Psychiatric News May 6, 2005
Volume 40 Number 9
© 2005 American Psychiatric Association
p. 12
Fetal Alcohol Syndrome: Preventable Tragedy
Susan D. Rich, M.D., M.P.H.
Susan D. Rich, M.D., M.P.H., is the member-in-training trustee on APA's
Board of Trustees.
I was furious when I first
heard the term "funny-looking kid," or FLK, almost 12 years ago. A
rural pediatrician was describing how doctors overlook the possibility of
fetal alcohol syndrome (FAS), the physical and neuropsychiatric effects of
prenatal alcohol exposure. He said, "They look at the parents and say,
`They're pretty funny looking, too.. .so, I guess it's genetic.'" My
passion for prevention of alcohol-related birth defects has been fueled by
such attitudes.
In that spirit of prevention, I co-wrote a recent APA action paper with Dr.
Roger Peele, APA's Area 3 trustee, with much guidance from Dr. Kieran O'Malley
of the University of Washington's Fetal Alcohol and Drug Unit and assistance
from the National Organization on Fetal Alcohol Syndrome (NOFAS). The paper
advocates for APA to explore having fetal alcohol-related disorders included
in DSM-IV-TR and later editions of the manual. Fetal alcohol spectrum
disorder (FASD) is an umbrella term describing the continuum of complex
neuropsychiatric, cognitive, behavioral, and physical symptoms associated with
all levels of prenatal alcohol exposure.
Currently there is no consistent way for psychiatrists to diagnose FASD,
although we are usually the ones to prescribe medications to treat the
associated neuropsychiatric sequelae. Pediatric dysmorphologists diagnose FAS,
but many pediatricians believe there are no treatments available, so why
diagnose the condition?
Lack of standardized psychiatric diagnostic coding prevents families and
individuals with FASD from receiving appropriate comprehensive services and
results in poor outcomes for those individuals and costly consequences for
communities. Early diagnosis has been shown effective in preventing secondary
disabilities, such as school failure, juvenile delinquency, mental health
problems, homelessness, and unemployability. Individuals with undiagnosed FASD
often end up as recidivist clients in institutional settings, including jails,
mental health programs, psychiatric hospitals, and homeless shelters.
NOFAS estimates that at least 12,000 children each year are born with FAS,
and as many as 36,000 more have alcohol-related neurodevelopment disorder
(ARND), a population larger than those with Down syndrome, cerebral palsy, and
spina bifida combined. ARND is characterized by neuropsychiatric pathology as
severe as that in FAS but without the associated facial features.
From an epidemiologic point of view, the failure to diagnose these
disorders results in underreporting and interferes with informing women of
childbearing age about the lifelong psychopathology associated with drinking
alcohol during pregnancy. The Centers for Disease Control and Prevention
reported in 1997 that the rates of women drinking alcohol during pregnancy
rose fourfold from 1991 to 1995. This alarming increase may be related to the
decline in public-awareness campaigns that occurred just after the 1989
warning label on the dangers of drinking for women who are pregnant or of
childbearing age was mandated for alcoholic beverages.
Diagnosis of FASD is a diagnosis for two, ideally ensuring that appropriate
systems can be put in place to prevent the mother from having another affected
child. Since a majority of physical birth defects occur in the first eight
weeks of pregnancy, unintentional early and binge exposures lead to the facial
dysmorphology and other malformations associated with FAS. Researchers have
demonstrated differences on brain MRIs of children with FAS, such as a thin or
missing corpus collosum, hypoplasia of the basal ganglia, and decreased size
of the cerebellum. As the quintessential neurobehavioral teratogen, alcohol
can affect the embryo and fetus throughout pregnancy. Many neurobehavioral
effects are related to second- and third-trimester exposure, when the complex
wiring of the central nervous system is occurring.
Unfortunately, alcohol advertising fails to inform adequately about the
dangers associated with alcohol use by childbearing-age consumers. The label
adopted by the alcohol industry suggests that alcohol should be avoided during
pregnancy because of the risk of birth defects, which may occur before a woman
knows she is pregnant. Since many pregnancies are unplanned or mistimed, women
may unintentionally expose their offspring to alcohol without realizing it. As
clinicians, we should be asking appropriate lifestyle screening questions of
our patients to provide a way to inform sexually active, childbearing-age
alcohol consumers of the risks associated with unintended
pregnancy—similar to informing patients about the teratogenicity of
certain medications.
As a fellow in child and adolescent psychiatry, I believe it is our duty as
psychiatrists to apply our professional knowledge and clinical skills to
provide the best care possible for our patients. In this era of advanced
technologies, this may mean obtaining a neuroimaging study to look for
acquired brain injuries in cases of prenatal exposures. But it is also
important for us to practice with passion and conviction that which we came
into the field to do.
I feel very fortunate to have found my life's work years ago and to have
had mentors along the way to help make a difference. The children are our
future, and we must protect them at all cost! 
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