FETAL ALCOHOL SYNDROME (FAS)
The relative impact of internal and external factors on post-natal symptoms manifesting themselves as FAS
This literature review pertains to an overview of the magnitude of the impact of parental alcoholism on the unborn child and subsequent physical and mental effects later in the infant’s life. It can be observed from the relevant literature (see the review of random and controlled trials by O’Connor and Olson, 2001:271-290) that the literature on Fetal Alcohol Syndrome actually branches into the FAS developing as a consequence of prenatal exposure for the infant as well as the post natal attitude of the alcoholic mother to the child contributing to the effects of the FAS. For the purposes of the literature review, the author has chosen to focus upon controlled and random trials seeking to explore the area of maternal pre- natal alcohol abuse and its impact on the Fetus.
Statement of Research
This literature review explores the varying patterns of alcoholism, metabolism, and nutritional status, genetic and racial influences through a review of random and controlled trials and the relevant contemporary literature to show how such results can vary due to the presence or the lack of such factors. It should also be noted that most of this literature is fairly recent as the concept of FAS only appeared in the early seventies. This might also account for the gaps and incoherence in the rather limited available research. Important gaps in the bibliographical result were filled through Medline and the Cochrane controlled clinical trials register. No foreign language literature relevant to this topic was found. The outcomes and the inclusion/exclusion criteria have been accordingly studied and acknowledged. The basis for further research into the ‘grey’ areas has been accordingly acknowledged.
Important perspectives were gained about the etiological, genetic, nutritional and gender based aspects of the impacts of Fetal Alcohol Syndrome through the study of: the Infant Mental Health Journal, Michigan Association for Infant Mental Health Alcohol Health & Research World, Annals of the New York Academy of Sciences, the Journal of Neurobehavioral Toxicology and Teratology Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Clinical and Experimental Research, Journal of Clinics in Perinatology, American Journal of Medical Genetics, Journal of Neurotoxicology and Teratology,Journal of. Development and Psychopathology and the American Journal of Obstetrics & Gynecology. These journals were accessed through the Athens and Proudest portals as well as through the online subscriptions provided by the University. The main key words were “fetal” “alcohol” “syndrome” and the sub-searches consisted of word like “twin studies” “random” “controlled” “trials” “genetic” “etiological”, “mental” “physical” “neurological” “prevention” “cure”. A lot of positive insights were also drawn through research in local libraries and this helped a detailed analysis of the dynamics of FAS cure and a study of its causes. Please see the Appendix for more details.
Introduction and some definitions
FAS develops as a result of maternal alcoholism during pregnancy. Jones and Smith (1973) were the first in medical academia to refer to use the term FAS (fetal alcohol syndrome), which collectively referred to mental and physical impairments of the fetus in later life after being pre-natally exposed to alcohol. At the outset these impairments were thought, perhaps wrongly, to be a consequence of etiological and nutritional deficiencies (Phillips et al, 1989). Sokol and Clarren (1989) define the criteria for the determination of the FAS as physical abnormalities pertaining to underweight babies, nervous defects, stunted growth and mental degradation. The same author has stated that FAS is one of the top causes of birth defects in babies around the world, particularly in Western Countries.
Research Gap and Coherence of the available literature
Some of the main problems in exploring the impacts of FAS, as noted by the rest of the literature review, are caused by methodological problems as the current literature sees that most of the studies are recorded at the time of the birth of the infant and/or at the time FAS is diagnosed. Problems are also seen in the variations within random and controlled studies. Very few authors have bothered to conduct follow up studies with their research participants, and thus it is apparent that fewer studies have followed the development of such children over time during their teenage years and later life to observe coherently the potentially far reaching complications of the same. (Abel and Sokol, 1986)
This causes two possible data discrepancies. Firstly, when the children are checked at birth for FAS the symptoms may be too subtle to detect and this may cause underestimation of the magnitude of the population suffering from the same. Secondly, cognitive impairments do not become obvious until several years after birth (Abel and Sokol, 1986). This may cause severe defects in the credibility of the data due to over or under estimation of the FAS magnitude and impacts amongst the population. AASE (1981) have duly pointed out impacts of the varying patterns of alcoholism, metabolism, and nutritional status, genetic and racial influences to show how such results can vary due to the admission or the lack thereof of such factors.
How much is too much and for who? Genetic, gender based and etiological factors affecting FAS outcomes.
In terms of the mental effects on the infant post birth a random study by O’Connor and Olson (2001:271-290) showed that “women in a middle-class sample who drank more heavily during pregnancy had infants with higher levels of negative affect and insecure attachments” (p.271). The study also showed that as a result of FAS these infants were more likely to develop depression as a result of ‘prenatal alcohol exposure’ combined with post-natal mental depression of the mother O’Connor and Olson (2001:271-290)
According to an estimate there are approximately 221,000 births per year of children to drug addicted (including alcoholic) mothers (Smeriglio & Wilcox, 1999 cited in O’Connor and Olson (2001:271-290)). Although these problems range from a number of facial, physical, mental and nervous abnormalities, a combination of one or both of these symptoms can be diagnosed as FAS. Literature has recorded a wealth of evidence dealing with the effects of subsequent cognitive and social-emotional traumas children with alcoholic mothers may face later on (Hawkins et al 1992; Lieberman, 2000; cited in O’Connor and Olson (2001:271-290).
There is considerable academic disagreement, however, over the query “how much is too much” in terms of the magnitude of alcohol consumption and its relative impact on the gravity of FAS (Shah et al 1999). The reason that FAS poses a serious threat to the young population is that there is a tendency for young persons, particularly within childbearing age groups, to resort to substance abuse on both sides of the Atlantic as shown by a recent 2000 study by Zucker et al (2000 cited in O’Connor and Olson (2001:271-290). The significance of the study of FAS is to advance research and better methodologies for the prevention of the same for a future healthier population (Connor et al 1999).
Teratology v. Psychology: the postnatal attitude of the alcoholic mother
The dangers of FAS are often stated as “numerous, pervasive, costly, and often enduring” for the infant in later life (Weinberg, 1997:1177 cited by O’Connor and Olson (2001:271-290.) The literature has at times separately referred to the area and ambit of a primary interest in the “teratogenic effects of prenatal exposure” (Day & Richardson, (2000) cited O’Connor and Olson (2001:271-290), or “the developmental impact of rearing by an alcoholic or alcohol-abusing mother and/ or father” (controlled studies by Fitzgerald, Zucker, Puttler, Caplan & Mun, 2000 as cited by O’Connor and Olson (2001:271-290). It has also been suggested in modern literature that these two points of view can generate more credible conclusions when not dealt with in isolation from each other O’Connor and Olson (2001:271-290).
Other academics(Zuckerman et al 1989) have sought to approach the issue of the FAS through the ambit of teratology with the thesis that alcohol abuse itself will hinder and deter the development of the unborn fetus by causing imbalance within the infant’s brain, and nerve chemicals at multiple levels which can later impair the development of the infant considerably in terms of cognitive, behavioural, speech/language, and sensory-motor functions as well as social behaviour, psychiatric normalcy (Zucker et al 2000).
Academics like Riikonen, (1994) and Streissguth & DeHaene, (1993) have discussed the effects of alcoholic mothers on their fetuses through creating variables in terms of the amount of alcohol consumed by the pregnant mother, genetic influences, the pregnancy period in which there was alcohol exposure .Many studies have also examined the effects of ethnic and environmental influences on the children in terms of prenatal alcohol exposure, as well as the age, nutrition and the financial status of the parents (qualitative analysis by Kranenberg, M.J. 1999).
Pre-natal FAS impact later on in life
A review of the relevant literature has also revealed a lack of research upon FAS in the child later on in life reaching into adulthood. The emphasis has mostly been on clinically affected children and much hope for treatment has been seen mostly for those children who are diagnosed with the FAS at an early stage in life. In a study by Streissguth et al (1997) it is possible to see that the longer the FAS patient resided with abusive or alcoholic parents the more pronounced the symptoms and damage became for the patients. This would show that there is a link between the aggravation of the FAS and environments which are unhealthy and thus non-conducive to the welfare of the patient.
Interestingly, there is also a correlation between the financial status of the parent, their nutrition intake and whether they are chronic, social or regular drinkers, with FAS and its magnitude and aggravation. Studies have also drawn a parallel and a definite link between post-natal and pre-natal drinking by the maternal parent (gestational alcohol use) (Kranenberg, M.J. 1999).
Possible triangulation v. isolation of these factors?
Other academics have identified a triangulation between genetic and environmental inﬂuences on the child, in addition to their maternal ancestor’s pre-natal drinking to teenage alcoholism as a consequence of early fetal exposure to alcohol. There is thus a definite parallel to be drawn between etiologic and nutritional behaviours of the parent, and subsequently the child, in assessing the magnitude of the impact of the FAS exposure.
It is a fact nonetheless which can be concluded from the available literature that the impacts of gestational drinking on the fetus are life-long in terms of mental and physical developmental repercussions for the children (Kranenberg, M.J. 1999)
In addition to this, it can also be noted that the core of the current literature review has focused on chronic or addictive alcoholics (Fitzgerald et al., 2000).Very rarely has there been a research involving FAS as a root of alcoholism in young persons exposed to alcohol as fetuses. Important perspectives in this field come from Sher (1991) and Heath (1995) who exposed that the gender of the infant is not a variable for exposure to FAS as a result of their twin studies which revealed similar results for fetuses of both sexes. Another factor is genetic influence. Sher (1991) has, however, pointed out that there may be a point of variation in the outcomes of FAS in infants based on their gender despite similarities in the gene pool during twin studies.
Based on the above not only is it not feasible to treat all these genetic, prenatal and postnatal factors in isolation when analyzing the magnitude of FAS on infant health, but the same can also become a difficult task due to the interconnection between all these factors (Streissguth et al, 1997). However, there have been recent studies in this area pertaining to studies focused entirely on the teratogenic perspective of FAS in exclusion of etiological ,genetic and post-natal factors (see for example Day & Richardson, 2000 and Jacobson & Jacobson, 2000).
The environment, etiology and magnitude of FAS
The symptoms of FAS can begin to manifest themselves at any time from early childhood to much later in life in terms of mental and physical impairments (Weinberg, N.Z.1997). These can emerge as a failure of the affected individual to relate or respond to his immediate environment, anti-social behaviour and depression. In terms of whether postnatal factors are more prominent in contrast to pre-natal exposure, a study comparing animals and humans by Kelly, et al (2000) shows that this is mainly due to prenatal alcohol exposure. Thus the teratogenic effect of alcohol over-rides the genetic and etiological perspective (Olson et al 1997). Again it is worth mentioning the literature gap distinguishing chronic alcoholism and “binge drinking” and the varying effects of both on the FAS patient(O’Connor and Olson (2001:271-290). From the teratologic perspective, Roebuck, et (1999)( cited by O’Connor and Olson (2001:271-290)) have found that “high rates of depression have also been found among prenatally-exposed individuals with IQs above 70 and tested by different research teams, across the age range from childhood to adulthood ….using psychiatric interviews, 27% of children evaluated in a clinic specializing in the diagnosis of FAS were found to have depressive disorders; none had full FAS” (O’Connor and Olson (2001:276) citing Shah et al (1999).
Lack of a solid premise: the multidimensional nature of FAS causes
Finally, despite the diversity of the studies undertaken in this field, no solid conclusion has been reached to show the link between high levels of alcohol intake being proportional to the gravity of the impacts of Alcohol (Weinberg, N.Z.1997). In fact, severe physical abnormalities have often been a result of a minimal condition of alcoholism. The diversity in the impacts and their gravity arising as a result of gestational drinking cannot bring a solid and predictable table of “effects” therefore, and consequently we have to refer to the concept of FAS collectively to represent the range of postnatal defects and impairments arising as a consequence of alcoholism during pregnancy. Furthermore, even though this area has not exactly been fully explored, the effects and impacts of alcoholism vary for the baby depending upon the time or the month of pregnancy the fetus was exposed to alcohol.
According to a random study by O’Connor and Kasari (2000) cited by O’Connor and Olson (2001:280 ) it has been noted that “data showing an association between maternal alcohol abuse and depression in children have generally been interpreted as reﬂecting the impact of the postnatal environment, and especially the effects of living with an alcoholic mother…… [these authors] have an interaction between maternal alcohol use and depression, based on ﬁndings such as cosegregation of depression and alcoholism in mothers of depressed children ….and data indicating that pregnant women who are depressed tend to drink more ……”(page 280).
Towards some conclusions and recommendations for future research
The way ahead for research in this area is that it should focus on the effect and impact of the FAS by focusing on variables and models that take into account environmental effects as well as the atmosphere the patient has grown up in pertaining to teaching, emotional treatment and nutrition the infant is subjected to post-birth. This is because it has been seen that FAS depends upon both internalizing and externalizing factors, which interact to bring about unique symptoms in the child. Therefore, no study can be conclusive as to impacts of FAS without taking into account the interplay between both impacts as in the magnitude and gravity of the mother’s alcoholism, and secondly the external dimension to the same. This external dimension should not ignore the early mother child relationship post birth.
A framework of analysis has been proposed by O’Connor and Olson (2001) as inclusive of “infancy and early childhood issues include the development of homeostatic and physiological regulation, affect differentiation and the modulation of attention and arousal, as well as the development of a secure attachment relationship and of high self-esteem”. (P.283). In the matter of a ‘cure’ for FAS, it remains to be seen how the young patient has developed in these areas and invariably the success or failure of growth in both has a heavy reliance upon the way the child is treated in the early days of infancy, and not just upon the amount of alcohol the maternal parent consumed during gestation (Weinberg, N.Z.1997). At times, FAS can seemingly be avoided merely through better ‘upbringing” which would mean careful attention being paid to the child’s early development and education. Such early care should offer the child security of action and emotion to lay a solid foundation for the mental health of the child into their teen years and later life.
Conclusion of findings
Finally, the findings of the literature review can be summed up as follows:
- This area can find much benefit from the integration of both pre and post natal influences
- A suggested framework for FAS analysis would include all types of models of development like the pre- and postnatal nuances
- These approaches would have profound outcomes for future research. Thus a consideration of the promotional exposure to alcohol along with etiological and genetic influences would help explain the situation better in terms of the long-term impacts and the root thereof in FAS patients.
- There is indeed a link between physical impairment and childhood depression and maternal alcoholism during pregnancy, but studies have not been able to conclude whether this link will vary by gender or the amount of alcohol consumed.
- Thus the FAS can appear through a triangulation of prenatal exposure to the effects of alcohol and the subsequent insecurity the child is subject to through an alcoholic or abusive parent.
- O’Connor and Olson (2001) Lessons Learned From Study Of The Developmental Impact Of Parental Alcohol Use: Infant Mental Health Journal, Vol. 22(3), 271 – 290 (2001) Michigan Association for Infant Mental Health
- JONES, K.L., & Smith, D.W. Recognition of the fetal alcohol syndrome in early infancy. Lancet 2:999-1001, 1973.
- PHILLIPS, D.K.; Henderson, G.I.; & Shenker, S. Pathogenesis of fetal alcohol syndrome: Overview with emphasis on the possible role of nutrition. Alcohol Health & Research World 13(3): 219-227, 1989.
- SOKOL, R.J., & Clare, S.K. Guidelines for use of terminology describing the impact of prenatal alcohol on the offspring. Alcoholism: Clinical and Experimental Research 13(4): 597-598, 1989. (6)
- STREISSGUTH, A.P.; Sampson, P.D.; & Barr, H.M. Neurobehavioral dose-response effects of prenatal alcohol exposure in humans from infancy to adulthood. Annals of the New York Academy of Sciences 562:145-158, 1989.
- ABEL, E.L., & Skolt, R.J. Fetal alcohol syndrome is now leading cause of mental retardation. Lancet 2:1222, 1986.
- AASE, J.M. The fetal alcohol syndrome in American Indians: A high-risk group. Neurobehavioral Toxicology and Teratology 3(2): 153-156, 1981. (
- Carmichael Olson, H., Streissguth, A.P., Sampson, P.D., Barr, H.M., Bookstein, F.L., & Theide, K. (1997). Association of prenatal alcohol exposure with behavioral and learning problems in early Adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1187 – 1194.
- Jacobson, J.L., & Jacobson, S.W. (1995). Strategies for detecting the effects of prenatal alcohol exposure: Lessons learned from research on alcohol. In M. Lewis & Lieberman, D.Z. (2000). Children of alcoholics: An update. Current Opinions in Pediatrics, 12(4), 336 –340.
- O’Connor, M.J., & Kasari, C. (2000). Prenatal alcohol exposure and depressive features in children. Alcoholism: Clinical and Experimental Research, 24(7), 1084 – 1092.
- Shah, B.G., O’Connor, M.J., Cronin, P., & Graham, J. (1999). Psychopathology in children with varying levels of prenatal alcohol exposure. Poster presented at the annual meeting of the Research Society on Alcoholism, Santa Barbara, CA.
- Sher, K.J. (1991). Psychological characteristics of children of alcoholics: Overview of research methods and ﬁndings. Recent Developments in Alcoholism, 9, 301 – 326.
- Smeriglio, V.L., & Wilcox, H.C. (1999). Prenatal drug exposure and child outcome. Clinics in Perinatology: Prenatal Drug Exposure and Child Outcome, 26(1), 1 – 16.
- Steinhausen, H.C., & Spohr, H.L. (1998). Long-term outcome of children with fetal alcohol syndrome: Psychopathology, behavior, and intelligence. Alcoholism: Clinical & Experimental Research, 22, 334 – 338.
- Streissguth, A.P., & Dehaene, P. (1993). Fetal alcohol syndrome in twins of alcoholic mothers: Concordance of diagnosis and IQ. American Journal of Medical Genetics, 47, 857 – 861.
- Streissguth, A.P., Barr, H.M., Kogan, J., & Bookstein, F.L. (1997). Primary and secondary disabilities in fetal alcohol syndrome. In A.P. Streissguth & J. Kanter (Eds.), The challenge of fetal alcohol syndrome: Overcoming secondary disabilities (pp. 25 – 39). Seattle, WA: University of Washington Press.
- Streissguth, A.P., Bookstein, F.L., Sampson, P.D., & Barr, H.M. (1989). Neurobehavioral effects of prenatal alcohol: Part III. PLS analyses of neuropsychologic tests. Neurotoxicology and Teratology, 11, 493 – 507.
- Kranenberg, M.J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae. Development and Psychopathology, 11, 225 – 249. .
- Weinberg, N.Z. (1997). Cognitive and behavioral deﬁcits associated with parental alcohol use. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1177 – 1186.
- Zucker, R.A., Fitzgerald, H.E., Reﬁor, S.K., Puttler, L.I., Pallas, D.M., & Ellis, D.A. (2000). The clinical and social ecology of childhood for children of alcoholics: Description of a study and implications for a differentiated social policy. In H.E. Fitzgerald, B.M. Lester, & B. Zuckerman (Eds.), Children of addiction: Research, health, and public policy issues (pp. 109 – 142). New York: Falmer Press.
- Zuckerman, B., Amaro, H., Bauchner, H., & Cabral, H. (1989). Depressive symptoms during pregnancy: Relationship to poor health behaviors. American Journal of Obstetrics & Gynecology, 160, 1107 – 1111.
Appendix 1-flowchart of the methodology and the research processes