The Knotted Cord: An Update on Transgenerational Alcohol. Is a follow up to the original The Knotted Cord published by Nova Science in 2014. It is written as a conversation between myself in 2014 and then in 2019. The conversation is structured around the chapters of the initial book. Thus Ireland's toxic romance with alcohol, the stigma of transgenerational alcohol and the ethical dilemma of diagnosing and managing Neurodevelopmental Disorder prenatal alcohol exposure offer the beginning thrust to the book showing what has changed in the intervening five years and what has not changed. Overall the book is a critical and academic update on the complexities of understanding transgenerational alcohol and its impacts on societies worldwide. Management has clearly been placed in a Systems of Care paradigm, which is consistent with the 2014 book. However the intervening five years have produced a new clinical instrument, the Early Childhood Service Intensity Instrument (ECSII). The clinical emphasis on mothers and children under five years of age has become the entry into decreasing the impact of transgenerational alcohol. At the moment, the teratogenic effect of alcohol on the developing fetus remains frozen in being only related to a dysmorphic face. This is far from the truth as this prenatal acquired brain injury causes a mainly hidden, non-IQ, non-Face driven Global neurodevelopmental disorder, now more correctly diagnosed as Neurodevelopmental Disorder prenatal alcohol exposure, NDPAE, DSM 5.Code 315. Lastly, the challenge of approaching transgenerational alcohol and its impacts is a challenge to traditional medical practices of child and adult care. This disconnected model of care does not fit as medical, nursing, addiction and social workers need to move out of their silos and communicate with health professionals across the age range and accept this 'orphan' condition.

The title of the book harks back to Michael Dorris's seminal work The Broken Cord (1987) which eloquently brought this hidden' population into the light. However, the metaphorical umbilical cord is not truly broken, and the unique neurodevelopmental disorder resulting from prenatal alcohol exposure will continue to be one ghost in our delivery rooms, nurseries, and lives which haunts us. Why a different knot'? Because management becomes knotted with the origins of the infant's prenatal life, whether they are birthed, fostered, adopted, either same culture or inter-country adopted. The knot' (as in Not it'), also speaks to medical professionals and society's continued ambivalence to acknowledging another inconvenient truth. Maternal drinking in pregnancy causes Alcohol Related Neurodevelopmental Disorder (ARND) whether dysmorphic, called Fetal Alcohol Syndrome (FAS), or non dysmorphic, ARND itself. These are both transgenerational developmental psychiatric disorders. The prevalence of ARND continues to be under-recognised as it is mainly presented as a faceless 'hidden disability' (masquerading as ADHD, Mood Disorder or ASD), rather than a facial dysmorphic disorder. The subtle denial and minimisation of transgenerational alcohol abuse is aided only by diagnosing the far less frequent dysmorphic ARND (FAS). This creates a false security across social classes concerning alcohol's true transgenerational epigenetic effect. Thus, the real financial costs and health care burden of trans-generational ARND , with an international prevalence of 1 in 100 live births, is avoided.

The title of the book harks back to Michael Dorris's seminal work The Broken Cord (1987) which eloquently brought this hidden' population into the light. However, the metaphorical umbilical cord is not truly broken, and the unique neurodevelopmental disorder resulting from prenatal alcohol exposure will continue to be one ghost in our delivery rooms, nurseries, and lives which haunts us. Why a different knot'? Because management becomes knotted with the origins of the infant's prenatal life, whether they are birthed, fostered, adopted, either same culture or inter-country adopted. The knot' (as in Not it'), also speaks to medical professionals and society's continued ambivalence to acknowledging another inconvenient truth. Maternal drinking in pregnancy causes Alcohol Related Neurodevelopmental Disorder (ARND) whether dysmorphic, called Fetal Alcohol Syndrome (FAS), or non dysmorphic, ARND itself. These are both transgenerational developmental psychiatric disorders. The prevalence of ARND continues to be under-recognised as it is mainly presented as a faceless 'hidden disability' (masquerading as ADHD, Mood Disorder or ASD), rather than a facial dysmorphic disorder. The subtle denial and minimisation of transgenerational alcohol abuse is aided only by diagnosing the far less frequent dysmorphic ARND (FAS). This creates a false security across social classes concerning alcohol's true transgenerational epigenetic effect. Thus, the real financial costs and health care burden of trans-generational ARND , with an international prevalence of 1 in 100 live births, is avoided.