The contributions of Dr. Kathleen K. Sulik to fetal alcohol spectrum disorders research and prevention

Alcohol 69 (2018) 15e24

Contents lists available at ScienceDirect

Alcohol journal homepage: http://www.alcoholjournal.org/

The contributions of Dr. Kathleen K. Sulik to fetal alcohol spectrum disorders research and prevention Scott E. Parnell a, *, Edward P. Riley b, Kenneth R. Warren c, Kathleen T. Mitchell d, Michael E. Charness e a Bowles Center for Alcohol Studies, Department of Cell Biology and Physiology, Carolina Institute for Developmental Disabilities, University of North Carolina, CB#7178, Chapel Hill, NC 27599, United States b Center for Behavioral Teratology, San Diego State University, 6330 Alvarado Ct. #100, San Diego, CA 92120, United States c National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health (NIH), 5635 Fishers Lane, Bethesda, MD 20892-9304, United States d National Organization on Fetal Alcohol Syndrome (NOFAS), 1200 Eton Court, NW Third Floor, Washington, DC 20007, United States e VA Boston Healthcare System, Harvard Medical School, Boston University School of Medicine, 1400 VFW Parkway, West Roxbury, MA 02132, United States

a r t i c l e i n f o

a b s t r a c t

Article history: Received 2 October 2017 Received in revised form 30 October 2017 Accepted 30 October 2017

Dr. Kathleen Sulik (Kathy) has spent 35 years studying fetal alcohol syndrome (FAS) and fetal alcohol spectrum disorders (FASD). Beginning with her landmark 1981 Science paper describing the early gestational window when alcohol can cause the craniofacial malformations characteristic of FAS, Kathy has contributed a vast amount of research furthering our knowledge of FASD. After her seminal work that definitively demonstrated that alcohol is the causative factor in FAS, she and her lab went on to explore and define the stage-dependent effects of early gestational alcohol exposure on the face and brain in numerous different ways throughout her career. She explored and discovered numerous mechanisms of alcohol's effects on the embryo, as well as describing several genetic factors that can modify susceptibility to developmental alcohol exposure. She did not restrict her research to the face and brain; her lab described in intricate detail the effects of developmental alcohol exposure on many different organs, including the heart, ears, kidneys, and limbs. In addition to her research, and in conjunction with NIAAA and the National Organization on Fetal Alcohol Syndrome (NOFAS), Kathy developed several FASD prevention curricula that are still in use today. Finally, as part of her drive to eradicate FAS and FASD, Kathy labored tirelessly with public policy makers to change how FASD is viewed by the public, how FASD is identified in affected individuals, and how FASD is studied by researchers. While no article could fully cover Kathy's contributions to FASD research and prevention, or her other contributions to embryology and teratology, this review will attempt to illustrate some of the highlights of Kathy's remarkable career. © 2017 Elsevier Inc. All rights reserved.

Keywords: Kathleen K. Sulik Fetal alcohol syndrome Fetal alcohol spectrum disorders Mouse model of FAS

Introduction Dr. Kathleen K. Sulik (Kathy) has had a long and distinguished career in the field of teratology and embryology research. She began her career studying craniofacial development, which naturally led to her discovery of the embryological origins of the craniofacial characteristics of fetal alcohol syndrome (FAS). Subsequently, most of her work has been in the field of FAS, but has not been limited to craniofacial development. Throughout her career, she has studied the effects of developmental alcohol

* Corresponding author. E-mail address: [email protected] (S.E. Parnell). https://doi.org/10.1016/j.alcohol.2017.10.008 0741-8329/© 2017 Elsevier Inc. All rights reserved.

exposure on the brain, heart, limbs, kidneys, and other organs. She has explored the pathogenic events leading to these alcoholinduced dysmorphologies and the molecular mechanisms of ethanol's actions. Her broad work in teratology spanned many more teratogens than just alcohol. In addition to her work in teratology, she has been dedicated to achieving a better understanding of normal development, and many of her studies have contributed greatly to the field of embryology. Her research has had a profound impact on the scientific community, but as a highly skilled educator and communicator, she has also influenced public policy and developed FAS prevention programs with priceless societal benefits.

16

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

Significant research discoveries about fetal alcohol syndrome Alcohol is a teratogen: proof from an animal model For many years after the identification of FAS in 1973 by Jones and Smith (1973), there was considerable skepticism regarding whether alcohol was indeed a teratogen and whether there was a characteristic pattern of malformation resulting from prenatal alcohol exposure. A number of alternative factors were postulated, such as smoking, socioeconomic status, nutrition, or other drugs of abuse, and in reality, skepticism was warranted given the number of confounds inherent in human teratological studies. However, in view of the relatively low incidence of full-blown FAS, large collaborative studies conducted over many years would be required to amass the sample sizes necessary to identify the teratogenic effects of alcohol in humans. Work on the use of animal models to study the teratogenic effects of alcohol began to be conducted in the late 1970s (Boggan, Randall, DeBeukelaer, & Smith, 1979; Chernoff, 1977; Randall & Taylor, 1979). These early models showed increases in fetal resorptions and various malformations, as well as decreases in fetal body weight as a function of alcohol exposure. The effects were dose- and strain-dependent and did mimic some of the effects reported in human studies. However, truly convincing data demonstrating a distinct pattern of malformations involving facial features did not become available until the report by Sulik et al., in 1981 (Sulik, Johnston, & Webb, 1981). Exposure of C57BL/6J mice to ethanol at a single point in development caused growth retardation, microencephaly, and a constellation of facial dysmorphology that strongly resembled the abnormalities reported by Jones and

Smith (Jones & Smith, 1973). Her paper revolutionized the field, providing clear evidence that a specific pattern of malformations did indeed result from prenatal alcohol exposure, even when other potential confounds were controlled or absent. Visually, the similarity of the pattern of malformations between the mouse and the human was striking and clear (Fig. 1). This single landmark paper is remarkable for the breadth and duration of its impact. Dr. Sulik's animal model clearly established that ethanol is a teratogen. The observation that alcohol exposure at a single period of development could reproduce the cardinal facial features of FAS raised concerns that a single, ill-timed episode of binge drinking, even in women who are not alcoholic, might result in FAS. More ominously, the critical period for alcohol-induced dysmorphology corresponded to the third week of gestation (gastrulation), when many women are unaware of their pregnancy. A clear public health message was emerging from the human and animal studies: binge drinking in women of childbearing age might result in FAS. Not surprisingly, this classic paper is among the top 10 cited in the field of FAS research. Molecular mechanisms underlying fetal alcohol spectrum disorders Sulik's first paper on FAS made yet another important contribution to the field. Histological examination of the brains of mouse embryos revealed abnormalities in the neurepithelium within 24 h of ethanol exposure. Because the neuroepithelium gives rise to many of the craniofacial and neural structures affected by prenatal ethanol exposure, this animal model also identified a putative cellular target of ethanol, paving the way for studies that explored mechanisms by which ethanol causes both facial and brain

Fig. 1. Children with FAS (A and B) and 14-day-old mouse fetuses from ethanol-treated (C) and control (D) mothers. Both children had thin vermilion borders and were microcephalic, and the child in (B) had small corneas. The affected mouse fetus also had small eyes and was microcephalic. [Figure reprinted from Sulik et al., 1981 with permission].

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

anomalies. This subject of ethanol and programmed cell death or apoptosis was widely pursued by many investigators, but pioneered by the Sulik lab, which discovered that neural crest cells, the progenitors of many craniofacial structures, were particularly sensitive to ethanol-induced apoptosis (Chen & Sulik, 1996). In their quest to better understand the mechanisms by which ethanol causes apoptosis, the Sulik lab also demonstrated that ethanolinduced cell death in neural crest cells could be attenuated by antioxidants and was mediated in part by free radicals (Kotch, Chen, & Sulik, 1995). A second set of mechanistic investigations involved the study of drugs that block ethanol inhibition of cell adhesion mediated by the L1 neural cell adhesion molecule, a developmentally critical molecule. The peptides NAP and SAL and the alcohol 1-octanol blocked ethanol inhibition of L1 adhesion, prevented ethanolinduced cell death in C57BL/6J embryos, mitigated ethanolinduced growth retardation, and prevented neural tube defects (Chen, Charness, Wilkemeyer, & Sulik, 2005; Chen, Wilkemeyer, Sulik, & Charness, 2001; Parnell et al., 2006; Wilkemeyer et al., 2003). Phosphorylation of a key residue on the L1 cytoplasmic domain by the MAP kinase-signaling pathway was necessary for ethanol inhibition of L1 adhesion. Importantly, levels of MAP kinase activity were lower in C57BL/6N mice than in C57BL/6J mice, reflecting their differential sensitivity to ethanol teratogenesis (Dou et al., 2013). These observations suggested a novel mechanism of genetic susceptibility to ethanol e differential modification of a target protein to modulate its sensitivity to ethanol. The timing of prenatal alcohol exposure causes specific effects on the face and the brain Another influential early paper demonstrated that the pattern of malformations depended on the timing of ethanol administration (Sulik, Cook, & Webster, 1988). Exposure of mice to ethanol on day 7 of gestation (i.e., during gastrulation) caused a pattern of facial abnormalities similar to those observed in humans with FAS; however, exposure at slightly later neurulation stages caused a very different pattern that more resembled DiGeorge syndrome or retinoic acid embryopathy. Interestingly, retinoic acid caused similar patterns of malformations when administered at the same two time periods. Both teratogens potentiated region- and stagespecific programmed cell death. These findings highlighted the importance of timing in the genesis of teratogen-induced dysmorphology and identified the potentiation of programmed cell death as a putative mechanism, a suggestion that was later confirmed in studies by the Sulik lab (Dunty, Chen, Zucker, Dehart, & Sulik, 2001). The observation that ethanol could induce distinctive patterns of facial dysmorphology depending on the timing of exposure was not sufficiently appreciated at the time, but anticipated the broadening of diagnostic categories to include a spectrum of findings e fetal alcohol spectrum disorders (FASD) e wherein FAS represented just one specific pattern of facial dysmorphology. Since the first diagnosis of FAS, it has been widely recognized that alcohol-induced neurocognitive and behavioral deficits could also accompany other patterns of dysmorphology, and that such deficits can also occur in the complete absence of facial dysmorphology. Dr. Sulik's animal research broadened the search for diverse outcomes of prenatal alcohol exposure and facilitated the diagnosis of more individuals with FASD. Effects of the timing of prenatal alcohol exposure on regional brain morphology Early studies in the Sulik lab revealed marked variability in the severity of alcohol-induced dysmorphology, both within and across

17

litters of alcohol-exposed gastrulation-stage embryos (Sulik & Johnston, 1982; Sulik, Lauder, & Dehart, 1984). At the most severe end of the spectrum was a series of abnormalities that resembled the holoprosencephaly (HPE) spectrum. The proposal that FAS might represent a mild form of holoprosencephaly led to a number of important predictions. In 1984, Dr. Sulik stated presciently, “The results of the present study support our hypothesis that severe forms of the Fetal Alcohol Syndrome mimic certain aspects of the HPE spectrum, and indicate that special attention should be paid to possible deficiencies in the septal nuclei and basal ganglia (italics added) of children born to women who abuse alcohol” (Sulik et al., 1984). Subsequently, numerous human MRI studies confirmed that the basal ganglia are reduced in volume in individuals with FASD (Donald et al., 2015), even after accounting for overall brain size. Indeed, the basal ganglia, or more specifically the caudate nucleus, might be one of the most susceptible structures to prenatal alcohol exposure. In that same paper, the authors also noted “… the cerebellar plate does not appear to have grown as far towards the midline, which could result in abnormalities of the cerebellar vermis later in life.” Again, numerous reports confirmed the presence of cerebellar anomalies, particularly involving the cerebellar vermis, in children with FAS (Sowell et al., 1996). Finally, the concept of FAS as a mild form of holoprosencephaly predicted hypoplasia or absence of the corpus callosum. Agenesis of the corpus callosum was among the first neuroanatomical malformations reported in imaging studies of small numbers of children with FAS (Mattson et al., 1992; Riley et al., 1995), and reports of anomalies in both morphology and white matter integrity of the corpus callosum continue to appear in the literature. In fact, corpus callosum dysmorphology is one of the most consistent neuroanatomical anomalies in FASD (Donald et al., 2015; Yang, Phillips, et al., 2012; Yang, Roussotte, et al., 2012). Hence, three predictions from Dr. Sulik's early work were borne out in decades of human studies, lending more credence to human data that often were conducted on small samples with incomplete control of confounding variables. A striking feature of Dr. Sulik's work was her effortless blending of elegant science and beautiful images. Dr. Sulik began her career as a medical illustrator, and the aesthetics of embryology permeated her scientific publications. Later in her career, the esthetic and scientific allure of high-resolution magnetic resonance imaging (MRI) stimulated a renaissance in her exploration of the embryology of FAS. Dr. Sulik revisited a central theme of her work e the importance of timing in the genesis of alcohol-induced fetal dysmorphology. A landmark series of papers used MRI to describe the impact of alcohol exposure at different stages of early gestation on the development of the face and brain. Guided by basic principles of embryology, the Sulik lab elaborated in three dimensions some of the foundational concepts that she had contributed decades earlier. To accomplish this, the Sulik lab used high field-strength magnets (7Te9T) to scan fetal mice at a resolution of 10e20 mm (magnetic resonance microscopy or MRM; Fig. 2). MRM demonstrated that neurulation-stage (gestational day [GD] 8) ethanol exposure results in an expansion of the rostroventral aspects of the brain and a diminution of the more dorsal and caudal parts (Parnell et al., 2009). Exposure at later stages of neurulation (GD 9 or 10) resulted in similar expansions of the rostroventral brain, although in slightly different regions, suggesting that ethanol acts through similar mechanisms in progressively more caudal regions as neurulation progresses (O'Leary-Moore et al., 2010; Parnell et al., 2013). In addition to highlighting the stage-dependent effects of early gestational ethanol exposure, these studies also provided insight into potential pathogenic mechanisms. Returning to the development period of Dr. Sulik's seminal work on FAS, the Sulik lab used MRM to better characterize the brains of

18

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

Fig. 2. MRM scans of GD 17 mouse fetuses. Shown in A is a mid-sagittal view of the entire fetus, while BeE are horizontal sections at varying levels through the fetal brain. Illustrated in FeH are the segmented brain regions in the coronal (F), sagittal (G), and horizontal (H) planes. The three-dimensional reconstruction of these segmented brain regions is shown in (I), where the upper right quadrant has been removed to visualize the internal regions. [Figures modified from Parnell et al., 2009 with permission].

mice exposed acutely to alcohol during gastrulation (GD 7), which induces the characteristic FAS face (Fig. 3). In addition to demonstrating the spectrum of HPE, these mice also showed cortical heterotopias (Godin et al., 2010), consistent with earlier reports in humans (Clarren, Alvord, & Hall, 1980) and with results after chronic exposure in animals (Sakata-Haga, Sawada, Hisano, & Fukui, 2002). Cortical heterotopias, typically resulting from migration errors, are associated with seizures, and the incidence of seizures in FASD is significantly higher (3e21%) than in the general population (1%) (Bell et al., 2010). The concordance between human

and animal studies continues to demonstrate the clinical relevance of Dr. Sulik's mouse model. More recently, in collaboration with the Collaborative Initiative on FASD (CIFASD; directed by Dr. Edward Riley), the Sulik lab used MRM to more completely compare the facial phenotypes in mice derived from a gastrulation stage exposure (GD 7) with those from slightly later, neurulation stage exposures (GD 8e9). Ethanol administration on GD 7 produced craniofacial abnormalities characteristic of FAS and distinctive brain abnormalities indicative of midline hypoplasia (Lipinski et al., 2012). In contrast, ethanol

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

19

Fig. 3. Shown are the face and reconstructed brain of a control GD 17 fetal mouse along with the faces and brains of ethanol-exposed fetuses having semilobar and alobar holoprosencephaly (HPE). As compared to the control face (A), those fetuses with HPE (BeF) have varying degrees of midfacial abnormality; each presenting with a long (from nose to mouth) upper lip, a small nose with closely set nostrils, and micrognathia (narrow, pointed chin), the latter of which is severe in the specimens shown in (B) and (F). Segmented magnetic resonance microscopy scans of control (G, M, S) and ethanol-exposed fetuses (HeL, NeR, TeX) were reconstructed to yield whole brain (frontal view, GeL; dorsal view, MeR) and ventricular system (SeX) images. Notable forebrain abnormalities include varying degrees of olfactory bulb deficiency and rostral union of the cerebral hemispheres, accompanied by dysmorphic lateral ventricles. From a dorsal view, the mid- and hindbrain and their ventricles appear relatively normal in all of the affected fetuses. Color codes for the segmented brain regions are shown at the bottom of the figure. [Figure modified from Godin et al., 2010, with permission].

administration on GD 8e9 produced a very different pattern of face (and brain) abnormalities, consistent with midline hyperplasia (Lipinski et al., 2012; Parnell et al., 2009, 2013). These findings reinforced Dr. Sulik's earlier conclusion that the “classic” FAS face was the consequence of ethanol exposure at a very specific period of gestation, prompting a search by CIFASD for the spectrum of craniofacial abnormalities that result from ethanol exposure at different developmental periods (Suttie et al., 2017). Finally, the Sulik lab applied diffusion tensor imaging techniques to their mouse model to elucidate the influence of timing of ethanol exposure on white matter development (Cao et al., 2014; O'LearyMoore, Parnell, Lipinski, & Sulik, 2011).

Recognizing the importance of the Hedgehog signaling pathway in the holoprosencephaly spectrum and phenotypic similarities between holoprosencephaly and FAS, the Sulik lab investigated the role of Hedgehog signaling in the pathogenesis of FAS. By crossbreeding for haploinsufficiency in sonic hedgehog (Shh) and Gli2, they were able to demonstrate an important ethanol interaction with each of these genes (e.g., Kietzman et al., 2014), further strengthening the connection between FAS and holoprosencephaly. Dr. Sulik's work has spawned a search for other genes that modify the effects of prenatal ethanol exposure (Swartz et al., 2014).

Genetic susceptibility to prenatal alcohol exposure

Dr. Sulik's study of alcohol teratology was not limited to effects of alcohol on the brain and face. She utilized her remarkable skills as an embryologist to explore how prenatal alcohol exposure affected the heart, ears, kidneys, limbs, and other organs (Daft, Johnston, & Sulik, 1986; Gage & Sulik, 1991; Johnson, Zucker, Hunter, & Sulik, 2007; Kotch, Dehart, Alles, Chernoff, & Sulik, 1992). Nor were her studies limited to alcohol teratology. She began her career studying the pathogenesis of cleft lip and palate

Another productive CIFASD collaboration was in the study of genetic susceptibility to FASD. CIFASD investigators identified genetic factors of risk and resilience in zebrafish (McCarthy et al., 2013), mice (Kietzman, Everson, Sulik, & Lipinski, 2014), and humans (Dou et al., 2018), highlighting the ability of ethanol to reveal haploinsufficiency in developmentally important genes.

Beyond the face and the brain

20

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

(Johnston & Sulik, 1979; Miller & Atnip, 1977; Miller, 1977; Sulik & Atnip, 1978; Sulik, Johnston, Ambrose, & Dorgan, 1979; Tyan & Miller, 1978). She moved on to investigate the normal development of the inner ear and other structures derived from neural crest cells (Cotanche & Sulik, 1982, 1983, 1984, 1985; Cotanche, Cotton, Gatzy, & Sulik, 1987; Sulik et al., 2001), the pathogenesis of diverse developmental disorders, such as Treacher Collins and Smith-Lemli-Opitz syndromes (Dehart, Lanoue, Tint, & Sulik, 1997; Sulik, Johnston, Smiley, Speight, & Jarvis, 1987; Sulik, Smiley, Turvey, Speight, & Johnston, 1989; Waage-Baudet, Dunty, Dehart, Hiller, & Sulik, 2005), and the teratology of retinoic acid, anticonvulsants, ochratoxin, chemotherapeutic agents, and infectious agents (Alles & Sulik, 1990; Chernoff et al., 1989; Cook & Sulik, 1988; Darab, Minkoff, Sciote, & Sulik, 1987; Francis et al., 1990; Mesrobian, Sessions, Lloyd, & Sulik, 1994; Peiffer, McCullen, Alles, & Sulik, 1991; Sulik et al., 1987, 1989, 1979; Sulik & Dehart, 1988; Sulik, Dehart, Rogers, & Chernoff, 1995; Webster, Johnston, Lammer, & Sulik, 1986). Finally, she was the first to show that the primitive node, the site on the embryo that initiates gastrulation (the formation of the three germ layers), contained motile cilia (Sulik et al., 1994), structures that are crucial to determining left-right asymmetry (Zhang, Ramalho-Santos, & McMahon, 2001). Impact on public education and FASD prevention worldwide Dr. Sulik also demonstrated a remarkable commitment to public education about FASD, engaging lay audiences of all ages. She possessed a unique ability to communicate complex ideas with simplicity, clarity, and passion. Her creativity and artistry permeate every slide and graphic she designed for her educational presentations, the most compelling being a single comparison of the craniofacial features of FAS in mouse and in humans (Fig. 1). That slide has conveyed a simple, but powerful message e that a single exposure to alcohol can impact an unborn baby e to thousands of audiences all over the world, including middle and high school students, villagers in remote areas of the Yukon, and large international professional conferences. Throughout her career, Dr. Sulik provided leadership and handson effort to basic education on FASD. She secured funding to support the creation of a science lab on wheels (UNC-CH Destiny science learning program). This mobile science lab traveled to schools throughout North Carolina, allowing students to experience a hands-on science lab experiment with brine shrimp and to witness first-hand the damaging effects that alcohol had on their development. She also led an initiative to develop the first FASD prevention curriculum for middle and high school students; Better Safe than Sorry (https://pubs.niaaa.nih.gov/publications/Science/ curriculum.html). She cleverly included in those materials a picture of a dime with a tiny human embryo on the ear of President Roosevelt. She also ingeniously described the size of the embryo at the beginning of gastrulation (the time when alcohol causes the characteristic facial dysmorphology of FAS) as being able to fit in the zero on a penny (Fig. 4). Through these graphics, she was able to illustrate to students how an embryo could be damaged very early in development, even before pregnancy recognition. These images also stimulated professional groups to highlight the importance of alcohol screening and brief intervention for all women of childbearing age. Dr. Sulik's latest effort to teach students about alcohol and pregnancy is the An Ounce of Prevention curriculum (Realityworks, https://store.realityworks.com/products/dvd—an-ounce-ofprevention/). Dr. Sulik's creation of a brain model (Fig. 5) for the National Organization on Fetal Alcohol Syndrome (NOFAS) K-12 FASD Prevention Curriculum was a singular integration of science, art, and education. This 6th- to 9th-grade module teaches students about

Fig. 4. Dr. Sulik ingeniously demonstrated the size of the embryo at the time of gastrulation by showing that it could fit in the zero on a penny, highlighting how prenatal alcohol exposure can damage the embryo very early in pregnancy.

the major regions and functions of the human brain. Students interact with a life-size plastic brain model sliced in half. One half depicts a healthy brain; the other half depicts a brain prenatally exposed to alcohol, illustrating in color the brain regions selectively damaged by alcohol, including the basal ganglion, cerebellum, and corpus callosum. The curriculum imparts several basic lessons, many of which are rooted in Dr. Sulik's research findings: an embryo can be damaged early in pregnancy before a woman knows she is pregnant; the actual day that drinking takes place can predict the type and extent of the birth defect; drinking at any time during pregnancy can result in brain damage; and specific parts of the brain may be more vulnerable than others to the teratogenic effects of alcohol, resulting in permanent, lifelong brain damage. The curricula and brain model have been deployed by K-12 educators, college professors, and FASD educators in classrooms throughout the world and remain in demand. They have been widely distributed throughout Canada, the United States, and Europe, as well as in many tribal communities. In Utah, the FASD curriculum is required in the state's core health curriculum. Dr. Sulik has been an active advocate for FASD. She has never declined a request from NOFAS. She was a panelist at the 2005 NOFAS Briefing to the United States Congress on FASD, where she fascinated members of Congress with her embryology lesson using her seminal research and Lincoln pennies as her teaching methodology. She has served as an expert advisor over the years to NOFAS and was featured in their Ask the Expert column. She traveled to Washington to be a guest lecturer at the NOFAS selective on FASD at the Georgetown University School of Medicine. In 2007, Dr. Kathy Sulik was awarded the NOFAS Excellence award for her pioneering research and distinguished contributions to the FAS field. Impact on FASD public policy It is important to reflect on the influence Kathy Sulik's research has had on the public debate with respect to drinking in pregnancy, as well as the development of United States and global public health policy on this topic. Prior to the publication of clinical reports by Kenneth Lyons Jones and David Smith (Jones, Smith, Ulleland, & Streissguth, 1973)

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

21

Fig. 5. Brain model of alcohol's effects on the brain created for NOFAS Ke12 FASD Prevention Curriculum. [Used with permission of NOFAS].

and their naming of the fetal alcohol syndrome (Jones & Smith, 1973), the accepted view among the general public and the medical establishment was that alcohol was safe at virtually any dose over the entire course of pregnancy. Alarmingly, very high-dose alcohol administration (reaching and maintaining 0.16 g percent for a period of up to 10 h) was employed in obstetric practice to prevent premature labor (Fuchs, Fuchs, Poblete, & Risk, 1967). Warner and Rosett (1975) were the first to illuminate how this misunderstanding of alcohol's safety in pregnancy had come about. They pointed to the credible evidence that had existed during the pre-prohibition period related to the adverse effects of drinking during pregnancy. Some evidence dated back to the London Gin Epidemic and a petition put forth to the House of Commons in 1724; other evidence arose from clinical and scientific studies by investigators such as William Sullivan in England (Sullivan, 1889) and Taav Laitinen in Finland (Laitinen, 1909, 1911), among others (for review, see Warren, 2015). However, all of these findings and reports were summarily rejected in the backlash that followed the passage of the Twenty-First Amendment to the United States Constitution, the repeal of Prohibition. Rejection of the prior evidence can be seen in the statements of distinguished alcohol scholars of the time, such as Haggard and Jellinek (1942) and Mark Keller (1955). With obstetricians using high-dose ethanol in their clinical practice and the prevailing attitude on the safety of alcohol in pregnancy, it is not surprising that the Jones and Smith

observations did not elicit a rapid change in either professional or public attitudes on drinking during pregnancy. While their reports did lead to the undertaking of three epidemiological studies on alcohol and pregnancy supported by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (Warren, 2015) and several basic animal studies, the impact on public perception was limited. As already noted, the early human observational studies were unable to unequivocally address the criticism that other factors, such as smoking, poor nutrition, other drug use, and even a deviant lifestyle, found in comparatively higher rates among heavy consumers of alcohol, could be responsible for the observed adverse pregnancy outcomes. The early animal studies could and did address these issues, but they did not fully model the specific physical features observed in children with FAS. Dr. Sulik's initial paper in Science (Sulik et al., 1981) was published at the same time that the first Surgeon General's advisory on drinking in pregnancy was issued (“Surgeon General's Advisory on Alcohol and Pregnancy,” 1981). Dr. Sulik's seminal discoveries and her iconic photograph of FAS in mice and humans lent significant scientific support to the Surgeon General's advisory of 1981, stating that the most prudent course was to avoid all alcohol during pregnancy. This advisory superseded 1977 recommendations from the Department of Health, Education, and Welfare (now the Department of Health and Human Services) warning against high levels of alcohol intake and recommending limits of two drinks per day during pregnancy (Warren, 2015). With the iconic photo in

22

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

hand, the NOFAS helped convince Congress that alcohol was the cause of FAS and that FAS was indeed a serious public health problem. These efforts culminated in the U.S. government's enactment of the Alcoholic Beverage Labeling Act of 1988. This law requires that a warning label containing information on the adverse effects of drinking during pregnancy be placed on all beverage alcohol sold in the U.S. e the first such legislation passed by any nation. In addition, Dr. Sulik's research provided important evidence considered in the Congressional decision to request a consensus report on FAS from the Institute of Medicine of the National Academies of Science. This landmark report (Stratton, Howe, & Battaglia, 1996) articulated the major diagnostic categories that now constitute the range of fetal alcohol spectrum disorders (FASD), provided an authoritative perspective on the epidemiology of these disorders, and outlined a path to FAS prevention. Dr. Sulik's clear message on the ways alcohol could damage a developing fetus also helped prompt Congress to authorize the formation of the Fetal Alcohol Syndrome/Fetal Alcohol Effects Task force in 1998. Congress later appropriated millions of dollars to government agencies to address FASD. Among these were NIAAA, Centers for Disease Control and Prevention (CDC), and the Substance Abuse Mental Health Services Administration (SAMHSA). Dr. Sulik participated in SAMHSA's Fetal Alcohol Spectrum Disorder Center for Excellence Steering Committee, which is devoted to the prevention and identification of FASD and has always been a visible leader in the FASD field. Dr. Sulik's enduring research contributions continued to inform public policy in the United States and globally, including the re-issuance of the Surgeon General's advisory in 2005 (U.S. Surgeon General Advisory on Alcohol Use in Pregnancy, 2005) and the World Health Organization's Guidelines for the Identification and Management of Substance Use and Substance Use Disorders in Pregnancy (WHO, 2014). Summary Throughout her research career, Kathy Sulik has published almost 150 papers and contributed almost 50 book chapters and books. In addition to numerous prestigious lectureships, such as the Research Society on Alcoholism (RSA) TK Li Lectureship, and the NIAAA Mark Keller Honorary Lecture, Dr. Sulik has been awarded many teaching and research awards, including the Henry Rosett Award from the RSA Fetal Alcohol Spectrum Disorders Study Group for her work on FASD. In this body of work, she demonstrated a unique capacity to integrate knowledge from the fields of embryology, teratology, genetics, and imaging to draw novel connections between diverse fields. At the same time, she was able to reduce complex ideas to their crystalline essence and communicate the excitement of her discoveries to scientists outside her field and to lay audiences. Those audiences have always appreciated her love of science and her admiration for the enormous complexity and remarkable beauty of human development. However, the quality that stands out so strongly in Dr. Sulik is her passion, caring, and heartfelt empathy for the families living with FASD. Brilliant researcher, innovator, passionate educator, accomplished artist e rarely are these qualities blended in a single person and rarely do they engender the rich professional contributions that we owe to Kathy Sulik. Hers is a rare legacy. Acknowledgments The authors would like to thank Drs. Fulton T. Crews and A. Leslie Morrow, Director and Associate Director, respectively, of the Bowles Center for Alcohol Studies, for conceiving and planning this article and for reading the final version. We also would like to thank Dr. Eric W. Fish and Deborah D. Dehart for proofreading the article.

References Alles, A. J., & Sulik, K. K. (1990). Retinoic acid-induced spina bifida: Evidence for a pathogenetic mechanism. Development, 108, 73e81. Bell, S. H., Stade, B., Reynolds, J. N., Rasmussen, C., Andrew, G., Hwang, P. A., et al. (2010). The remarkably high prevalence of epilepsy and seizure history in fetal alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research, 34, 1084e1089. https://doi.org/10.1111/j.1530-0277.2010.01184.x. Boggan, W. O., Randall, C. M., DeBeukelaer, M., & Smith, R. (1979). Renal anomalies in mice prenatally exposed to ethanol. Research Communications in Chemical Pathology and Pharmacology, 23, 127e142. Cao, W., Li, W., Han, H., O'Leary-Moore, S. K., Sulik, K. K., Allan Johnson, G., et al. (2014). Prenatal alcohol exposure reduces magnetic susceptibility contrast and anisotropy in the white matter of mouse brains. NeuroImage, 102(Pt 2), 748e755. https://doi.org/10.1016/j.neuroimage.2014.08.035. Chen, S. Y., Charness, M. E., Wilkemeyer, M. F., & Sulik, K. K. (2005). Peptidemediated protection from ethanol-induced neural tube defects. Developmental Neuroscience, 27, 13e19. https://doi.org/10.1159/000084528. Chen, S. Y., & Sulik, K. K. (1996). Free radicals and ethanol-induced cytotoxicity in neural crest cells. Alcoholism: Clinical and Experimental Research, 20, 1071e1076. Chen, S. Y., Wilkemeyer, M. F., Sulik, K. K., & Charness, M. E. (2001). Octanol antagonism of ethanol teratogenesis. FASEB Journal, 15, 1649e1651. Chernoff, G. F. (1977). The fetal alcohol syndrome in mice: An animal model. Teratology, 15, 223e229. https://doi.org/10.1002/tera.1420150303. Chernoff, N., Rogers, J. M., Alles, A. J., Zucker, R. M., Elstein, K. H., Massaro, E. J., et al. (1989). Cell cycle alterations and cell death in cyclophosphamide teratogenesis. Teratogenesis, Carcinogens, and Mutagenesis, 9, 199e209. Clarren, S. K., Alvord, E. C., Jr., & Hall, J. G. (1980). Congenital hypothalamic hamartoblastoma, hypopituitarism, imperforate anus, and postaxial polydactylyea new syndrome? Part II: Neuropathological considerations. American Journal of Medical Genetics, 7, 75e83. https://doi.org/10.1002/ ajmg.1320070111. Cook, C. S., & Sulik, K. K. (1988). Keratolenticular dysgenesis (Peters' anomaly) as a result of acute embryonic insult during gastrulation. Journal of Pediatric Ophthalmology and Strabismus, 25, 60e66. Cotanche, D. A., Cotton, C. U., Gatzy, J. T., & Sulik, K. K. (1987). Ultrastructural and electrophysiological maturation of the chick tegmentum vasculosum. Hearing Research, 25, 125e139. Cotanche, D. A., & Sulik, K. K. (1982). Scanning electron microscopy of the developing chick tegmentum vasculosum. Scanning Electron Microscope, 1982(Pt 3), 1283e1294. Cotanche, D. A., & Sulik, K. K. (1983). Early differentiation of hair cells in the embryonic chick basilar papilla. A preliminary report. Archives of Otorhinolaryngology, 237, 191e195. Cotanche, D. A., & Sulik, K. K. (1984). The development of stereociliary bundles in the cochlear duct of chick embryos. Brain Research, 318, 181e193. Cotanche, D. A., & Sulik, K. K. (1985). Parameters of growth in the embryonic and neonatal chick basilar papilla. Scanning Electron Microscopy, 1985(Pt 1), 407e417. Daft, P. A., Johnston, M. C., & Sulik, K. K. (1986). Abnormal heart and great vessel development following acute ethanol exposure in mice. Teratology, 33, 93e104. https://doi.org/10.1002/tera.1420330112. Darab, D. J., Minkoff, R., Sciote, J., & Sulik, K. K. (1987). Pathogenesis of median facial clefts in mice treated with methotrexate. Teratology, 36, 77e86. https://doi.org/ 10.1002/tera.1420360111. Dehart, D. B., Lanoue, L., Tint, G. S., & Sulik, K. K. (1997). Pathogenesis of malformations in a rodent model for Smith-Lemli-Opitz syndrome. American Journal of Medical Genetics, 68, 328e337. Donald, K. A., Eastman, E., Howells, F. M., Adnams, C., Riley, E. P., Woods, R. P., et al. (2015). Neuroimaging effects of prenatal alcohol exposure on the developing human brain: A magnetic resonance imaging review. Acta Neuropsychiatrica, 27, 251e269. https://doi.org/10.1017/neu.2015.12. Dou, X., Wilkemeyer, M. F., Menkari, C. E., Parnell, S. E., Sulik, K. K., & Charness, M. E. (2013). Mitogen-activated protein kinase modulates ethanol inhibition of cell adhesion mediated by the L1 neural cell adhesion molecule. Proceedings of the National Academy of Sciences of the United States of America, 110, 5683e5688. https://doi.org/10.1073/pnas.1221386110. Dou, X., Menkari, C., Mitsuyama, R., Foroud, T., Wetherill, L., Hammond, P., et al., Collaborative Initiative on Fetal Alcohol Spectrum Disorders. (2018 Mar). L1 coupling to ankyrin and the spectrin-actin cytoskeleton modulates ethanol inhibition of L1 adhesion and ethanol teratogenesis. FASEB J, 32(3), 1364e1374. Dunty, W. C., Jr., Chen, S. Y., Zucker, R. M., Dehart, D. B., & Sulik, K. K. (2001). Selective vulnerability of embryonic cell populations to ethanol-induced apoptosis: Implications for alcohol-related birth defects and neurodevelopmental disorder. Alcoholism: Clinical and Experimental Research, 25, 1523e1535. Francis, B. M., Rogers, J. M., Sulik, K. K., Alles, A. J., Elstein, K. H., Zucker, R. M., et al. (1990). Cyclophosphamide teratogenesis: Evidence for compensatory responses to induced cellular toxicity. Teratology, 42, 473e482. https://doi.org/10.1002/ tera.1420420504. Fuchs, F., Fuchs, A. R., Poblete, V. F., Jr., & Risk, A. (1967). Effect of alcohol on threatened premature labor. American Journal of Obstetrics and Gynecology, 99, 627e637.

S.E. Parnell et al. / Alcohol 69 (2018) 15e24 Gage, J. C., & Sulik, K. K. (1991). Pathogenesis of ethanol-induced hydronephrosis and hydroureter as demonstrated following in vivo exposure of mouse embryos. Teratology, 44, 299e312. https://doi.org/10.1002/tera.1420440307. Godin, E. A., O'Leary-Moore, S. K., Khan, A. A., Parnell, S. E., Ament, J. J., Dehart, D. B., et al. (2010). Magnetic resonance microscopy defines ethanol-induced brain abnormalities in prenatal mice: Effects of acute insult on gestational day 7. Alcoholism: Clinical and Experimental Research, 34, 98e111. https://doi.org/ 10.1111/j.1530-0277.2009.01071.x. Haggard, H. W., & Jellinek, E. M. (1942). Alcohol explored. Garden City, NY: Doubleday, Doran and Company. Johnson, C. S., Zucker, R. M., Hunter, E. S., 3rd, & Sulik, K. K. (2007). Perturbation of retinoic acid (RA)-mediated limb development suggests a role for diminished RA signaling in the teratogenesis of ethanol. Birth Defects Research. Part A, Clinical and Molecular Teratology, 79, 631e641. https://doi.org/10.1002/ bdra.20385. Johnston, M. C., & Sulik, K. K. (1979). Some abnormal patterns of development in the craniofacial region. Birth Defects Original Article Series, 15, 23e42. Jones, K. L., & Smith, D. W. (1973). Recognition of the fetal alcohol syndrome in early infancy. Lancet, 302, 999e1001. Jones, K. L., Smith, D. W., Ulleland, C. N., & Streissguth, P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet, 1, 1267e1271. Keller, M. (1955). Popular pamphlet #3. In Rutgers Centers for the Study of Alcohol. New Brunswick, NJ. Kietzman, H. W., Everson, J. L., Sulik, K. K., & Lipinski, R. J. (2014). The teratogenic effects of prenatal ethanol exposure are exacerbated by Sonic Hedgehog or GLI2 haploinsufficiency in the mouse. PLoS One, 9, e89448. https://doi.org/10.1371/ journal.pone.0089448. Kotch, L. E., Chen, S. Y., & Sulik, K. K. (1995). Ethanol-induced teratogenesis: Free radical damage as a possible mechanism. Teratology, 52, 128e136. https:// doi.org/10.1002/tera.1420520304. Kotch, L. E., Dehart, D. B., Alles, A. J., Chernoff, N., & Sulik, K. K. (1992). Pathogenesis of ethanol-induced limb reduction defects in mice. Teratology, 46, 323e332. https://doi.org/10.1002/tera.1420460403. Laitinen, T. (1909). The XII international conference on alcoholism. Finland: Helsingfor. Laitinen, T. (1911). In S. J. T. C. Wilbur Fisk Crafts (Ed.), The world book of temperance. Washington, DC: The International Reform Bureau. Lipinski, R. J., Hammond, P., O'Leary-Moore, S. K., Ament, J. J., Pecevich, S. J., Jiang, Y., et al. (2012). Ethanol-induced face-brain dysmorphology patterns are correlative and exposure-stage dependent. PLoS One, 7, e43067. https://doi.org/ 10.1371/journal.pone.0043067. Mattson, S. N., Riley, E. P., Jernigan, T. L., Ehlers, C. L., Delis, D. C., Jones, K. L., et al. (1992). Fetal alcohol syndrome: A case report of neuropsychological, MRI and EEG assessment of two children. Alcoholism: Clinical and Experimental Research, 16, 1001e1003. McCarthy, N., Wetherill, L., Lovely, C. B., Swartz, M. E., Foroud, T. M., & Eberhart, J. K. (2013). Pdgfra protects against ethanol-induced craniofacial defects in a zebrafish model of FASD. Development, 140, 3254e3265. https://doi.org/ 10.1242/dev.094938. Mesrobian, H. G., Sessions, R. P., Lloyd, R. A., & Sulik, K. K. (1994). Cloacal and urogenital abnormalities induced by etretinate in mice. The Journal of Urology, 152, 675e678. Miller, K. K. (1977). Commercial dietary influences on the frequency of cortisoneinduced cleft palate in C57B1/6J mice. Teratology, 15, 249e251. https://doi.org/ 10.1002/tera.1420150306. Miller, K. K., & Atnip, R. L. (1977). T1Wh, a promising mouse strain with chromosomal markers for cleft palate research. Teratology, 16, 41e46. https://doi.org/ 10.1002/tera.1420160107. O'Leary-Moore, S. K., Parnell, S. E., Godin, E. A., Dehart, D. B., Ament, J. J., Khan, A. A., et al. (2010). Magnetic resonance microscopy-based analyses of the brains of normal and ethanol-exposed fetal mice. Birth Defects Research Part A, Clinical and Molecular Teratology, 88, 953e964. https://doi.org/10.1002/bdra.20719. O'Leary-Moore, S. K., Parnell, S. E., Lipinski, R. J., & Sulik, K. K. (2011). Magnetic resonance-based imaging in animal models of fetal alcohol spectrum disorder. Neuropsychology Review, 21, 167e185. https://doi.org/10.1007/s11065-011-9164-z. Parnell, S. E., Dehart, D. B., Wills, T. A., Chen, S. Y., Hodge, C. W., Besheer, J., et al. (2006). Maternal oral intake mouse model for fetal alcohol spectrum disorders: Ocular defects as a measure of effect. Alcoholism: Clinical and Experimental Research, 30, 1791e1798. https://doi.org/10.1111/j.1530-0277.2006.00212.x. Parnell, S. E., Holloway, H. T., O'Leary-Moore, S. K., Dehart, D. B., Paniaqua, B., Oguz, I., et al. (2013). Magnetic resonance microscopy-based analyses of the neuroanatomical effects of gestational day 9 ethanol exposure in mice. Neurotoxicology and Teratology, 39, 77e83. https://doi.org/10.1016/j.ntt.2013. 07.009. Parnell, S. E., O'Leary-Moore, S. K., Godin, E. A., Dehart, D. B., Johnson, B. W., Allan Johnson, G., et al. (2009). Magnetic resonance microscopy defines ethanolinduced brain abnormalities in prenatal mice: Effects of acute insult on gestational day 8. Alcoholism: Clinical and Experimental Research, 33, 1001e1011. https://doi.org/10.1111/j.1530-0277.2009.00921.x. Peiffer, R. L., McCullen, R., Alles, A. J., & Sulik, K. K. (1991). Relationship of cell death to cyclophosphamide-induced ocular malformations. Teratogenesis, Carcinogenesis, and Mutagenesis, 11, 203e212. Randall, C. L., & Taylor, W. J. (1979). Prenatal ethanol exposure in mice: Teratogenic effects. Teratology, 19, 305e311. https://doi.org/10.1002/tera.1420190305.

23

Riley, E. P., Mattson, S. N., Sowell, E. R., Jernigan, T. L., Sobel, D. F., & Jones, K. L. (1995). Abnormalities of the corpus callosum in children prenatally exposed to alcohol. Alcoholism: Clinical and Experimental Research, 19, 1198e1202. Sakata-Haga, H., Sawada, K., Hisano, S., & Fukui, Y. (2002). Administration schedule for an ethanol-containing diet in pregnancy affects types of offspring brain malformations. Acta Neuropathologica, 104, 305e312. https://doi.org/10.1007/ s00401-002-0560-6. Sowell, E. R., Jernigan, T. L., Mattson, S. N., Riley, E. P., Sobel, D. F., & Jones, K. L. (1996). Abnormal development of the cerebellar vermis in children prenatally exposed to alcohol: Size reduction in lobules I-V. Alcoholism: Clinical and Experimental Research, 20, 31e34. Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol Syndrome: Diagnosis, epidemiology, prevention and treatment. Washington, D.C.: National Academy Press. Sulik, K. M., & Atnip, R. L. (1978). Allophenic mice in cleft-palate investigations. Journal of Embryology and Experimental Morphology, 47, 169e177. Sulik, K. K., Cook, C. S., & Webster, W. S. (1988). Teratogens and craniofacial malformations: Relationships to cell death. Development, (103 Suppl), 213e231. Sulik, K. K., & Dehart, D. B. (1988). Retinoic-acid-induced limb malformations resulting from apical ectodermal ridge cell death. Teratology, 37, 527e537. https://doi.org/10.1002/tera.1420370602. Sulik, K., Dehart, D. B., Iangaki, T., Carson, J. L., Vrablic, T., Gesteland, K., et al. (1994). Morphogenesis of the murine node and notochordal plate. Developmental Dynamics, 201, 260e278. https://doi.org/10.1002/aja.1002010309. Sulik, K. K., Dehart, D. B., Johnson, C. S., Ellis, S. L., Chen, S. Y., Dunty, W. C., Jr., et al. (2001). Programmed cell death in extraocular muscle tendon/sclera precursors. Molecular Vision, 7, 184e191. Sulik, K. K., Dehart, D. B., Rogers, J. M., & Chernoff, N. (1995). Teratogenicity of low doses of all-trans retinoic acid in presomite mouse embryos. Teratology, 51, 398e403. https://doi.org/10.1002/tera.1420510605. Sulik, K. K., & Johnston, M. C. (1982). Embryonic origin of holoprosencephaly: Interrelationship of the developing brain and face. Scanning Electron Microscopy, (Pt 1), 309e322. Sulik, K. K., Johnston, M. C., Ambrose, L. J., & Dorgan, D. (1979). Phenytoin (dilantin)induced cleft lip and palate in A/J mice: A scanning and transmission electron microscopic study. The Anatomical Record, 195, 243e255. https://doi.org/ 10.1002/ar.1091950201. Sulik, K. K., Johnston, M. C., Smiley, S. J., Speight, H. S., & Jarvis, B. E. (1987). Mandibulofacial dysostosis (Treacher Collins syndrome): A new proposal for its pathogenesis. American Journal of Medical Genetics, 27, 359e372. https://doi.org/ 10.1002/ajmg.1320270214. Sulik, K. K., Johnston, M. C., & Webb, M. A. (1981). Fetal alcohol syndrome: Embryogenesis in a mouse model. Science, 214, 936e938. Sulik, K. K., Lauder, J. M., & Dehart, D. B. (1984). Brain malformations in prenatal mice following acute maternal ethanol administration. International Journal of Developmental Neuroscience, 2, 203e214. https://doi.org/10.1016/0736-5748(84) 90014-5. Sulik, K. K., Smiley, S. J., Turvey, T. A., Speight, H. S., & Johnston, M. C. (1989). Pathogenesis of cleft palate in Treacher Collins, Nager, and miller syndromes. The Cleft Palate Journal, 26, 209e216. discussion 216. Sullivan, W. C. (1889). A note on the influence of maternal inebriety on the offspring. Journal of Mental Science, 45, 489e503. Surgeon General's Advisory on Alcohol and Pregnancy (1981). FDA Drug Bulletin, 11, 9e10. Suttie, M., Wetherill, L., Jacobson, S. W., Jacobson, J. L., Hoyme, H. E., Sowell, E. R., et al. (2017). Facial curvature detects and explicates ethnic differences in effects of prenatal alcohol exposure. Alcoholism: Clinical and Experimental Research, 41, 1471e1483. https://doi.org/10.1111/acer.13429. Swartz, M. E., Wells, M. B., Griffin, M., McCarthy, N., Lovely, C. B., McGurk, P., et al. (2014). A screen of zebrafish mutants identifies ethanol-sensitive genetic loci. Alcoholism: Clinical and Experimental Research, 38, 694e703. https://doi.org/ 10.1111/acer.12286. Tyan, M. L., & Miller, K. K. (1978). Genetic and environmental factors in cortisone induced cleft palate. Proceedings of the Society for Experimental Biology and Medicine, 158, 618e621. U.S. Surgeon general's advisory on alcohol and pregnancy (2005). Washington, DC: U.S. Department of Health and Human Services. Available at: http://come-over. to/FAS/SurGenAdvisory.htm. (Accessed 12 March 2018). Waage-Baudet, H., Dunty, W. C., Jr., Dehart, D. B., Hiller, S., & Sulik, K. K. (2005). Immunohistochemical and microarray analyses of a mouse model for the smith-lemli-opitz syndrome. Developmental Neuroscience, 27, 378e396. https:// doi.org/10.1159/000088453. Warner, R. H., & Rosett, H. L. (1975). The effects of drinking on offspring: An historical survey of the American and British literature. Journal of Studies on Alcohol, 36, 1395e1420. Warren, K. R. (2015). A review of the history of attitudes toward drinking in pregnancy. Alcoholism: Clinical and Experimental Research, 39, 1110e1117. https://doi.org/10.1111/acer.12757. Webster, W. S., Johnston, M. C., Lammer, E. J., & Sulik, K. K. (1986). Isotretinoin embryopathy and the cranial neural crest: An in vivo and in vitro study. Journal of Craniofacial Genetics and Developmental Biology, 6, 211e222. WHO. (2014). Guidelines for the identification and management of substance use and substance use disorders in pregnant women. World Health Organization, Geneva, Switzerland: World Health Organization.

24

S.E. Parnell et al. / Alcohol 69 (2018) 15e24

Wilkemeyer, M. F., Chen, S. Y., Menkari, C., Brenneman, D., Sulik, K. K., & Charness, M. E. (2003). Differential effects of ethanol antagonism and neuroprotection in peptide fragment NAPVSIPQ prevention of ethanol-induced developmental toxicity. Proceedings of the National Academy of Sciences of the United States of America, 100, 8543e8548. https://doi.org/10.1073/pnas.1331636100. Yang, Y., Phillips, O. R., Kan, E., Sulik, K. K., Mattson, S. N., Riley, E. P., et al. (2012). Callosal thickness reductions relate to facial dysmorphology in fetal alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research, 36, 798e806. https://doi.org/10.1111/j.1530-0277.2011.01679.x.

Yang, Y., Roussotte, F., Kan, E., Sulik, K. K., Mattson, S. N., Riley, E. P., et al. (2012). Abnormal cortical thickness alterations in fetal alcohol spectrum disorders and their relationships with facial dysmorphology. Cerebral Cortex, 22, 1170e1179. https://doi.org/10.1093/cercor/bhr193. Zhang, X. M., Ramalho-Santos, M., & McMahon, A. P. (2001). Smoothened mutants reveal redundant roles for Shh and Ihh signaling including regulation of L/R symmetry by the mouse node. Cell, 106, 781e792.