AACP Newsletter, Volume 12, Number 4, Autumn 1998
President's Column: Fetal Alcohol Exposure:
A Public Health Problem with Implications for
Community Psychiatry
I wanted to take the occasion of the announcement of this program to share more observations regarding fetal alcohol exposure and to consider it as a model for other forms of brain disorders caused by environmental damage. While there appears to be some unique traits in the personalities of individuals suffering the effects of fetal alcohol exposure, there are similarities to the personality traits of those with brains damaged from other causes. Some suffer with diffuse injuries due to traumatic brain damage secondary to trauma in the early years of life. Fetal damage from other teratogens may cause effects similar to alcohol. I have wondered about the effects of fetal malnutrition or even of fetal or early childhood exposures to some environmental toxins. It is clear to those of us who know of the research at the University of Washington that fetal alcohol exposure is responsible for damaging effects on brain function far more frequently than is reflected by the incidence of the full FAS syndrome with its requisite facial and long bone physical signs. It may indeed by very common, but hidden. I would speculate that the damage manifests frequently in behavior that we mistakenly label Conduct Disorder.
In my practice of adolescent psychiatry I have evaluated many kids who have gross, unremitting impulsivity, colossally bad judgment and their conversation is full of interrupted thoughts. Their conversation flits between new and incongruous observations or ideas. I have felt that talking to such individuals was like observing a Mark Toby painting; lots of fascinating little squiggles on the canvas, seemingly unrelated to other little squiggles and not having any coherency, at least for my untutored eye. These teens have often been diagnosed with ADHD, and indeed they do often meet criteria. But most often they receive little or no relief from stimulant medications or any other symptom targeted medication. When I ask and find that an individual had significant fetal alcohol exposure, I strongly suspect a syndrome, despite the lack of any physical signs. In the emerging nomenclature surrounding the research at UW many are calling a syndrome without physical stigmata Alcohol Related Neurodevelopemental Disorders or ARND. The criteria are as yet ill defined but the clinical picture appears to be one that could be subject to research and more precise definition. I have felt comfortable using the DSM IV Axis I code 310.1, Personality Change Secondary to a Physical Condition.
No one has a clue regarding incidence of such syndromes because we don't really have agreed upon criteria. Most affected individuals will never have an evaluation adequate to diagnose such a condition. Many of these individuals suffer from poor judgment and impulsivity and they may be extremely vulnerable to achieving criminal status. How many individuals with subtle brain damage are in our jails? How many are involved in sexual offenses or in compulsive drinking or use of drugs? How many suffer further trauma due to their poor ability to practice reasonable self care and protection? We have great compassion for the unfortunate souls with brain disorders such as Schizophrenia and Bipolar illness who inhabit our jails. The AACP advocates for these individuals. We are committed to their care and protection. But what of those souls with damaged brains who don't learn, seem oblivious to their offending and are confused about the consequences. We are more inclined to see them as appropriate for the general jail population. They are easily viewed as bad individuals who deserve their punishment because they presumably made a moral choice. No one can see how their brain fails them.
It should be a priority of community psychiatrists to learn more about Fetal Alcohol Syndrome in adults. It will broaden the way we think about Serious and Persistent Mental Illness. Brain damage is a particularly tragic phenomenon and deserves more recognition as a legitimate focus for psychiatry. It was central to our origins, yet with the exception of senile dementia, we seem to have forgotten to look for it. We need to get trauma histories for sure, but we need to go further and plumb sources within families for pregnancy and delivery histories and developmental histories. This is indeed a quaint rejoinder from your child psychiatrist President! It is what us kid docs do all the time. Occasionally we get big hints at the pathology before us from such explorations.
We also need to develop effective means for treating the psychiatric consequences of brain damage. Individuals with FAS are indeed tragically strapped with chronic disabilities, as are all others with brain damage. The spirit of psychosocial rehabilitation allows for identifying and building on strengths. So often those with brain damage have good capacities to relate and care about others. Such traits can be mobilized and strengthened. We need residential settings with clear contingencies and structure for many individuals so affected. Jails are not good places for brain damaged individuals to achieve rehabilitation. Luckily there is an emerging advocacy group interested in FAS and related syndromes. I hope that these families will find common ground with families in NAMI and will help to broaden the scope of other advocacy movement.
Charles Huffine, M.D.
President
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