1.2. Epidemiological Data of Prenatal Exposure to Alcohol (PEA) and FASD
Globally, women consume alcohol in lower amounts and less frequently than men. However, the gender gap has been decreasing and even disappearing in some EU countries [
3]. Prenatal alcohol exposure is considered one of the major public health challenges [
4]. Alcohol is the most common teratogenic agent in all cultures throughout history. It is considered, excluding the causes of genetic origin, the most important determinant for mental and behavioral disorders. In fact, it is considered the leading preventable, non-genetic cause of mental retardation in the Western world. The deleterious outcomes caused by prenatal exposure to alcohol are related to several different variables such as dose, time, duration and pattern of substance consumption during the different stages of pregnancy, as demonstrated in animal studies [
2,
5].
Alcohol consumption during pregnancy may result in a series of adverse effects to the fetus including congenital anomalies and behavioral, cognitive and adaptive deficits grouped under the term of fetal alcohol spectrum disorders (FASD). The FASD continuum includes four different disorders: fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (PFAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) (
Table 1) [
2,
6,
7,
8]. The only sound recommendation related to alcohol consumption during pregnancy is that no amount of alcohol can be considered safe during pregnancy based on research evidence [
2].
A global recent systematic review and meta-analysis estimated that the global prevalence of alcohol use during pregnancy in the general population amounts to 9.8% [
9]. However, this percentage is usually based on questionnaires, reaching 45% when assessed by biological biomarkers as neonatal meconium or maternal hair [
10,
11]. In addition, at the country level, it was observed that binge drinking during pregnancy ranged from 0.2% to 13.9% [
12]. The European area leads the ranking for alcohol use during pregnancy with a prevalence of 25.2% [
3,
4,
9,
12]. Spain ranked third among European countries with a higher prevalence of alcohol consumption during pregnancy (45.0% population) [
10,
13]. Furthermore, FASD prevalence could still be underestimated because of numerous undiagnosed and misdiagnosed cases.
The last published systematic review about the prevalence of alcohol consumption during pregnancy and fetal alcohol syndrome (FAS, defined by growth retardation, facial malformations and central nervous system impairment) indicated that the five countries with the highest estimated prevalence of alcohol use during pregnancy were Ireland (60.4%), Belarus (46.6%), Denmark (45.8%), the UK (41.3%) and Russia (36.5%) [
9,
12].
In relation to the prevalence of FAS, the systematic review by Popova indicates that the five countries with the highest prevalence of FAS are South Africa (58.5 per 1000), Croatia (11.5 per 1000), Ireland (8.9 per 1000), Italy (8.0 per 1000) and Belarus (6.9 per 1000) [
3,
4,
9,
12]. In a previous study in Italy, FASD prevalence in school children was found to be as high as 4.0–7.0% [
14]. In two recent prevalence screening studies in the UK, prevalence of FASD was found to be 17% in the general population and 25% in adopted children [
15,
16].
The global prevalence of FAS among the general population is estimated to be 1.46 per 1000 (95% CI 9.4–23.3) [
4,
9]. One in every 67 women who consumed alcohol during pregnancy would deliver a child with FAS, which translates into about 119,000 children born with FAS in the world every year [
9]. Moreover, the global prevalence of FASD among children and youth was 7.7 per 1000 in the general population (95% CI, 4.9–11.7 per 1000 population), with the European region having the highest overall prevalence at 19.8 per 1000 population (95% CI, 14.1–28.0 per 1000 population) [
12].
Another recent systematic review and meta-analysis found that 428 conditions (which spanned 18 of the 22 International Classification of Diseases (ICD)-10 chapters) co-occurred with FASD [
17], some of the most common health problems being congenital malformations, chromosomal abnormalities, prenatal and postnatal growth delays, intellectual disability, behavioral disorders, speech and language difficulties, visual and audiological impairments, cardiac deformities and urogenital problems. Finally, recent research found high prevalence rates (from 10 to 40 times) in children in foster care and in correctional, special education, specialized clinical and Aboriginal populations (95% confidence interval, 4.9–11.7) in global prevalence in the general population [
18].
Previous research estimated that 4.3% of children born among heavy drinking pregnant women (defined as an average of two or more drinks per day, or five to six drinks per occasion) will be diagnosed with FAS, which is about three times greater than the quotient estimated among women in the general population who consumed any amount of alcohol during pregnancy [
4]. FAS is a preventable disease but its prevalence could increase around the world in the coming years. The averages of alcohol use, binge drinking and drinking during pregnancy are increasing among young women in a lot of countries; moreover, a lot of pregnancies in developing and developed countries are unplanned, with the increased risk of involuntary exposition of the embryo to alcohol in the earliest stage of pregnancy, when brain development is more sensitive to its effects [
4].
1.3. FASD Prevalence in Adopted Children from Eastern European Countries
The prevalence of FASD among special sub-populations is very high, i.e., in adopted and foster care or orphanage children and particularly in internationally adopted children from countries with a great consumption of alcohol in the general population such as Eastern European countries. FASD can be neurodevelopmentally and behaviorally indistinguishable from other neurodevelopmental disorders. In addition, the lack of expertise in diagnosing FASD and mixed neurodevelopmental and behavioral signs due to abandonment trauma complicate a timely diagnosis [
18,
19,
20,
21,
22].
According to published data, the prevalence of FASD in children from Russian orphanages is estimated to be between 30% and 66% [
7]. A total of 90% of Russian women at fertile age consume alcohol and up to 20% continue to consume it during pregnancy. In a study conducted in Sweden in 2010 with 71 children adopted from Eastern Europe, 52% presented FASD, including 30% FAS, 14% partial FAS and 9% alcohol-related neurodevelopmental disorders [
23]. In a cohort of 36 (15 females) adoptees with FASD followed-up for 15.5 years (range 13 to 17), the same authors found that 20 (56%) were dependent on social support. The median intelligence quotient (IQ) of 86 during childhood declined significantly to 71 during adulthood (mean difference: 15.5; 95% CI 9.5–21.4). Psychiatric disorders were diagnosed in 88% of the subjects followed up, especially attention deficit hyperactivity disorder (70%). Three or more disorders were diagnosed in 48%, and 21% had attempted suicide [
24,
25].
Spain is the second country in the world in the number of international adoptions from Eastern European countries, after the United States. During the period from 2006 to 2018, 23,460 international adoptions took place in Spain, of which 8634 were from Eastern European countries (36.8% of international adoptions). Catalonia is the Spanish Autonomous Community with the most international adoptions in absolute terms, with 5120 adoptions from Russia and Ukraine during the period from 1998 to 2015. [
26]
After the clinical observation of a high prevalence of neurocognitive and behavioral disorders among adopted children from Eastern European countries, we hypothesized, as in other countries, that a large number of these adopted children may be also affected by FASD and that FASD could still be underestimated because of numerous undiagnosed and misdiagnosed cases [
5,
13]. This study aimed to estimate the prevalence of FASD in adopted children from Russia and Ukraine living in Catalonia from a representative sample of adopted children from these European regions.