THE IMPACT OF FRAGILE X NEWBORN SCREENING RESULTS ON REPRODUCTIVE CHOICES AND SURVEILLANCE FOR FMR1- ASSOCIATED DISORDERS

Transcription

1 THE IMPACT OF FRAGILE X NEWBORN SCREENING RESULTS ON REPRODUCTIVE CHOICES AND SURVEILLANCE FOR FMR1- ASSOCIATED DISORDERS A Project Presented to the Faculty of California State University, Stanislaus In Partial Fulfillment of the Requirements for the Degree of Master of Science in Genetic Counseling By Patricia Lauren Miranda June 2014

2 CERTIFICATION OF APPROVAL THE IMPACT OF FRAGILE X NEWBORN SCREENING RESULTS ON REPRODUCTIVE CHOICES AND SURVEILLANCE FOR FMR1- ASSOCIATED DISORDERS By Patricia Lauren Miranda Signed Certification of Approval Page is on file with the University Library Liane J. Abrams, MS, LCGC Genetic Counselor East Bay Genetic Counseling and Consultation Date Flora Tassone, PhD Professor in Residence Department of Biochemistry & Molecular Medicine University of California, Davis, MIND Institute Date Janey Youngblom, PhD Professor of Genetics Biology Department California State University, Stanislaus Date

3 2014 Patricia Lauren Miranda ALL RIGHTS RESERVED

4 DEDICATION This work is dedicated in memory of my late grandfathers, Delfin Dimagiba and Jesus Miranda. iv

5 ACKNOWLEDGEMENTS Thank you to Dr. Flora Tassone, Liane Abrams, Dr. Janey Youngblom, Kirin Basuta, and the rest of the Tassone Lab for your invaluable support and guidance on this project. Thank you to the CSU Stanislaus MS in Genetic Counseling Program Class of 2014 for providing me with the inspiration and support to complete this project. I would also like to thank my parents, sisters, and Ben I could not have completed this project without your encouragement. v

6 TABLE OF CONTENTS PAGE Dedication... Acknowledgements... iv v List of Tables... viii List of Figures... Abstract... ix x CHAPTER I. Introduction... 1 Background... 1 Statement of Purpose II. Methods III. Results Demographics Parental Concern and Surveillance of Child with Premutation 16 Premutation and Intermediate Allele Carriers Self-Surveillance 22 Reproductive Plans Emotional and Psychological Impact of FMR1 NBS IV. Discussion Case Report Implications for Practice Limitations of the Study Future Studies vi

7 References Appendices A. Questionnaire for Parents of the Child with a Premutation B. Questionnaire for Other Family Members of the Child with a Premutation 68 C. Informed Consent vii

8 LIST OF TABLES TABLE PAGE 1. FMR1 Status of Participants and Relationship to Child Detected Through Newborn Screening Parents Responses to Why They Do Not Worry About Child Meeting Developmental Milestones Emotional and Psychological Impact of FMR1 Newborn Screening on Parents and Extended Family Members viii

9 LIST OF FIGURES FIGURE PAGE 1. Methodology for Participant Recruitment Flow Chart Parents Responses to How Serious They View Their Child s Premutation as a Medical Condition for Children Parents Responses to How Likely They Perceive Their Child to be at Risk for FMR1-Associated Disorders Summary of Parental Concern and Surveillance Practices for Child with a Premutation Detected Through FMR1 Newborn Screening Parents Plans for Informing the School or Daycare Regarding Their Child s Premutation Pedigree of a Family with an Atypical Transmission of the FMR1 Allele Through Three Generations ix

10 ABSTRACT The aim of the study was to explore the impact of the identification of a fragile X (FX) premutation (PM) through newborn screening (NBS) on family members reproductive plans and surveillance for FMR1-associated disorders. A proposed benefit of detecting newborns with a PM is early intervention, considering the potential risks of learning, behavioral, medical, and mental health issues. Identification of relatives with the PM may be beneficial for surveillance and treatment of FX-associated tremor ataxia syndrome (FXTAS) and primary ovarian insufficiency (FXPOI). However, it may cause worries for families, even though presentation of problems is uncommon and uncertain. Quantitative and qualitative data collection included a survey administered to family members of newborns with a PM, which was analyzed using descriptive statistics. All parents reported that they do not worry about their child meeting their developmental milestones; although some expressed worry in the beginning. The majority of parents did not think it was likely that their children were at risk for FMR1-associated disorders. Individuals at-risk for having additional children with a PM or FX syndrome reported that they have not changed their reproductive plans; although some indicated consideration of alternate reproductive options. Two participants were found to be PM carriers and both were not concerned about developing FXTAS or FXPOI. Thus, in this study, the outcome of NBS did not seem to cause additional concerns for families of newborns with a PM, considering the risks for FMR1-associated disorders in infancy or childhood and adult onset risks for PM carrier relatives. x

11 CHAPTER I INTRODUCTION Background Fragile X syndrome (FXS) is the most common inherited cause of intellectual disability and the most common single gene cause of autism. This condition is caused by a CGG (cytosine-guanine-guanine) trinucleotide expansion in the 5 untranslated region of the FMR1 gene, which encodes the fragile X mental retardation protein (FMRP). This expansion leads to inhibition of gene transcription, which then leads to gene methylation and consequent absence of FMRP (Sutcliffe, et al., 1992). Variability in the CGG repeat number defines the four types of alleles categories. Normal CGG repeat sizes are less than 45 repeats. Alleles with repeats between 45 and 54 are known as intermediate or grey zone alleles. Alleles with 55 to 200 repeats are known as premutations and alleles with greater than 200 repeats, are termed full mutation and cause fragile X syndrome (FXS) (Fu, et al., 1991). Premutations are known to expand to full mutations in the following generations. The smallest allele known to expand to a full mutation in one generation has 56 repeats (Fernandez- Carvajal, Posadas, Pan, Raske, Hagerman, & Tassone, 2009). Individuals with CGG repeat numbers greater than 200 have the full mutation or FXS. Individuals with the full mutation have decreased or absent FMRP. Some of the hallmark physical characteristics of FXS in males include large and prominent ears, a long narrow face, hyperextensible joints, a large head, strabismus, a high- 1

12 2 arched palate, and macroorchidism. Social, behavioral, and emotional characteristics include anxiety, attention deficit hyperactivity disorder (ADHD), hypersensitivity to sensory stimuli, hand flapping, and poor eye contact. Males with FXS usually have mild to severe intellectual disability. In females, the degree of phenotypic involvement ranges from normal cognitive function to intellectual disability. Since females have two X chromosomes, the extent to which a female with FXS exhibits symptoms of FXS depends on X inactivation and resulting levels of FMRP (Hagerman & Hagerman, 2002). Affected females with the full mutation have shown to have social anxiety, learning and behavioral disorders, varying levels of intellectual disability and extreme shyness. To date, no large-scale study has looked at the prevalence of males and females with a full mutation in the United States. Population studies have estimated the prevalence in Caucasian males to be about 1 in 4,000 to 1 in 5,000 (Coffee, et al., 2009). A newborn screening study of 5,267 blood spots from Spain estimated a prevalence of 1 in 2,633 (Fernandez-Carvajal, Walichiewicz, Xiaosen, Pan, Hagerman, & Tassone, 2009). A screening of ethnically diverse newborn blood spots in Georgia estimated a prevalence of 1 in 5,161(95% confidence interval of 1 in 2,500 to 1 in 10,653) (Coffee, et al., 2009). As far as the prevalence of the full mutation in females, one study of Israeli women found a prevalence of about 1 in 5,000 (Toledano-Alhadef, et al., 2001). Individuals with repeats have the premutation allele. Premutation carriers produce normal to subnormal levels of FMRP. Initially, premutation carriers were considered to be clinically uninvolved. However, a range of clinical phenotypes

13 3 has now been well described. Individuals with the premutation, on rare occasions, present with physical, cognitive and behavioral features associated with FXS (Aziz, et al., 2003). About 20% of women with the fragile X premutation experience fragile X- associated primary ovarian insufficiency (FXPOI), or menopause before age 40, compared to 1% in the general population (Sherman S. L., 2000). Fragile X- associated tremor ataxia syndrome (FXTAS), which is characterized by tremor, problems with walking and balance, peripheral neuropathy with decreased sensation in lower extremities, and loss of memory and cognitive function, is observed in about 40% of male premutation carriers and about 8% of female premutation carriers (Hagerman, et al., 2001; Jacquemont, et al., 2004; Coffey, et al., 2008). A recent study by Tassone et al. reported that approximately 1 in 430 males and 1 in 209 females are carriers of the FMR1 premutation (Tassone, et al., 2012). Individuals with the grey zone or intermediate allele have CGG repeats. Although there is limited information on grey zone allele carriers, there have been some studies that have shown clinical involvement similar to premutation carriers in these individuals. Indeed, recent studies and case reports have shown an association between grey zone alleles and a small increased risk for conditions such as Parkinsonism, FXTAS, and FXPOI (Bodega, et al., 2006; Bretherick, Fluker, & Robinson, 2005; Hall, et al., 2011; Liu, Winarni, Zhang, Tassone, & Hagerman, 2013; Loesch, et al., 2009).

14 4 The current guidelines published by the American College of Medical Genetics (ACMG) recommend FMR1 testing for fetuses of known carrier mothers and individuals who have intellectual disabilities, developmental delay, or autism, especially if they have physical or behavioral characteristics of fragile X syndrome, a family history of fragile X syndrome, or relatives with undiagnosed mental retardation. FMR1 testing should be considered for women experiencing infertility especially when the fertility problems are due to elevated follicle-stimulating hormone (FSH) levels and when there is a family history of fragile X syndrome undiagnosed intellectual disability, or premature ovarian insufficiency. Testing should also be considered for men and women who are experiencing late onset intentional tremor and cerebellar ataxia of unknown origin. Finally, the ACMG recommends DNA testing for those who had previously tested positive for the less accurate fragile X cytogenetic test (Sherman, Pletcher, & Driscoll, 2005). Population screening for FXS has long been controversial and is currently not recommended by the American College of Medical Genetics (ACMG). In 2006, the ACMG s Newborn Screening Expert Group was commission by the Maternal and Child Health Bureau (MCHB) of the Health Resources and Services Administration (HRSA) to develop recommendations for a uniform newborn screening panel. ACMG came to the agreement that in order for a condition to be added to the newborn screening panel, it must meet the following minimum criteria: (1) The disorder must be identifiable 24 to 48 hours after birth at which time it would not be detected clinically; (2) A test that is both sensitive and specific is available for this condition;

15 5 (3) There are proven benefits for early detection and intervention. There must also be an effective treatment for this condition. According to the American College of Medical Genetics Newborn Screening Expert Group, FXS did not meet these criteria (Watson, Mann, Lloyd-Puryear, Rinaldo, & Howell, 2006). The resistance to include FMR1 testing in the NBS mandatory program has mainly been due to technical limitations, high cost of testing, and the lack of effective treatment. More recently, an inexpensive blood spot screening test, which is both sensitive and specific, has been developed (Tassone, et al., 2012). In addition, although there is currently no cure for FXS, promising targeted treatments are being investigated. Stimulants have been shown to be effective in treating individuals with FXS who also have ADHD. Selective serotonin reuptake inhibitors (SSRIs) have been shown to be helpful in relieving anxiety. Risperidone, aripiprazole, and lithium have demonstrated promising results in alleviating behavioral issues. In addition, mglur5 antagonist drugs have been shown to ameliorate the core features of FXS in animal models (Hagerman, Lauterborn, Au, & Berry-Kravis, 2012). These recent advances in the realm of FXS have pushed for the consideration of FMR1 NBS. One of the main proposed benefits of including FXS in NBS is to relieve families of the overwhelming burden of having to go through a diagnostic odyssey. A survey of parents of children with FXS showed that the average age of diagnosis for boys is about 31.5 months and 6 months later in girls. On average, a diagnosis of FXS was confirmed greater than 18 months after the initial concern about the child s development. Boys did not start receiving early intervention or special education

16 6 services until about 2 years old. In addition, in a study of 274 families, 191 children were born after the birth of a child with FXS and before the FXS diagnosis. Of these 191 children, 109 (57%) had a fragile X full mutation allele (Bailey, Skinner, & Sparkman, 2003). This highlights yet another potential benefit of early screening, as parents have the option of exploring reproductive options based on the screening results. On the other hand, in his 2010 Commentary on Population Screening For Fragile X Syndrome, Coffee highlights the three major concerns with FMR1 NBS for FXS: (1) With X inactivation, it is not possible to determine which females with a full mutation will have FXS. This raises the concern of these girls being at risk for vulnerable child syndrome, where the expectation of the disease actually causes disease or worsens subtle manifestations of the disease. (2) FMR1 NBS could incidentally identify sex chromosome aneuploidies in newborns. (3) FMR1 NBS will identify premutation carriers, whose risks for childhood and adult-onset learning, behavioral, and medical issues are variable and uncertain (Coffee, 2010). One of the major concerns is the impact this information may have on families of newborns that are detected with premutation alleles. Parental anxiety around genetic risks might affect parent-child bonding and relationships. In addition, disclosure of risk information to other extended family members might also impact family dynamics. As for the newborn detected through NBS with the premutation, he or she might live with the uncertainty of ever developing symptoms throughout his or her lifetime.

17 7 However, several studies have shown that parents of children with FXS support voluntary NBS. A 2003 study of FXS parents showed that 82.6% of parents either agreed or strongly agreed that genetic testing for FXS should be offered to newborns. In general, parents agreed that the positive outcomes outweighed the negative outcomes of screening. Through open-ended responses, parents expressed that [testing] immediately after birth would benefit everyone, especially the baby. Support could be given immediately and parents could learn and make decisions about very best choices. In this study, 94.3% of parents also reported that they would like to know the carrier status of their babies as newborns. In general, parents believed that learning their child s carrier status as newborns would allow for better decision-making, preparation, education, and future reproductive planning (Skinner, Sparkman, & Bailey, 2003). A FMR1 NBS study in Australia surveyed mothers of newborns who were screened. An overwhelming majority of the mothers (93%) agreed that an early diagnosis would be beneficial, as it would help them prepare for a child with additional needs. 76% agreed that it would be better to find out earlier instead of waiting for signs to occur. 64% agreed that they would use this information for future reproductive planning. A minority of respondents expressed concerns about the potential negative impact of testing in the newborn period. For instance, some were concerned about the possibility of false positive results while others were concerned about the potential emotional impact of receiving positive results (Christie, et al., 2013).

18 8 Regarding professional attitudes toward FMR1 NBS, a 2009 survey of geneticists and genetic counselors reported that 60% of these genetic health professionals (GHP) supported universal FMR1 NBS. Of those who were in favor of FMR1 NBS, 79% preferred for the program to be voluntary while 21% wanted it to be mandatory (Acharya & Friedman Ross, 2009). A recent study of developmental and behavioral pediatricians (DBP) showed that among DBP, 74% support FMR1 NBS. DBP noted the following as reasons why FXS should be tested for in the newborn period: (1) To allow for treatment and intervention. (2) To help the family prepare for a child with a disability. (3) To provide parents with reproductive choice (Acharya & Schindler, 2013). The University of California, Davis (UCD) MIND Institute began the Fragile X Newborn Screening Pilot Study (NBS) in 2008 in collaboration with Rush University Medical Center, Chicago (RUMC) and University of North Carolina (UNC) Hospital. The aim of this study was to gather data on the feasibility, benefits, and risks of FMR1 NBS. The study also aimed to gather data on the prevalence of FXS, premutation, and grey zone allele carriers. Finally, one of the study s main goals was also to gain more insight on the psychosocial impact of NBS and cascade testing for FX on families. To date, a total of 14,207 newborns have been screened (7,312 males and 6,895 females) at all three study sites. One male has tested positive for the full mutation, 170 (105 females and 65 males) have grey zone alleles, and 50 (33 females and 17 males) have tested positive for premutation alleles. 27 samples were excluded

19 9 from the analysis due to discordance between test results and sex of the newborn (Tassone, et al., 2012). After a newborn has been identified with FXS or a premutation, the parents may then choose to disclose these results to other at-risk family members. These other family members may then decide to pursue FMR1 testing, thus beginning a process called cascade testing. Cascade testing may provide other family members, who may not have been tested otherwise, with information about their FMR1 carrier status. These individuals may then use this information to make informed decisions regarding their future medical and reproductive plans. Disclosing genetic test results to other family members may cause stress and end up being a burden for some families. It is possible that other family members may not want to know that they are at risk of having an expanded FMR1 allele. For these reasons, although cascade testing may have some benefits for making informed decisions, it may also potentially impact family dynamics. Sorensen et al. (2012) reported three case examples from the UCD MIND Institute, which highlight the benefits of NBS and cascade testing of family members. In these case examples, cascade testing was able to identify multiple extended family members of the newborn carrier of a premutation allele. These family members, most of whom were asymptomatic and would not have been tested otherwise, are at risk for the adult onset conditions associated with a premutation and for passing on the premutation or full mutation on to their children. In these families, cascade testing and the detection of the premutation allele in extended family members also provided

20 10 an explanation for medical issues such as cognitive decline, tremors, panic attacks, sleep problems, learning difficulties, and dysfunctional bleeding (related to FXPOI), at 32 years of age in one of the subjects tested. Finally, in one particular family described in the study, NBS and cascade testing brought up concerns about future pregnancies. With the information that they received from testing, the family actively explored potential options for future pregnancies such as sperm sorting, adoption, and natural conception (Sorensen, Gane, Yarborough, Hagerman, & Tassone, 2012). There is still considerable debate on the potential benefits and harms of FMR1 NBS and detecting newborns with a premutation allele. One proposed benefit is early intervention or treatment, considering the small risk of developing behavioral and learning problems, seizures, and mental health issues. Subsequent identification of extended family members with the premutation allele may be beneficial for surveillance and treatment of FMR1-associated disorders. Counseling parents of the newborn and extended family members of their premutation status may help them make more informed decisions about future reproduction. Despite the benefits that FMR1 NBS may confer, concerns still remain regarding risks in asymptomatic adults and children. Detecting premutation allele carriers in newborns may cause unnecessary worries for families, since presentation of problems is uncommon and uncertain (Chonchaiya, Utari, Pereira, Tassone, Hessl, & Hagerman, 2009). Statement of Purpose There are three specific aims of this study: (1) Explore parental concern and surveillance practices for FMR1-associated disorders for their child with the

21 11 premutation. (2) Assess premutation carriers (parents and extended family members) concern and self-surveillance practices for FMR1-associated disorders. (3) Assess whether learning about their FMR1 status has affected parents and other family members future reproductive plans. Specific questions about concerns regarding risks associated with a child being a premutation carrier, frequency of doctor visits, resources and special services being sought, vigilance of keeping track of developmental milestones, and anxiety over child meeting milestones, were asked to provide more insight on how parents responded to a premutation detection in their newborn. Considering the uncertain and uncommon risks of developmental delay, ADHD, speech and language delays, and other characteristics of autism spectrum disorders in premutation carriers, this study aimed to find out how seriously parents perceive their children s risks for these conditions to be and what parents are doing preemptively to prepare for or potentially minimize the presentation of these symptoms. Specific questions were asked regarding the impact of newborn screening on future reproductive plans. Questions included whether or not parents and extended relatives are thinking of having any more biological children, if they would consider other reproductive options such as preimplantation genetic diagnosis (PGD) with vitro fertilization (IVF), sperm or egg donors, or adoption, and whether or not the child s premutation status, which was determined through NBS, has changed their reproductive plans.

22 12 Specific questions were also asked regarding the emotional and psychological impact of cascade FMR1 testing on parents and other relatives of the child tested through NBS. Finally, this study also aimed to better understand what premutation carriers (parents of the newborns and extended family members detected through cascade testing) are doing in response to their risk of developing fragile X-associated primary ovarian insufficiency (FXPOI) and/or fragile X-associated tremor ataxia syndrome (FXTAS). Questions regarding if and how often carriers are seeking information about FMR1-associated disorders and what types of alternative or traditional medicinal treatments they are taking could give us a sense of what (if any) proactive measures could be taken to potentially prevent and/or treat symptoms of these conditions. An interesting case that involved a family completing the survey is described in this study. One of the newborns with a premutation identified through NBS had three family members complete the survey: her father, mother, and paternal grandmother. The newborn s paternal grandmother had a premutation, which contracted to an intermediate allele when transmitted to her son (the newborn s father). The intermediate allele expanded to a premutation allele in the newborn. The newborn s mother had a normal allele.

23 CHAPTER II METHODS The methods of quantitative and qualitative data collection included an online survey questionnaire targeted at current knowledge, concerns, and practices of parents and extended family members of newborns who were identified with a fragile X premutation. Qualitative data were also collected via open-ended questions included in the online survey. The online survey questionnaire was pre-tested and modifications were made based upon feedback from test participants. The online survey questionnaire was translated into a hard copy for participants who requested a paper version. The families of eighteen newborns who tested positive for a premutation and agreed to continue to be a part of the FXS NBS pilot study after their newborn was identified at the University of California Davis MIND Institute were considered as potential participants for this study. Eleven out of these eighteen families were contacted for participation in the study. Thirty-three individuals (parents and extended family members) from these eleven families were initially contacted to participate through and phone calls. Fourteen of these individuals were reached, while we did not receive a response from nineteen. Thirteen out of the fourteen individuals that were reached agreed to participate in the study. One declined participation because of her age and hearing impairment. Each participant was provided a link to complete the anonymous online survey or was mailed an 13

24 14 n=33 contacted to participate through and phone calls n=13 consented to participate in study n=14 reached though e- mail or phone n=1 declined participation n=19 unable to be reached n=4 requested paper version of survey n=9 requested link to online survey n=4 completed and returned survey n=1 survey not returned n=7 completed survey n=2 survey not completed n=3 parents who originally consented to participate n=1* spouse of participant (other parent of newborn) completed and returned extra copy of survey originally meant for extended relatives Figure 1. Methodology for participant recruitment flow chart. Total number of participants who consented to participate in the study was n=13. Total number of participants who completed the survey was n=11. *One participant, who was mailed a paper version of the survey, had her spouse fill out the extra survey in the packet that was meant for extended family members. Since this version of the survey was meant for extended family members, it did not include questions about the child with the premutation. Therefore, this survey was incomplete, but was still included in our data analysis

25 15 anonymous paper version of the survey. Two versions of the survey were available: one for parents and another for extended family members. All survey questions were the same for both parents and extended family members. However, the survey for parents included additional questions about their child with the premutation. Since the survey was anonymous, individuals who requested paper versions of the survey were mailed both the parent and extended family member versions of the survey. The paper version of the survey included instructions on which survey to fill out based on whether the participant was a parent or an extended family member. Of the thirteen participants who agreed to participate, four were mailed paper versions and nine opted for the electronic version of the survey. One participant, who was mailed a paper version of the survey, had her spouse fill out the extra survey in the packet that was meant for extended family members. Since this version of the survey was meant for extended family members, it did not include questions about the child with the premutation. Therefore, this survey was incomplete. However, since the spouse provided information about his own fragile X mutation status, we included his responses in our analysis. Although we originally mailed out four paper surveys and one was not returned, we still received a total of four completed paper surveys. Seven online surveys were completed, which added up to a total of eleven completed surveys. The study pathway is summarized in Figure 1. Data were analyzed using descriptive statistics.

26 CHAPTER III RESULTS Demographics All participants of this study were recruited through the Fragile X Newborn Screening Pilot Study (FMR1 NBS) at the UC Davis MIND Institute accordingly to an approved UC Davis IRB protocol. Thirty-three individuals were contacted to participate in the study and a total of eleven family members returned the completed surveys either electronically or by mail. Out of these eleven family members, six were parents of the children who were determined to have premutation alleles through FMR1 NBS. Five were other relatives: one grandfather, two grandmothers, and two did not specify their relationship to the child with a premutation detected through NBS (Table 1). The average age of the children who were determined to have a premutation allele through NBS was 26.2 months. Parental Concern and Surveillance of Child with Premutation Parents were given a checklist of developmental concerns for their child with a premutation detected through NBS. Parents were asked to select if their child has any of the following conditions: behavioral issues, medical conditions (for example: seizures, thyroid problems, hypertension, muscle pain, etc.), mental health issues (For example: anxiety, depression, etc.), developmental delay and/or learning disabilities, or none of the above. For any of the conditions selected, parents were asked to provide an explanation. One out of the five (20%) parents who answered this portion 16

27 of the survey reported that her 24-month-old child was having behavioral issues. She described his issues as aggressive behavior and plays rough, hits/bites other children at school. Four out of five (80%) parents did not report any conditions. Table 1 FMR1 Status of Participants and Relationship to Child Detected Through Newborn Screening Normal allele FMR1 status Premutation allele Intermediate allele Mother Father Grandfather Grandmother Unknown Total 17 When asked how serious they viewed their child s premutation, two out of five (40%) parents said their child s premutation was not serious at all, three (60%) said it was either somewhat serious or very serious (Figure 2).

28 18 How Serious Do Parents View Their Child's PM? 60% (n=3) 40% (n=2) "Not serious at all" "Somewhat serious" or "Very serious" Figure 2. Parents responses to how serious they view their child s premutation as a medical condition for children. Parents were also asked how likely they think their child is at risk for each of the following conditions: behavioral issues, reproductive/fertility or ovarian issues, medical conditions (seizures, thyroid problems, hypertension, muscle pain, balance problems, unintentional shaking, etc.), and mental health issues. Regarding behavioral issues, three out of five (60%) parents thought that it was either unlikely or very unlikely that their child was at risk, while one (20%) parent thought it was somewhat likely. One (20%) parent was undecided. Regarding reproductive/fertility or ovarian issues, four out of five parents (80%) thought that it was unlikely, somewhat unlikely, or very unlikely that their child was at risk. One (20%) was undecided. Regarding medical conditions, four (80%) parents thought it was unlikely or very unlikely, and one (20%) was undecided. Regarding mental health issues, four (80%) parents thought it was unlikely or very unlikely, and one (20%) was undecided (Figure 3).

29 19 Parents Perceptions of How Likely Their Child is at Risk for FMR1-Associated Disorders Number of Parents "Unlikely"/"Somewhat Unlikely"/"Very Unlikely" 0 Behavioral Issues Reproductive/Fertility/ Ovarian Issues Medical Conditions Mental Health Issues "Likely"/"Somewhat Likely"/"Very Likely" Undecided FMR1-Associated Disorders Figure 3. Parents responses to how likely they perceive their child to be at risk for FMR1-associated disorders. When parents were asked how often their child sees his/her pediatrician (on average), five out of five (100%) parents reported that their child saw a pediatrician less than once a month (Figure 4). Parents were also asked to specify if their child was seeing other specialists (neurologist, behavioral therapist, physical therapist, etc.) other than his or her pediatrician. The majority, four out of five (80%) parents reported that their child was not seeing another specialist. One out of five (20%) parents reported that his 18-month-old son was seeing an optometrist twice a year for visual development. Parents were asked whether they still seek information about fragile X and what sources they consult to obtain information, and how often. Four out of five

30 20 (80%) parents reported that they no longer seek information about fragile X (Figure 4). Although one (20%) parent reportedly still seeks information all of the time from the internet, often from a pediatrician, sometimes from textbooks, and rarely from scientific journals, genetic counselors, and social workers. Parental Concern and Surveillance Practices for Child with a PM Detected Through FMR1 NBS Do not worry about child meeting developmental milestones No longer seek information about fragile X Child seeing pediatrician less than once a month Number of Parents Figure 4. Summary of parental concern and surveillance practices for child with a premutation detected through FMR1 newborn screening. Parents were asked if their child was receiving special services from the government. Five out of five (100%) parents reported that their child was not receiving any special services from the government. When asked if they thought additional services from the government should be available to their child based on his or her premutation, the majority of parents (four out of five) responded that they did not think any additional services should be offered by the government. One parent responded that mental health services should be available to her daughter as she gets older. Parents were also asked whether their family is paying out-of-pocket for

31 21 special services related to their child s premutation. All parents (five out of five) responded that they do not pay out-of-pocket for any services. Regarding their plans for informing their child s school or daycare about his or her premutation, three out of five (60%) of parents do not plan on informing the school or daycare. One was unsure and one reported that she would tell the child s school or daycare if it needs to be brought up (Figure 5). Parents' Plans For Informing School or Daycare Regarding Child's Premutation 20% (n=1) 60% (n=3) 20% (n=1) Do no plan on informing school or daycare Unsure Plans on informing school or daycare ("If it needs to be brought up") Figure 5. Parents plans for informing the school or daycare regarding their child s premutation. Regarding their child s developmental milestones, parents were asked how often they check to make sure their child is meeting their developmental milestones. Five out of five (100%) parents reported checking at least sometimes if their child is meeting their milestones. Two reported checking sometimes, two often, and one all

32 22 the time. Three out of five (60%) parents kept records of their child s milestones through paper or a baby book. Two out of five (40%) reported not keeping any records. 100% of parents reported that they do not worry about their child meeting his or her developmental milestones (Figure 4). Table 2 highlights the free-responses parents provided when asked to elaborate on why they do not worry about their child meeting his or her developmental milestones. Table 2 Parents Responses to Why They Do Not Worry About Child Meeting Developmental Milestones Parent Child s age Child s Response (months) gender Father 18 Male He s fine Mother 11 Female Not concerned Mother 42 Male We worried when he was very young but now that he s older and meeting even surpassing milestones it s no longer a concern. He is very smart and can grasp new information and teachings very easily. If he starts to show signs of not meeting milestones then we will worry. I m a teacher and I look out for all kinds of things. Mother 24 Male He has met all of his milestones at either the appropriate or advanced time. Premutation and Intermediate Allele Carriers Self-Surveillance Two participants (one mother and one grandmother), who are unrelated, reported having genetic testing for FMR1 and were carriers of a premutation allele. When asked how serious the two premutation carriers viewed the fragile X premutation as a medical condition for adults, the mother responded somewhat

33 23 serious, while the grandmother responded not serious at all. They were also asked how likely they thought they were at risk for FMR1-associated disorders (behavioral issues, reproductive/fertility or ovarian issues, medical conditions (i.e. seizures, thyroid problems, hypertension, muscle pain, balance problems, unintentional shaking, etc.), and mental health issues). Both the mother and the grandmother responded that it was either very unlikely or unlikely that they would develop any of these conditions. In order to assess their knowledge of the symptoms associated with fragile X- associated primary ovarian insufficiency (FXPOI), premutation carriers were given a checklist of symptoms and were asked to check all of the symptoms that they think are related to FXPOI. Both the mother and the grandmother with the premutation alleles selected the option, I don t know any symptoms associated with POI. In addition, they both reported that they were not currently exhibiting any symptoms of FXPOI. When asked to mark on a scale their perceived risk percentage of developing FXPOI, the mother marked 30%, while the grandmother marked 0%. When asked how concerned they were about developing FXPOI, the mother responded, somewhat concerned, while the grandmother said, not concerned at all. They both reported that they had not talked to any healthcare professionals (primary care physician, gynecologist, genetic counselors, social workers, nurses, etc.) about FXPOI. Both are reportedly not taking any medications or herbal supplements to prevent and/or treat symptoms of FXPOI.

34 24 Premutation carriers knowledge of fragile X-associated tremor ataxia syndrome (FXTAS) was also assessed with a checklist of symptoms. They were asked to check all of the symptoms that they thought were associated with FXTAS. Both the mother and the grandmother selected that they did not know any symptoms associated with FXTAS. The mother reported that her perceived risk for developing FXTAS is 24%, while the grandmother reported 0%. Both reported that they were not concerned about developing FXTAS. Both had not talked to any healthcare professionals about FXTAS nor were they taking any medications and/or herbal supplements to prevent and/or treat symptoms of FXTAS. Questions regarding surveillance for FXTAS and FXPOI were only meant to be answered by premutation allele carriers. However, one father with an intermediate allele responded to these questions on the paper version of the survey. We included his responses in our analysis since he is reportedly showing signs and symptoms of FXTAS. The father with the intermediate allele reported viewing fragile X intermediate allele as a medical condition for adults that was somewhat serious. When asked how likely he believed to be at risk for each of the following issues: behavioral issues, medical conditions (seizures, thyroid problems, hypertension, balance problems, unintentiontional shaking, etc.), and mental health issues, he responded either somewhat unlikely or unlikely for each of the conditions. On the checklist to assess knowledge of symptoms for FXTAS, the father selected two (peripheral neuropathy and memory loss) out of the ten symptoms

35 25 related to FXTAS on the list. He also reported that he is currently exhibiting symptoms of FXTAS: Num[b]ness in fingers/hand almost at all times. Memory is not good. These reported symptoms are the same symptoms he had checked off in the checklist to assess his knowledge of symptoms for FXTAS. He reported that after being tested for fragile X and prior to developing symptoms for FXTAS, he was not concerned about developing FXTAS. He reports sometimes speaking to his chiropractor about FXTAS, but no other health professionals. He also reports taking LifeVantage Protandim as a supplement to prevent and/or treat symptoms of FXTAS. Reproductive Plans Three out of eleven (27%) respondents reported that they were at least somewhat likely to have more children. When asked to indicate on a scale of 1 to 10 how concerned they were about having children with the premutation (1 being not concerned at all to 10 being very concerned), the average response was When asked to indicate from a scale of 1 to 10 how concerned they were with having children with the full mutation (1 being not concerned at all to 10 being very concerned), the average response was at 6.67, higher than concern for having children with premutations. The mother with the premutation and the father with the intermediate allele indicated that they would consider other reproductive options. Both indicated that they would consider preimplantation genetic diagnosis (PGD) with in vitro fertilization (IVF) and adoption. In addition, the father with the intermediate allele indicated that he would also consider sperm or egg donors. The grandmother with the

36 26 premutation allele indicated that she would not consider any other reproductive options. However, she reported that she is seventy-one years old and is past the age of reproduction. All participants (eleven out of eleven) indicated that learning about their fragile X status has not changed their future reproductive plans. Both the mother with the premutation and the father with the intermediate allele also indicated that learning about their fragile X status has not changed their future reproductive plans; although they had also indicated their consideration of alternate reproductive options. Emotional and Psychological Impact of FMR1 NBS All participants were asked in a free-response question to describe what (if any) emotional or psychological impact the results of the NBS test had on them. Four out of eleven (36%) responded, none. Some of the themes that presented in the free responses were: concern, stress, worry, curiosity, and fear. One respondent expressed guilt for passing on this condition. The same respondent noted that the NBS results also had some impact on the mother-in-law and daughter-in-law relationship. Some respondents also expressed that the NBS results are no longer concerning to them, as they either have the normal allele or have not had any symptoms of FMR1-associated disorders. Table 3 provides more detail on these responses.

37 27 Table 3 Emotional and Psychological Impact of FMR1 Newborn Screening on Parents and Extended Family Members stress and worry curiosity, slight concern In the beginning I was really scared, now I m okay with it I felt guilty at passing on this genetic condition, even though I knew it wasn t something over which I have any control. It added a layer of stress to the mother-inlaw and daughter-in-law relationship I was slightly concerned about my future children until I got my (normal) test results Way past this. Haven t had an[y] real behavioral, medical, or mental health issues I believe are related to X. I do have high blood pressure but think weight, lack of exercise, job and family and environment are more a factor.

38 CHAPTER IV DISCUSSION One of the main concerns surrounding FMR1 newborn screening, is the longterm anxiety and concern it might cause families of newborns who are identified with a premutation, considering the uncertain and uncommon risks for learning, behavioral, and various medical issues (Coffee, 2010). The concern for identification of carriers with unpredictable risks is reminiscent of the concern for including a condition such as alpha-1 antitrypsin deficiency (AATD) to newborn screening panels. AATD is a genetic condition of variable presentation within and among families that can cause lung and liver disease. Presentation of symptoms can occur anytime from the neonatal period to adulthood and prediction of the severity of the disease is not possible even when the individual s genotype is known. The main concern with population-based screening for this condition is that it might identify asymptomatic children with the disease who may or may not present with symptoms until adulthood (Teckman, et al., 2014). From , a newborn screening pilot study for AATD was implemented in Sweden, which found that the majority of parents of the participants identified with AATD initially perceived AATD as being a serious danger to their child s health. These parents reported having had long-term emotional reactions such as worry, anxiety, and fear after receiving information about their child s AATD (Thelin, Sveger, & McNeil, 1996). 28

39 29 In order to address this issue in FMR1 newborn screening, one of the aims of this study was to explore parental concern for their child with a premutation by assessing their perceived likeliness of their child being at risk for behavioral, reproductive, medical, and mental health issues. Our results showed that an overwhelming majority of parents did not think it was likely that their children with premutations were at risk for behavioral, reproductive, medical, or mental health issues. Considering that parents provided mixed responses to the question asking how serious they viewed their child s premutation, it is interesting that the majority of parents did not think it was likely that their children were at risk for these specific issues. Although some parents may view the premutation status in general as serious, they may not necessarily think their child is at risk for these associated conditions. To assess parental worry and concern for their child with the premutation, we also asked parents questions that were meant to explore their vigilance in surveillance for developmental or medical concerns. 100% of parents reported that their child sees their pediatrician less than once a month. Only one parent reported that their child was seeing another medical specialist other than his/her pediatrician. This child was reportedly seeing an optometrist about twice a year for vision issues, which is probably unrelated to the child s premutation. Our data show that most parents are not seeking extra attention from their pediatrician or other medical specialists for their child s premutation. This finding is consistent with the majority of parental perceptions that their children are not likely to be at risk for behavioral, reproductive, medical, or mental health issues. If parents think that their children are unlikely to be

40 30 at risk for these conditions, they are also probably unlikely to seek extra medical attention for their children. We also wanted to assess if parents were worried about their child meeting their developmental milestones. Our results showed that 100% of the parents were not concerned about this. Some parents expressed being worried in the beginning, however, since they have observed their child developing well and appropriately meeting their milestones at an average age of 26.2 months, this no longer seems to be a concern for them. In addition, we wanted to assess parental worry about their child s premutation by asking if they are still seeking information about fragile X at an average of 26.2 months after initial detection by NBS. The majority of parents (80%), reported that they no longer seek information about fragile X from sources such as the internet, scientific journals, textbooks, or health professionals. At an average of 26.2 months after the initial detection of their child s premutation, parents seem to be content with the information that they have about fragile X, since they are no longer seeking information. This finding also supports parental reports that after observing that their children are normally developing, the fragile X premutation is no longer a concern for them. The identification of premutation and intermediate allele carriers has been a controversial aspect of FMR1 NBS, as premutation carriers and intermediate allele carriers do not always develop FMR1-associated disorders. The concern for identification of carriers with uncertain risks is similar to the concerns for including

41 31 AATD to prenatal and preconception expanded carrier screening. Identification of asymptomatic individuals with the diseaes through prenatal or preconception carrier screening could arguably cause unanticipated psychological harm as these individuals might not have wanted to be informed about genetic predisposition (Wienke, Brown, Farmer, & Strange, 2014). Similarly, the identification of a newborn with an FMR1 expansion is much like an inadvertent detection of an asymptomatic individual, as it automatically implies that one of the parents also carries an FMR1 expansion, more than likely, a premutation allele. More studies are needed to fully understand the acute and long-term implications of this test on premutation carriers who were identified subsequent to a newborn being detected through NBS. Considering the uncertain risks for FXTAS and FXPOI and cognitive and behavioral issues, a second aim of this study was to assess premutation carriers (parents and extended family members) concern and surveillance practices for these conditions (Aziz, et al., 2003; Hagerman, et al., 2001; Sherman S. L., 2000). Ultimately, the questions we wanted to explore were: Do parents and extended family members with premutation alleles continue to worry about their risk for FXTAS, FXPOI and cognitive and behavioral issues about two years after their child was detected with the premutation? What types of surveillance, treatments, or preventative measures, if any, are they pursuing? We received responses from two premutation carriers: one mother and one grandmother. Both participants were not very concerned about their risks for FXTAS and FXPOI. The grandmother s age being 71 years old and past the reproductive age

42 32 might provide an explanation as to why she is not concerned about FXPOI and somewhat less about FXTAS. Her age might also serve as an explanation as to why she indicated a perceived risk of 0% for developing both FXTAS and FXPOI. At 71 years old, she might believe that she is past the age of being at risk for these conditions. Interestingly, both premutation carriers also reported that they did not know any symptoms associated with FXTAS and FXPOI. Despite reportedly not knowing any symptoms, the mother did indicate a perceived risk of 24% and 30% for developing FXTAS and FXPOI, respectively. It is unclear why she indicated these specific risk numbers without knowing what FXTAS and FXPOI are. Nevertheless, neither the mother nor the grandmother expressed excessive worry over their risk for any FMR1-associated disorders. In fact, both premutation carriers reported that their perceived risk of having any behavioral, reproductive, medical, or mental health issues related to the premutation was somewhat unlikely, unlikely, or very unlikely. Neither of them reported talking to any health professionals about these issues nor did they report taking any medications or supplements to prevent onset of these symptoms. It is possible that both sets of responses were due to either of the following explanations: (1) insufficient knowledge regarding FMR1-associated disorders; or (2) awareness of the variable presentation of symptoms in premutation carriers. However, it is also possible that family members have come to accept their premutation status, as supported by data from previous studies (McConkie-Rosell, Spiridigliozzi, Sullivan, Dawson, & Lachiewicz, 2001).

43 33 We were also able to gain some insight from an intermediate allele carrier who filled out the portion of the survey meant for premutation carriers. This father reported having symptoms related to FXTAS: numbness in his hands and fingers and memory loss. However, he reported that he has only talked to his chiropractor about these issues and no other health professionals. He also reports taking a supplement called LifeVantage Protandim to prevent and/or treat any symptoms of FXTAS. On LifeVantage s website, it states that Protandim reduces oxidative stress an average of 40% in 30 days. [It] is a daily dietary supplement that combats oxidative stress through Nrf2 activation. Oxidative stress is inevitable for everyone. Protandim significantly reduces oxidative stress through Nrf2 activation. Nrf2 helps to regulate survival genes (LifeVantage Corporation, 2014). At this date, there is nothing on the LifeVantage website nor is there any scientific literature that names LifeVantage Protandim as an effective treatment or prevention for FXTAS. The final question we aimed to explore in the study was whether learning about their FMR1 mutation status has affected parents and other family members future reproductive plans. 100% of participants (parents and extended family members) reported that learning about their FMR1 mutation status has not changed their future reproductive plans. However, two of our participants were grandparents, who are most likely no longer planning on having any more children. Two other participants were relatives of unknown relations to the child. These two unknown relatives might also be past their reproductive ages.

44 34 There are, however, inconsistencies in the responses by the mother with the premutation and the father with the intermediate allele. Although both reported that their future reproductive plans have not changed, they also reported that they would consider other reproductive options such as PGD with IVF, gamete donors, or adoption. The question about whether or not their FMR1 mutation status has changed their future reproductive plans might have been interpreted as whether their plans to have additional children might have been affected by their FMR1 mutation status. In this case, the mother with the premutation and the father with the intermediate allele might still have the same plans as far as whether or not they plan to have more children. Their FMR1 mutation status might have just affected their consideration of other reproductive options for family building. Both the mother with the premutation and the father with the intermediate allele reported their concerns on a scale of 1 to 10 (1 being not concerned at all to 10 being very concerned) for having a child with a premutation as 8 and 10, respectively. This finding, in combination with their consideration of other reproductive technologies, shows that having another child with a premutation is concerning to these parents and that they would potentially consider other methods of reproduction to avoid this. Case Report Of anecdotal interest is that the intermediate allele identified in the father who participated in this study was inherited in an atypical fashion. Wheras most unstable FMR1 alleles expand when transmitted, in some cases like this one, the premutation

45 35 allele contracted in size giving rise to an intermediate allele of approximately half the size of the transmitting parent s premutation. Specifically, the grandmother s premutation allele of 109 CGG repeats contracted to 52 repeats in the father of the proband (newborn) and then expanded to 59 repeats in the newborn identified by NBS (Figure 6). The contraction of premutation alleles in one generation has been previously reported in the literature (Alfaro, Cohen, & Vnencak-Jones, 2013; Brown, et al., 1996; Vits, et al., 1994). The family s gene properties are being extensively studied by the UC Davis molecular laboratory and may have an impact on our understanding of FMR1 allele behavior.

46 36 Figure 6. Pedigree of a family with an atypical transmission of the FMR1 allele through three generations. The newborn identified with a premutation through FMR1 NBS (proband) is indicated by an arrow. FMR1 testing was done on the the proband s paternal great-grandfather (I-1), who had a normal CGG repeat of 29. I-2 could not be tested as she was deceased by the time cascade testing was initiated. Since I-1 does not carry the premutation, I-2 is an obligate carrier. The proband s paternal grandmother (II-2) was determined to carry the a premutation allele with 109 CGG repeats. This allele contracted to 52 repeats in the proband s father (III-2), which then expanded to 61 and 59 repeats in the proband s sister (IV-2) and the proband, repectively. The proband s mother (III-3) also had FMR1 testing and was determined to have CGG repeats in the normal range. Implications for Practice Although this study focused on families that participated in the UC Davis MIND Institute Fragile X Newborn Screening Pilot Study, the information drawn from this study may be useful for genetic counselors working with families affected by fragile X. The results of this study may indeed provide some anticipatory guidance for families with newborns or young children identified to have a fragile X premutation. It may be helpful for families to know that other families with newborns identified with a premutation in the newborn period felt some stress, worry, and guilt. However, most individuals that participated in this study reported that they are no longer concerned about their children s premutation. They have observed that their

47 37 children are normally developing and meeting all of their milestones, as is the case for most children with a fragile X premutation. Some parents who were planning on having additional children reported that they would consider other reproductive options such as PGD with IVF, gamete donors, or adoption. It might be valuable for genetic counselors to include a discussion of these different reproductive options in their sessions with families at risk for having children with a fragile X premutation or full mutation. Genetic counselors working with families affected by fragile X should have some knowledge about these reproductive options. Genetic counselors working with these families might also consider keeping a list of reproductive genetic counselors who have provided reproductive services to families at risk for having children with a fragile X premutation or full mutation in order to be able to provide appropriate referrals for these families. Both individuals with a premutation who participated in this study reported that they did not know any symptoms related to FXPOI. Considering that about 20% of women with the fragile X premutation experience FXPOI, genetic counselors should include a discussion of symptoms for this condition in their sessions with families affected by a fragile X premutation (Sherman S. L., 2000). For family planning purposes, it might be beneficial for women who are premutation carriers to be aware that they might undergo menopause at an earlier stage. In addition, both individuals did not know any symptoms associated with FXTAS. About 40% of male and about 8% of female premutation carriers develop FXTAS (Hagerman, et al.,

48 ; Jacquemont, et al., 2004; Coffey, et al., 2008). Knowledge of symptoms associated with FXTAS is important for premutation allele carriers, especially for the purpose of educating family members. As FXTAS progresses, individuals might develop cognitive decline. Iosif et al. reports having observed individuals with FXTAS accusing spouses of infidelity, feeling set up or left out of family decisions when they had in fact forgotten about conversations. It is important for family members to be aware that these symptoms are related to FXTAS to prevent conflicts from arising between the individual with the premutation and family members. Knowing about these symptoms might help reduce caregiver stress and increase caregiver support (Iosif, Sciolla, Brahmbhatt, & Seritan, 2013). Finally, it is important for genetic counselors working with families affected by fragile X to recognize that the identification of an FMR1 expansion in one individual could potentially have an impact on an entire family s dynamics. One participant from this study reported that the NBS screening results had an impact on the mother-in-law and daughter-in-law relationship. Indeed, family relationships might become strained as blame may be directed towards individuals who passed on the expanded FMR1 allele. Depending on family dynamics, it may be difficult for families to disseminate information about an identified FMR1 expansion to other family members. It may be beneficial for genetic counselors to help these families strategize on ways to talk to other family members about this information. A family letter with main points about the FMR1 expansion may also be useful for these families.

49 39 Limitations of the Study The small sample size is a major limitation of this study. Many families participating in the UC Davis Fragile X Newborn Screening Pilot Study have been contacted multiple times to participate in many studies; thus a potential explanation for our low response rate is that these families may be experiencing research participation fatigue. Caution must be taken when making generalizations about the findings of this study. Parent participants of this study have known about the newborn s premutation for at least 11 months. The length of time extended family members have known about the newborn s premutation might vary according to when the parents of the newborn decided to disclose this information to other family members. Those who decided to participate in this study may have been willing to participate because they are no longer worried or anxious about their child s and their own FMR1 mutation status. Individuals who are still worried or anxious about their child s or their own FMR1 mutation status might not have been willing to participate in this study. Thus, an ascertainment bias may be present. In addition, individuals who participated in this study might have responded to the survey differently if they had found out about the newborn s premutation six months ago or if they had known about this for ten years. Future Studies Future studies including more family members of the newborns identified with a premutation at the UC Davis MIND Institute will provide further insight on the effect of FMR1 NBS on these families. Half of the parents who participated in this

50 40 study were the parents who did not carry the expanded FMR1 allele. For these families, it would be interesting to administer the same survey to the other parent in each household who carries the expanded FMR1 allele and compare the responses between each pair of parents to see how much concordance or differences exist in their viewpoints. In addition, It would be interesting to pursue a longitudinal study administering the same survey to parents throughout different time points of their children s lives to see if their concerns and worries about the premutation and FMR1 NBS change over time. Previous studies exploring the impact of carrier screening for other diseases such as cystic fibrosis and Tay-Sachs disease have reported that carriers have a poorer perception of their current and future health compared to noncarriers (Axworthy, Brock, Bobrow, & Marteau, 1996, Marteau, Van Duijn, & Ellis, 1992). It would be of interest to study whether this perception is the same for individuals detected with an FMR1 intermediate or premutation allele. More studies on the psychosocial impact of FMR1 NBS on families are needed, as the identification of a newborn with a fragile X premutation has the potential to impact an entire family. One respondent from this study reported that the NBS had some impact on the mother-in-law and daughter-in-law relationship. To this regard it would also be interesting to conduct interviews of family members of a newborn identified with a premutation focusing on how the information was disseminated throughout the family and how it has affected family dynamics.

51 REFERENCES

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57 47 Tassone, F., Pan, R., Amiri, K., Taylor, A. K., & Hagerman, P. J. (2008). A rapid polymerase chain reaction-based screening method for identification of all expanded alleles of the Fragile X (FMR1) gene in newborn and high-risk populations. Journal of Molecular Diagnostics, 10 (1), Toledano-Alhadef, H., Basel-Vanagaite, L., Magal, N., Davidov, B., Drasinover, S. V., Taub, E., et al. (2001). Fragile-X Carrier Screening and the Prevalence of Premutation and Full-Mutation Carriers in Israel. Am J Hum Genet, 69, Vits, L., De Boulle, K., Reyniers, E., Handig, I., Darby, J., Oostra, B., et al. (1994). Apparent regression of the CGG repeat in FMR1 to an allele of normal size. Human Genetics, 94 (5), Watson, M. S., Mann, M. Y., Lloyd-Puryear, M. A., Rinaldo, P., & Howell, R. R. (2006). Newborn Screening: Toward a uniform screening panel and system. Genetics in Medicine, 8 (5). Wienke, S., Brown, K., Farmer, M., & Strange, C. (2014). Expanded carrier screening panels-does bigger mean better? J Community Genet, 5,

58 APPENDICES

59 49 APPENDIX A QUESTIONNAIRE FOR PARENTS OF THE CHILD WITH A PREMUTATION The Impact of Positive Fragile X Newborn Screening Results on Reproductive Choices and Surveillance For Fragile X-Associated Disorders *If you have any questions that come up while taking this survey, please contact Kirin Basuta at (916) *Should you feel the need for more space to answer some of the questions, please feel free to attach additional pages of paper. Section 1 Questions For PARENTS of Child With Premutation What is your relationship to the child who has tested positive for the Fragile X premutation? m Mother m Father How old is your child? Age m days m weeks m months m years What is your child's gender? m Male m Female

60 50 About how long have you known about your child's premutation status? m less than 1 year m 1 to 3 years m 3 to 5 years m Greater than 5 years Please select any of these conditions that your child has. For any condition that you select, please provide an explanation. q Behavioral issues q Medical conditions ( For example: seizures, thyroid problems, hypertension, muscle pain, etc.) q Mental health issues ( For example: anxiety, depression, etc.) q Developmental delay and/or learning disabilities q None of the above How serious do you view Fragile X premutation as a medical condition for your child? m very serious m serious m somewhat serious m not serious at all How likely do you think your child is at risk for the following conditions? Very Unlikely Unlikely Somewhat Unlikely Undecided Somewhat Likely Likely Very Likely Behavioral issues m m m m m m m Reproductive/fertility or ovarian issues m m m m m m m Medical conditions (seizures, thyroid problems, hypertension, muscle pain, balance problems, unintentional shaking, etc.) m m m m m m m

61 51 Mental health issues m m m m m m m On average, how often does your child see his/her pediatrician? m Never m Less than Once a Month m Once a Month m 2-3 Times a Month m Once a Week m 2-3 Times a Week m Daily Is your child seeing other specialists (for example: neurologist, behavioral therapist, physical therapist, etc.) other than his/her pediatrician? m Yes m No IF YOU ANSWERED YES to the previous question, please indicate what types of specialist(s) (for example: neurologist, behavioral therapist, physical therapist, etc.) your child visits, how often, and the reason for being seen by these specialists.

62 52 Specialist On average, how often? For what reason(s)? Once a month Once every other month Twice a year Once a year Less than once a year One visit Reason 1 Reason 2 1. m m m m m m 2. m m m m m m 3. m m m m m m 4. m m m m m m 5. m m m m m m When the premutation was initially detected, what sources did you consult to obtain your information about Fragile X? (select all that apply) q Internet q Textbooks q Scientific journals q Pediatrician q Genetic Counselor q Social Worker q Other - Specify Do you still seek information about Fragile X? m Yes m No

63 53 IF YOU ANSWERED YES to the previous question, how often do you CURRENTLY seek information from the following sources? Never Rarely Sometimes Often All of the Time Internet m m m m m Textbooks m m m m m Scientific journals m m m m m Pediatrician m m m m m Genetic Counselor m m m m m Social Worker m m m m m Other - Specify m m m m m Is your child receiving any special services from the government? m Yes m No m I don't know IF YOU ANSWERED YES to the previous question, what special services is your child receiving from the government? Do you think other services from the government should be available to your child based on his/her premutation status? m Yes m No IF YOU ANSWERED YES to the previous question, what services?

64 54 Is your family paying out-of-pocket for special services related to your child's premutation status? m Yes m No m I don't know IF YOU ANSWERED YES to the previous question, what services are your family paying out-of-pocket for? Have you or are you planning to share your child's premutation status with his/her school or daycare? m Yes m No m I don't know Why or why not? Do you keep records of when your child is meeting basic developmental milestones (for example: when he/she started walking, rolling over, talking, etc.)? m Yes m No IF YOU ANSWERED YES to the previous question, how do you keep these records? Is your child meeting his/her appropriate developmental milestones? m Yes m No m I don't know

65 55 How often do you check to make sure he/she is meeting these milestones? m Never m Rarely m Sometimes m Often m All of the Time Do you worry about your child meeting his/her milestones? m Yes m No Why or why not? Have you been tested for the Fragile X premutation? m Yes m No IF YOU ANSWERED NO to the previous question, why not? THEN PLEASE PROCEED TO SECTION 2: QUESTIONS ABOUT REPRODUCTIVE PLANS Questions for individuals who have been tested for the Fragile X premutation: What is your Fragile X testing result? m Normal allele (less than 45 repeats) m Intermediate allele (45-54 repeats) m Premutation allele ( repeats) m Full mutation (greater than 200 repeats) IF YOU HAVE THE NORMAL ALLELE, please skip to question What (if any) emotional or psychological impact did the results of the test have on you?

66 56 IF YOU HAVE THE PREMUTATION ALLELE, how serious do you view Fragile X premutation as a medical condition for adults? m Very serious m Serious m Somewhat serious m Not serious at all IF YOU HAVE THE INTERMEDIATE ALLELE, how serious do you view being a Fragile X intermediate allele carrier as a medical condition for adults? m Very serious m Serious m Somewhat serious m Not serious at all

67 57 IF YOU HAVE THE FULL MUTATION, how serious do you view Fragile X syndrome as a medical condition for adults? m Very serious m Serious m Somewhat serious m Not serious at all How likely do you think you are at risk for the following issues? Very Unlikely Unlikely Somewhat Unlikely Undecided Somewhat Likely Likely Very Likely Behavioral issues m m m m m m m Reproductive/fertility or ovarian issues m m m m m m m Medical conditions (seizures, thyroid problems, hypertension, muscle pain, balance problems, unintentional shaking, etc.) m m m m m m m Mental health issues m m m m m m m What (if any) emotional or psychological impact did the results of the test have on you? Did you speak to a genetic counselor before proceeding with testing for Fragile X? m Yes m No m I don't know Did you speak to a genetic counselor after testing for Fragile X? m Yes m No m I don t know

68 58 PLEASE PROCEED TO SECTION 2 Section 2 Questions About Reproductive Plans How likely are you to have more biological children? m Very Unlikely m Unlikely m Somewhat Unlikely m Undecided m Somewhat Likely m Likely m Very Likely On a scale from 1 to 10, how concerned are you about having more children with the PREMUTATION? (1 being not concerned at all to 10 being very concerned) m 1 m 2 m 3 m 4 m 5 m 6 m 7 m 8 m 9 m 10 On a scale from 1 to 10, how concerned are you about having children with the FULL MUTATION (Fragile X Syndrome)? (1 being not concerned at all to 10 being very concerned) m 1 m 2 m 3 m 4 m 5 m 6 m 7 m 8 m 9 m 10

69 Would you consider other reproductive options such as preimplantation genetic diagnosis (PGD) with in vitro fertilization (IVF), sperm or egg donors or adoption for future children? Please select all that apply. q Preimplantation genetic diagnosis (PGD) with in vitro fertilization (IVF) q Sperm or egg donors q Adoption q Other - Specify q None of the above 59 Has your Fragile X premutation status changed your future reproductive plans m Yes m No

70 60 IF YOU ANSWERED YES to the previous question, how has your child s premutation status changed your future reproductive plans? IF YOU DO NOT HAVE THE PREMUTATION ALLELE, please proceed to the SECTION 5 If you are FEMALE WITH THE PREMUTATION ALLELE, please proceed to SECTION 3 IF you are MALE WITH THE PREMUTATION ALLELE, please proceed to SECTION 4 SECTION 3 for FEMALE participants only Questions About Primary Ovarian Insufficiency (POI) Please check all of the symptoms that you think are related to Primary Ovarian Insufficiency (POI). q Early menopause q Hot flashes q Night sweats q Irregular periods q Infertility q Irritability and/or difficulty concentrating q Decreased sexual desire q I don't know any symptoms associated with POI Are you currently exhibiting any symptoms of POI? m Yes (See Box A)

71 61 m No (See Box B) Box A: IF YOU ARE CURRENTLY EXHIBITING ANY SYMPTOMS OF POI: Please list the symptoms of POI that you are currently exhibiting After being tested for Fragile X and prior to exhibiting any symptoms for POI, what did you think your risk was for developing POI? (Please indicate your perceived risk percentage by marking an X on the appropriate location on the scale) After being tested for Fragile X and prior to developing symptoms for POI, were you concerned about developing symptoms for POI? m Yes m No IF YOU ANSWERED YES to the previous question, how concerned were you about developing POI? m Very concerned m Concerned m Somewhat concerned m Not concerned at all

72 62 Box B: IF YOU ARE NOT CURRENTLY EXHIBITING ANY SYMPTOMS OF POI: What do you think your risk is of developing POI? (Please indicate your perceived risk percentage by marking an X on the appropriate location on the scale) How concerned are you about developing POI? m Very concerned m Concerned m Somewhat concerned m Not concerned at all Have you talked to any healthcare professionals (primary care physician, gynecologist, genetic counselors, social workers, nurses, etc.) about POI? m Yes m No

73 63 IF YOU ANSWERED YES to the previous question, please indicate the types of healthcare professionals (primary care physician, gynecologist, genetic counselors, social workers, nurses, etc.) and how often you speak to them about POI. Are you taking any medications or herbal supplements to prevent and/or treat any Healthcare Professional Rarely Sometimes Often All of the Time 1. m m m m 2. m m m m 3. m m m m 4. m m m m 5. m m m m symptoms of POI? m Yes m No

74 64 IF YOU ANSWERED YES to the previous question, please list the types of medications or herbal supplements you are taking to prevent and/or treat any symptoms of POI. PLEASE PROCEED TO SECTION 4 SECTION 4 For both MALE AND FEMALE participants Questions About Fragile X-Associated Tremor Ataxia Syndrome (FXTAS) Please check all of the symptoms that you think are related to Fragile X-Associated Tremor Ataxia Syndrome (FXTAS). q Tremor (uncontrollable trembling or shaking) q Ataxia (gait or balance problems) q Peripheral neuropathy (numbness and/or tingling in the fingers and/or toes) q Bladder and bowel problems q Erectile dysfunction (in males) q Memory loss q Muscle weakness q Hearing loss q Difficulty swallowing q Mood changes q I don't know any symptoms associated with FXTAS Are you currently exhibiting any symptoms of FXTAS? m Yes (See Box A) m No (See Box B)

75 65 Box A: IF YOU ARE CURRENTLY EXHIBITING ANY SYMPTOMS OF FXTAS: Please list the symptoms of FXTAS that you are currently exhibiting After being tested for Fragile X and prior to exhibiting any symptoms for FXTAS, what did you think your risk was for developing FXTAS? (Please indicate your perceived risk percentage by marking an X on the appropriate location on the scale) After being tested for Fragile X and prior to developing symptoms for FXTAS, were you concerned about developing symptoms for FXTAS? m Yes m No IF YOU ANSWERED YES to the previous question, how concerned were you about developing FXTAS? m Very concerned m Concerned m Somewhat concerned m Not concerned at all

76 66 Box B: IF YOU ARE NOT CURRENTLY EXHIBITING ANY SYMPTOMS OF FXTAS: What do you think your risk is of developing FXTAS? (Please indicate your perceived risk percentage by marking an X on the appropriate location on the scale) How concerned are you about developing FXTAS? m Very concerned m Concerned m Somewhat concerned m Have you talked to any healthcare professionals (primary care physician, neurologist, genetic counselors, social workers, nurses, etc.) about FXTAS? m Yes m No Please indicate what types of healthcare professionals (primary care physician, neurologist, genetic counselors, social workers, nurses, etc.) and how often you speak to them about FXTAS. Healthcare Professional Rarely Sometimes Often All of the Time 1. m m m m m m m m m m m m

77 m m m m m m m m Are you taking any medications and/or herbal supplements to prevent and/or treat the symptoms of FXTAS? m Yes m No IF YOU ANSWERED YES to the previous question, please list the types of medications or herbal supplements you are taking to prevent and/or treat any symptoms of FXTAS. PLEASE PROCEED TO SECTION 5 SECTION 5 Any other comments about your experience with the Fragile X Newborn Screening Study that you would like to add? This study is being conducted in collaboration with the UC Davis MIND Institute Fragile X Newborn Screening Pilot Study under the direction of Professor Flora Tassone. If you have any questions regarding this survey please call Kirin at (916) For more information about Fragile X Syndrome please visit: or call: (800) Thank you for taking this survey! We appreciate your participation and contribution to Fragile X research.

78 68 APPENDIX B QUESTIONNAIRE FOR OTHER FAMILY MEMBERS OF THE CHILD WITH A PREMUTATION The Impact of Positive Fragile X Newborn Screening Results on Reproductive Choices and Surveillance For Fragile X-Associated Disorders *If you have any questions that come up while taking this survey, please contact Kirin Basuta at (916) *Should you feel the need for more space to answer some of the questions, please feel free to attach additional pages of paper. Section 1 Questions For OTHER FAMILY MEMBERS of Child With Premutation What is your relationship to the child who tested positive for the premutation? What is your Fragile X testing result? m Normal allele (less than 45 repeats) m Intermediate allele (45-54 repeats) m Premutation allele ( repeats) m Full mutation (greater than 200 repeats) IF YOU HAVE THE NORMAL ALLELE, please skip to question Who was the first person to contact you informing you of your risk for carrying a Fragile X mutation?