Previous Research

The MSACD Project has been involved since the late 1980s in a longitudinal study of children who were prenatally exposed to cocaine. Both children who were exposed to cocaine before birth and non-exposed children were recruited forthe study; they have been followed into their teen years.  Beginning with the adolescent follow-up, we worked with an expert in brain imaging, Dr. Xiaoping Hu, Emory Department of Biomedical Engineering. The goal of this study was to examine effects of prenatal cocaine exposure on teens, especially on how their brains work. The teens were asked to complete magnetic resonance imaging sessions (MRI) at Emory University Hospital. Images or pictures were taken of how the brain works. The cocaine-exposed teens showed patterns of brain activation that were different from those in the non-exposed teens. The cocaine-exposed adolescents were more affected by emotional arousal than the non-exposed teens. This result is very important because it is similar to behavioral and physiological findings when the children were younger.  Prenatal cocaine exposure consistently affects later emotional regulation. 

Dr. Xiaoping Hu and MSACD researchers are now collaborating with another brain imaging group at the University of Georgia to examine how prenatal exposure to cocaine alters connections in the brain and brain networks. In this phase of the project, the brain scans collected in the teen follow-up study are being examined again. New, more advanced methods are now available to define or map brain networks. The researchers will compare the networks and patterns of connectivity in the cocaine-exposed and non-exposed teens. Eventually, the differences in the brain networks will be related to other measures from the study such as teen behavior, emotional adjustment, and cognitive processes.

The researchers with the MSACD project began studying effects of prenatal cocaine exposure (PCE) in the late 1980s when crack cocaine became much more available, use increased dramatically, and there was grave concern about the welfare of “crack babies.” This study, directed by Dr. Claire Coles, focused initially on development from birth to two years; subsets of children were then followed up at 8 years, and twice during the teen years. Mothers were recruited shortly after birth and asked to participate in the study with their babies. The sample included both children whose mothers used cocaine during pregnancy and children whose mothers did not. Recruitment took place at an urban hospital in Atlanta serving a predominantly low-income, African-American population. In all analyses, children with PCE were compared to children from similar socioeconomic backgrounds who were not exposed.

The researchers examined development of children in a wide range of areas. Physical development, intellectual development, arousal regulation, social development, and behavior were all examined in this study across developmental periods. Arousal regulation was a focus of the study because cocaine is a stimulant and the researchers wanted to examine how it might affect these physiologically-based responses of children. Children with arousal problems may have difficulty developing self-control and this can be related to later problems with behavior. The evaluations in the teen years also included brain imaging sessions so potential long-term effects of PCE on brain function could be examined. In addition, characteristics of the home environment were examined for these children. Sometimes mothers who use drugs in pregnancy have difficulty providing adequate care for their babies. For this reason, the caregiving environment provided at home was examined in relation to the potential physiological effects of PCE.    

When the caregiving environment was controlled, the study has shown few effects of PCE on physical, intellectual, or social development, but has mapped extensive effects on arousal regulation across each developmental period examined. Differences in patterns of arousal regulation were detected as early as eight weeks of age. Physiological effects on arousal also occurred at the 8-year follow-up when physiological measures of arousal (for example, heart rate, respiratory rate) were examined. Behavior problems related to dysregulation or lack of self-control also were reported more frequently at eight years for the PCE group. Effects on arousal regulation again appeared in the brain–imaging studies at adolescence. For these studies, the focus was on areas of the brain involved in emotional arousal such as the amygdala. The teens with PCE showed activation patterns different from those of the non-exposed teens in that they were more affected by emotional arousal than the non-exposed group.

In summary, the study has shown that PCE consistently affects arousal regulation in childhood and adolescence. Outcomes in other areas were not strongly affected when effects of the child-rearing environment were taken into account. The alarm sounded in the 1980s about the “crack babies,” especially in the area of school performance, was generally not supported by the research data.

The MSACD study of effects of prenatal alcohol exposure (PAE) on children began over 30 years ago.  The study, directed by Dr. Claire Coles, provides one of the most comprehensive data sets in existence on this topic. The study began in the early 1980s before much information was available about effects of PAE on development.  Pregnant women were recruited to be in the study at a hospital serving a predominantly African-American, low income population. Both mothers who drank during pregnancy and those who did not were included in the sample.  The children were evaluated in infancy and then subsets of the sample were seen in early childhood, at age seven, in the teen years, and in early adulthood. In all studies, alcohol-affected participants were compared to those from similar backgrounds who were not affected.

Many aspects of development were examined during this study. In the early years, the focus was on physical development, such as height, weight, head circumference, and facial features know to be affected by prenatal alcohol exposure. Infant behavior also was studied, including motor performance, orienting behavior and state regulation. At school age and later, the focus shifted to intellectual development, attention, behavior problems, and social development. In early adulthood, the researchers added the examination of brain structure and function by adding magnetic resonance imaging (MRI) sessions to the evaluation.

The study has provided data-based information on effects of PAE on physical development, intellectual development, attention, memory, and behavior problems. Deficits in these areas have been related to PAE across developmental periods in this sample in physical and cognitive areas; data on  problem behaviors such as substance use and delinquency in this community sample have not been consistently related to PAE. In addition, the study contributed to our knowledge of how prenatal alcohol exposure actually affects brain structure and how the brain works. PAE is related to decreased size of the brain overall and to many parts of the brain as well as altered brain connection patterns in a variety of areas.  

The Emory Language Development Study was a prospective longitudinal study of the impact of prenatal tobacco exposure (PTE) on child development.  The study took place between 2003 and 2009 and was directed by Dr. Claire Coles.  The focus of the study was on how PTE affects early language development and behavior during the first two years of life.  Mothers were recruited for the sample from the postpartum units of two hospitals in Atlanta.  Over 300 mothers enrolled in the study.  Both mothers who smoked during pregnancy and mothers who did not were included.  Follow-up visits and evaluations were scheduled when the children were 6 months, 15 months, and 24 months old.  During the follow-up visits, measures of the child’s early language development, auditory processing, and behavior as well as measures of the home environment and maternal characteristics were completed.

Results of the study analyses suggest that PTE is related to auditory processing, language development and behavior during the first two years.  At six months, the auditory processing of infants with PTE was less efficient than that of infants who were not exposed. Effects of PTE on language and behavior were examined in the children at 24 months of age. Most two-year-olds were in the average range on outcomes, but some significant effects of PTE did occur.  Based on infant testing and parent reports of their children’s behavior, the researchers found that PTE was related to lower test scores on language development and to higher ratings of behavior problems.  Additional analyses showed that the effect of PTE on behavior problems was mediated by the child’s language development, which implies that PTE affects behavior through a delay in language, not by affecting behavior directly. Overall, the study results suggest that there are subtle effects of PTE on these aspects of child development in the first two years of life.

Atlanta’s Multisite Neurobehavioral Assessment of Fetal Alcohol Spectrum Disorders project was part of large network of sites throughout the country working to identify core diagnostic features of Fetal Alcohol Spectrum Disorders that differentiate this disorder from typically developing children as well as children with other disorders. The goal was to develop clinically relevant and feasible measurement tools to accurately identify children who are affected by prenatal alcohol exposure. This study contributed to an existing database derived from data collected from children between 8-16 years of age, across multiple clinical sites throughout the world. Two age groups (5-7 years and 10-16 years) were recruited. Data was collected from children with prenatal alcohol exposure, non-exposed controls and heterogeneous clinical contrast subjects. This research helped improve our understanding of fetal alcohol spectrum disorders (FASD) by continuing efforts to develop and refine a sensitive and specific neurobehavioral profile. These data were combined with data from other CIFASD projects to develop models that accurately capture the greatest number of affected children using multidisciplinary methodology.  Some participants were asked to participate in two additional components of the CIFASD project: Neuroimaging and Genetics.

The neuroimaging component looked at brain connectivity in FASDs and the long-term development of the brain. Participants were asked to have two neuroimaging scans over a two year period to assess changes in brain development. The goal of this project was to determine if innovative techniques were used to identify brain alterations, neurobehavioral deficits and facial characteristics and relationships between these variables to help further define/diagnose prenatal alcohol spectrum disorders (FASDs).

The genetic component of the CIFASD project is designed to extend preliminary genetic studies through collection of DNA samples from saliva. The goal was to further evaluate candidate genes identified in the basic science components of the CIFASD project.

The project was funded by the National Institute on Alcoholism and Alcohol-Abuse.

• Principle Investigator: Julie A. Kable, PhD
• Principle Investigator (Neuroimaging Subcomponent): Claire D. Coles, PhD

View abstracts regarding the study’s outcomes.

Previous to the Collaboration on FASD Prevalence (CoFASP), there was no study that examined the prevalence of FASD in the United States using active case ascertainment. In this consortium we collaborated with researchers from the University of New Mexico and the University of California to identify alcohol-affected children in first grade class room in several regions including the Southwest, the upper Midwest and the South. MSACD scientists at Emory University School of Medicine worked with the principal investigators on these projects to design and implement measures of the behavioral effects of prenatal alcohol exposure. The goal was to establish a more accurate and representative prevalence estimate by using standardized diagnostic criteria for FASD. As part of the study, updated diagnostic guidelines were developed (Holme, et al. 2016) and studies were done on reliability of the FASD diagnosis (Coles, et al, 2016; Kable & Coles, 2017). In addition, the study resulted in a database of those children and families who participated that can be of use to future research studies. The study found that the prevalence of alcohol effects in first graders was higher than previously believed (May, et al, 2018). The project was funded by the National Institute on Alcohol Abuse and Alcoholism.

• Coles CD, Gaily A, Mulle J, Kable JA, Lynch ME, & Jones KL (2016) A comparison among five methods for the clinical diagnosis of Fetal Alcohol Spectrum Disorders (FASD). Alcoholism: Clinical and Experimental Research. 40(8):1000-1009.
• Hoyme HE, Kalberg WO, Elliott AJ, Bankenship J, Buckley D, Marais A-S, Manning MA, Robinson LK, Adam MP, Abdul-Rahman O, Jewell T, Coles CD, Chambers C, Jones KL, Adnams CM, Shah PE, Riley EP, Charness ME, Warren KR, & May PA (2016) Updated Clinical Guidelines for Diagnosing Fetal Alcohol Spectrum Disorders. Pediatrics doi: 10.1542/peds.2015-4256.
• Kable JA, & Coles CD (2017) Evidence supporting the internal validity of the proposed ND-PAE disorder. Child Psychiatry and Human Development, Published on line June, 20, 2017
• May PA, Chambers CD, Kalberg WO, Zellner J, Feldman H, Buckley D, Kopald D, Hasken JM, Xu R, Honerkamp-Smith G, Taras H, Manning MA, Robinson LK, Adam MP, Abdul-Rahman O, Vaux K, Jewett T, Elliott AJ, Kable JA, Askhoomoff N, Faulk D, Arroyo JA, Hereld D, Riley EP, Charness M, Coles CD, Warren KR, Jones KJ, Hoyme HE, and the CoFASP.  (2018) Prevalence of Fetal Alcohol Spectrum Disorders in Four Communities of the United States: Results from the Collaboration on Fetal Alcohol Spectrum Disorders Prevalence (CoFASP). Journal of the American Medical Association.