Fetal Alcohol Spectrum Disorder (FASD)

Fetal Alcohol Spectrum Disorder This chapter has been taken in part from the chapter on FASD in my first book by Dr Sterling Clarren.

Fetal Alcohol Spectrum Disorder is an umbrella term for conditions that are caused as a result of drinking alcohol during pregnancy but is not a diagnosis. Alcohol is a substance that causes birth defects and as such can affect the unborn child’s development. If a woman drinks while she is pregnant the alcohol, no matter how much or how little, crosses the placental barrier and circulates through the baby’s system. However, it remains with the baby longer because the mother metabolises the alcohol with a fully formed liver, whereas the baby’s liver is small and undeveloped so the blood alcohol level of the baby is the same as that of the mother. This means that there is no known level of alcohol consumption during pregnancy that is safe for the baby.

There is a range of effects on the spectrum from mild to severe.

The mild effects may not result in mental retardation, but it is possible that the brain has been damaged and the executive functioning (the higher-order thinking and judgment skills) of that person is compromised. While the child grows and appears normal there could be subtle, and not-so-subtle, behavioural problems associated with the prenatal injury.

At the severe end, there can be the same behavioural problems but the child will also have the distinctive facial features of FAS. These facial features and more detailed symptoms and characteristics are described later in this chapter.

Much of the research that has been conducted has been in North America by researchers such as Professors Sterling Clarren, Susan Astley and Ab Chudley. Sterling Clarren’s primate and mouse research on alcohol and pregnancy found that the lip and philtrum anomaly of (full) FAS occurred in a very small window of time which would be on the 19th to 20th day after conception in the human – the period called gastrulation. Since the diagnosis of FAS depends on having the full set of facial features then it is likely that only exposures that include the 19th or 20th day will attract the diagnosis of FAS. However, a child can still have a serious brain injury without facial characteristics.

This work strengthens the importance of referring to the condition in terms of the full spectrum rather than the syndrome alone.

This is why there is a perception in Australia that fetal alcohol spectrum disorder is rare. Our medical profession has had very limited training in the diagnosis and many only recognise, if at all, those children with very obvious facial features – those with full-blown fetal alcohol syndrome.

However, according to Professor Clarren’s research, if a mother does not drink on the 19th or 20th day, the child may still have brain damage but no facial features. It is well documented in North America that children with facial features are only the tip of the iceberg. Overseas studies show that for every child diagnosed with full FAS there will be another three to ten with alcohol-related neurodevelopmental disorders, the conditions that remain on the spectrum when the full syndrome is removed.

In North America and Canada, multidisciplinary teams are trained to diagnose FASD. Team members typically include, but are not limited to, physicians, psychiatrists, psychologists, speech/language pathologists, occupational therapists, and social workers.

There are NO such interdisciplinary teams in Australia, nor are there many ‘experts’. So, it is particularly concerning that we have high-profile members of the medical profession who have obviously had no training in the diagnosis of FASD and presumably very limited understanding of the disability, making uninformed and dangerously misleading statements indicating that in order to get a diagnosis of full Fetal Alcohol Syndrome at least eight drinks a day would have to be consumed when in fact obtaining a diagnosis of full FAS is not reliant on how much is consumed but when it is consumed.

This condition is not restricted to the indigenous population or alcoholic women

It is easier to identify in the children of alcoholic women but FASD can and does strike a family who may have no idea that their child is affected until he or she reaches puberty when behavioural problems become more marked. By then it may be difficult to relate back to the pregnancy and the few glasses of wine each day or even, in some cases, each week.

Dr Margaret Clarke, an eminent Canadian FASD researcher, has found that in Canada 96% of mothers with alcohol-affected children are social drinkers, and only 4% are alcohol dependent. This makes an accurate diagnosis more difficult and having a multidisciplinary team undertake the diagnosis is more necessary.

FASD can cause behavioural problems similar to those caused by the environment.

However, the antisocial or delinquent behaviour caused by the environment sometimes can be resolved. This is especially if given appropriate and consistent assistance at the right time because while the behaviour and the psychology are abnormal, the brain has not been physically injured. People who have FASD have a brain injury so will not be able to make the necessary changes, even though they seem to have the ability to do so. FASD is not an excuse for bad behaviour; it is the reason for it.

Sufferers often try to do what is expected of them, but it is like assuming persons in wheelchairs will be able to walk just because we tell them to. The difference, of course, is that we wouldn’t expect people with paraplegia or quadriplegia to walk if we yell at them enough, but everyday people with brain injuries are expected to ‘walk’ when they are in metaphorical wheelchairs. Moreover, no one can see their ‘wheelchair’, no one knows about this injury because it is not visible, and it would certainly not be obvious that they have FASD simply by talking with them for a short time unless they have distinctive facial features or a lower IQ.

A common mistake is to assume that because a person can ‘talk the talk’ he or she can also ‘walk the walk’.

This is not true for people with FASD. Their expressive language is far better than their receptive language. So they can say they understand what is being said, and can even repeat what has been said. But if it’s a complicated or abstract concept or if there is more than one idea, instruction or topic, then it is unlikely that information will be accurately interpreted.

Only a relatively small number of people with FASD have a low IQ. These individuals will usually have access to services as a result. However, gaining access to services is challenging for affected people without an advocate. It is because they won’t always present as having a disability yet will have compromised executive functioning. For them, it will be a ‘catch-22’ situation where without a low IQ, they will be difficult for others to identify, yet because of prenatal alcohol exposure are generally unable to advocate for themselves. Without either an advocate or insight into their disability these individuals will be unlikely to proactively access the services they will desperately need during their lifetime. One of the ways they are likely to access services is involuntarily through legal direction or because of florid mental illness.

So with no diagnosis, friends, family and other significant people in their lives will not fully understand the reasons for their behaviours. They may believe it’s because of dysfunctional parenting, abuse, mental illness, genetics, drugs, alcohol, or just plain irrepressible immaturity. In fact, it is because their brains have been saturated with alcohol, destroying brain cells, when they were in their mother’s wombs.

The diagnosis of full fetal alcohol syndrome is based on three features:

Pre- and post-natal growth deficiency;
A distinct pattern of craniofacial malformations; and
Brain and central nervous system (CNS) dysfunction.

The pattern of facial and other anomalies as a result of maternal drinking can include:

small eye openings (palpebral fissures)
flat midface (cheekbones)
the flattened groove between the nose and upper lip (philtrum)
thin upper lip
low birth weight

Central Nervous System abnormalities, of at least one of the following:

small head size
structural abnormalities of the brain
neurological problems (such as impaired motor skills, poor coordination, hearing loss, and visual problems)
behavioural and/or cognitive problems such as:
- intellectual disability
- learning difficulties
- poor impulse control
- problems in social perception
- problems in memory, attention, reasoning and judgment; and
- deficits in some mathematical and language skills

Alcohol is a behavioural teratogen. A teratogen is a substance that causes birth defects. A behavioural teratogen is a substance that also causes behavioural problems.

Although alcohol exposure presents a physical risk to the fetus much like mercury and thalidomide. It is in the area of behaviour that alcohol seems to do the most long-term damage. People with FASD may have trouble setting personal boundaries and observing other people’s boundaries. They often have emotional problems, can be impulsive, may not be able to sustain relationships, and often cannot anticipate consequences. They have difficulty paying attention, have poor organisational skills and struggle to complete tasks.

FASD is permanent, irreversible brain damage and this brain injury is the primary disability. However, secondary disabilities may occur. This is especially if the primary disability is not recognised and appropriate strategies and interventions are put into place. Although the primary disabling conditions of prenatal alcohol exposure last a lifetime, the secondary disabilities can be prevented.

From life history interviews of 415 individuals with FASD using 450 questions, Dr Streissguth from the University of Washington found that:

94% of people diagnosed with FASD experienced mental health problems – which was the most prevalent secondary disability
43% of people of school age experienced disrupted school experience (suspension, expulsion or dropout)
42% of people and 60% aged 12 and over had been in trouble with the law. (involvement with authorities, charged or convicted of a crime)
60% had been confined (inpatient treatment for mental health, alcohol/drug problems, or incarceration for crime)
45% aged 12 and over were reported to have exhibited inappropriate sexual behaviour
30% of people over the age of 12 experienced alcohol and drug problems

Problems with employment were indicated in 80% of adults with FASD. Problems with parenting: Of the 100 females of childbearing age, 30 had given birth; 40% drank during pregnancy, and more than half no longer had the child in their care. Of their children, 30% have been diagnosed with or were suspected of having FASD.

If it is not possible to halt the secondary disabilities through appropriate interventions, strategies and environmental modifications, then it is vital that they be understood so that relevant management strategies can be developed and implemented.

Dr Streissguth’s research found that secondary disabilities could be prevented if the following occurs:

Early diagnosis is a universal protective indicator for all secondary disabilities. Only 11% of individuals with FASD were diagnosed by the age of six years.
Eligibility for services from disability agencies is another strong protective factor. (including Disability Support Pension, Disability Open Employment Agencies, Vocational Rehabilitation and assessments from appropriate allied health professionals). Most individuals with FASD need these services, yet most do not qualify.
Living in a stable home with nurturing parents and minimum household changes.
Protection from violence – from witnessing or being victimised by violence.

The brain injury that results from FASD is an information processing deficit. An inability to reason in the way that others do, and a distressing inability to fit in with the rules and behaviours required by society because of the damage to the corpus callosum.

The corpus callosum is the part of the brain that links the right brain and the left brain. The right-brain handles creativity, intuition and impulse and the left brain handle the rules, logic, order and thoughts. When the two cannot link properly because of prenatal exposure to alcohol or a brain injury of some sort, then the person cannot always predict the outcome of his actions even though he knows and can repeat the ‘rules’. Most often, affected individuals are seen as lazy, unmotivated, disorganised, in denial, or dishonest.

Typical primary characteristics in children, adolescents, and adults:

Memory problems
Difficulty storing and retrieving information
Inconsistent performance (‘on’ and ‘off’ days)
Impulsivity, distractibility, disorganisation
Ability to repeat instructions, but the inability to put them into action
Difficulty with abstractions, such as maths, money management, and time concepts
Cognitive processing deficits (may think more slowly)
Slow auditory pace (may only understand every third word of normally paced conversation)
Developmental lags (may act younger than chronological age)
Inability to predict outcomes or understand consequences, inability to show remorse

Common strengths

Highly verbal
Bright in some areas
Artistic, musical, mechanical
Athletic
Friendly, outgoing and affectionate
Determined, persistent
Willing and helpful
Generous
Good with younger children.

Diagnosis

From my experience, it seems difficult for Australian health professionals to identify and diagnose people with FASD. This is even with a definite connection between alcohol and pregnancy. Let alone when the mother is not an alcoholic and finds it hard to remember details of her pregnancy many years before. The possible consequences of a right or a wrong diagnosis would be devastating. This is especially for the doctor, the individual and his or her family.

Therefore in order to provide adequately for affected Australians, diagnostic clinics should, at a minimum, be located in all capital cities in Australia. Preferably, the diagnostic clinics should also be in many of the regional centres. Unfortunately, neither a blood test nor a simple medical examination, at this stage in research, will reveal the presence of FASD in an individual.

In October 2006, I was honoured to be present at the release of preliminary findings of a study. This study is made by Susan Astley, Director of the FAS Diagnostic and Prevention Network at the University of Washington, and her colleagues. Research into whether Magnetic Resonance Imaging (MRI), Magnetic Resonance Spectroscopy (MRS) and Functional Magnetic Resonance Imaging (fMRI) can serve as non-invasive methods for definitively identifying global and/or focal brain damage in patients presenting with cognitive/behavioural dysfunction and prenatal alcohol exposure. The study compared children along the full continuum of FASD. This includes children with FAS and Partial FAS, to children with normal development and no prenatal alcohol exposure. The results will be published later in the year. This will represent a huge leap forward in the diagnosis of this condition.

Links to related Australian sites

Article reproduced with permission from Elizabeth Russell (2008)