Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE) are birth defects caused by prenatal alcohol exposure. Unlike many birth defects which are identified at birth and often treated surgically, FAS and FAE are usually over-looked at birth and treated later by mental health specialists -- often unknowingly.
Recent research on over 400 patients with Fetal Alcohol Syndrome and Fetal Alcohol Effects has revealed that almost all such patients are seen at some point in their lives by mental health specialists -- psychiatrists, psychologists, social workers -- to whom they are referred for mental health problems. Understanding that such patients may actually have a dual diagnosis (FAS or FAE and a DSM-IV diagnosis) can facilitate more effective treatment.
In FAS and FAE, the primary birth defect involves central nervous system (CNS) damage that occurs in utero. When this prenatal brain damage is undetected and behavioral problems arising from it are not understood, the growing child is at risk of developing additional "secondary disabilities" that can be tremendously debilitating. Understanding these are secondary disabilities and recognizing the linkages between the secondary and primary disabilities are important first steps in effective treatment. A critical key in this process is obtaining information about prenatal alcohol exposure and possible maternal alcohol abuse at the intake interview for any mental health assessment or treatment.1
A recent study on secondary disabilities in patients with Fetal Alcohol Syndrome and Fetal Alcohol Effects carried out at the University of Washington School of Medicine focused on six secondary disabilities. The 415 patients ranged in age from 6 to 51 years (median age 14.2 years) and ranged in intellectual function from a few who were severely handicapped to some who had average or even above average intelligence (median IQ for those with FAS was 80; for those with FAE was 90). Data were obtained by interviewing parents or caretakers on a comprehensive life history interview.
Practical Implications for Professionals
The Secondary Disabilities Study of FAS and FAE offers a window into treatment strategies for the mental health professional. All six of the mental health problems identified have practical clinical relevance in the treatment of patients with FAS and FAE.
As the study demonstrated, depression, suicidal threats and attempts, attention deficit problems, panic attacks and auditory and visual hallucinations were all present in this patient population. With the exception of attention deficit problems, all of these problems increased with age. (See chart.)
The management of FAS/FAE patients involves an appreciation of the impact on the patient of the social environment, as well as the organic brain damage. This requires a sensitivity of the mental health professional to the clinical presentation of a combination of developmental disability with mental health problems. It is not sufficient to see these patients as solely organically brain damaged or as solely emotionally disturbed. It is essential to understand that patients with FAS/FAE often present a dual diagnosis.
As the University of Washington study showed, over 90 percent of the patients with FAS/FAE had mental health problems. It is wiser to begin treatment by attempting to look at areas of stress in the environment than to plunge into the use of medication. Patients with FAS/FAE who have attentional problems often respond to simple changes in the physical environment (for example, decreasing visual and auditory distractions, using clear concise directions, setting realistic expectations and so forth). Also, depression and suicidal gestures should always be taken seriously no matter what age the patient is. They are a cry for help and may necessitate an examination of environmental conditions through coordination with caretakers and teachers.
It is important for the clinician to remember that although these patients have organic brain damage as an etiological factor, there are often complex family systems that can also contribute to psychopathology in the child. Treatment must involve a multi-modal approach. Family therapy, special education, cognitive testing and psychopharmaco-therapy are all important considerations in therapy. At the moment, however, there are no controlled studies of medications to show their efficacy in FAS/FAE patients, and safety is an issue because of A.R.B.D (alcohol-related birth defects). Deficiencies in nutritional elements such as zinc, magnesium, iron folate and B12 need further study.
Mental health professionals should not be intimidated by the presumptive diagnosis of FAS/FAE, but should take the opportunity to inform themselves of the epidemiological data (such as the University of Washington secondary disabilities study) in order to be better able to anticipate the risk factors in FAS/FAE and facilitate the protective factors2 in this unique and challenging condition.
Mental health professionals have an essential role in advocating for the needs of patients with FAS/FAE, who often do not have the cognitive or social skills to advocate for themselves, and in advocating for their families or caregivers, who are often overwhelmed by the patients' primary and secondary disabilities.
A final report on the secondary disabilities study,3 a volume of selected papers on treatment and community responses to FAS/FAE secondary disabilities4 and a new book on FAS/FAE5 are available for further information on this topic.
References
1. Streissguth, A.P. & Novick, N.J., "Identifying Clients With Possible Fetal Alcohol Syndrome in the Treatment Setting," Treatment Today, vol. 7, no. 3, pgs. 14-15, (1995).
2. Grizenko, N. & Fisher, C., "Reviews of Studies of Risk and Protective Factors for Psychopathology in Children," Canadian Journal of Psychiatry, vol. 37, pgs. 711-721, (1992).
3. Streissguth, A.P., Barr, H.M., Kogan, J. & Bookstein, F. L., "Understanding the Occurrence of Secondary Disabilities in Clients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE)," Final Report to the Centers for Disease Control and Prevention (CDC), August, 1996, Seattle: University of Washington, Fetal Alcohol & Drug Unit, Tech. Rep. No. 96-06, (1996).
4. Streissguth, A.P., & Kanter, J. (Eds.), "The Challange of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities," Seattle: University of Washington Press, (1997).
5. Streissguth, A.P., "Fetal Alcohol Syndrome: A Guide for Families and Communities," Baltimore, MD: Paul H. Brookes Publishing Co., (1997)
Ann P. Streissguth is a professor in the department of psychiatry and behavioral sciences at the University of Washington School of Medicine in Seattle and director of the fetal alcohol and drug unit.
Kieran D. O'Malley is a board certified psychiatrist who works in Calgary, Alberta, Canada. He ran the Edmonton FAS clinic at the Glenrose Hos-pital child and family psychiatry unit from 1992 to 1996.