<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Fetal alcohol spectrum disorder and can you explain it in depth? [/INST] Fetal alcohol spectrum disorders (FASDs) are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. Symptoms can include an abnormal appearance, short height, low body weight, small head size, poor coordination, behavioural problems, learning difficulties, and problems with hearing and sight. Those affected are more likely to have trouble with school, the legal system, alcohol, other drugs, and other areas of high risk. The several forms of the condition (in order of most severe to least severe) are: Fetal Alcohol Syndrome (FAS), Partial Fetal Alcohol Syndrome (pFAS), Alcohol-Related Birth Defects (ARBD),Static Encephalopathy, Alcohol-Related Neurodevelopmental Disorder (ARND) and Neurobehavioral Disorder associated with Prenatal Alcohol Exposure (ND-PAE). Some authorities accept only FAS as a diagnosis, seeing the evidence as inconclusive with respect to other types.Fetal alcohol spectrum disorders are caused by the mothers drinking alcohol while pregnant with the affected person. Surveys from the United States found that about 10% of pregnant women drank alcohol in the past month, and 20% to 30% drank at some point during the pregnancy. 3.6% of pregnant American women met criteria for an alcohol use disorder in a 2001 epidemiological study. The risk of FASD depends on the amount consumed, the frequency of consumption, and the points in pregnancy at which the alcohol is consumed. Other risk factors include the mothers older age, smoking, and poor diet. There is no known safe amount or time to drink alcohol during pregnancy. Although drinking small amounts does not cause facial abnormalities, it may cause behavioral problems. Alcohol crosses the blood–brain barrier and both directly and indirectly affects a developing fetus. Diagnosis is based on the signs and symptoms in the person.Fetal alcohol spectrum disorders are preventable by the mothers avoiding alcohol during pregnancy. For this reason, medical authorities recommend that women completely avoid drinking alcohol during pregnancy and while trying to conceive. Although the condition is permanent, treatment can improve outcomes. Interventions may include parent–child interaction therapy, efforts to modify child behavior, and drugs.FASD is estimated to affect between 1% and 5% of people in the United States and Western Europe. FAS is believed to occur in between 0.2 and 9 per 1,000 live births in the United States. In South Africa, some populations have rates as high as 9%. The negative effects of alcohol during pregnancy have been described since ancient times. The lifetime cost per child with FAS in the United States was $2 million in 2002; however in 2021, Canada revealed that the annual cost for FASD individuals was $9.7 billion (including the costs of the Criminal Justice System, healthcare, and education among others). The term fetal alcohol syndrome was first used in 1973.

Types
FASDs encompass a range of physical and neurodevelopmental problems that can result from prenatal alcohol exposure. The most severe condition is called fetal alcohol syndrome (FAS), which refers to individuals who have a specific set of birth defects and neurodevelopmental disorders characteristic of the diagnosis.Some accept only FAS as a diagnosis, seeing the evidence as inconclusive with respect to other types.
Fetal alcohol syndrome (FAS)
Partial fetal alcohol syndrome (pFAS) refers to individuals with a known, or highly suspected, history of prenatal alcohol exposure who have alcohol-related physical and neurodevelopmental deficits that do not meet the full criteria for FAS. pFAS-subtypes:
Alcohol-related neurodevelopmental disorder (ARND)
Alcohol-related birth defects (ARBD). In addition to FAS, pFAS
Alcohol-Related Neurodevelopmental Disorder (ARND)
Alcohol-Related Birth Defects (ARBD)
Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure (ND-PAE)
Static EncephalopathyThese conditions believed to be related to prenatal alcohol exposure, such as spontaneous abortion and sudden infant death syndrome (SIDS), are also considered to be on the spectrum of related disorders. It is unclear as of 2017 if identifying a FASD-related condition benefits the individual.In 2013, the American Psychiatric Association introduced neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) into the DSM-V as a "condition for further study" and as a specified condition under, "other specified neurodevelopmental disorders" as a way to better study the behavioral aspects of all FASD disorders. Though similar sounding, ND-PAE is the spectrum-wide term for the psychiatric, behavioral, and neurological symptoms of all FASDs, where as ARND is the specific diagnosis of the non-dysmorphic type of FASD where a majority of the symptoms are witnessed.

Signs and symptoms
The key of FASD can vary between individuals exposed to alcohol during pregnancy. While consensus exists for the definition and diagnosis of FAS, minor variations among the systems lead to differences in definitions and diagnostic cut-off criteria for other diagnoses across the FASD continuum.The central nervous system damage criteria particularly lacks clear consensus. A working knowledge of the key features is helpful in understanding FASD diagnoses and conditions, and each is reviewed with attention to similarities and differences across the four diagnostic systems. More than 400 problems, however, can occur with FASD.

Growth
In terms of FASD, growth deficiency is defined as significantly below average height, weight or both due to prenatal alcohol exposure and can be assessed at any point in the lifespan. Growth measurements must be adjusted for parental height, gestational age (for a premature infant), and other postnatal insults (e.g., poor nutrition), although birth height and weight are the preferred measurements. Deficiencies are documented when height or weight falls at or below the 10th percentile of standardized growth charts appropriate to the population. Prenatal or postnatal presentation of growth deficits can occur, but are most often postnatal.Criteria for FASD are least specific in the Institute of Medicine (IOM) diagnostic system ("low birth weight..., decelerating weight not due to nutrition..., [or] disproportional low weight to height" p. 4 of executive summary), while the CDC and Canadian guidelines use the 10th percentile as a cut-off to determine growth deficiency. The "4-Digit Diagnostic Code" allows for mid-range gradations in growth deficiency (between the 3rd and 10th percentiles) and severe growth deficiency at or below the 3rd percentile. Growth deficiency (at severe, moderate, or mild levels) contributes to diagnoses of FAS and pFAS, but not ARND or static encephalopathy.Growth deficiency is ranked as follows by the "4-Digit Diagnostic Code":
Severe: Height and weight at or below the 3rd percentile.
Moderate: Either height or weight at or below the 3rd percentile, but not both.
Mild: Either height or weight or both between the 3rd and 10th percentiles.
None: Height and weight both above the 10th percentile.In the initial studies that discovered FAS, growth deficiency was a requirement for inclusion in the studies; thus, all the original people with FAS had growth deficiency as an artifact of sampling characteristics used to establish criteria for the syndrome. That is, growth deficiency is a key feature of FASD because growth deficiency was a criterion for inclusion in the study that defined FAS. This suggests growth deficiency may be less critical for understanding the disabilities of FASD than the neurobehavioral sequelae to the brain damage.

Facial features
Several characteristic craniofacial abnormalities are often visible in individuals with FAS. The presence of FAS facial features indicates brain damage, although brain damage may also exist in their absence. FAS facial features (and most other visible, but non-diagnostic, deformities) are believed to be caused mainly during the 10th to 20th week of gestation.Refinements in diagnostic criteria since 1975 have yielded three distinctive and diagnostically significant facial features known to result from prenatal alcohol exposure and distinguishes FAS from other disorders with partially overlapping characteristics. The three FAS facial features are:

A smooth philtrum: The divot or groove between the nose and upper lip flattens with increased prenatal alcohol exposure.
Thin vermilion: The upper lip thins with increased prenatal alcohol exposure.
Small palpebral fissures: Eye width decreases with increased prenatal alcohol exposure.Measurement of FAS facial features uses criteria developed by the University of Washington. The lip and philtrum are measured by a trained physician with the Lip-Philtrum Guide, a five-point Likert scale with representative photographs of lip and philtrum combinations ranging from normal (ranked 1) to severe (ranked 5). Palpebral fissure length (PFL) is measured in millimeters with either calipers or a clear ruler and then compared to a PFL growth chart, also developed by the University of Washington.Ranking FAS facial features is complicated because the three separate facial features can be affected independently by prenatal alcohol. A summary of the criteria follows:
Severe: All three facial features ranked independently as severe (lip ranked at 4 or 5, philtrum ranked at 4 or 5, and PFL two or more standard deviations below average).
Moderate: Two facial features ranked as severe and one feature ranked as moderate (lip or philtrum ranked at 3, or PFL between one and two standard deviations below average).
Mild: A mild ranking of FAS facial features covers a broad range of facial feature combinations:
Two facial features ranked severe and one ranked within normal limits,
One facial feature ranked severe and two ranked moderate, or
One facial feature ranked severe, one ranked moderate and one ranked within normal limits.
None: All three facial features ranked within normal limits.

Central nervous system
Central nervous system (CNS) damage is the primary feature of any FASD diagnosis. Prenatal alcohol exposure, which is classified as a teratogen, can damage the brain across a continuum of gross to subtle impairments, depending on the amount, timing, and frequency of the exposure as well as genetic predispositions of the fetus and mother. While functional abnormalities are the behavioral and cognitive expressions of the FASD disability, CNS damage can be assessed in three areas: structural, neurological, and functional impairments.All four diagnostic systems allow for assessment of CNS damage in these areas, but criteria vary. The IOM system requires structural or neurological impairment for a diagnosis of FAS, but also allows a "complex pattern" of functional anomalies for diagnosing PFAS and ARND. The "4-Digit Diagnostic Code" and CDC guidelines allow for a positive CNS finding in any of the three areas for any FASD diagnosis, but functional anomalies must measure at two standard deviations or worse in three or more functional domains for a diagnosis of FAS, PFAS, and ARND. The "4-Digit Diagnostic Code" also allows for an FASD diagnosis when only two functional domains are measured at two standard deviations or worse. The "4-Digit Diagnostic Code" further elaborates the degree of CNS damage according to four ranks:

Definite: Structural impairments or neurological impairments for FAS or static encephalopathy.
Probable: Significant dysfunction of two standard deviations or worse in three or more functional domains.
Possible: Mild to moderate dysfunction of two standard deviations or worse in one or two functional domains or by judgment of the clinical evaluation team that CNS damage cannot be dismissed.
Unlikely: No evidence of CNS damage.

Structural
Structural abnormalities of the brain are observable, physical damage to the brain or brain structures caused by prenatal alcohol exposure. Structural impairments may include microcephaly (small head size) of two or more standard deviations below the average, or other abnormalities in brain structure (e.g., agenesis of the corpus callosum, cerebellar hypoplasia).Microcephaly is determined by comparing head circumference (often called occipitofrontal circumference, or OFC) to appropriate OFC growth charts. Other structural impairments must be observed through medical imaging techniques by a trained physician. Because imaging procedures are expensive and relatively inaccessible to most people, diagnosis of FAS is not frequently made via structural impairments, except for microcephaly.Evidence of a CNS structural impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and neurological and functional impairments are highly likely.During the first trimester of pregnancy, alcohol interferes with the migration and organization of brain cells, which can create structural deformities or deficits within the brain. During the third trimester, damage can be caused to the hippocampus, which plays a role in memory, learning, emotion, and encoding visual and auditory information, all of which can create neurological and functional CNS impairments as well.As of 2002, there were 25 reports of autopsies on infants known to have FAS. The first was in 1973, on an infant who died shortly after birth. The examination revealed extensive brain damage, including microcephaly, migration anomalies, callosal dysgenesis, and a massive neuroglial, leptomeningeal heterotopia covering the left hemisphere.In 1977, Dr. Clarren described a second infant whose mother was a binge drinker. The infant died ten days after birth. The autopsy showed severe hydrocephalus, abnormal neuronal migration, and a small corpus callosum (which connects the two brain hemispheres) and cerebellum. FAS has also been linked to brainstem and cerebellar changes, agenesis of the corpus callosum and anterior commissure, neuronal migration errors, absent olfactory bulbs, meningomyelocele, and porencephaly.

Neurological
When structural impairments are not observable or do not exist, neurological impairments are assessed. In the context of FASD, neurological impairments are caused by prenatal alcohol exposure which causes general neurological damage to the central nervous system (CNS), the peripheral nervous system, or the autonomic nervous system. A determination of a neurological problem must be made by a trained physician, and must not be due to a postnatal insult, such as meningitis, concussion, traumatic brain injury, etc.All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS or pFAS, and functional impairments are highly likely.Neurological problems are expressed as either hard signs, or diagnosable disorders, such as epilepsy or other seizure disorders, or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired fine motor skills, neurosensory hearing loss, poor gait, clumsiness, and poor hand - eye coordination. Many soft signs have norm-referenced criteria, while others are determined through clinical judgment. "Clinical judgment" is only as good as the clinician, and soft signs should be assessed by either a pediatric neurologist, a pediatric neuropsychologist, or both.

Functional
When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to prenatal alcohol exposure to be assessed in terms of functional impairments. Functional impairments are deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or postnatal insults) in observable and measurable domains related to daily functioning, often referred to as developmental disabilities. There is no consensus on a specific pattern of functional impairments due to prenatal alcohol exposure and only CDC guidelines label developmental delays as such, so criteria (and FASD diagnoses) vary somewhat across diagnostic systems.
The four diagnostic systems list various CNS domains that can qualify for functional impairment that can determine an FASD diagnosis:

Evidence of a complex pattern of behavior or cognitive abnormalities inconsistent with developmental level in the following CNS domains – Sufficient for a pFAS or ARND diagnosis using IOM guidelinesLearning disabilities, academic achievement, impulse control, social perception, communication, abstraction, math skills, memory, attention, judgment
Performance at two or more standard deviations on standardized testing in three or more of the following CNS domains – Sufficient for an FAS, pFAS or static encephalopathy diagnosis using 4-Digit Diagnostic CodeExecutive functioning, memory, cognition, social/adaptive skills, academic achievement, language, motor skills, attention, activity level
General cognitive deficits (e.g., IQ) at or below the 3rd percentile on standardized testing – Sufficient for an FAS diagnosis using CDC guidelines
Performance at or below the 16th percentile on standardized testing in three or more of the following CNS domains – Sufficient for an FAS diagnosis using CDC guidelinesCognition, executive functioning, motor functioning, attention and hyperactive problems, social skills, sensory processing disorder, social communication, memory, difficulties responding to common parenting practices
Performance at two or more standard deviations on standardized testing in three or more of the following CNS domains – Sufficient for an FAS diagnosis using Canadian guidelines
Cognition, communication, academic achievement, memory, executive functioning, adaptive behavior, motor skills, social skills, social communication

Related signs
Other conditions may commonly co-occur with FAS, stemming from prenatal alcohol exposure. However, these conditions are considered alcohol-related birth defects and not diagnostic criteria for FAS.

Heart: A heart murmur that frequently disappears by one year of age. Ventricular septal defect, atrial septal defect, Tetralogy of Fallot, coarctation of the aorta, and/or cardiac rhythm dysfunction.
Bones: Joint anomalies including abnormal position and function, altered palmar crease patterns, small distal phalanges, and small fifth fingernails.
Kidneys: Horseshoe, aplastic, dysplastic, or hypoplastic kidneys.
Eyes: Strabismus, optic nerve hypoplasia (which may cause light sensitivity, decreased visual acuity, or involuntary eye movements).
Occasional problems: ptosis of the eyelid, microphthalmia, cleft lip with or without a cleft palate, webbed neck, short neck, spina bifida, and hydrocephalus.

Cause
Fetal alcohol spectrum disorder is caused by a woman consuming alcohol while pregnant. Alcohol crosses through the placenta to the unborn child and can interfere with normal development. Alcohol is a teratogen (causes birth defects) and there is no known safe amount of alcohol to consume while pregnant and there is no known safe time during pregnancy to consume alcohol to prevent birth defects such as FASD. Evidence of harm from low levels of alcohol consumption is not clear and since there are not known safe amounts of alcohol, women are suggested to completely abstain from drinking when trying to get pregnant and while pregnant. Small amounts of alcohol may not cause an abnormal appearance, however, small amounts of alcohol consumption while pregnant may cause milder symptoms such as behavioral problems and also increases the risk of miscarriage.Among those women who are alcoholic, an estimated one-third of their children have FAS.

Mechanism
Despite intense research efforts, the exact mechanism for the development of FAS or FASD is unknown. On the contrary, clinical and animal studies have identified a broad spectrum of pathways through which maternal alcohol can negatively affect the outcome of a pregnancy. Clear conclusions with universal validity are difficult to draw, since different ethnic groups show considerable genetic polymorphism for the hepatic enzymes responsible for ethanol detoxification.Genetic examinations have revealed a continuum of long-lasting molecular effects that are not only timing specific but are also dosage specific; with even moderate amounts being able to cause alterations.A human fetus appears to be at triple risk from maternal alcohol consumption:
The placenta allows free entry of ethanol and toxic metabolites like acetaldehyde into the fetal compartment. The so-called placental barrier is practically absent with respect to ethanol.
The developing fetal nervous system appears particularly sensitive to ethanol toxicity. The latter interferes with proliferation, differentiation, neuronal migration, axonic outgrowth, integration, and fine-tuning of the synaptic network. In short, all major processes in the developing central nervous system appear compromised.
Fetal tissues are quite different from adult tissues in function and purpose. For example, the main detoxicating organ in adults is the liver, whereas the fetal liver is incapable of detoxifying ethanol, as the ADH and ALDH enzymes have not yet been brought to expression at this early stage. Up to term, fetal tissues do not have significant capacity for the detoxification of ethanol, and the fetus remains exposed to ethanol in the amniotic fluid for periods far longer than the decay time of ethanol in the maternal circulation. The lack of significant quantities of ADH and ALDH means that fetal tissues have much lower quantities of antioxidant enzymes, like SOD, glutathione transferases, and glutathion peroxidases, resulting in antioxidant protection being much less effective.Additionally, ethanol may alter fetal development by interfering with retinoic acid signaling. Acetaldehyde, the main ethanol metabolite, can compete with retinaldehyde and prevent its oxidation to retinoic acid.

Diagnosis
Because admission of alcohol use during pregnancy can stigmatize birth mothers, many are reluctant to admit to drinking or to provide an accurate report of the quantity they drank. This complicates diagnosis and treatment of the syndrome. As a result, diagnosis of the severity of FASD relies on protocols of observation of the childs physiology and behavior rather than maternal self-reporting.
Presently, four FASD diagnostic systems that diagnose FAS and other FASD conditions have been developed in North America:

The Institute of Medicines guidelines for FAS, the first system to standardize diagnoses of individuals with prenatal alcohol exposure;
The University of Washingtons "The 4-Digit Diagnostic Code", which ranks the four key features of FASD on a Likert scale of one to four and yields 256 descriptive codes that can be categorized into 22 distinct clinical categories, ranging from FAS to no findings;
The Centers for Disease Controls "Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis", which established consensus on the diagnosis FAS in the U.S. but deferred addressing other FASD conditions; and
Canadian guidelines for FASD diagnoses, which established criteria for diagnosing FASD in Canada and harmonized most differences between the IOM and University of Washingtons systems.Each diagnostic system requires that a complete FASD evaluation includes an assessment of the four key features of FASD, described below. A positive finding on all four features is required for a diagnosis of FAS. However, prenatal alcohol exposure and central nervous system damage are the critical elements of the spectrum of FASD, and a positive finding in these two features is sufficient for an FASD diagnosis that is not "full-blown FAS".While the four diagnostic systems essentially agree on criteria for fetal alcohol syndrome (FAS), there are still differences when full criteria for FAS are not met. This has resulted in differing and evolving nomenclature for other conditions across the spectrum of FASD, which may account for such a wide variety of terminology. Most individuals with deficits resulting from prenatal alcohol exposure do not express all features of FAS and fall into other FASD conditions. The Canadian guidelines recommend the assessment and descriptive approach of the "4-Digit Diagnostic Code" for each key feature of FASD and the terminology of the IOM in diagnostic categories, excepting ARBD.Thus, other FASD conditions are partial expressions of FAS. However, these other FASD conditions may create disabilities similar to FAS if the key area of central nervous system damage shows clinical deficits in two or more of ten domains of brain functioning. Essentially, even though growth deficiency and/or FAS facial features may be mild or nonexistent in other FASD conditions, yet clinically significant brain damage of the central nervous system is present. In these other FASD conditions, an individual may be at greater risk for adverse outcomes because brain damage is present without associated visual cues of poor growth or the "FAS face" that might ordinarily trigger an FASD evaluation. Such individuals may be misdiagnosed with primary mental health disorders such as ADHD or oppositional defiance disorder without appreciation that brain damage is the underlying cause of these disorders, which requires a different treatment paradigm than typical mental health disorders. While other FASD conditions may not yet be included as an ICD or DSM-IV-TR diagnosis, they nonetheless pose significant impairment in functional behavior because of underlying brain damage.

Fetal alcohol syndrome
The following criteria must be fully met for an FAS diagnosis:
Growth deficiency: Prenatal or postnatal height or weight (or both) at or below the 10th percentile
FAS facial features: All three FAS facial features present
Central nervous system damage: Clinically significant structural neurological, or functional impairment
Prenatal alcohol exposure: Confirmed or Unknown prenatal alcohol exposureFetal alcohol syndrome (FAS) is the first diagnosable condition of FASD that was discovered. FAS is the only expression of FASD that has garnered consensus among experts to become an official ICD-9 and ICD-10 diagnosis. To make this diagnosis or determine any FASD condition, a multi-disciplinary evaluation is necessary to assess each of the four key features for assessment. Generally, a trained physician will determine growth deficiency and FAS facial features. While a qualified physician may also assess central nervous system structural abnormalities and/or neurological problems, usually central nervous system damage is determined through psychological, speech-language, and occupational therapy assessments to ascertain clinically significant impairments in three or more of the Ten Brain Domains. Prenatal alcohol exposure risk may be assessed by a qualified physician, psychologist, social worker, or chemical health counselor. These professionals work together as a team to assess and interpret data of each key feature for assessment and develop an integrative, multi-disciplinary report to diagnose FAS (or other FASD conditions) in an individual.

Partial FAS
Partial FAS (pFAS) was previously known as atypical FAS in the 1997 edition of the "4-Digit Diagnostic Code". People with pFAS have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the complete facial stigmata. Central nervous system damage is present at the same level as FAS. These individuals have the same functional disabilities but "look" less like FAS.The following criteria must be fully met for a diagnosis of Partial FAS:
Growth deficiency: Growth or height may range from normal to deficient
FAS facial features: Two or three FAS facial features present
Central nervous system damage: Clinically significant structural, neurological, or functional impairment in three or more of the Ten Brain Domains
Prenatal alcohol exposure: Confirmed prenatal alcohol exposure

Fetal alcohol effects
Fetal alcohol effects (FAE) is a previous term for alcohol-related neurodevelopmental disorder and alcohol-related birth defects. It was initially used in research studies to describe humans and animals in whom teratogenic effects were seen after confirmed prenatal alcohol exposure (or unknown exposure for humans), but without obvious physical anomalies. Smith (1981) described FAE as an "extremely important concept" to highlight the debilitating effects of brain damage, regardless of the growth or facial features. This term has fallen out of favor with clinicians because it was often regarded by the public as a less severe disability than FAS, when in fact its effects can be just as detrimental.

Alcohol-related neurodevelopmental disorder
Alcohol-related neurodevelopmental disorder (ARND) was initially suggested by the Institute of Medicine to replace the term FAE and focus on central nervous system damage, rather than growth deficiency or FAS facial features. The Canadian guidelines also use this diagnosis and the same criteria. While the "4-Digit Diagnostic Code" includes these criteria for three of its diagnostic categories, it refers to this condition as static encephalopathy. The behavioral effects of ARND are not necessarily unique to alcohol however, so use of the term must be within the context of confirmed prenatal alcohol exposure. ARND may be gaining acceptance over the terms FAE and ARBD to describe FASD conditions with central nervous system abnormalities or behavioral or cognitive abnormalities or both due to prenatal alcohol exposure without regard to growth deficiency or FAS facial features.The following criteria must be fully met for a diagnosis of ARND or static encephalopathy:
Growth deficiency: Growth or height may range from normal to minimally deficient
FAS facial features: Minimal or no FAS facial features present
Central nervous system damage: Clinically significant structural, neurological, or functional impairment in three or more of the Ten Brain Domains
Prenatal alcohol exposure: Confirmed prenatal alcohol exposure;0

Alcohol-related birth defects
Alcohol-related birth defects (ARBD), formerly known as possible fetal alcohol effect (PFAE), was a term proposed as an alternative to FAE and PFAE. The IOM presents ARBD as a list of congenital anomalies that are linked to maternal alcohol use but have no key features of FASD. PFAE and ARBD have fallen out of favor because these anomalies are not necessarily specific to maternal alcohol consumption and are not criteria for diagnosis of FASD. The Canadian guidelines recommend that ARBD should not be used as an umbrella term or diagnostic category for FASD.

Exposure
Prenatal alcohol exposure is determined by interview of the biological mother or other family members knowledgeable of the mothers alcohol use during the pregnancy (if available), prenatal health records (if available), and review of available birth records, court records (if applicable), chemical dependency treatment records (if applicable), chemical biomarkers, or other reliable sources.
Exposure level is assessed as confirmed exposure, unknown exposure, and confirmed absence of exposure by the IOM, CDC and Canadian diagnostic systems. The "4-Digit Diagnostic Code" further distinguishes confirmed exposure as High Risk and Some Risk:
High Risk: Confirmed use of alcohol during pregnancy known to be at high blood alcohol levels (100 mg/dL or greater) delivered at least weekly in early pregnancy.
Some Risk: Confirmed use of alcohol during pregnancy with use less than High Risk or unknown usage patterns.
Unknown Risk: Unknown use of alcohol during pregnancy.
No Risk: Confirmed absence of prenatal alcohol exposure.

Confirmed exposure
Amount, frequency, and timing of prenatal alcohol use can dramatically impact the other three key features of FASD. While consensus exists that alcohol is a teratogen, there is no clear consensus as to what level of exposure is toxic. The CDC guidelines are silent on these elements diagnostically. The IOM and Canadian guidelines explore this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol consumption in determining, but offer no standard for diagnosis. Canadian guidelines discuss this lack of clarity and parenthetically point out that "heavy alcohol use" is defined by the National Institute on Alcohol Abuse and Alcoholism as five or more drinks per episode on five or more days during a 30-day period."The 4-Digit Diagnostic Code" ranking system distinguishes between levels of prenatal alcohol exposure as high risk and some risk. It operationalizes high risk exposure as a blood alcohol concentration (BAC) greater than 100 mg/dL delivered at least weekly in early pregnancy. This BAC level is typically reached by a 55 kg female drinking six to eight beers in one sitting.

Unknown exposure
For many adopted or adults and children in foster care, records or other reliable sources may not be available for review. Reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol use is ongoing. In these cases, all diagnostic systems use an unknown prenatal alcohol exposure designation. A diagnosis of FAS is still possible with an unknown exposure level if other key features of FASD are present at clinical levels.

Confirmed absence of exposure
Confirmed absence of exposure would apply to planned pregnancies in which no alcohol was used or pregnancies of women who do not use alcohol or report no use during the pregnancy. This designation is relatively rare, as most people presenting for an FASD evaluation are at least suspected to have had a prenatal alcohol exposure due to presence of other key features of FASD.

Biomarkers
Evidence is insufficient for the use of chemical biomarkers to detect prenatal alcohol exposure. Biomarkers being studied include fatty acid ethyl esters (FAEE) detected in the meconium (first feces of an infant) and hair. FAEE may be present if chronic alcohol exposure occurs during the 2nd and 3rd trimester since this is when the meconium begins to form. Concentrations of FAEE can be influence by medication use, diet, and individual genetic variations in FAEE metabolism however.

Ten brain domains
A recent effort to standardize assessment of functional CNS damage has been suggested by an experienced FASD diagnostic team in Minnesota. The proposed framework attempts to harmonize IOM, 4-Digit Diagnostic Code, CDC, and Canadian guidelines for measuring CNS damage vis-à-vis FASD evaluations and diagnosis. The standardized approach is referred to as the Ten Brain Domains and encompasses aspects of all four diagnostic systems recommendations for assessing CNS damage due to prenatal alcohol exposure. The framework provides clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines intervention considerations that address the complex nature of FASD with the intention to avoid common secondary disabilities.The proposed Ten Brain Domains include:
Achievement, adaptive behavior, attention, cognition, executive functioning, language, memory, motor skills, multisensory integration or soft neurological problems, social communicationThe Fetal Alcohol Diagnostic Program (FADP) uses unpublished Minnesota state criteria of performance at 1.5 or more standard deviations on standardized testing in three or more of the Ten Brain Domains to determine CNS damage. However, the Ten Brain Domains are easily incorporated into any of the four diagnostic systems CNS damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for FASD.

Differential diagnosis
The CDC reviewed nine syndromes that have overlapping features with FAS; however, none of these syndromes include all three FAS facial features, and none are the result of prenatal alcohol exposure:
Aarskog syndrome
Williams syndrome
Noonan syndrome
Dubowitz syndrome
Brachman-DeLange syndrome
Toluene syndrome
Fetal hydantoin syndrome
Fetal valproate syndrome
Maternal PKU fetal effectsOther disorders that have overlapping behavioral symptoms and/or that might be comorbid to Fetal Alcohol Spectrum Disorder might include:
Attention deficit hyperactive disorder
Autism spectrum disorder
Reactive attachment disorder
Oppositional defiant disorder
Sensory integration dysfunction
Bipolar disorder
DepressionMost people with an FASD have most often been misdiagnosed with ADHD due to the large overlap between their behavioral deficits.

Prevention
The only certain way to prevent FAS is to avoid drinking alcohol during pregnancy. In the United States, the Surgeon General recommended in 1981, and again in 2005, that women abstain from alcohol use while pregnant or while planning a pregnancy, the latter to avoid damage even in the earliest stages (even weeks) of a pregnancy, as the woman may not be aware that she has conceived. The Centers for Disease Control and the American College of Obstetricians and Gynecologists also recommend no alcohol during pregnancy. In the United States, federal legislation has required that warning labels be placed on all alcoholic beverage containers since 1988 under the Alcoholic Beverage Labeling Act.There is some controversy surrounding the "zero-tolerance" approach taken by many countries when it comes to alcohol consumption during pregnancy. The assertion that moderate drinking causes FAS is said to lack strong evidence and, in fact, the practice of equating a responsible level of drinking with potential harm to the fetus may have negative social, legal, and health impacts. In addition, special care should be taken when considering statistics on this disease, as prevalence and causation is often linked with FASD, which is more common and causes less harm, as opposed to FAS.

Treatment
There is no current cure for FASD, but treatment is possible. Early intervention from birth to age 3 has been shown to improve the development of a child born with FASD. Because CNS damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type that works for everyone.Between 2017 and 2019 researchers made a breakthrough when they discovered a possible cure using Neural Stem Cells(NSCs) they propose that if applied to a newborn, the damage can be reversed and prevent any lasting effects in the future.

Medication
Psychoactive drugs are frequently tried on those with FASD as many FASD symptoms are mistaken for or overlap with other disorders, most notably ADHD.

Behavioral interventions
Behavioral interventions are based on the learning theory, which is the basis for many parenting and professional strategies and interventions. Along with ordinary parenting styles, such strategies are frequently used by default for treating those with FAS, as the diagnoses oppositional defiance disorder (ODD), conduct disorder, reactive attachment disorder (RAD) often overlap with FAS (along with ADHD), and these are sometimes thought to benefit from behavioral interventions. Frequently, a persons poor academic achievement results in special education services, which also utilizes principles of learning theory, behavior modification, and outcome-based education.

Developmental framework
Many books and handouts on FAS recommend a developmental approach, based on developmental psychology, even though most do not specify it as such and provide little theoretical background. Optimal human development generally occurs in identifiable stages (e.g., Jean Piagets theory of cognitive development, Erik Eriksons stages of psychosocial development, John Bowlbys attachment framework, and other developmental stage theories). FAS interferes with normal development, which may cause stages to be delayed, skipped, or immaturely developed. Over time, an unaffected child can negotiate the increasing demands of life by progressing through stages of development normally, but not so for a child with FAS.By knowing what developmental stages and tasks children follow, treatment and interventions for FAS can be tailored to helping a person meet developmental tasks and demands successfully. If a person is delayed in the adaptive behavior domain, for instance, then interventions would be recommended to target specific delays through additional education and practice (e.g., practiced instruction on tying shoelaces), giving reminders, or making accommodations (e.g., using slip-on shoes) to support the desired functioning level. This approach is an advance over behavioral interventions, because it takes the persons developmental context into account while developing interventions.

Advocacy model
The advocacy model takes the point of view that someone is needed to actively mediate between the environment and the person with FAS. Advocacy activities are conducted by an advocate (for example, a family member, friend, or case manager) and fall into three basic categories. An advocate for FAS: (1) interprets FAS and the disabilities that arise from it and explains it to the environment in which the person operates, (2) engenders change or accommodation on behalf of the person, and (3) assists the person in developing and reaching attainable goals.The advocacy model is often recommended, for example, when developing an Individualized Education Program (IEP) for the persons progress at school.An understanding of the developmental framework would presumably inform and enhance the advocacy model, but advocacy also implies interventions at a systems level as well, such as educating schools, social workers, and so forth on best practices for FAS. However, several organizations devoted to FAS also use the advocacy model at a community practice level as well.

Public health and policy
Treating FAS at the public health and public policy level promotes FAS prevention and diversion of public resources to assist those with FAS. It is related to the advocacy model but promoted at a systems level (rather than with the individual or family), such as developing community education and supports, state or province level prevention efforts (e.g., screening for maternal alcohol use during OB/GYN or prenatal medical care visits), or national awareness programs. Several organizations and state agencies in the U.S. are dedicated to this type of intervention.The US Centers for Disease Control estimates 3 million women in the United States are at risk of having a baby with FASD, and recommended that women of child-bearing age should be on birth control or abstain from drinking alcohol as the safest way to avoid this.

Prognosis
The prognosis of FASD is variable depending on the type, severity, and if treatment is issued.Prognostic disabilities are divided into Primary & Secondary Disabilities:

Primary disabilities
The primary disabilities of FAS are the functional difficulties with which the child is born as a result of CNS damage due to prenatal alcohol exposure.Often, primary disabilities are mistaken as behavior problems, but the underlying CNS damage is the originating source of a functional difficulty, rather than a mental health condition, which is considered a secondary disability. The exact mechanisms for functional problems of primary disabilities are not always fully understood, but animal studies have begun to shed light on some correlates between functional problems and brain structures damaged by prenatal alcohol exposure. Representative examples include:

Learning impairments are associated with impaired dendrites of the hippocampus
Impaired motor development and functioning are associated with reduced size of the cerebellum
Hyperactivity is associated with decreased size of the corpus callosumFunctional difficulties may result from CNS damage in more than one domain, but common functional difficulties by domain include: Note that this is not an exhaustive list of difficulties.

Achievement: Learning disabilities
Adaptive behavior: Poor impulse control, poor personal boundaries, poor anger management, stubbornness, intrusive behavior, too friendly with strangers, poor daily living skills, developmental delays
Attention: Attention-Deficit/Hyperactivity Disorder (ADHD), poor attention or concentration, distractible
Cognition: Intellectual disability, confusion under pressure, poor abstract skills, difficulty distinguishing between fantasy and reality, slower cognitive processing
Executive functioning: Poor judgment, Information-processing disorder, poor at perceiving patterns, poor cause and effect reasoning, inconsistent at linking words to actions, poor generalization ability
Language: Expressive or receptive language disorders, grasp parts but not whole concepts, lack understanding of metaphor, idioms, or sarcasm
Memory: Poor short-term memory, inconsistent memory and knowledge base
Motor skills: Poor handwriting, poor fine motor skills, poor gross motor skills, delayed motor skill development (e.g., riding a bicycle at appropriate age)
Sensory processing and soft neurological problems: sensory processing disorder, sensory defensiveness, undersensitivity to stimulation
Social communication: Intrude into conversations, inability to read nonverbal or social cues, "chatty" but without substance

Secondary disabilities
The secondary disabilities of FAS are those that arise later in life secondary to CNS damage. These disabilities often emerge over time due to a mismatch between the primary disabilities and environmental expectations; secondary disabilities can be ameliorated with early interventions and appropriate supportive services.Six main secondary disabilities were identified in a University of Washington research study of 473 subjects diagnosed with FAS, PFAS (partial fetal alcohol syndrome), and ARND (alcohol-related neurodevelopmental disorder):
Mental health problems: Diagnosed with ADHD, Clinical Depression, or other mental illness, experienced by over 90% of the subjects
Disrupted school experience: Suspended or expelled from school or dropped out of school, experienced by 60% of the subjects (age 12 and older)
Trouble with the law: Charged or convicted with a crime, experienced by 60% of the subjects (age 12 and older)
Confinement: For inpatient psychiatric care, inpatient chemical dependency care, or incarcerated for a crime, experienced by about 50% of the subjects (age 12 and older)
Inappropriate sexual behavior: Sexual advances, sexual touching, or promiscuity, experienced by about 50% of the subjects (age 12 and older)
Alcohol and drug problems: Alcohol use disorder or dependence, experienced by 35% of the subjects (age 12 and older)Two additional secondary disabilities exist for adults:
Dependent living: Group home, living with family or friends, or some sort of assisted living, experienced by 80% of the subjects (age 21 and older)
Problems with employment: Required ongoing job training or coaching, could not keep a job, unemployed, experienced by 80% of the subjects (age 21 and older)

Protective factors and strengths
Eight factors were identified in the same study as universal protective factors that reduced the incidence rate of the secondary disabilities:
Living in a stable and nurturing home for over 73% of life
Being diagnosed with FAS before age six
Never having experienced violence
Remaining in each living situation for at least 2.8 years
Experiencing a "good quality home" (meeting 10 or more defined qualities) from age 8 to 12 years old
Having been found eligible for developmental disability (DD) services
Having basic needs met for at least 13% of life
Having a diagnosis of FAS (rather than another FASD condition)Malbin (2002) has identified the following areas of interests and talents as strengths that often stand out for those with FASD and should be utilized, like any strength, in treatment planning:
Music, playing instruments, composing, singing, art, spelling, reading, computers, mechanics, woodworking, skilled vocations (welding, electrician, etc.), writing, poetry
Participation in non-impact sport or physical fitness activities

Lifespan
One study found that the people with FASD had a significantly shorter life expectancy. With the average life span of 34 years old, a study found that 44% of the deaths were of "external cause", with 15% of deaths being suicides.

Epidemiology
FASD is estimated to affect between 2% and 5% of people in the United States and Western Europe. FAS is believed to occur in between 0.2 and 9 per 1000 live births in the United States. The lifetime costs of an individual with FAS were estimated to be two million USD in 2002. Drinking any quantity during pregnancy, the risk of giving birth to a child with FASD is about 15%, and to a child with FAS about 1.5%. Drinking large quantities, defined as 2 standard drinks a day, or 6 standard drinks in a short time, carries a 4.3% risk of a FAS birth (i.e. one of every 23 heavy-drinking pregnant women will deliver a child with FAS). In a recent count the prevailence of having any FASD disorder was 1 person out of 20, but some people estimate it could be as high as 1 in 7.

Australia
FASD among Australian youth is more common in indigenous Australians. The only states that have registered birth defects in Australian youth are Western Australia, New South Wales, Victoria and South Australia. In Australia, only 12% of Australian health professionals are aware of the diagnostics and symptoms of FASD. In Western Australia, the rate of births resulting in FASD is 0.02 per 1,000 births for non-Indigenous Australians, however among indigenous births the rate is 2.76 per 1,000 births. In Victoria, there have been no registered FASD related births for indigenous Australians, but the rate for the general population in Victoria is 0.01–0.03 per 1000 births. There have been no dedicated FASD clinics within Western Australia, but there are also no nationally supported diagnostic criteria anywhere in Australia. Passive surveillance is a prevention technique used within Australia to assist in monitoring and establishing detectable defects during pregnancy and childhood.

History
From the 1960s to the 1980s, alcohol was commonly used as a tocolytic, a method to stop preterm labor. The method originated with Dr. Fritz Fuchs, the chairman of the department of obstetrics and gynecology at Cornell University Medical College. Doctors recommended a small amount of alcohol to calm the uterus during contractions in early pregnancy or Braxton Hicks contractions. In later stages of pregnancy, the alcohol was administered intravenously and often in large amounts. "Women experienced similar effects as occur with oral ingestion, including intoxication, nausea and vomiting, and potential alcohol poisoning, followed by hangovers when the alcohol was discontinued." Vomiting put the mother at a high risk for aspiration and was "a brutal procedure for all involved". Because the alcohol was being given intravenously, the doctor could continue giving the treatment to the mother long after she had passed out, resulting in her being more intoxicated than would otherwise be possible. Such heavy intoxication is highly likely to contribute to FASD.

Historical references
Admonitions against prenatal alcohol use from ancient Greek, Roman, Talmudic, and possibly Biblical sources indicate a historical awareness of links between alcohol use and fetal development, although sources rarely if ever distinguish maternal alcohol consumption from paternal. For example, Plato writes in his fourth-century B.C. Laws (6.775): "Drinking to excess is a practice that is nowhere seemly [...] nor yet safe. [...] It behooves both bride and bridegroom to be sober [...] in order to ensure, as far as possible, in every case that the child that is begotten may be sprung from the loins of sober parents." Likewise, the sixth-century A.D. Talmud (Kethuboth 60b) cautions, "One who drinks  intoxicating liquor will have ungainly children." In such ancient sources, the warnings against alcohol consumption for fetal development are more frequently concerned with conception than pregnancy.
In 1725, British physicians petitioned the House of Commons on the effects of strong drink when consumed by pregnant women saying that such drinking is "too often the cause of weak, feeble, and distempered children, who must be, instead of an advantage and strength, a charge to their country." There are many other such historical references. In Gaelic Scotland, the mother and nurse were not allowed to consume ale during pregnancy and breastfeeding. Claims that alcohol consumption caused idiocy were also part of the Teetotalisms message in the 19th century, but such claims, despite some attempts to offer evidence, were ignored because no mechanism could be advanced.The earliest recorded observation of possible links between maternal alcohol use and fetal damage was made in 1899 by Dr. William Sullivan, a Liverpool prison physician who noted higher rates of stillbirth for 120 alcoholic female prisoners than their sober female relatives; he suggested the causal agent to be alcohol use. This contradicted the predominating belief at the time that heredity caused intellectual disability, poverty, and criminal behavior, which contemporary studies on the subjects usually concluded. A case study by Henry H. Goddard of the Kallikak family—popular in the early 1900s—represents this earlier perspective, though later researchers have suggested that the Kallikaks almost certainly had FAS. General studies and discussions on alcoholism throughout the mid-1900s were typically based on a heredity argument.Prior to fetal alcohol syndrome being specifically identified and named in 1973, only a few studies had noted differences between the children of mothers who used alcohol during pregnancy or breast-feeding and those who did not, and identified alcohol use as a possible contributing factor rather than heredity.

Recognition as a syndrome
Fetal alcohol syndrome was named in 1973 by two dysmorphologists, Drs. Kenneth Lyons Jones and David Weyhe Smith of the University of Washington Medical School in Seattle, United States. They identified a pattern of "craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay" in eight unrelated children of three ethnic groups, all born to mothers who were alcoholics. The pattern of malformations indicated that the damage was prenatal. News of the discovery shocked some, while others were skeptical of the findings.Dr </s>


<s> [INST] <<SYS>> You are a responsible assistant committed to providing accurate and helpful responses. Avoid sharing harmful or biased content. Clarify any unclear or incorrect questions rather than providing false or misleading information. <</SYS>> What is Childhood obesity and can you explain it in depth? [/INST] Childhood obesity is a condition where excess body fat negatively affects a childs health or well-being. As methods to determine body fat directly are difficult, the diagnosis of obesity is often based on BMI. Due to the rising prevalence of obesity in children and its many adverse health effects it is being recognized as a serious public health concern. The term overweight rather than obese is often used when discussing childhood obesity, as it is less stigmatizing, although the term overweight can also refer to a different BMI category. The prevalence of childhood obesity is known to differ by sex and gender.

Classification
Body mass index (BMI) is acceptable for determining obesity for children two years of age and older. It is determined by the ratio of weight to height.The normal range for BMI in children vary with age and sex. While a BMI above the 85th percentile is defined as overweight, a BMI greater than or equal to the 95th percentile is defined as obesity by Centers for Disease Control and Prevention. It has published tables for determining this in children.The US Preventive Service Task Force reported that not all children with a high BMI need to lose weight though. High BMI can identify a possible weight problem, but does not differentiate between fat or lean tissue. Additionally, BMI may mistakenly rule out some children who do have excess adipose tissue. It is therefore beneficial to supplement the reliability of a BMI diagnosis with additional screening tools such as adipose tissue or skin fold measurements.

Effects on health
Psychological
The first problems to occur in obese children are usually emotional or psychological. Obese children often experience bullying by their peers. Some are harassed or discriminated against by their own family. Stereotypes abound and may lead to low self-esteem and depression.

Physical
Childhood obesity however can also lead to life-threatening conditions including diabetes, high blood pressure, heart disease, sleep problems, cancer, and other disorders. Some of the other disorders would include liver disease, early puberty or menarche, eating disorders such as anorexia and bulimia, skin infections, and asthma and other respiratory problems.The early physical effects of obesity in adolescence include, almost all of the childs organs being affected, gallstones, hepatitis, sleep apnoea and increased intracranial pressure. Overweight children are also more likely to grow up to be overweight adults. Obesity during adolescence has been found to increase mortality rates during adulthood.A 2008 study has found that children who are obese have carotid arteries which have prematurely aged by as much as thirty years as well as abnormal levels of cholesterol.

Long-term effects
Children who are obese are likely to be obese as adults. Thus, they are more at risk for adult health problems such as heart disease, type 2 diabetes, stroke, several types of cancer, and osteoarthritis. One study showed that children who became obese as early as age 2 were more likely to be obese as adults. According to an article in The New York Times all of these health effects are contributing to a shorter lifespan of five years for these obese children. It is the first time in two centuries that the current generation of children in America may have a shorter lifespan than their parents.

Causes
Childhood obesity can be brought on by a range of factors which often act in combination. "Obesogenic environment" is the medical term set aside for this mixture of elements. The greatest risk factor for child obesity is the obesity of both parents. This may be reflected by the familys environment and genetics. Other reasons may also be due to psychological factors and the childs body type.
A 2010 review stated that childhood obesity likely is the result of the interaction of natural selection favouring those with more parsimonious energy metabolism and todays consumerist society with easy access to energy dense cheap foods and less energy requirements in daily life.Factors include the increase in use of technology, increase in snacks and portion size of meals, and the decrease in the physical activity of children. A study found kids that use electronic devices 3 or more hours a day had between a 17- 44% increased risk of being overweight, or a 10- 61% increased risk of obese (Cespedes 2011).Childhood obesity is common among children from, low-income, African American and Hispanic communities. This is mainly because minority children spend less time playing outside the house and staying active. Some contributors to childhood obesity is that parents would rather have their children stay inside the home because they fear that gang, drug violence, and other dangers might harm them.

Genetics
Childhood obesity is often the result of an interplay between many genetic and environmental factors. Polymorphisms in various genes controlling appetite and metabolism predispose individuals to obesity when sufficient calories are present. Over 200 genes affect weight by determining activity level, food preferences, body type, and metabolism. Having two copies of the allele called FTO increases the likelihood of both obesity and diabetes.As such, obesity is a major feature of a number of rare genetic conditions that often present in childhood:

Prader–Willi syndrome with an incidence between 1 in 12,000 and 1 in 15,000 live births is characterized by hyperphagia and food preoccupations which leads to rapid weight gain in those affected.
Bardet–Biedl syndrome
MOMO syndrome
Leptin receptor mutations
Congenital leptin deficiency
Melanocortin receptor mutationsIn children with early-onset severe obesity (defined by an onset before ten years of age and body mass index over three standard deviations above normal), 7% harbor a single locus mutation.One study found that 80% of the offspring of two obese parents were obese in contrast to less than 10% of the offspring of two parents who were of normal weight. The percentage of obesity that can be attributed to genetics varies from 6% to 85% depending on the population examined.

Family practices
In the recent decades, family practices have significantly changed, and several of these practices greatly contribute to childhood obesity:
With a decreasing number of mothers who breast-feed, more infants become obese children as they grow up and are reared on infant formula instead.
Less children go outside and engage in active play as technology, such as television and video games, keep children indoors.
Rather than walking or biking to a bus-stop or directly to school, more school-age children are driven to school by their parents, reducing physical activity.
As family sizes decrease, the childrens pester power, their ability to force adults to do what they want, increases. This ability enables them to have easier access to calorie-packed foods, such as candy and soda drinks.
The social context around family meal-time plays a role in rates of childhood obesity

Social policies
Different communities and nations have adopted varying social practices and policies that are either beneficial or detrimental to childrens physical health. These social factors include:
the quality of school lunches
the emphasis of schools on physical activity
access to vending machines and fast-food restaurants
prevalence of and access to parks, bike paths, and sidewalks
government subsidies for corn oil and sugar
advertising of fast-food restaurants and candy
prices of healthy and unhealthy foods
access to fresh, healthy, and affordable food

Advertising
Advertising of unhealthy foods correlates with childhood obesity rates. In some nations, advertising of candy, cereal, and fast-food restaurants is illegal or limited on childrens television channels. The media defends itself by blaming the parents for yielding to their childrens demands for unhealthy foods.

Socioeconomic status
It is much more common for young people who come from a racial or ethnic minority, or for those who have a lower socioeconomic status, to be overweight and to engage in less healthy behaviors and sedentary activities.

Prevention
Schools play a large role in preventing childhood obesity by providing a safe and supporting environment with policies and practices that support healthy behaviors. At home, parents can help prevent their children from becoming overweight by changing the way the family eats and exercises together. The best way children learn is by example, so parents should lead by example by living a healthy lifestyle. Screening for obesity is recommended in those over the age of six. Both physical activity and diet can help to reduce the risk of obesity in children from 0 to 5 years old; meanwhile, exclusive physical activity can reduce the risk of obesity for children aged from 6 to 12 years old, and adolescents aged from 13 to 18 years old. The implementation of strategies to improve childcare services such as preschools, nurseries, daycare, and kindergarten on healthy eating, physical activity, and obesity prevention shows little effect on a childs diet, physical activity, and weight status.

Maternal Body Mass Index
Maternal body mass index (BMI) is an important predictor of childhood obesity. Mothers with pre-pregnancy obesity, as defined by BMI ≥30 kg/m2, are known to have children that have higher growth rates and more likely to have obesity.

Dietary
The effects of eating habits on childhood obesity are difficult to determine. A three-year randomized controlled study of 1,704 3rd grade children which provided two healthy meals a day in combination with an exercise program and dietary counsellings failed to show a significant reduction in percentage body fat when compared to a control group. This was partly due to the fact that even though the children believed they were eating less their actual calorie consumption did not decrease with the intervention. At the same time observed energy expenditure remained similar between the groups. This occurred even though dietary fat intake decreased from 34% to 27%. A second study of 5,106 children showed similar results. Even though the children ate an improved diet there was no effect found on BMI. Why these studies did not bring about the desired effect of curbing childhood obesity has been attributed to the interventions not being sufficient enough. Changes were made primarily in the school environment while it is felt that they must occur in the home, the community, and the school simultaneously to have a significant effect.A Cochrane review of a lower fat diet in children (30% or less of total energy) to prevent obesity found the existing evidence of very low to moderate quality, and firm conclusions could not be made.Calorie-rich drinks and foods are readily available to children. Consumption of sugar-laden soft drinks may contribute to childhood obesity. In a study of 548 children over a 19-month period the likelihood of obesity increased 1.6 times for every additional soft drink consumed per day.Calorie-dense, prepared snacks are available in many locations frequented by children. As childhood obesity has become more prevalent, snack vending machines in school settings have been reduced by law in a small number of localities. Some research suggests that the increase in availability of junk foods in schools can account for about one-fifth of the increase in average BMI among adolescents over the last decade. Eating at fast food restaurants is very common among young people with 75% of 7th to 12th grade students consuming fast food in a given week. The fast food industry is also at fault for the rise in childhood obesity. This industry spends about $4.2 billion on advertisements aimed at young children. McDonalds alone has thirteen websites that are viewed by 365,000 children and 294,000 teenagers each month. In addition, fast food restaurants give out toys in childrens meals, which helps to entice children to buy the fast food. According to a 2010 report, 40% of children aged 2 to 11 asked their parents to take them to McDonalds at least once a week, and 15%of preschoolers asked to go every day. To make matters worse, out of 3000 combinations created from popular items on childrens menus at fast food restaurants, only 13 meet the recommended nutritional guidelines for young children. Some literature has found a relationship between fast food consumption and obesity. Including a study which found that fast food restaurants near schools increases the risk of obesity among the student population.Whole milk consumption verses 2% milk consumption in children of one to two years of age had no effect on weight, height, or body fat percentage. Therefore, whole milk continues to be recommended for this age group. However the trend of substituting sweetened drinks for milk has been found to lead to excess weight gain.

Legal
Some jurisdictions use laws and regulations in an effort to steer children and parents towards making healthier food choices. Two examples are calorie count laws and banning soft drinks from sale at vending machines in schools. In the United Kingdom the Obesity Health Alliance has called on whichever party wins the general election to take measures to reduce childhood obesity, for example by banning advertisements for unhealthy foods before 9:00 pm and banning sports sponsorship by manufacturers of unhealthy foods. The failure of the present UK government to cut sugar, fat and salt content in foods has been criticised. Health experts, the health select committee and campaigners described Conservative plans over childhood obesity as, "weak" and "watered down".

Physical activity
Physical inactivity of children has also shown to be a serious cause, and children who fail to engage in regular physical activity are at greater risk of obesity. Researchers studied the physical activity of 133 children over a three-week period using an accelerometer to measure each childs level of physical activity. They discovered the obese children were 35% less active on school days and 65% less active on weekends compared to non-obese children.
Physical inactivity as a child could result in physical inactivity as an adult. In a fitness survey of 6,000 adults, researchers discovered that 25% of those who were considered active at ages 14 to 19 were also active adults, compared to 2% of those who were inactive at ages 14 to 19, who were now said to be active adults. Staying physically inactive leaves unused energy in the body, most of which is stored as fat. Researchers studied 16 men over a 14-day period and fed them 50% more of their energy required every day through fats and carbohydrates. They discovered that carbohydrate overfeeding produced 75–85% excess energy being stored as body fat and fat overfeeding produced 90–95% storage of excess energy as body fat.Many children fail to exercise because they spend long periods of time engaging in sedentary activities such as computer usage, playing video games or watching television. Technology has a large factor on the childrens activeness. Researchers provided a technology questionnaire to 4,561 children, ages 14, 16, and 18. They discovered children were 21.5% more likely to be overweight when watching 4+ hours of TV per day, 4.5% more likely to be overweight when using a computer one or more hours per day, and unaffected by potential weight gain from playing video games. A randomized trial showed that reducing TV viewing and computer use can decrease age-adjusted BMI; reduced calorie intake was thought to be the greatest contributor to the BMI decrease.Technological activities are not the only household influences of childhood obesity. Low-income households can affect a childs tendency to gain weight. Over a three-week period researchers studied the relationship of socioeconomic status (SES) to body composition in 194 children, ages 11–12. They measured weight, waist girth, stretch stature, skinfolds, physical activity, TV viewing, and SES; researchers discovered clear SES inclines to upper class children compared to the lower class children.Childhood inactivity is linked to obesity in the United States with more children being overweight at younger ages. In a 2009 preschool study 89% of a preschoolers day was found to be sedentary while the same study also found that even when outside, 56 percent of activities were still sedentary. One factor believed to contribute to the lack of activity found was little teacher motivation, but when toys, such as balls were made available, the children were more likely to play.

Home environment
Childrens food choices are also influenced by family meals. Researchers provided a household eating questionnaire to 18,177 children, ranging in ages 11–21, and discovered that four out of five parents let their children make their own food decisions. They also discovered that compared to adolescents who ate three or fewer meals per week, those who ate four to five family meals per week were 19% less likely to report poor consumption of vegetables, 22% less likely to report poor consumption of fruits, and 19% less likely to report poor consumption of dairy foods. Adolescents who ate six to seven family meals per week, compared to those who ate three or fewer family meals per week, were 38% less likely to report poor consumption of vegetables, 31% less likely to report poor consumption of fruits, and 27% less likely to report poor consumption of dairy foods. The results of a survey in the UK published in 2010 imply that children raised by their grandparents are more likely to be obese as adults than those raised by their parents. An American study released in 2011 found the more mothers work the more children are more likely to be overweight or obese.

Developmental factors
Various developmental factors may affect rates of obesity. Breast-feeding for example may protect against obesity in later life with the duration of breast-feeding inversely associated with the risk of being overweight later on. A childs body growth pattern may influence the tendency to gain weight. Researchers measured the standard deviation (SD [weight and length]) scores in a cohort study of 848 babies. They found that infants who had an SD score above 0.67 had catch up growth (they were less likely to be overweight) compared to infants who had less than a 0.67 SD score (they were more likely to gain weight). Additionally, breastfeeding for less than 6 months, compared to 6 months or more, has been shown to result in a higher growth rate and higher zBMI at 18, 36, and 72 months of age.A childs weight may be influenced when he/she is only an infant. Researchers also did a cohort study on 19,397 babies, from their birth until age seven and discovered that high weight babies at four months were 1.38 times more likely to be overweight at seven years old compared to normal weight babies. High weight babies at the age of one were 1.17 times more likely to be overweight at age seven compared to normal weight babies.

Medical illness
Cushings syndrome (a condition in which the body contains excess amounts of cortisol) may also influence childhood obesity. Researchers analyzed two isoforms (proteins that have the same purpose as other proteins, but are programmed by different genes) in the cells of 16 adults undergoing abdominal surgery. They discovered that one type of isoform created oxo-reductase activity (the alteration of cortisone to cortisol) and this activity increased 127.5 pmol mg sup when the other type of isoform was treated with cortisol and insulin. The activity of the cortisol and insulin can possibly activate Cushings syndrome.Hypothyroidism is a hormonal cause of obesity, but it does not significantly affect obese people who have it more than obese people who do not have it. In a comparison of 108 obese patients with hypothyroidism to 131 obese patients without hypothyroidism, researchers discovered that those with hypothyroidism had only 0.077 points more on the caloric intake scale than did those without hypothyroidism.

Psychological factors
Researchers surveyed 1,520 children, ages 9–10, with a four-year follow up and discovered a positive correlation between obesity and low self-esteem in the four-year follow up. They also discovered that decreased self-esteem led to 19% of obese children feeling sad, 48% of them feeling bored, and 21% of them feeling nervous. In comparison, 8% of normal weight children felt sad, 42% of them felt bored, and 12% of them felt nervous.Stress can influence a childs eating habits. Researchers tested the stress inventory of 28 college females and discovered that those who were binge eating had a mean of 29.65 points on the perceived stress scale, compared to the control group who had a mean of 15.19 points. This evidence may demonstrate a link between eating and stress.
Feelings of depression can cause a child to overeat. Researchers provided an in-home interview to 9,374 adolescents, in grades seven through 12 and discovered that there was not a direct correlation with children eating in response to depression. Of all the obese adolescents, 8.2% had said to be depressed, compared to 8.9% of the non-obese adolescents who said they were depressed. Antidepressants, however, seem to have very little influence on childhood obesity. Researchers provided a depression questionnaire to 487 overweight/obese subjects and found that 7% of those with low depression symptoms were using antidepressants and had an average BMI score of 44.3, 27% of those with moderate depression symptoms were using antidepressants and had an average BMI score of 44.7, and 31% of those with major depression symptoms were using antidepressants and had an average BMI score of 44.2.Several studies have also explored the connection between Attention-deficit Hyperactivity Disorder (ADHD) and obesity in children. A study in 2005 concluded that within a subgroup of children who were hospitalized for obesity, 57.7% had co-morbid ADHD. This relationship between obesity and ADHD may seem counter-intuitive, as ADHD is typically associated with higher level of energy expenditure, which is thought of as a protective factor against obesity. However, these studies determined that children exhibited more signs of predominantly inattentive-type ADHD rather than combined-type ADHD. It is possible, however, that the symptoms of hyperactivity typically present in individuals with combined-type ADHD are simply masked in obese children with ADHD due to their decreased mobility. The same correlation between obesity and ADHD is also present in adult populations. Existing underlying explanations for the relationship between ADHD and obesity in children include but are not limited to abnormalities in the hypo-dopaminergic pathway, ADHD creating abnormal eating behaviors which leads to obesity, or impulsivity associated with binge eating leading to ADHD in obese patients. A systematic review of the literature on the relationship between obesity and ADHD concluded that all reviewed studies reported ADHD patients were heavier than expected. However, the same systematic review also claimed that all the evidence supporting this connection was still limited and further research is still necessary to learn more about this connection. Given the prevalence rates of both obesity and ADHD in children, understanding the possible relationship between the two is important for public health, particularly when exploring treatment and management options.
Direct intervention for psychological treatment of childhood obesity has become more prevalent in recent years. A meta-analysis of the psychological treatment of obesity in children and adolescents found family-based behavioral treatment (FBT) and Parent-Only Behavior treatment to be the most effective practices in treating obesity in children within a psychological framework.

Management
Obesity in children is treated with dietary changes and physical activity. Dieting and missing meals should; however, be discouraged. The benefit of tracking BMI and providing counselling around weight is minimal.

Lifestyle
Exclusive breast-feeding is recommended in all newborn infants for its nutritional and other beneficial effects. Parents changing the diet and lifestyle of their offspring by offering appropriate food portions, increasing physical activity, and keeping sedentary behaviors at a minimum may also decrease the obesity levels in children.If children were more mobile and less sedentary, the rate of obesity would decrease. Parents should recognize the signs and encourage their children to be more physically active. By walking or riding a bike, instead of using motorised transport or watching television, will reduce sedentary activity.

Medications
There are no medications currently approved for the treatment of obesity in children. The American Academy of Pediatrics recommends medications for obesity be discourage. Orlistat and sibutramine may be helpful in managing moderate obesity in adolescence. Metformin is minimally useful. A Cochrane review in 2016 concluded that medications might reduce BMI and bodyweight to a small extent in obese children and adolescents. This conclusion was based only on low quality evidence.

Surgery
As of 2015 there is not good evidence comparing surgery to lifestyle change for obesity in children, though there are a number of high quality ongoing studies looking at this issue. Bariatric surgical procedures are increasingly used amongst adolescents with severe adolescent obesity to promote weight loss.

Epidemiology
From 1980 to 2013, the prevalence of overweight and obesity in children increased by nearly 50%. Currently 10% of children worldwide are either overweight or obese. In 2014, the World Health Organization established a high-level commission to end childhood obesity.With more than 42 million overweight children around the world, childhood obesity is increasing worldwide. Since 1980, the number of obese children has doubled in all three North American countries, Mexico, the United States, and Canada. Although the rate of childhood obesity in the United States has stopped increasing, the current rate remains high. In 2010, 32.6 percent of 6- to 11-year-olds were overweight, and 18 percent of 6- to 9-year-olds were obese.

Canada
The rate of overweight and obesity among Canadian children has increased dramatically in recent years. In boys, the rate increased from 11% in the 1980s to 30% in the 1990s.

Brazil
The rate of overweight and obesity in Brazilian children increased from 4% in the 1980s to 14% in the 1990s. In 2007 the prevalence of children overweight and childhood obesity was 11.1% and 2.7% in girls, 8.2% and 1.5% in boys, respectively.

United States
The rate of obesity among children and adolescents in the United States has nearly tripled between the early 1980s and 2000. It has however not changed significantly between 2000 and 2006 with the most recent statistics showing a level just over 17 percent. In 2008, the rate of overweight and obese children in the United States was 32%, and had stopped climbing. In 2011, a national cohort study of infants and toddlers found that nearly one-third of US children were overweight or obese at 9 months and 2 years old. In a follow-up study, infant weight status (healthy and obese) was strongly associated with preschool weight status.

Australia
Since the onset of the 21st century, Australia has found that childhood obesity has followed trend with the United States. Information garnered has concluded that the increase has occurred in the lower socioeconomic areas where poor nutritional education has been blamed.

Research
A study of 1800 children aged 2 to 12 in Colac, Australia tested a program of restricted diet (no carbonated drinks or sweets) and increased exercise. Interim results included a 68% increase in after school activity programs, 21% reduction in television viewing, and an average of 1 kg weight reduction compared to a control group.A survey carried out by the American Obesity Association into parental attitudes towards their childrens weight showed the majority of parents think that recess should not be reduced or replaced. Almost 30% said that they were concerned with their childs weight. 35% of parents thought that their childs school was not teaching them enough about childhood obesity, and over 5% thought that childhood obesity was the greatest risk to their childs long-term health.A Northwestern University study indicates that inadequate sleep has a negative impact on a childs performance in school, their emotional and social welfare, and increases their risk of being overweight. This study was the first nationally represented, longitudinal investigation of the correlation between sleep, Body Mass Index (BMI) and overweight status in children between the ages of 3 and 18. The study found that an extra hour of sleep lowered the childrens risk of being overweight from 36% to 30%, while it lessened older childrens risk from 34% to 30%.A 2018 Cochrane review on the impact of physical activity, diet and other behavioral interventions for improving cognition and school achievement in children and adolescents found that school and community-based programs as part of an overall prevention program were beneficial.Obese children and adolescents are more likely to become obese as adults </s>