Fetal Alcohol Syndrome (FAS): Causes, Symptoms and Treatment

Introduction

Fetal alcohol syndrome is a set of birth defects caused by maternal alcohol consumption during pregnancy. The occurrence of FAS varies from 0.5 to 3.0 per 1,000 live births. However, it can be much higher depending on the community; low socioeconomic status and race seem to be a contributing factor in those who are most at risk. (play therapy) The prevalence of FAS is thought to be underestimated for several reasons. This includes the physical features are often understated and difficult to recognize, a lack of clinical expertise, and the stigma that comes with maternal alcohol use. So not only do these mothers report their alcohol use less, clinicians may also be reluctant to ask women about their alcohol use (Jones). Fetal alcohol syndrome is the leading nonhereditary cause of mental retardation and specific facial abnormalities and altered growth. (Prenatal exposure to alcohol, 2000). Not all children who are exposed to alcohol get FAS. This suggests that there must be a critical does of alcohol and a sensitive period in the development of the fetus.

Description

The effects of exposure to alcohol are referred to as fetal alcohol spectrum disorder. This includes full-blown fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder, and alcohol-related birth defects (Landgraf et al. 2013). “The amount of maternal alcohol consumption, the timing of consumption, and the duration all affect which level of fetal alcohol spectrum disorder a child is placed under” (Batshaw et al. 2013). Alcohol consumption in the first two months leads to more adverse affects on the fetus. Alcohol also negatively affects the fetus in certain ways in each trimester. In the first trimester brain cells are affected. In the second trimester the facial features are affected. Finally, in the third the hippocampus in the brain is affected. (play therapy)This is due to how much development still needs to occur and can be affected by the alcohol. A mother’s age may also have a play in whether FAS occurs. According to O’Leary “ the risk of impairment in offspring of women drinking five or more drinks per occasion at least weekly, is increased by 2-5 times when the mother is 30 years of age or older.” Alcohol crosses the placenta during pregnancy so it is known that they main reason for FAS is maternal alcohol consumption. However, paternal alcohol consumption may also pass on effects to the fetus from the sperm.

History

Fetal Alcohol syndrome was first reported in the United States in 1973. Eleven unrelated children, whose mothers continued to drink heavily during pregnancy, had similar patterns of growth deficiency and morphogenesis. After these reports, it was found that this connection was not a new observation. A committee to study drunkenness was formed in the 18th century of individuals in the British House of Commons. Their results were that infants born to alcoholic women had a “starved, shriveled, and imperfect look.” (Jones et al. 2010). Then in 1899, a doctor studied infants of alcoholic females. He recognized an increased frequency of early fetal and infant death in the infants. However, despite troublesome indications the medical community continued to disregard the issue.

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In the case in 1973, Dr. David Smith was asked by Dr. Shirley Anderson to come down to look at eight children who had been born to alcoholic mothers. These children came to the Pediatric Outpatient Clinic at the King County Hospital due to Dr. Christie Ulleland’s interest in the area. One night, she was informed that an alcoholic woman was about to give birth so she went to find out everything she could about the effects of alcohol on fetal development and found that there was no information available (Jones et al. 2010). So she decided to learn everything she could about the topic. Over the next year she found eleven infants who had been born to alcoholic women. She then turned the children to the care of Dr. Anderson when another opportunity presented itself. Dr. Anderson then invited eight of those children to the outpatient clinic for the evaluation with Dr. Smith. As each child was examined a “specific pattern of malformations that included: microcephaly, short, palpebral fissures, and a smooth philtrum” was noticed in half of the children (Jones et al. 2010).

Soon after Dr. Smith’s “unknown files” were searched for, for the same three features. These files consisted of “hundreds of children with birth defects whom he had evaluated but had been unable to diagnose” (Jones et al. 2010). Two children were found to have the same features so their mother’s charts were studied and it was revealed that both children had been born to alcoholic women. As time went on more children were identified with the same features all to mother’s who were alcoholics. Since the initial findings it has been found that exposure to alcohol in the womb may produce a broad spectrum of defects which is now known as the Fetal Alcohol Spectrum Disorder. (Jones et al. 2010).

Diagnosis

There are many key features of Fetal Alcohol Syndrome; these can be grouped by growth retardation, characteristic facial features, and central nervous system abnormalities and dysfunction, structural or functional (O’Leary et al. 2004). These categories are used for in the diagnosis of a patient with Fetal Alcohol Syndrome. The patient must have at least one growth abnormality, all three characteristic facial features, and one functional or structural abnormality or the Central Nervous System (Landgraf et al. 2013). Liles states that “prenatal and postnatal deficiencies in height, weight, head circumference, brain growth, and brain size would all be included under growth retardation. A deficiency in height and weight is considered at or below the 10^th percentile and head circumference is considered when below the third percentile.” According to Landgraf et al. (2013), the diagnosis of growth disturbances excludes “familial microsomia, constitutional developmental retardation, prenatal deficiency states, skeletal dysplasia, hormonal disorders, genetic syndromes, chronic diseases, malabsorption, malnutrition, and neglect.”

The characteristic facial abnormalities that are used in diagnosis of FAS include a smooth philtrum (the groove between the upper lip and nose), short palpebral fissure length (shortened openings between the eyelids), and thin vermillion (the upper lip) (PLAY THERAPY). Functional impairments in the Central Nervous System are considered intellectual deficits when below the third or the 16^th percentile in three of six areas: “cognitive or developmental abnormalities, insufficient executive functioning skills, motor functioning delays, inattention or hyperactivity, deficient social skills, or sensory, pragmatic language, or memory problems.” (Play therapy)

Symptoms

Along with the criteria for diagnosis, children with Fetal Alcohol Syndrome have many other symptoms. Spontaneous abortion, stillbirth, preterm birth, and Sudden Infant Death Syndrome have all been found to relate to alcohol exposure in infants. Spontaneous abortion is defined as fetal loss prior to 20 weeks of gestation. The reason for the death is usually unknown but certain risk factors are found in some cases. Evidence found, as early as 1980, suggested that drinking during pregnancy was associated with an increased rate of spontaneous abortion. Studies have been done that suggest that the risk is not increased unless at least three drinks per week are consumed. Stillbirth is when fetal loss occurs after 20 weeks of gestation. (PRENATAL EXPOSURE) Originally, studies suggested that an intake of 14 or more drinks per week was associated with stillbirth. Later a study found that more than five drinks per week could lead to a three times increased risk of stillbirth. Another study found a 40 percent increase in the possibility of stillbirth for women who consumed any amount of alcohol compared with those who did not. Exposure to alcohol also shown to be associated “placental dysfunction decreased placental size, impaired blood flow and nutrient transport, and endocrine changes.” (PRENATAL EXPOSURE) All which could result in stillbirth.

Preterm birth is delivery occurring before 37 weeks of gestation. Researchers found it difficult to study the trend between preterm birth and maternal alcohol due to small sample sizes, insufficient assessment of alcohol exposure, and unreliable gestational date among other factors. However, some studies have been completed and one found that 10 or more drink per week may lead to three times increased risk for preterm delivery. There is no known reason why Sudden Infant Death Syndrome occurs. However, there are many theorized reasons including prenatal alcohol exposure. Although studies have been done, they are not reliable due to small sample sizes. (STILLBORN)

According to Batshaw (2013) imaging studies found a decrease in brain volume and abnormalities of the corpus callosum, basal ganglia, and other brain structures. The death of certain cells may be responsible for a small size of the cerebellum. The corpus callosum sometimes fails to even develop in something children with FAS. Autopsies of brains also included malformations of the gray and white matter regions of brain tissue and failure of cells to migrate during brain development to the correct position.

An infant’s cry is another characteristic which can be affected by exposure to alcohol. Research has found that the intensity, time between a stimulus and infant’s cry, and the pitch of the cry are significantly different in children who were exposed to alcohol than those who were not (PRENATAL EXPSOURE TO ALC). The infants may also have a weak sucking response. Children with FAS may have delayed intellectual development, neurological abnormalities, vision, hearing, and balance problems. These children also may have “heart and limb problems, sleep disturbances, jitteriness, trembling, heart disease, spina bifida, renal, orthopedic, dermatologic, connective tissue, and respiratory problems, as well as bedwetting, voluntary or involuntary passing of stools, tremors, seizures, echolalia, and schizophrenia.” (play therapy)

Long Term Implications

Many long term implications have been identified that affect children born with Fetal Alcohol Syndrome. Many have oversensitivity to stimuli such as bright lights or sounds, certain smells, and even certain textures. Exposure to ethanol can also lead to ADHD and executive functioning deficits (Batshaw et al. 2013). A study has shown that 85 percent of children diagnosed with FAS also are diagnosed with ADHD (Liles). Organizing, sequencing, planning, and certain forms of abstract thinking are all tasks that are included in executive functioning. Those with problems in executive functioning are unable to be independent because they are unable to do daily tasks like getting dressed. Other long term implications include motor control. Most parents start seeing a delay in fine and gross motor skills by 12-13 months of age. Motor control is influence by the Central Nervous System. There are many functions that are involved in the CNS. The sensory organs including ears, eyes, and skin provide feedback to the CNS, motor reactions and balance may be affected due to problems located in the inner ear (Prenatal exposure to alc). Communication delays including receptive and expressive language and hearing disorders are often common in children with FAS. Hearing disorders in children with FAS include auditory maturation, sensorineural hearing loss, and intermittent conductive hearing loss (o’leary).

Children with FAS also have a wide range of behavior and developmental abnormalities. These children may be antisocial and one third of children exposed to alcohol prenatally show significant aggressive behavior. (O’Leary) Since these children experience social issues, it may result in an increased likelihood of depression, suicidal ideology, anxiety and panic attacks, and other various psychiatric disorders (Liles).

With problems in communication, executive functioning, and social issues, among others, these children often experience lower cognitive ability. Many studies done show a high possibility for children with FAS have IQs that would place them in the category of mental retardation, an IQ lower than 70. They also have problems in “spelling, mathematics, and completion of carious classroom tasks.” (Liles) These individuals are more likely to drop out of school and have higher rates of drug and alcohol abuse, delinquency, and abnormal sexual behaviors (Landgraf et al. 2013). This shows the importance in the support and treatments child with FAS need.

As children with FAS get older, the long term implications not only follow them to their adult life but also cause other problems. They may have mental health problems, become victims of crime, get into trouble with the law, or may not be able to live on their own. They may not be able to work which also means even if they have the ability to work, they do not have the resources to. The problems with social ability also may affect their potential to have intimate relationships.

Treatments

Treatments can be very important in helping those with FAS, so they are able to cope with daily living. According to the National Organization of Fetal Alcohol Syndrome (2014) home intervention and early school intervention are important to help overcome issues an individual may be having.

There are many services for individuals with FAS these include prenatal, birth to age 3, children 3-6 and school age, adolescents, and adults. Prenatal services are targeted at the mother; physicians should provide women with information about the effects of drinking during pregnancy. Since early intervention is so important for children with FAS a physician can recommend part C in IDEA. This allows for children birth to age 3 at risk of later developmental delay to receive services before meeting criteria eligibility. A stable and nurturing environment is critical for these children and so the family needs to be educated about the importance of caregiver attachment. (NOFAS)

Once a child reaches the age of three, early intervention services stop and families are refereed to preschool handicapped programs or special needs preschool through Part B of IDEA. Unlike Part C, a child must be eligible for this program to receive services. This becomes a problem for some children with Fetal Alcohol Syndrome because few meet the criteria. Categories they may qualify for include other health impairments, behavior disorder, or learning disorder. This allows for services such as physical therapy, occupational therapy, speech and language therapy, or social skills training (NOFAS).

Adolescents with Fetal Alcohol Syndrome may have more prominent behavioral and mental health issues, so parents should not dismiss concerns they have. Adolescents with FAS miss out on skills like observational learning or basic maturity so vocational and transitional services are important. Giving them explicit instruction along with lifestyle support is important while in school to increase the possibility of a better outcome as an adult. Open communication and close supervision is incredibly important since adolescents with FAS often do not know appropriate boundaries or how to read subtle social cues. As an adult it may be difficult for those with FAS to receive services unless they have met the eligibility criteria before the age of 22. Adults living with FAS may qualify for Social Security Disability Benefits, Medicaid, and Section 8 Housing subsidies. (NOFAS)

It is important at any age in the lifespan to have a routine for those living with FAS. The National Organization of Fetal Alcohol Syndrome (2014) gives strategies for handling symptoms at each stage of life for those living with FAS. For infants, seeing specialists in areas is suggested to help with delays or a nutritionist for poor weight gain. Toddlers who are distracted easily may need a routine established or specific structure. School age children who have problems making and keeping friends may need to be paired with a child who is a year or two younger and need activities to be short and exciting. Parents of adolescence who are being victimized need to monitor the activities the children are engaging in. Adults living with FAS may also have difficulty obtaining or keeping jobs so looking into trade schools job training programs may be beneficial for them. (NOFAS)

Although no studies have been done to see how play therapy can help children with Fetal Alcohol Syndrome, research has been done with children who have similar characteristics and behaviors; this includes but not limited to low self-esteem, aggression, and hyperactivity. This allows practitioners to help children with FAS (Liles et al. 2009). “Develop a more positive self-concept, assume greater self-responsibility, become more self-directing, become more self-accepting, become more self-reliant, engage in self-determined decision making, experience a feeling of control, become sensitive to the process of coping, develop an internal source of evaluation, and become more trusting of himself/herself” are recommendations during play therapy given by Liles for children with Fetal Alcohol Syndrome

Conclusion

Although, some say an occasional glass of wine won’t affect your baby, the best way to avoid FAS is to refrain from drinking while pregnant. Educating women and men on the risks of prenatal alcohol exposure is important. Medical practitioners should also be educated on new information that is found regarding Fetal Alcohol Syndrome so they can pass the information along to clients. For women who are trying to get pregnant refraining from drinking is crucial because the early stages of development are the most impacted by alcohol exposure.

Individuals affected with FAS will have to deal with it their whole lives. Although treatments are available, the disorder is not curable. Early diagnosis is important so that support measures can be taken in the individuals’ environment which may help to avoid problems later in life. As information becomes available and technology increases more can be studied about Fetal Alcohol Syndrome.