Fetal alcohol spectrum disorder

Fetal alcohol spectrum disorders are a vibrant area of development and research. Awareness about this preventable group of conditions appears to be growing.

In fact, the Centers for Disease Control and Prevention has released an app that emphasizes how to recognize, prevent, and treat fetal alcohol spectrum disorders. Earlier rates of fetal alcohol syndrome were estimated at 1/1,000, but FASD is estimated to occur at rates of 1/100. However, as I will illustrate below, the rates of FASD are even higher – much higher among some populations than previously thought.

Dr. Carl C. Bell

The DSM-5 included in its appendix the diagnostic category of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE), which theoretically should help psychiatrists identify FASD. Of course, the DSM-5 also includes an official diagnosis of disruptive mood dysregulation disorder (DMDD), and for the life of me, I have a difficult time differentiating between the two clinically except that children and adults with ND-PAE, in contrast to patients with DMDD who are described as persistently irritable or angry most of the day, can be very amicable, naive, and overly friendly between outbursts. The other difference is that ND-PAE needs a history of the mother’s having more than minimal exposure to alcohol during gestation, including prior to pregnancy recognition, and DMDD does not have this criteria, although it may be present. And, lastly DMDD is official and ND-PAE not.

Last year, Philip A. May, Ph.D., and his associates published an important paper, “Prevalence and Characteristics of Fetal Alcohol Spectrum Disorders” (Pediatrics 2014 [doi.10.1542/peds.2013-3319]). The authors looked at a representative Midwestern U.S. community with a population base of 160,000, 87% of which were white. The per-capita income of the population was $28,000, the median household income was $51,800, and 11% were below the poverty line.

Dr. May and his associates examined 70.5% (1,433 of 2,033) of all first-graders. Using one method of prevalence estimation, they found that 28.6/1,000 had FASD. Using a second method of prevalence estimation calculated from cases of FASD, they found an FASD rate of 82/1,000. The take-home message is, regardless of the academic fine points of how prevalence is estimated, these prevalence rates are much higher than previously reported.

In a second paper by Dr. Ira J. Chasnoff and his associates – “Misdiagnosis and Missed Diagnosis in Foster Care and Adopted Children with Prenatal Alcohol Exposure” – also published in Pediatrics, the rates of FASD in foster care and adopted youth were estimated to be even higher.

This study looked at 547 youth (50.6% African American, 1.3% Asian, 32.2% white, 0.7% Native American, 12.2% biracial, and 3% other/unknown) referred for severe behavioral disorders. The researchers found that 28.5% of these youth had FASD, 86.5% of the youth had never been diagnosed or were misdiagnosed, and 26.4% of these youth were misdiagnosed as having ADHD (Pediatrics 2014 [doi:10.1542/peds.2014-2171]).

Radhika L. Chimata and I published the third paper of significance online in Psychiatric Services. This paper, which is also slated for publication in print, focused on our work in a family medicine clinic on Chicago’s South Side, serving a population of 143,000. We looked at 611 patients (96% African American with a median household income of $33,809 – only 21 were youth, the rest were adults) and found that 297 (49%) of the adults and youth had neurodevelopmental disorders with 237 (39%) having clinical profiles consistent with neurobehavioral disorders associated with prenatal alcohol exposure. Thus, this clinic population has a rate of 388/1,000.

Considering emerging research that suggests that this acquired biological disorder is being driven by the social determinants of health, for example, some low-income African Americans are living not only in food deserts but food swamps (where the liquid is alcohol; consider the plethora of liquor stores in low-income African American communities), we must recognize that FASD can be prevented prenatally and possibly improved postnatally by increasing the amount of choline in the diet. This is a potential prevention intervention issue that we cannot afford to overlook if psychiatry is going to maintain its relevance in the 21st century.

Dr. Bell is a retired professor of psychiatry and public health at the University of Illinois at Chicago and staff psychiatrist at Jackson Park Hospital’s Outpatient Family Practice Clinic in Chicago. Dr. Bell is the former president and CEO of the Community Mental Health Council and former director of the Institute for Juvenile Research (birthplace of child psychiatry) at the university.