doi. org/10.1111/acer.12930
9. Donald KA, Fouche JP, Roos A, Koen N, Howells FM, Riley EP, et al. Alcohol exposure in utero is associated with decreased gray matter volume in neonates. Metab Brain Dis. 2016;31(1):81– 91. https://doi.org/10.1007/s11011-015-9771-0
10. Hwang HM, Ku RY, Hashimoto-Torii K. Prenatal environment that affects neuronal migration. Front Cell Dev Biol. 2019;7:138. https://doi.org/10.3389/ fcell.2019.00138
11. Donald KA, Eastman E, Howells FM, Adnams C, Riley EP, Woods RP, et al. Neuroimaging effects of prenatal alcohol exposure on the developing human brain: a magnetic resonance imaging review. Acta Neuropsychiatr. 2015;27(5):251–69. https://doi.org/10.1017/neu.2015.12
12. Lebel CA, McMorris CA, Kar P, Ritter C, Andre Q, Tortorelli C, et al. Characterizing adverse pre¬natal and postnatal experiences in children. Birth Defects Res. 2019;111(12):848–58. https://doi. org/10.1002/bdr2.1464
13. McLennan JD, Braunberger P. A critique of the New Canadian Fetal Alcohol Spectrum Disorder guideline. J Can Acad Child Adolesc Psychiatry. 2017;26(3):179–83.
14. McLennan JD. Misattributions and potential consequences: The case of child mental health problems and Fetal Alcohol Spectrum Disorders. Can J Psychiatry. 2015;60(12):587–90. https://doi. org/10.1177/070674371506001210
15. Flannigan K, Gill K, Pei J, Andrew G, Rajani H, McFarlane A, et al. Deferred diagnosis in children assessed for fetal alcohol spectrum disorder. Appl Neuropsychol Child. 2019;8(3):213–22. https://doi. org/10.1080/21622965.2018.1427094
16. Astley S. Diagnostic guide for Fetal Alcohol Spectrum Disorders: The 4-digit diagnostic code. 3rd ed. Seattle: University of Washington; 2004.
17. Astley SJ. Validation of the Fetal Alcohol Spectrum Disorder (FASD): 4-Digit diagnostic code. J Popul Ther Clin Pharmacol. 2013;20(3):e416–e467.
18. Knobloch H, Stevens MF, Malone AF. Manual of developmental diagnosis: The administration and interpretation of the Revised Gesell and Amartruda development and neurologic examination. Hagerstown, MD: Harper & Row; 1987. 286 p.
19. Wiig EH, Semel EM, Secord W, Pearson Education, Inc. (Firm), PsychCorp (Firm). CELF Preschool-2: Clinical evaluation of language fundamentals preschool. 2nd ed. San Antonio, TX: Pearson/ PsychCorp; 2004.
20. Zimmerman IL, Steiner VG, Pond RE, Psychological Corporation. Preschool language scale. 4th ed. San Antonio, TX: The Psychological Corporation; 2002. https://doi.org/10.1037/t15140-000
21. Dunn W. Sensory profile: User’s manual. San Antonio, TX: Psychological Corp.; 1999. https:// doi.org/10.1037/t15155-000
22. Henderson SE, Sugden DA, Barnett AL, Petermann F, Bös K, Jascenoka J. Movement assess¬ment battery for children-2: (Movement ABC-2) – Manual. Frankfurt am Main: Pearson; 2015.
23. Beery KE, Beery NA. The Beery-Buktenica developmental test of Visual Motor Integration (Beery VMI). Bloomington, MN: Pearson; 2010. https:// doi.org/10.1037/t48947-000
24. Gioia GA, Epsy KA, Isquith PK. BRIEF: Behavior rating inventory of executive function – Preschool version. Lutz, FL: Psychological Assessment Resources; 2003.
25. Harrison PL, Oakland T. Adaptive behavior assessment system. 3rd ed. San Antonio, TX: Psychological Corporation; 2015.
26. Jones KL, Smith DW. Recognition of the fetal alcohol syndrome in early infancy. Lancet. 1973;302(7836):999–1001. https://doi.org/10.1016/ S0140-6736(73)91092-1
27. Lemoine P HH, Borteryu JT, Menuet JC. Les Enfants des parents alcoholiques: anomalies observees a propos de 127 cas. Ouest Medical. 1968;21:476–82.
28. Maatta S, Laakso ML, Tolvanen A, Ahonen T, Aro T. Developmental trajectories of early communication skills. J Speech Lang Hear Res. 2012;55(4):1083–96. https://doi.org/10.1044/1092-4388(2011/10-0305)
29. de Beer M, Kritzinger A, Zsilavecz U. Young children with fetal alcohol spectrum disorder – communication profiles. S Afr J Commun Disord. 2010;57:33–42. https://doi.org/10.4102/sajcd.v57i1.47
30. Kalberg WO, Buckley D. Educational planning for children with fetal alcohol syndrome. Ann Ist Super Sanita. 2006;42(1):58–66.
31. Doney R, Lucas BR, Watkins RE, Tsang TW, Sauer K, Howat P, et al. Visual-motor integration, visual perception, and fine motor coordination in a population of children with high levels of Fetal Alcohol Spectrum Disorder. Res Dev Disabil. 2016;55:346– 57. https://doi.org/10.1016/j.ridd.2016.05.009
32. Doney R, Lucas BR, Jones T, Howat P, Sauer K, Elliott EJ. Fine motor skills in children with prenatal alcohol exposure or fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2014;35(9):598–609. https://doi.org/10.1097/DBP.0000000000000107
33. Stephen JM, Kodituwakku PW, Kodituwakku EL, Romero L, Peters AM, Sharadamma NM, et al. Delays in auditory processing identified in preschool children with FASD. Alcohol Clin Exp Res. 2012;36(10):1720–7. https://doi. org/10.1111/j.1530-0277.2012.01769.x
34. Jirikowic T, Olson HC, Kartin D. Sensory processing, school performance, and adaptive behavior of young school-age children with fetal alcohol spectrum disorders. Phys Occup Ther Pediatr. 2008;28(2):117–36. https://doi. org/10.1080/01942630802031800
35. Wengel T, Hanlon-Dearman AC, Fjeldsted B. Sleep and sensory characteristics in young children with fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2011;32(5):384–92. https://doi. org/10.1097/DBP.0b013e3182199694
36. Fjeldsted B, Xue L. Sensory processing in young children with fetal alcohol spectrum disorder. Phys Occup Ther Pediatr. 2019;39(5):553–65. https://doi. org/10.1080/01942638.2019.1573775
37. Tavassoli T, Brandes-Aitken A, Chu R, Porter L, Schoen S, Miller LJ, et al. Sensory over-responsivity: Parent report, direct assessment measures, and neural architecture. Mol Autism. 2019;10(1):4. https:// doi.org/10.1186/s13229-019-0255-7
38. Brandes-Aitken A, Anguera JA, Chang YS, Demopoulos C, Owen JP, Gazzaley A, et al. White matter microstructure associations of cognitive and visuomotor control in children: A sensory processing perspective. Front Integr Neurosci. 2018;12:65. https://doi.org/10.3389/fnint.2018.00065
39. Pryweller JR, Schauder KB, Anderson AW, Heacock JL, Foss-Feig JH, Newsom CR, et al. White matter correlates of sensory processing in autism spectrum disorders. Neuroimage Clin. 2014;6:379–87. https://doi.org/10.1016/j. nicl.2014.09.018
40. Owen JP, Marco EJ, Desai S, Fourie E, Harris J, Hill SS, et al. Abnormal white matter microstructure in children with sensory processing disorders. Neuroimage Clin. 2013;2:844–53. https://doi. org/10.1016/j.nicl.2013.06.009
41. Jaegermann N, Klein PS. Enhancing mothers’ interactions with toddlers who have sensory-processing disorders. Infant Ment Health J. 2010;31(3):291– 311. https://doi.org/10.1002/imhj.20257
42. Huhdanpaa H, Klenberg L, Westerinen H, Bergman PH, Aronen ET. Impairments of exec¬utive function in young children referred to child psychiatric outpatient clinic. Clin Child Psychol Psychiatry. 2019;24(1):95–111. https://doi. org/10.1177/1359104518786537
43. McKinnon RD, Blair C, Family Life Project I. Does early executive function predict teach¬er-child relationships from kindergarten to second grade? Dev Psychol. 2018;54(11):2053–66. https:// doi.org/10.1037/dev0000584
44. Fuglestad AJ, Whitley ML, Carlson SM, Boys CJ, Eckerle JK, Fink BA, et al. Executive functioning deficits in preschool children with fetal alcohol spectrum disorders. Child Neuropsychol. 2015;21(6):716–31. https://doi.org/10.1080/0929704 9.2014.933792
45. Rasmussen C, Bisanz J. Executive functioning in children with Fetal Alcohol Spectrum Disorders: Profiles and age-related differences. Child Neuropsychol.2009;15(3):201–15. https://doi. org/10.1080/09297040802385400
46. Rasmussen C, Horne K, Witol A. Neurobehavioral functioning in children with fetal alcohol spectrum disorder. Child Neuropsychol. 2006;12(6):453–68. https://doi.org/10.1080/09297040600646854
47. Taylor NM, Enns LN. Factors predictive of a fetal alcohol spectrum disorder diagnosis: Parent and teacher ratings. Child Neuropsychol. 2018;12:1–21.
48. Greenbaum RL, Stevens SA, Nash K, Koren G, Rovet J. Social cognitive and emotion processing abilities of children with fetal alcohol spectrum disorders: A comparison with attention deficit hyperactivity disorder. Alcohol Clin Exp Res. 2009;33(10):1656–70. https://doi. org/10.1111/j.1530-0277.2009.01003.x
49. O’Connor MJ, Frankel F, Paley B, Schonfeld AM, Carpenter E, Laugeson EA, et al. A controlled social skills training for children with fetal alcohol spectrum disorders. J Consult Clin Psychol. 2006;74(4):639–48. https://doi. org/10.1037/0022-006X.74.4.639
50. Rasmussen C, Becker M, McLennan J, Urichuk L, Andrew G. An evaluation of social skills in children with and without prenatal alcohol exposure. Child Care Health Dev. 2011;37(5):711–18. https:// doi.org/10.1111/j.1365-2214.2010.01152.x
51. Molteno CD, Jacobson JL, Carter RC, Dodge NC, Jacobson SW. Infant emotional withdrawal: A precursor of affective and cognitive disturbance in fetal alcohol spectrum disorders. Alcohol Clin Exp Res. 2014;38(2):479–88. https://doi.org/10.1111/ acer.12240
52. Zoorob R, Aliyu MH, Hayes C. Fetal alcohol syndrome: Knowledge and attitudes of family medicine clerkship and residency directors. Alcohol. 2010;44(4):379–85. https://doi.org/10.1016/j. alcohol.2009.10.012
53. Zarnegar Z, Hambrick EP, Perry BD, Azen SP, Peterson C. Clinical improvements in adopted children with fetal alcohol spectrum disorders through neurodevelopmentally informed clinical intervention: A pilot study. Clin Child Psychol Psychiatry. 2016;21(4):551–67. https://doi. org/10.1177/1359104516636438
54. Rasmussen C, Kully-Martens K, Denys K, Badry D, Henneveld D, Wyper K, et al. The effectiveness of a community-based intervention program for women at-risk for giving birth to a child with Fetal Alcohol Spectrum Disorder (FASD). Community Ment Health J. 2012;48(1):12–21. https://doi. org/10.1007/s10597-010-9342-0
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Jul 27, 2020
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Hanlon-Dearman, A., Proven, S., Scheepers, K., Cheung, K., Marles, S., & Centre Team, T. M. F. (2020). Ten years of evidence for the diagnostic assessment of preschoolers with prenatal alcohol exposure. Journal of Population Therapeutics and Clinical Pharmacology, 27(3), e49-e68. https://doi.org/10.15586/jptcp.v27i3.718
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Author Biography
Ana Hanlon-Dearman, Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Manitoba, Canada; Manitoba FASD Centre/MB FASD Network, Winnipeg, Manitoba, Canada.
Dr. Hanlon-Dearman is a developmental pediatrician and the Medical Director of the Manitoba FASD Centre and the Child Development Clinic at Specialized Services for Children and Youth in Winnipeg Manitoba. She is a Full Professor of Pediatrics and Child Health at the Max Rady College of Medicine in the Rady Faculty of Health Sciences at the University of Manitoba where she is the Section Head of Developmental Pediatrics. She is a Diagnostic Co-Lead (Pediatrics) with CanFASD and is involved in FASD research nationally.
How to Cite
Hanlon-Dearman, A., Proven, S., Scheepers, K., Cheung, K., Marles, S., & Centre Team, T. M. F. (2020). Ten years of evidence for the diagnostic assessment of preschoolers with prenatal alcohol exposure. Journal of Population Therapeutics and Clinical Pharmacology, 27(3), e49-e68. https://doi.org/10.15586/jptcp.v27i3.718