Earlier this year, I touted the need for increased recognition of fetal alcohol spectrum disorders in every branch of medicine. I pointed out the extent to which prenatal alcohol exposure was often facilitated by the social determinate of health, that is, the prevalence of liquor stores in some communities (most notably African American and Native American), and how our own work in a family medicine clinic serving a low-income African American community on Chicago’s Southside found FASD rates of 388/1,000.
Since then I have become aware of the work of Susan Astley, Ph.D., and her colleagues. They found the rates of FASD in Washington state’s foster care population were 10-15/1,000. In addition, Dr. Astley has developed an FAS facial photographic screening tool that provides a more-objective measure to identify this common neurodevelopmental problem. Considering the findings that FASD is common in foster-care populations, it would be prudent to use this software in child protective services across the country.
Dr. Carl C. Bell
Adult patients with FASD often present thinking they have bipolar disorder, because they are always “snapping off” or expressing an explosive temper. However, this is a sign of affective dysregulation instead of a persistent manic or depressed mood. Unfortunately, many do not distinguish between emotions or affects and moods. These patients also report late-onset auditory hallucinations, for example, that start in their 30s, but a careful exploration of the hallucinatory content does not reveal the characteristic running commentary, hearing one or more voices arguing, or hearing one’s own thoughts out loud that patients with schizophrenia suffer. Additionally, adult patients with FASD have more interpersonal skills than do patients with schizophrenia, although they can be very naive and childlike. Additionally, these patients often report that they are depressed because of their unhappiness about their chronic inability to improve their social, academic, or occupational functioning.
The prevalence of FASD turns out to be more common than previously realized and like other neurodevelopmental disorders, patients with these disorders do not “outgrow” them, but rather, carry them into adulthood. Accordingly, asking all patients about their childhood histories of neonatal standing, childhood educational trajectories, and employment history provides useful clues that might suggest a prenatal problem of alcohol exposure.
A neonatal history that indicates the possibility of FASD is a history of low-birth weight (< 5 pounds 8 ounces) or prematurity, heart murmurs, strabismus, hypertelorism, and deformities of the hands, joints, and bones. Frequently, patients with prenatal alcohol exposure have vestiges of fetal alcohol facies (epicantal folds, a flat mid-face, an indistinct philtrum, and a thin upper lip), and evidence of subtle brain damage characterized by central nervous system dysfunction. A childhood educational trajectory reveals developmental disabilities (intellectual disability, learning disability, attention-defici/hyperactivity symptoms, speech and language difficulties, and affect dysregulation usually in the form of a bad temper). Finally, an employment history that reveals chronic poor job performance, for example, if the longest time a patient was employed at one job was less than 6 months, the poor adaptability characteristic of FASD is revealed.
As physicians, our capacity to recognize FASD is sorely bereft of competence. A recent study by Dr. Pat Rojmahamongkol and colleagues showed that only 17% of physicians correctly identified fetal alcohol syndrome, while 74% were able to correctly identify Williams Syndrome; considering that Williams Syndrome occurs in only 1/7,500 people, this is akin to being better at locating jaguars in the United States than finding house cats. We have to do a better job of identifying this common problem that has been found to be extraordinarily widespread in certain high-risk populations. In the aforementioned study, more than 90% of the pediatricians were concerned about stigmatizing patients by making a diagnosis of FASD. However, considering that 50% of pregnancies are unplanned, many women may not be aware that they are pregnant while they are drinking alcohol. Besides, you cannot be a competent physician and be a wimp. We are in a hard conversation business, and we cannot fix problems if we stick our heads in the sand.
Knowing a patient’s intellectual capacity is an extremely important consideration in all branches of medicine. Trying to teach patients how to manage their diabetes or cardiac disease when patients have the subtle brain damage from FASD is more than a notion – such patients have difficulty understanding what we are teaching, and, if they do understand, they often cannot remember the lesson.
Lastly, for as long as I can remember, the prematurity rates for African Americans have been double that of European Americans. However, for half a century, no one has figured out why. As usual, the answer is right in front of us: FASD. We need to do better.