Fetal Alcohol Spectrum
Disorders: from Birth to
Adulthood
Dr Moira Plant
Emeriti Professor of Alcohol Studies
Department of Health & Life Sciences
University of the West of England
Bristol
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Diagnostic paradigms
Features at different ages
Maternal Issues
Should we be concerned?
Diagnostic Paradigms
• 1973
Fetal Alcohol Syndrome
– Pre and post natal growth deficiency
– Physical anomalies
» distinctive facial features
– Central nervous system dysfunction
» Severe learning/living difficulties
– “Identifiable” drinking problem in mother
• 1973
Fetal Alcohol Effects
Diagnostic Paradigms:
Fetal Alcohol Spectrum Disorders
(FASD) 2002
1)
2)
3)
4)
Growth
Facial features
Brain
Maternal Drinking History
FAS FACIAL FEATURES
FAS Diagnostic Guide and CD-ROM
Fetal Alcohol Spectrum
Disorders
• FASD is an umbrella term which covers
the range of harms.
• It is NOT a diagnosis.
• Other terms now in use
• Alcohol related neurodevelopmental
disorders (ARND)
• Alcohol related Behavioural Disorders
(ARBD)
Some of the Confusion
• More recently alcohol-related foetal harm
is being seen mainly in terms of brain
damage.
• The facial features are being almost
downgraded in terms of their importance.
• This is mainly because the facial features
are only present if alcohol is consumed in
higher doses in the first trimester.
Even More Confusion!
• Not all children with alcohol related harm
have low IQ.
• We do not know how much alcohol
causes what severity of harm.
• People use the terms FAS and FASD
interchangeably.
• Different organisations use different advice
eg Royal Colleges, NICE, Depts of
Health
Prevalence of FAS
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Range from 1 per 1,000 low risk populations (US).
4 per 1000 in moderate risk populations,
39.2 per 1000 in (high risk) (May, 2001)
South Africa 40+ per 1000 (very high risk) ( Molteno, 2008).
Southern Australia to be 0.18 per 1,000 (O’Leary 2002)
Indigenous communities 1 in 170 live births (Golden, 2005).
UK we don’t know - drinking pattern vary between
countries
• In France and Germany 1 in 330, Sweden 1 in 600
(Blackburn et al 2009)
Simple View of Causation
An individual child’s risks of FASD are influenced by;
• Quantity of alcohol consumed by mother during
pregnancy.
• Pattern of alcohol consumption.
• Frequency (how often) the mother drinks.
• Timing of drinking in relation to period of gestation.
Critical Periods of Human Development
Moore et al 1988
Anti-depressants in Pregnancy
• Study of 673,853 Danish women - 35,737
had a diagnosis of depression and/or used
SSRIs before the end of pregnancy women;
– Use of anti-depressants during pregnancy slightly
increases the rate of Small for Gestational Age (SGA)
– Use of anti-depressants associated with increased
low Apgar scores
Jensen et al (2013)
Additional Factors
• “In the US, the vast majority of postpartum
women with depression are not
identified or treated even though they are at
higher risk for psychiatric disorders--- A woman’s
mental health has a profound effect on fetal
development as well as her child’s physical and
emotional development.”
Wisner et al 2013
Birth to 36 months
• May have been diagnosed as “failure to
thrive” (one of many diagnoses given over
time).
• Difficulties with feeding.
• Difficulties in establishing a regular sleeping
pattern.
• Irritability very active/hyperactive.
• Frequent bouts of illness.
• Delay in reaching milestones.
• Indiscriminate, people are interchangeable.
FAS/FAE Support Network
Vancouver
Alcohol and Breast Feeding
• Breast-fed infants experience significantly
less active sleep after exposure to alcohol
in their mothers’ milk than do breast-fed
infants not exposed to alcohol.
• Compensatory increases in active sleep
were then observed in the next 20.5 h,
when mothers refrained from drinking
alcohol.
Mennella et al 1991, 1997, 2001
Alcohol and Breast Feeding
• No difference in the caloric content of mother’s
milk.
BUT
• Infants consume significantly less milk during the
4 hour period immediately after exposure to
alcohol in mothers’ milk compared to controls.
• Compensatory increases in intake can be
observed during the 8 – 16 hours after exposure
when mothers refrained from drinking.
Mennella J (2001)
Alcohol and Breast Feeding
• Significant differences in motor
development at one year of age in those
babies subjected regularly to alcohol
through breast milk.
National Institute of Child Health
and Human Development
Koren, G 2002
Motherisk Programme
Failure to
grasp
cause and
effect?
Three to Five Years
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Easily overwhelmed.
Frequent lengthy temper tantrums.
May be physically aggressive.
Reacts badly to and resists change.
Unable to learn from experience.
Accident prone.
Fearless/unable to comprehend danger.
FAS/FAE Support Network
Vancouver
Jason 4
Years old
Adam
Six to Ten
•Short in Height/Light in Weight.
•No “Catch up” Growth.
•Difficulty in grasping the
concept of cause and effect.
FAS/FAE Support Network
Vancouver
Adam
Six to Ten
•Visual memory better than
auditory memory.
•Information seems to “slip in
and out” Remembers today,
forgets tomorrow and
remembers again next week.
Interpreted by teachers?
•Difficulty separating fact from
fantasy.
FAS/FAE Support Network
Vancouver
Ten to Fourteen
• Initially may be seen as intelligent based on
language skills.
• Lots of words but quantity masks quality.
• Speech problems e.g. stammering.
• Gets lost quickly in conversation and loses
interest.
• Trouble following directions.
• Little understanding of social norms.
• Increased risk of drink/drug use.
FAS/FAE Support Network
Vancouver
Fourteen to Eighteen
• No sense of personal space or boundaries.
• May be sexually inappropriate/does not
understand risks.
• Overly affectionate with people s/he does not
know well.
• May be teased or bullied by other adolescents.
• May bully or frighten others.
• Moves through extremes of behaviour in a short
space of time.
• May be diagnosed as “Conduct Disorder“.
• Burns people out.
FAS/FAE Support Network
Vancouver
Adult
• Judgement and critical thinking are poor
• Lacks social skills either aggressive or
withdrawn
• Blames others for own mistakes
• Involved in criminal activity
• Difficulty in keeping job
• Abusive relationships
• Mental health problems Counselling ?useful
» Depressed/ suicide attempts
» Anxious
FAS/FAE Support Network
Vancouver
Changes with Age
• Facial features become less obvious
• Developmental changes may be negative.
IQ may decrease by up to 15 points
between early childhood and adolescence.
Steinhausen et al 1994
CJ
8 Years
18 years
22 years
Younger V Older
Younger/Teenage
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Later recognition of
pregnancy due to irregular
periods, not wanting to
accept the fact so later
attendance at ante-natal
clinics
In Bristol 84% of mothers
under 20 years of age
reported having unplanned
pregnancies.
Will continue to drink at prepregnancy levels further into
their pregnancy
Lower weight gain; maternal
body at a stage when it
needs more nutrients for own
growth and development so
potential competition for
nutrients
•
Older
Longer drinking
history
Increased risk of
liver damage if
drinking heavily
May be aware of
being pregnant
earlier in pregnancy
IF they have been
pregnant before.
Younger V Older
– May be reduced flow of
nutrients to the foetus
due to immature
placental development
– Many teenagers do not
see a problem in
continuing to eat fast
foods with the high
sugar and fat content
– Eating disorders
associated with higher
risks if neural tube
defects, miscarriage,
low birth weight and
post partum depression
– Psychiatric illness
(mood, anxiety, thought
disorders)
– The fear of having
children taken away will
prevent women with
drinking problems
seeking help early.
– Chaotic lifestyle (living
with a problem
drinker).
– Poor nutrition (GI
problems, poverty).
– Poly-drug use
• You cannot ignore the
fact that this is a dyad
(triad?) CSA
• The guilt and shame
problem drinking women
feel is greater than we
can understand.
• The fear of having
children taken away will
prevent women with
drinking problems
seeking help early.
UK Review of the evidence
• “In summary, for most outcomes there was no
consistent evidence of adverse effects from lowmoderate alcohol consumption (1.5 UK units daily).
• “There was some evidence of adverse effects on
neurodevelopment of binge drinking in pregnancy”.
Gray and Henderson 2006
Why should we be concerned?
• Because families are being blamed for their
children’s behaviour and other issues. “Nothing the
birth mother could have done would account for this. You are just
not feeding him enough”
• Because children are failing in school through not
being diagnosed with FASD and getting help.
• Because it is possible/probable that there are
people in UK prisons who are there because they
cannot tell right from wrong and don’t understand
cause and effect due to their FASD.
Why should we be concerned?
• Because the vast majority of people
affected by FASD are not children but
adults.
• Because the cost to the National Health
Service has not yet been measured but
when it is-------!
Why should we be concerned?
•Because it is
preventable!
The Ideal
• FASD is understood to be a lifetime
condition.
• Access for initial diagnosis should be
available at any time in life that the
question of FASD is raised.
• Appropriate follow-up after diagnosis
should be available for as long as
necessary
Sterling Clarren Personal Communication 2013
What should the Message be?
• Don’t drink if you are
pregnant.
• If you are pregnant don’t
drink.
Unplanned Pregnancies
• UK Study: 84% of mothers under 24 years of
age reported having unplanned pregnancies.
(Dex and Joshi 2005)
• The majority of pregnant women continue a
their pre-pregnancy drinking levels until
pregnancy is confirmed.
(Tough et al 2006)
• Younger women will drink further in to their
pregnancies than older women.
What should the Message be?
• Don’t drink if you are pregnant.
• If you are pregnant don’t drink.
• If you’re drinking don’t get
pregnant.
• If your drinking don’t get
someone else pregnant.