Fetal Alcohol Syndrome
by Randi Hagerman, M.D.
Professor of Pediatrics, University of Colorado Health Sciences Center
and The Children's Hospital
Fetal alcohol syndrome is a disorder caused by alcohol exposure in the womb. Alcohol interferes with brain development in the fetus. It also causes unusual physical features in the fetus, including facial structure abnormalities and bone growth deficiencies.
Alcohol is a "teratogen," meaning it causes birth defects. When a mother drinks alcohol during her pregnancy, the alcohol in the bloodstream enters the fetal circulation and interferes with cell growth and migration. This particularly affects early brain development in the fetus. The growth of bones and organs, including the heart and the kidneys, also can be significantly affected by alcohol exposure in the womb.
A fetus exposed to significant amounts of alcohol may be affected with fetal alcohol syndrome; whereas, a fetus exposed to alcohol for limited times during pregnancy may not be as severely affected or show evidence of fetal alcohol syndrome. Both male and female fetuses can be affected.
The disorder affects individuals differently; some individuals have mild behavioral problems or intellectual deficits, while other individuals have more severe complications with bone and organ development. Exposure in the second and third trimester of pregnancy usually leads to full fetal alcohol syndrome; however, exposure in the first trimester may interfere with brain structure. Usually, if a mother stops drinking during the first trimester of pregnancy, it is likely that the fetus will not be significantly affected with fetal alcohol syndrome.
Alcohol interferes with the metabolism of cells, and it may cause early cell death or lack of normal replication or migration.
Most children affected with full fetal alcohol syndrome have characteristic facial abnormalities, including a small opening of the eye, underdevelopment of the mid-part of the face, a thin upper lip, and a flat "philtrum" (the part of the face between the upper lip and the bottom of the nose). In addition, individuals may have poor growth of the mandible or the upper jaw. The base of the nose may be underdeveloped, and the nose may be shorter than normal. Alcohol also may cause poor growth of the head so that the head circumference is smaller than normal. In addition, these individuals may have a short stature, and are usually thin.
Alcohol also causes dysfunction of the central nervous system, which may include mental retardation or learning disabilities. Hyperactivity, with a short attention span and poor impulse control, are very common. Depression, anxiety, and panic attacks, along with psychotic thinking, including delusions or hallucinations, also are relatively common, particularly in adolescence and adulthood.
Structural brain changes are not uncommon in individuals affected by fetal alcohol syndrome. Poor development of the "corpus collosum," the band of fibers in the brain that connects the left and the right side of the brain, is common. In addition, the "cerebellum," an older area of the brain, may be underdeveloped. Rarely, other more severe brain abnormalities may occur. A limited number of individuals with fetal alcohol syndrome also may experience seizures, particularly in childhood.
Organs may be significantly affected by alcohol exposure in the womb, to include the following:
- Kidneys: May often be small or underdeveloped
- Heart: Can have a defect in the wall between the atria or the ventricles, or more severe malformations
- Eyes: Abnormalities of the vessels in the retina, strabismus (lazy eye), or underdevelopment of the eyeball
- Auditory System: A sensory neural hearing loss may occur, along with frequent ear infections
- Skeletal System: Shortening of the fingers, vertebra, or long bones; scoliosis (curvature of the spine); or underdevelopment of the nails
Exposure to alcohol in the womb causes a wide range of abnormalities. The most severe level is Fetal Alcohol Syndrome (FAS). FAS must have a confirmed history of maternal alcohol exposure. For a full diagnosis of FAS, the patient must have the characteristic facial abnormalities, in addition to growth retardation, i.e., a low birth weight for gestational age or height/weight growth parameters less than the 10th percentile.
There also must be evidence of central nervous system neurodevelopmental abnormalities, such as small head size, structural brain abnormalities, or neurological hard or soft signs. Such signs include impaired fine motor skills, a sensory neural hearing loss, poor tandem walking, or poor hand/eye coordination.
Individuals also may be diagnosed with Partial Fetal Alcohol Syndrome (PFAS). A diagnosis of PFAS is confirmed by maternal alcohol exposure, in addition to some of the characteristic facial features, growth retardation, central nervous system neurodevelopmental abnormalities, or a complex pattern of behavioral or cognitive abnormalities.
Typically, these abnormalities are inconsistent with the child's development level, and cannot be explained by family background or environment. These features can include the following: learning difficulties; deficits in school performance; poor impulse control; problems in social perception; deficits in higher level expressive and receptive language development; poor capacity for abstraction; specific deficits in mathematical skills; or problems in memory, attention, or judgment.
Another alcohol exposure disorder is Alcohol Related Birth Defects (ARBD). ARBD requires the presence of congenital abnormalities, including malformations in the cardiac system, the skeletal system, the kidney system, the eyes, or the auditory system.
The Alcohol Related Neurodevelopmental Disorder (ARND) requires central nervous system neurodevelopmental abnormalities or a complex pattern of behavioral or cognitive abnormalities, including learning disabilities and attention deficit problems. ARND is the mildest form of fetal alcohol syndrome.
Usually, individuals have behavioral problems, such as hyperactivity or learning disabilities, but do not show abnormal facial features, which are typical of alcohol exposure. There is animal and human research indicating that abnormalities can occur in the brain, leading to learning problems or behavioral difficulties, without having abnormal facial features.
At the time of birth, newborns exposed to significant levels of alcohol may have severe withdrawal symptoms. In approximately 33% of the cases, seizures may occur. Medication, such as phenobarbital, can be given at the time of birth to control the seizures; however, for many infants, medications are not necessary to treat withdrawal symptoms. It is important to wrap the baby tightly, to dim the lights, to reduce the noise level to avoid overstimulation, to feed the baby frequently, and to massage the baby to help relaxation.
It is possible that the baby may have significant malformations at the time of birth, such as a cleft lip or a cleft palate, and, occasionally, even a neural tube defect can be related to alcohol exposure in the womb. The baby may have problems with feeding and abdominal distention related to alcohol withdrawal. Help with oral feeding may be obtained from an occupational therapist.
It also is important to treat the alcoholism of the mother. A treatment program-including advocacy and psychological support for the mother, help with obtaining services and entitlements, parent skills training, crisis intervention, guidance and feedback, general encouragement, and a substance abuse program-is very beneficial.
Infants and preschoolers with fetal alcohol syndrome disorders should be enrolled in a developmental program that has both language and motor therapy. Hyperactivity and distractibility, which are associated with Attention Deficit Hyperactivity Disorder (ADHD), often arises in preschool. Initially, behavioral techniques should be used to control hyperactivity, both at home and at school. Tantrums and aggression also may occur in preschool. If behavioral interventions are not adequate, then medication may be helpful, even in preschool. Useful medications include clonidine (to decrease hyperarousal) or stimulant medication, such as dextroamphetamine or methylphenidate.
There is some evidence that dextroamphetamine may be more effective than methylphenidate for children with ADHD. Sleep disturbances also may occur, and the "Baby Go To Sleep Tape" may be helpful. Medication, such as clonidine, can be used at bedtime. Melatonin, which is the natural sleep hormone, also may be beneficial.
For the school-age child with a fetal alcohol syndrome disorder, deficits in language and motor development also may continue, and may require individualized speech and language therapy and occupational therapy. Some children overreact to stimuli or have sensory motor integration problems. This can worsen hyperactive and tantrum behavior, and should be treated by a sensory integration occupational therapy program. Most children with fetal alcohol syndrome require special education support. A learning disability teacher can use a multi-sensory approach for teaching academic skills, such as reading or math.
Computers may enhance academic learning and language skills for children with fetal alcohol syndrome. Computer programs may help with visual spatial perceptual skills. Such programs as "KidPix," which enhances drawing and graphics, or "Blocks in Motion," which focuses on visual spatial processing, may be beneficial. Additionally, such programs as "Oregon Trails," "Interactive Journeys," and "Where in the World is Carmen Sandiego?" use problem solving skills through reading and listening cues, and are helpful for academic progress in math and reading. Programs that enhance writing skills, such as word prediction software, can expand written language abilities.
School-age children with fetal alcohol syndrome usually have problems with ADHD. Stimulant medication, such as dextroamphetamine (Adderall and Dexedrine) or methylphenidate (Ritalin), can be helpful in this age group.
Children who are affected by alcohol exposure in the womb should have a detailed psychological assessment that documents their intellectual abilities or IQ, as well as emotional difficulties. If significant emotional problems, such as anxiety, depression, or mood swings occur, then ongoing counseling should be helpful. Sometimes, if significant anxiety or depression exists, medication, such as Prozac or Zoloft, may be helpful.
If mood swings are a problem, then mood-stabilizing medication, such as Tegretol, Depakote, or risperidone, can be helpful. Usually, medication to treat emotional or behavioral problems work best when combined with counseling by a psychologist or a mental health professional.
The main complications associated with FAS, PFAS, or ARND are the secondary disabilities that are prominent in adolescence and adulthood. There is a high rate of mental health problems, and 94% of individuals experience these difficulties. The combination of mental health problems, in addition to a high rate of substance abuse, can lead to legal problems.
In a large study of over 400 individuals with fetal alcohol syndrome disorders, conducted in Seattle by Dr. Streissguth and her colleagues, it was found that 32% of adolescents and 42% of adults were jailed for a crime. Alcohol problems also occurred in 42% of adults. This high rate of social problems demands more intensive intervention in childhood to avoid these secondary disabilities.
Individuals also may suffer from complications related to medications. For instance, stimulant medications can decrease appetite and interfere with normal growth when weight loss occurs. Careful monitoring of blood levels and liver function studies are required with some of the mood stabilizers, because they may decrease the white blood cell count or irritate the liver.
Careful medical follow-up, particularly when individuals are treated with medication, is necessary. When taking medication, individuals should visit their doctor at least two to three times a year.
The prevention of secondary disabilities is a more complicated issue, and it requires intensive treatment from early childhood. Long-term counseling in adolescence and early adulthood, in addition to more intensive vocational training with a job skill trainer, is beneficial. Early education regarding the complications of drug and alcohol use also is important. If these problems develop, an intensive substance abuse program is necessary.
Research is being conducted regarding the prevention of fetal alcohol syndrome. There is a massive public health program to educate women regarding the problems associated with alcohol use when they are pregnant.
Very little research has been performed regarding the treatment of those individuals who are affected by fetal alcohol syndrome. There is a great need for controlled research regarding psychopharmacological interventions and educational interventions. Animal research has suggested that cholinergic drugs may be beneficial for treating hyperactivity and cognitive deficits; however, these, and other new drugs, have not yet been studied in humans.
Research regarding innovative computer programs that enhance learning, such as the "Fast Forward" program, using a computerized slowing of speech to improve auditory processing deficits, may be helpful. However, these studies also have yet to be conducted.
National Organization of Fetal Alcohol Syndrome (NOFAS)
1819 H Street NW, Suite 750
Washington, DC 20006
Phone: (202) 785-4585
Fax: (202) 466-6456
Family Empowerment Network: Supporting Families Affected by Fetal Alcohol Syndrome and Effects
University of Wisconsin
519 Lowell Hall
610 Langdon Street
Madison, WI 53703
Phone: (800) 462-5254
Fax: (608) 262-6590
Fetal Alcohol Information Service
P.O. Box 95597
eattle, WA 98145-2597
National Association for Perinatal Addiction Research and Education (NAPARE)
11 E. Hubbard Street 200
Chicago, IL 60611
Fetal Alcohol Education Program
Boston University School of Medicine
1975 Maine Street
Concord, MA 01742
Phone: (978) 369-7713
FAS Family Resource Institute (FAS*FRI)
P.O. Box 2525
Lynnwood, WA 98036
Phone: (800) 999-3429
Fetal Alcohol and Drug Unit
University of Washington
180 Nickerson Street, Suite 309
Seattle, WA 98109
Phone: (206) 543-7155
National Clearing House for Alcohol and Drug Information (NCAID)
P.O. Box 2345
Rockville, MD 20852
Phone: (800) 729-6686
The "Baby Go To Sleep" tape may be obtained by calling (800) 537-7748.
Dorris, M. (1989) The Broken Cord. New York: Harper Collins.
Kleinfeld, J.K. and Wescott, S. (eds.) (1993) Fantastic Antone Succeeds! Experiences in Educating Children with Fetal Alcohol Syndrome. Fairbanks: University of Alaska Press.
Streissguth, A.P. and Kanter, J. (eds.) (1997) The Challenge of Fetal Alcohol Syndrome: Overcoming Secondary Disabilities. Seattle: University of Washington Press.
Streissguth, A. (1997) Fetal Alcohol Syndrome: A Guide for Families and Communities. Baltimore, MD: Paul H. Brooks Publishing.
Hagerman, R.J. (1999) Fetal Alcohol Syndrome. In: Neurodevelopmental Disorders: Diagnosis and Treatment. New York: Oxford University Press.
About the Author
Dr. Hagerman received her M.D. from Stanford Medical School and completed her pediatric residency at Stanford and at the University of California San Diego. She is now a Professor of Pediatrics at the University of Colorado Health Sciences Center and Co-Section Head of Developmental and Behavioral Pediatrics.
Her research interests are in Fragile X Syndrome, Fetal Alcohol Syndrome, organic causes of ADHD and behavioral phenotypes.
Copyright 2012 Randi Hagerman, M.D., All Rights Reserved