Skip to main content
Erschienen in: Neuropsychology Review 2/2011

01.06.2011 | Review

Fetal Alcohol Spectrum Disorders: An Overview

verfasst von: Edward P. Riley, M. Alejandra Infante, Kenneth R. Warren

Erschienen in: Neuropsychology Review | Ausgabe 2/2011

Einloggen, um Zugang zu erhalten

Abstract

When fetal alcohol syndrome (FAS) was initially described, diagnosis was based upon physical parameters including facial anomalies and growth retardation, with evidence of developmental delay or mental deficiency. Forty years of research has shown that FAS lies towards the extreme end of what are now termed fetal alcohol spectrum disorders (FASD). The most profound effects of prenatal alcohol exposure are on the developing brain and the cognitive and behavioral effects that ensue. Alcohol exposure affects brain development via numerous pathways at all stages from neurogenesis to myelination. For example, the same processes that give rise to the facial characteristics of FAS also cause abnormal brain development. Behaviors as diverse as executive functioning to motor control are affected. This special issue of Neuropsychology Review addresses these changes in brain and behavior highlighting the relationship between the two. A diagnostic goal is to recognize FAS as a disorder of brain rather than one of physical characteristics.
Literatur
Zurück zum Zitat Aase, J. M., Jones, K., & Clarren, S. K. (1995). Do we need the term “FAE”? Pediatrics, 95(3), 428–430.PubMed Aase, J. M., Jones, K., & Clarren, S. K. (1995). Do we need the term “FAE”? Pediatrics, 95(3), 428–430.PubMed
Zurück zum Zitat Abel, E. L., & Sokol, R. J. (1991). A revised conservative estimate of the incidence of FAS and its economic impact. Alcoholism: Clinical and Experimental Research, 15(3), 514–524.CrossRef Abel, E. L., & Sokol, R. J. (1991). A revised conservative estimate of the incidence of FAS and its economic impact. Alcoholism: Clinical and Experimental Research, 15(3), 514–524.CrossRef
Zurück zum Zitat Astley, S. J., & Clarren, S. K. (2000). Diagnosing the full spectrum of fetal alcohol-exposed individuals: Introducing the 4-digit diagnostic code. Alcohol and Alcoholism, 35(4), 400–410.PubMedCrossRef Astley, S. J., & Clarren, S. K. (2000). Diagnosing the full spectrum of fetal alcohol-exposed individuals: Introducing the 4-digit diagnostic code. Alcohol and Alcoholism, 35(4), 400–410.PubMedCrossRef
Zurück zum Zitat Bertrand, J., Floyd, R. L., & Weber, M. K. (2005). Guidelines for identifying and referring persons with fetal alcohol syndrome. Morbidity and Mortality Weekly Report, 54(RR-11), 1–14. Bertrand, J., Floyd, R. L., & Weber, M. K. (2005). Guidelines for identifying and referring persons with fetal alcohol syndrome. Morbidity and Mortality Weekly Report, 54(RR-11), 1–14.
Zurück zum Zitat Burd, L., & Hofer, R. (2008). Biomarkers for detection of prenatal alcohol exposure: a critical review of fatty acid ethyl esters in meconium. Birth Defects Research. Part A, Clinical And Molecular Teratology, 82(7), 487–493.PubMedCrossRef Burd, L., & Hofer, R. (2008). Biomarkers for detection of prenatal alcohol exposure: a critical review of fatty acid ethyl esters in meconium. Birth Defects Research. Part A, Clinical And Molecular Teratology, 82(7), 487–493.PubMedCrossRef
Zurück zum Zitat Burd, L., Klug, M., & Martsolf, J. (2004). Increased sibling mortality in children with fetal alcohol syndrome. Addiction Biology, 9(2), 179–186.PubMedCrossRef Burd, L., Klug, M., & Martsolf, J. (2004). Increased sibling mortality in children with fetal alcohol syndrome. Addiction Biology, 9(2), 179–186.PubMedCrossRef
Zurück zum Zitat Calhoun, F., & Warren, K. (2007). Fetal alcohol syndrome: Historical perspectives. Neuroscience and Biobehavioral Reviews, 31(2), 168–171.PubMedCrossRef Calhoun, F., & Warren, K. (2007). Fetal alcohol syndrome: Historical perspectives. Neuroscience and Biobehavioral Reviews, 31(2), 168–171.PubMedCrossRef
Zurück zum Zitat Center for Disease Control and Prevention (CDC). (1993). Fetal alcohol syndrome—United States, 1979–1992. Morbidity and Mortality Reports, 42(17), 339–341. Center for Disease Control and Prevention (CDC). (1993). Fetal alcohol syndrome—United States, 1979–1992. Morbidity and Mortality Reports, 42(17), 339–341.
Zurück zum Zitat Center for Disease Control and Prevention (CDC). (1995). Update: Trends in fetal alcohol syndrome—United States, 1979–1993. Morbidity and Mortality Reports, 44(13), 249–51. Center for Disease Control and Prevention (CDC). (1995). Update: Trends in fetal alcohol syndrome—United States, 1979–1993. Morbidity and Mortality Reports, 44(13), 249–51.
Zurück zum Zitat Center for Disease Control and Prevention (CDC). (1997). Surveillance for fetal alcohol syndrome using multiple sources—Atlanta, Georgia, 1981–1989. Morbidity and Mortality Reports, 46(47), 1118–20. Center for Disease Control and Prevention (CDC). (1997). Surveillance for fetal alcohol syndrome using multiple sources—Atlanta, Georgia, 1981–1989. Morbidity and Mortality Reports, 46(47), 1118–20.
Zurück zum Zitat Center for Disease Control and Prevention (CDC). (2002). Fetal alcohol syndrome—Alaska, Arizona, Colorado, and New York, 1995–1997. Morbidity and Mortality Reports, 51(20), 433–435. Center for Disease Control and Prevention (CDC). (2002). Fetal alcohol syndrome—Alaska, Arizona, Colorado, and New York, 1995–1997. Morbidity and Mortality Reports, 51(20), 433–435.
Zurück zum Zitat Chudley, A. E., Conry, J., Cook, J. L., Loock, C., Rosales, T., & LeBlanc, N. (2005). Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journal, 172(5 Suppl), S1–S21.PubMedCrossRef Chudley, A. E., Conry, J., Cook, J. L., Loock, C., Rosales, T., & LeBlanc, N. (2005). Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journal, 172(5 Suppl), S1–S21.PubMedCrossRef
Zurück zum Zitat Clarren, S. K., & Smith, D. W. (1978). The fetal alcohol syndrome. The New England Journal of Medicine, 298(19), 1063–1067.PubMedCrossRef Clarren, S. K., & Smith, D. W. (1978). The fetal alcohol syndrome. The New England Journal of Medicine, 298(19), 1063–1067.PubMedCrossRef
Zurück zum Zitat Clarren, S. K., Chudley, A. E., Wong, L., Friesen, J., & Brant, R. (2010). Normal distribution of palpebral fissure lengths in Canadian school age children. Canadian Journal of Clinical Pharmacology, 17, e67–e78.PubMed Clarren, S. K., Chudley, A. E., Wong, L., Friesen, J., & Brant, R. (2010). Normal distribution of palpebral fissure lengths in Canadian school age children. Canadian Journal of Clinical Pharmacology, 17, e67–e78.PubMed
Zurück zum Zitat Datta, S., Turner, D., Singh, R., Ruest, L. B., Pierce, W. M., Jr., & Knudsen, T. B. (2008). Fetal alcohol syndrome (FAS) in C57BL/6 mice detected through proteomics screening of the amniotic fluid. Birth Defects Research Part A, Clinical and Molecular Teratology, 82(4), 177–186.PubMedCrossRef Datta, S., Turner, D., Singh, R., Ruest, L. B., Pierce, W. M., Jr., & Knudsen, T. B. (2008). Fetal alcohol syndrome (FAS) in C57BL/6 mice detected through proteomics screening of the amniotic fluid. Birth Defects Research Part A, Clinical and Molecular Teratology, 82(4), 177–186.PubMedCrossRef
Zurück zum Zitat Garcia-Algar, O., Kulaga, V., Gareri, J., Koren, G., Vall, O., Zuccaro, P., et al. (2008). Alarming prevalence of fetal alcohol exposure in a Mediterranean city. Therapeutic Drug Monitoring, 30(2), 249–254.PubMedCrossRef Garcia-Algar, O., Kulaga, V., Gareri, J., Koren, G., Vall, O., Zuccaro, P., et al. (2008). Alarming prevalence of fetal alcohol exposure in a Mediterranean city. Therapeutic Drug Monitoring, 30(2), 249–254.PubMedCrossRef
Zurück zum Zitat Gareri, J., Lynn, H., Handley, M., Rao, C., & Koren, G. (2008). Prevalence of fetal ethanol exposure in a regional population-based sample by meconium analysis of fatty acid ethyl esters. Therapeutic Drug Monitoring, 30(2), 239–45.PubMedCrossRef Gareri, J., Lynn, H., Handley, M., Rao, C., & Koren, G. (2008). Prevalence of fetal ethanol exposure in a regional population-based sample by meconium analysis of fatty acid ethyl esters. Therapeutic Drug Monitoring, 30(2), 239–45.PubMedCrossRef
Zurück zum Zitat Gifford, A. E., Farkas, K. J., Jackson, L. W., Molteno, C. D., Jacobson, J. L., Jacobson, S. W., et al. (2010). Assessment of benefits of a universal screen for maternal alcohol use during pregnancy. Birth Defects Research. Part A, Clinical and Molecular Teratology, 88(10), 838–846.PubMedCrossRef Gifford, A. E., Farkas, K. J., Jackson, L. W., Molteno, C. D., Jacobson, J. L., Jacobson, S. W., et al. (2010). Assessment of benefits of a universal screen for maternal alcohol use during pregnancy. Birth Defects Research. Part A, Clinical and Molecular Teratology, 88(10), 838–846.PubMedCrossRef
Zurück zum Zitat Goh, Y. I., Hutson, J. R., Lum, L., Roukema, H., Gareri, J., Lynn, H., et al. (2010). Rates of fetal alcohol exposure among newborns in a high-risk obstetric unit. Alcohol (Fayetteville, N.Y.), 44(7–8), 629–634. Goh, Y. I., Hutson, J. R., Lum, L., Roukema, H., Gareri, J., Lynn, H., et al. (2010). Rates of fetal alcohol exposure among newborns in a high-risk obstetric unit. Alcohol (Fayetteville, N.Y.), 44(7–8), 629–634.
Zurück zum Zitat Goodlett, C. R., Horn, K. H., & Zhou, F. C. (2005). Alcohol teratogenesis: mechanisms of damage and strategies for intervention. Experimental Biology And Medicine (Maywood, N.J.), 230(6), 394–406. Goodlett, C. R., Horn, K. H., & Zhou, F. C. (2005). Alcohol teratogenesis: mechanisms of damage and strategies for intervention. Experimental Biology And Medicine (Maywood, N.J.), 230(6), 394–406.
Zurück zum Zitat Hall, J. G. (2010). New palpebral fissure measurements. American Journal of Medical Genetics Part A, 152A, 1870.PubMedCrossRef Hall, J. G. (2010). New palpebral fissure measurements. American Journal of Medical Genetics Part A, 152A, 1870.PubMedCrossRef
Zurück zum Zitat Hall, J. G., Froster-Iskenius, U. G., & Allanson, J. E. (1989). Handbook of Normal Physical Measurements. New York: Oxford University Press. Hall, J. G., Froster-Iskenius, U. G., & Allanson, J. E. (1989). Handbook of Normal Physical Measurements. New York: Oxford University Press.
Zurück zum Zitat Harlap, S., & Shiono, P. H. (1980). Alcohol, smoking, and incidence of spontaneous abortions in the first and second trimester. Lancet, 2, 173–176.PubMedCrossRef Harlap, S., & Shiono, P. H. (1980). Alcohol, smoking, and incidence of spontaneous abortions in the first and second trimester. Lancet, 2, 173–176.PubMedCrossRef
Zurück zum Zitat Hoyme, H. E., May, P. A., Kalberg, W. O., Kodituwakku, P., Gossage, J. P., Trujillo, P. M., et al. (2005). A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics, 115(1), 39–47.PubMed Hoyme, H. E., May, P. A., Kalberg, W. O., Kodituwakku, P., Gossage, J. P., Trujillo, P. M., et al. (2005). A practical clinical approach to diagnosis of fetal alcohol spectrum disorders: clarification of the 1996 Institute of Medicine criteria. Pediatrics, 115(1), 39–47.PubMed
Zurück zum Zitat Hutson, J., Magri, R., Gareri, J., & Koren, G. (2010). The incidence of prenatal alcohol exposure in Montevideo Uruguay as determined by meconium analysis. Therapeutic Drug Monitoring, 32(3), 311–317.PubMedCrossRef Hutson, J., Magri, R., Gareri, J., & Koren, G. (2010). The incidence of prenatal alcohol exposure in Montevideo Uruguay as determined by meconium analysis. Therapeutic Drug Monitoring, 32(3), 311–317.PubMedCrossRef
Zurück zum Zitat Jones, K. L., & Smith, D. W. (1973). Recognition of the fetal alcohol syndrome in early infancy. Lancet, 2(7836), 999–1001.CrossRef Jones, K. L., & Smith, D. W. (1973). Recognition of the fetal alcohol syndrome in early infancy. Lancet, 2(7836), 999–1001.CrossRef
Zurück zum Zitat Jones, K. L., Smith, D. W., Ulleland, C. N., & Streissguth, A. P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet, 1(7815), 1267–1271.PubMedCrossRef Jones, K. L., Smith, D. W., Ulleland, C. N., & Streissguth, A. P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet, 1(7815), 1267–1271.PubMedCrossRef
Zurück zum Zitat Jones, K. L., Smith, D. W., & Hanson, J. W. (1976). The fetal alcohol syndrome: clinical delineation. Annals of the New York Academy of Sciences, 273, 130–139.PubMedCrossRef Jones, K. L., Smith, D. W., & Hanson, J. W. (1976). The fetal alcohol syndrome: clinical delineation. Annals of the New York Academy of Sciences, 273, 130–139.PubMedCrossRef
Zurück zum Zitat Kline, J., Shrout, P., Stein, Z., Susser, M., & Warburton, D. (1980). Drinking during pregnancy and spontaneous abortion. Lancet, 2(8187), 176–180.PubMedCrossRef Kline, J., Shrout, P., Stein, Z., Susser, M., & Warburton, D. (1980). Drinking during pregnancy and spontaneous abortion. Lancet, 2(8187), 176–180.PubMedCrossRef
Zurück zum Zitat Kulaga, V., Shor, S., & Koren, G. (2010). Correlation between drugs of abuse and alcohol by hair analysis: parents at risk for having children with fetal alcohol spectrum disorder. Alcohol (Fayetteville, N.Y.), 44(7–8), 615–621. Kulaga, V., Shor, S., & Koren, G. (2010). Correlation between drugs of abuse and alcohol by hair analysis: parents at risk for having children with fetal alcohol spectrum disorder. Alcohol (Fayetteville, N.Y.), 44(7–8), 615–621.
Zurück zum Zitat Lupton, C., Burd, L., & Harwood, R. (2004). Cost of fetal alcohol spectrum disorders. American Journal of Medical Genetics Part C (Seminars in Medical Genetics), 127C(1), 42–50.CrossRef Lupton, C., Burd, L., & Harwood, R. (2004). Cost of fetal alcohol spectrum disorders. American Journal of Medical Genetics Part C (Seminars in Medical Genetics), 127C(1), 42–50.CrossRef
Zurück zum Zitat May, P. A., & Gossage, J. P. (2001). Estimating the prevalence of fetal alcohol syndrome: a summary. Alcohol Research and Health, 25(3), 159–167.PubMed May, P. A., & Gossage, J. P. (2001). Estimating the prevalence of fetal alcohol syndrome: a summary. Alcohol Research and Health, 25(3), 159–167.PubMed
Zurück zum Zitat May, P. A., Fiorentino, D., Gossage, J. P., Kalberg, W. O., Hoyme, H. E., Robinson, L. K., et al. (2006). Epidemiology of FASD in a province in Italy: Prevalence and characteristics of children in a random sample of schools. Alcoholism, Clinical and Experimental Research, 30(9), 1562–1575.PubMedCrossRef May, P. A., Fiorentino, D., Gossage, J. P., Kalberg, W. O., Hoyme, H. E., Robinson, L. K., et al. (2006). Epidemiology of FASD in a province in Italy: Prevalence and characteristics of children in a random sample of schools. Alcoholism, Clinical and Experimental Research, 30(9), 1562–1575.PubMedCrossRef
Zurück zum Zitat May, P. A., Gossage, J. P., Marais, A., Adnams, C. M., Hoyme, H. E., Jones, K. L., et al. (2007). The epidemiology of fetal alcohol syndrome and partial FAS in a South African community. Drug and Alcohol Dependence, 88(2–3), 259–271.PubMedCrossRef May, P. A., Gossage, J. P., Marais, A., Adnams, C. M., Hoyme, H. E., Jones, K. L., et al. (2007). The epidemiology of fetal alcohol syndrome and partial FAS in a South African community. Drug and Alcohol Dependence, 88(2–3), 259–271.PubMedCrossRef
Zurück zum Zitat May, P. A., Gossage, J. P., Kalberg, W. O., Robinson, L. K, Buckley, D., Manning, M., et al. (2009). Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies. Developmental Disabilities Research Reviews, 15(3), 176–192.PubMedCrossRef May, P. A., Gossage, J. P., Kalberg, W. O., Robinson, L. K, Buckley, D., Manning, M., et al. (2009). Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies. Developmental Disabilities Research Reviews, 15(3), 176–192.PubMedCrossRef
Zurück zum Zitat Olson, H. C., Ohlemiller, M. M., O’Connor, M. J., Brown, C. W., Morris, C. A., & Damus, K., National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. (2009). A call to action: Advancing Essential Services and Research on Fetal Alcohol Spectrum Disorders—A report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, March 2009. www.cdc.gov/ncbddd/fas. Olson, H. C., Ohlemiller, M. M., O’Connor, M. J., Brown, C. W., Morris, C. A., & Damus, K., National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. (2009). A call to action: Advancing Essential Services and Research on Fetal Alcohol Spectrum Disorders—A report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, March 2009. www.​cdc.​gov/​ncbddd/​fas.
Zurück zum Zitat Petković, G., & Barisić, I. (2010). FAS prevalence in a sample of urban schoolchildren in Croatia. Reproductive Toxicology, 29(2), 237–241. Petković, G., & Barisić, I. (2010). FAS prevalence in a sample of urban schoolchildren in Croatia. Reproductive Toxicology, 29(2), 237–241.
Zurück zum Zitat Sampson, P. D., Streissguth, A. P., Bookstein, F. L., Little, R. E., Clarren, S. K., Dehaene, P., et al. (1997). Incidence of fetal alcohol syndrome and prevalence of alcohol-related neurodevelopmental disorder. Teratology, 56(5), 317–326.PubMedCrossRef Sampson, P. D., Streissguth, A. P., Bookstein, F. L., Little, R. E., Clarren, S. K., Dehaene, P., et al. (1997). Incidence of fetal alcohol syndrome and prevalence of alcohol-related neurodevelopmental disorder. Teratology, 56(5), 317–326.PubMedCrossRef
Zurück zum Zitat Sokol, R. J., Delaney-Black, V., & Nordstrom, B. (2003). Fetal alcohol spectrum disorder. JAMA: The Journal of the American Medical Association, 290(22), 2996–2999.CrossRef Sokol, R. J., Delaney-Black, V., & Nordstrom, B. (2003). Fetal alcohol spectrum disorder. JAMA: The Journal of the American Medical Association, 290(22), 2996–2999.CrossRef
Zurück zum Zitat Spohr, H. L., & Steinhausen, H. C. (2008). Fetal alcohol spectrum disorders and their persisting sequelae in adult life. Deutsches Ärzteblatt International, 105(41), 693–698.PubMed Spohr, H. L., & Steinhausen, H. C. (2008). Fetal alcohol spectrum disorders and their persisting sequelae in adult life. Deutsches Ärzteblatt International, 105(41), 693–698.PubMed
Zurück zum Zitat Stade, B., Ali, A., Bennett, D., Campbell, D., Johnston, M., Lens, C., et al. (2009). The burden of prenatal exposure to alcohol: revised measurement of cost. Canadian Journal of Clinical Pharmacolology, 16(1), e91–e102. Stade, B., Ali, A., Bennett, D., Campbell, D., Johnston, M., Lens, C., et al. (2009). The burden of prenatal exposure to alcohol: revised measurement of cost. Canadian Journal of Clinical Pharmacolology, 16(1), e91–e102.
Zurück zum Zitat Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy. Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, DC: National Academy.
Zurück zum Zitat Thomas, L. T., Gaitantzis, Y. A., & Frias, J. L. (1987). Palpebral fissure length from 29 weeks to 14 years. Journal of Pediatrics, 111(2), 267–268.PubMedCrossRef Thomas, L. T., Gaitantzis, Y. A., & Frias, J. L. (1987). Palpebral fissure length from 29 weeks to 14 years. Journal of Pediatrics, 111(2), 267–268.PubMedCrossRef
Metadaten
Titel
Fetal Alcohol Spectrum Disorders: An Overview
verfasst von
Edward P. Riley
M. Alejandra Infante
Kenneth R. Warren
Publikationsdatum
01.06.2011
Verlag
Springer US
Erschienen in
Neuropsychology Review / Ausgabe 2/2011
Print ISSN: 1040-7308
Elektronische ISSN: 1573-6660
DOI
https://doi.org/10.1007/s11065-011-9166-x

Weitere Artikel der Ausgabe 2/2011

Neuropsychology Review 2/2011 Zur Ausgabe

Leitlinien kompakt für die Neurologie

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Akuter Schwindel: Wann lohnt sich eine MRT?

28.04.2024 Schwindel Nachrichten

Akuter Schwindel stellt oft eine diagnostische Herausforderung dar. Wie nützlich dabei eine MRT ist, hat eine Studie aus Finnland untersucht. Immerhin einer von sechs Patienten wurde mit akutem ischämischem Schlaganfall diagnostiziert.

Niedriger diastolischer Blutdruck erhöht Risiko für schwere kardiovaskuläre Komplikationen

25.04.2024 Hypotonie Nachrichten

Wenn unter einer medikamentösen Hochdrucktherapie der diastolische Blutdruck in den Keller geht, steigt das Risiko für schwere kardiovaskuläre Ereignisse: Darauf deutet eine Sekundäranalyse der SPRINT-Studie hin.

Frühe Alzheimertherapie lohnt sich

25.04.2024 AAN-Jahrestagung 2024 Nachrichten

Ist die Tau-Last noch gering, scheint der Vorteil von Lecanemab besonders groß zu sein. Und beginnen Erkrankte verzögert mit der Behandlung, erreichen sie nicht mehr die kognitive Leistung wie bei einem früheren Start. Darauf deuten neue Analysen der Phase-3-Studie Clarity AD.

Viel Bewegung in der Parkinsonforschung

25.04.2024 Parkinson-Krankheit Nachrichten

Neue arznei- und zellbasierte Ansätze, Frühdiagnose mit Bewegungssensoren, Rückenmarkstimulation gegen Gehblockaden – in der Parkinsonforschung tut sich einiges. Auf dem Deutschen Parkinsonkongress ging es auch viel um technische Innovationen.

Update Neurologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.