AAAP News
The Official Newsletter of the American Academy of Addiction Psychiatry
March 2010
Volume 26, Number 1
NIAAA UPDATE
Prenatal Exposure to Alcohol: The Role of Addiction Psychiatry
By Howard B. Moss, MD
Associate Director for Clinical and Translational Research, National Institute on Alcohol Abuse and Alcoholism
When addiction psychiatrists think of Fetal Alcohol Syndrome (FAS), they may assume that this is simply mental retardation caused by gestational exposure to alcohol and don’t think that it is relevant to their practice, unless they are consultants to obstetrical programs. However, only 25% of individuals with FAS have IQ scores less than 70 but most have learning disabilities, behavioral problems, and lack the skills to live independently. Many are seen by psychiatrists for evaluations of their disabilities. In addition, results from emerging research on prenatal exposure to alcohol suggest that psychopathology is more common than previously thought, and is increasingly relevant to the scope of practice of the general, child and adolescent, and addiction psychiatrist.
In 1968, a French pediatrician, Paul Lemoine, reported a pattern of specific deficits seen in children of alcoholic mothers. Subsequently, Jones and Smith introduced the name “fetal alcohol syndrome (FAS)” to describe this syndrome of unique facial features (most typically, short palpebral fissures, a fl at elongated philtrum, and a thin upper vermillion lip border), growth impairment and CNS deficits. Recently the term fetal alcohol spectrum disorders (FASD) has been introduced in recognition that these adverse effects of prenatal alcohol exposure lie along a continuum with or without overt facial features. In the U.S., the prevalence of FAS has been estimated at 0.5-2.0 cases per 1000 births, with FASD projected to occur at several times that prevalence (10 per 1000 individuals). Thus, FASD is estimated to have a similar prevalence rate as schizophrenia. Despite a variety of prevention efforts, including point-of-sale warning signs, and bottle labeling, surveillance data indicate that 10% of pregnant women surveyed drank some alcohol in the preceding 30 days and 2% engaged in binge drinking. More than 12% of women who are not using contraception and are at-risk of becoming pregnant drink at levels that exceed 7 drinks per week or 4 or more drinks per occasion. Women who receive little or no prenatal care, are unemployed, are socially transient, have lost children to foster or adoptive care because of neglect, abuse, or abandonment are more likely to have alcohol use patterns that could affect pregnancy. Addiction psychiatrists should be aware that risk factors for having a child with FASD include an abusive pattern of alcohol use, alcohol dependence, and misuse of multiple substances, having had a previous alcohol-exposed pregnancy, and having a partner or family member who drinks heavily.
A substantial number of children with FASD also meet diagnostic criteria for ADHD. Problems with attentional regulation are common in children with FASD, as are problems with social interactions, impulse control, and conduct. These childhood deficits may contribute to psychosocial and mental health problems later in life. Longitudinal research has demonstrated that among adolescents and adults with FASD, suicidal ideation and attempts are among the most serious of these potential problems. A recent prospective study by Barr and colleagues (2006) showed that among young adults with FASD (followed from childhood) several psychiatric disorders were significantlyover-represented relative to controls: on Axis I, substance dependence or abuse disorders (odds ratio=2.56) and somatoform disorder (odds ratio=7.21) and on Axis II, paranoid personality disorder (odds ratio=3.87), passive-aggressive personality disorder (odds ratio=3.27), antisocial personality disorder (odds ratio=3.01), and other personality disorders (odds ratio=2.24). It is not unusual for children, adolescents and adults with FASD to present in clinical or criminal justice settings with cognitive and behavioral symptoms including impulse control
problems, attentional problems, substance dependence, sensory integration problems and affective symptoms.
FASD is under-diagnosed and it rarely enters into the differential diagnosis for patients presenting with complex social, behavioral and cognitive problems. Hopefully, this situation will change because FASD-specific interventions are currently under investigation. Several promising approaches to restoration or improvement of FASD-related neurobehavioral deficits are being explored in animal models and clinical studies. For example, motor skill training has shown efficacy in restoration of some function in children with FASD. Dietary supplementation with choline, a precursor of the neurotransmitter acetylcholine, has been shown to decrease hyperactivity and improve spatial and working memory in young rats that had been exposed to alcohol during gestation. Specific educational and skill-oriented interventions are emerging which address the learning and neurobehavioral deficits of those with FASD. Pilot studies with these populations are showing improvements in performance that can enhance the life skills of individuals with FASD. Integrated into addiction treatment programs, the best of these interventions could enhance the treatment outcomes of such patients with FASD. Addiction psychiatrists also have a role in clarifying the dangers of alcohol consumption during pregnancy, and identifying, and vigorously intervening with women at-risk for drinking during pregnancy. By incorporating expertise in FASD into our scope of practice, we can prevent the next generation from being afflicted with FASD.
References:
Barr, H. M., Bookstein, F. L., O’Malley, K. D., Connor, P. D., Huggins, J. E., & Streissguth, A. P. (2006). Binge drinking during pregnancy as a
predictor of psychiatric disorders on the Structured Clinical Interview for DSM-IV in young adult offspring. Am J Psychiatry, 163(6), 1061-1065.