Prenatal Alcohol Exposure. Alcohol is a known teratogen. Teratogens are substances that, when exposed to a developing fetus, impair normal development and cause birth defects in prenatal development. Teratogens can result in (Streissguth 1997): death malformations growth deficiency
Teratogens can result in (Streissguth 1997):
PAE during the first trimester generally results in damage to physical structure and PAE during the third trimester typically affects growth or size of the fetus. The brain (CNS) develops throughout the entire pregnancy, and is affected by alcohol exposure at any time during pregnancy (Streissgith, 1997).
FAS is characterized by:
From Streissguth and Little (1994).
The Institute of Medicine (IOM) identified 3 classifications of Fetal Alcohol Effects:
From: Sulik K, Johnston M, Webb M. Fetal alcohol syndrome: embryogenesis in a mouse model. Science 1981;214:936-8.
Chudley et al. recommend evaluating:
Birth mother no longer available
Biomarkers for PAE:
Fatty Acid Ethyl Esters (FAEE)
Found in meconium and hair of newborns
Research studies find high rates of FAEE
Chudley et al., 2005
Intellectual ability: decreased IQ in children and adults with FASD.
Attention and speed of processing:
Executive Functioning (EF): higher-order cognitive processes involved in goal-oriented behavior.
Language: some mixed effects, but children with FASD generally have poorer language abilities.
Visual Perception: most impaired on tasks that involve integration of information, planning, and visual-motor integration.
Learning and Memory: slower at learning
Number Processing: although children with FASD have difficulties in many academic areas, math appears to be the most severely affected.
Streissguth et al. (1994) conducted a large longitudinal study on children with PAE.
Classroom Behaviors: distractible, inattentive, hyperactive, restless
Adaptive Behavior: personal and social skills needed to live independently
Emotional Functioning: mental health disorders and emotional difficulties
Primary disabilities: those which directly result from the brain injuries of PAE and are evident in some form from birth.
Intelligence, memory, attention
Secondary Disabilities: result from primary disabilities and environmental interactions and are not evident from birth
In theory they are preventable with better understanding of appropriate interventions
Streissguth et al. (1996) conducted a longitudinal study on secondary disabilities in FASD.
The Life History Interview (LHI), which measures common secondary disabilities, was administered to 415 individuals (6-51 years old) with FAS and FAE.
The results were astounding:
More than 90% of the sample had mental health problems
49% of the adolescents/adults and 39% of the children demonstrated inappropriate sexual behaviors
More than 60% of adolescents/adults and 14% of the children had disrupted school experience
60% of adolescents/adults and 14% of the children had been in trouble with the law
50% of the adolescents/adults had been confined (e.g. incarceration, inpatient mental health programs, or alcohol and drug treatment programs)
35% of the adolescents/adults had alcohol and drug problems.
67% had experienced physical or sexual abuse, or were victims of domestic violence
80% were not reared by their biological mother
Three risk factors were identified that were associated with higher rates of secondary disabilities:
being diagnosed with FAE rather than FAS
having an IQ above 70
higher scores on the Fetal Alcohol Behavior Scale which measures behaviors of fetal alcohol exposure
Thus, having less severe physical effects (FAE instead of FAS) and a higher IQ were associated with a higher rate of secondary disabilities.
Streissguth et al identified 5 protective factors that resulted in lower rates of secondary disabilities:
living in a good quality stable home environment
infrequent changes in living arrangement
not being exposed to violence
receiving services for developmental disabilities
being diagnosed before the age of 6
Maladaptive behaviors: impulsivity, teasing/bullying, dishonesty (lying, cheating, stealing), avoiding school or work, destruction of property, physical aggression, and self-injury behaviors (LaDue et al, 1992).
FASD linked to behavior problems and delinquency in adolescents (Carmichael Olson et al., 1997).
Children with PAE have higher rates of delinquent behaviors than children with ADHD, including cruelty, bullying (48% of children), lying or cheating (90% of children), and stealing.
97% children with fetal alcohol exposure lacked guilt after misbehaving. Nash et al (2006)
PAE is also associated with conduct behaviors and lower overall moral maturity (Schonfeld et al., 2005)
Home environment related to delinquency in that youth living in biological or foster homes were more likely to engage in delinquent behaviors than youth living in adoptive homes.
It is clear that individuals with FASD are particularly prone to delinquent behaviors; however some researchers suggest that this may be due to factors (e.g., family and individual characteristics) other than prenatal alcohol exposure (Lynch et al, 2003).
Adolescents and adults with FASD are at particular risk for ending up in the criminal justice system.
In Streissguth’s studies 60% of adolescents and adults with FASD had been in trouble with the law and 50% had been confined.
A Canadian study found that 23% of youth remanded for a psychiatric inpatient assessment had an FASD (Fast et al., 1999).
A recent Canadian report indicated that 10% of inmates had an FASD, which is 10 times higher than in the general population (Sandrers, 2007).
High rates of psychiatric disorders among children with PAE: 87% met criteria for a psychiatric disorder including mood disorders (61%), bipolar disorder (35%), major depressive disorder (26%) (O’Connor et al., 2002)
PAE is linked to depressive symptoms among 6-year-old girls (O’Connor et al., 2001).
In one study 97% of the alcohol-exposed children were diagnosed with an axis 1 disorder (Fryer et al., 2007)
ADHD, depressive disorders, oppositional defiant disorder (ODD), conduct disorder (CD), phobias
Adults with binge alcohol exposure have higher rates of many disorders including: somatoform, substance dependence/abuse, paranoid, passive-aggressive, antisocial, and personality disorders (Barr et al (2006)
PAE is associated with alcohol problems in adolescents and adults (Baer et al. 2003)
In one sample of adults with PAE, 25% had an alcohol disorder. (Alati et al., 2006)
PAE is associated with the development of nicotine, alcohol and illicit drug dependence, even when biological parental alcohol abuse is controlled for. (Yates et al, 1998).
Adolescents and adults with FASD are at risk for suicide and attempted suicide.
O’Malley and Huggins (2005) carried out a pilot study of 11 individuals affected by FASD.
Over half (6) of the participants reported attempted suicide, a rate that is drastically higher than the general Canadian population rate of 4.6%.
The significant EF deficits in individuals with FASD likely contribute to high risk behaviors.
Impairments in EF skills such as planning, cause-effect reasoning, learning from past mistakes, and the lack of social adaptability may be related to why youth with FASD are overrepresented in the justice system.
The connection between poor executive functioning and juvenile delinquency has been well-documented in other populations.
Adolescent/adult offenders are impaired on many tests of EF
Inhibition appears to be one aspect of EF that is strongly related to delinquency and high risk behaviors.
Poor decision making is linked to the frontal lobe
Individuals with frontal lobe damage show similar risky and maladaptive behaviors as those with FASD.
PAE has a negative effect on the frontal cortex, thus putting individuals with FASD at increased risk for engaging in problematic behaviors.
Risk taking increases during adolescence because they are more sensation-seeking and reward-driven but have a prefrontal cortex that is still developing.
In FASD, adolescence is a time of heightened vulnerability, as these individuals have even more of a gap between their brain/cognitive development and their behaviors.