Fetal Alcohol Exposure
Fetal alcohol exposure occurs when a woman drinks while pregnant. Alcohol can disrupt fetal development at any stage during a pregnancy—including at the earliest stages before a woman even knows she is pregnant.
Research shows that binge drinking, which for women means consuming four or more drinks per occasion, and regular heavy drinking, put a fetus at the greatest risk for severe problems.1 However, even lesser amounts can cause damage.2,3 In fact, there is no known safe level of alcohol consumption during pregnancy.
Alcohol passes easily from a mother’s bloodstream into her developing baby’s blood. Alcohol present in a developing baby’s bloodstream can interfere with the development of the brain and other critical organs, structures, and physiological systems.
Prenatal alcohol exposure is a leading preventable cause of birth defects and neurodevelopmental abnormalities in the United States. It can cause a range of developmental, cognitive, and behavioral problems, which can appear at any time during childhood and last a lifetime.
The most profound effects of prenatal alcohol exposure are brain damage and the resulting impairments in behavioral and cognitive functioning.
Fetal Alcohol Spectrum Disorders (FASD)
Scientists define a broad range of effects and symptoms caused by prenatal alcohol exposure under the umbrella term Fetal Alcohol Spectrum Disorders (FASD).
The medical disorders collectively labeled FASD include the Institute of Medicine of the National Academies (IOM) diagnostic categories:4
- Fetal Alcohol Syndrome (FAS)
- Partial FAS (pFAS)
- Alcohol-Related Neurodevelopmental Disorder (ARND)
- Alcohol-Related Birth Defects (ARBD)
In addition to the IOM medical diagnoses, the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM–5) includes the psychiatric diagnosis, Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE).5 People who meet criteria for an FASD diagnosis according to the IOM may also meet criteria for ND-PAE.
The essential features common to the IOM medical diagnoses and the DSM–5 psychiatric diagnosis are prenatal alcohol exposure and central nervous system (CNS) involvement.
Evidence of CNS involvement can be structural (e.g., small brain size, alterations in specific brain regions) or functional (e.g., cognitive and behavioral deficits, motor and coordination problems). Advanced imaging studies have revealed differences in brain structure and activity that are consistent with data from neuropsychological testing, including deficits in sensory processing, cognition, and behavior in persons with FASD compared to people without FASD.6
Each individual with FASD experiences a unique combination of day-to-day challenges that may include medical, behavioral, educational, and social problems. People with FASD may have difficulty in the following areas:7
- Learning and remembering
- Understanding and following directions
- Shifting attention
- Controlling emotions and impulsivity
- Communicating and socializing
- Practicing daily life skills, including feeding, bathing, counting money, telling time, and minding personal safety
FASD-related brain damage makes it difficult to address routine life situations. It causes people to make bad decisions, repeat the same mistakes, trust the wrong people, and have difficulty understanding the consequences of their actions.
FASD cases are seriously under-diagnosed. FASD can be difficult for practitioners to distinguish from other developmental disorders since these disorders share certain learning and behavioral problems.
In addition, people with FASD are more likely to suffer from the following mental health disorders:8
- Attention Deficit Hyperactivity Disorder (ADHD)
- Depression and anxiety
- Problems with hyperactivity, conduct, and impulse control
- Increased incidence of alcohol and other substance use disorders
Relevant Clinical Diagnoses
Fetal Alcohol Syndrome (FAS)
Fetal Alcohol Syndrome (FAS) was the first form of FASD discovered and is the most well-known. Heavy alcohol use during the first trimester of pregnancy can disrupt normal development of the face and the brain. In fact, exposure at any point during gestation may affect brain development. An FAS diagnosis requires:
- Evidence of prenatal alcohol exposure
- Evidence of central nervous system (CNS) abnormalities (structural or functional)
- A specific pattern of three facial abnormalities: narrow eye openings, a smooth area between the lip and the nose (vs. the normal ridge), and a thin upper lip
- Growth deficits either prenatally, after birth, or both
Partial FAS (pFAS)
Partial FAS (pFAS) involves prenatal alcohol exposure, and includes some, but not all, of the characteristics of full FAS.
Alcohol-Related Neurodevelopmental Disorder (ARND)
A diagnosis of Alcohol-Related Neurodevelopmental Disorder (ARND) requires evidence of both prenatal alcohol exposure and CNS abnormalities, which may be structural or functional. Functional abnormalities may involve a complex pattern of cognitive or behavioral problems that are not consistent with developmental level, and that cannot be explained by factors other than prenatal alcohol exposure (e.g., family background, environment, and other toxicities). Facial abnormalities and growth retardation need not be present.
Alcohol-Related Birth Defects (ARBD)
This disorder includes medical conditions linked to prenatal alcohol exposure such as: heart, kidney, and bone problems and other malformations; difficulty seeing and hearing; and reduced immune function. Alcohol-Related Birth Defects (ARBD) is rarely seen alone but rather as a secondary disorder accompanying other FASD conditions (e.g., FAS and ARBD).
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) is a new psychiatric diagnosis in the DSM–5. It requires evidence of both prenatal alcohol exposure and CNS involvement, as indicated by impairments in the following three areas: cognition, self-regulation, and adaptive functioning. This new diagnosis for use by mental health professionals will improve understanding of the multifaceted behavioral deficits seen in some people exposed to alcohol prenatally, and facilitate improved diagnosis and treatment of these individuals.
The severity of alcohol’s effects on a fetus primarily depends on the following:
- Quantity—how much a pregnant woman drinks per occasion
- Frequency—how often a pregnant woman drinks
- Timing—in what stage of pregnancy a woman drinks and if she drinks heavily just as the fetus develops a particular feature or brain region
Other factors can also play a role in how fetal alcohol exposure can affect children. These include:
Research demonstrates that children may be more affected by prenatal alcohol exposure if their mothers:
- Have poor nutrition
- Have had multiple pregnancies and births
- Have lower-than-average weight, height, and body mass index (BMI)
- Are older
- Are a member of a family of heavy drinkers
Research demonstrates that children can be more affected by prenatal alcohol exposure if their mothers experience adverse-living conditions and high levels of stress. These may include: social isolation, living in circumstances where excessive drinking is common and accepted, and living in a community where resources for prenatal care are limited.
The extent of FASD symptoms may depend on the mother’s genetic make-up, her child’s genetic make-up, and changes in gene activity caused by prenatal alcohol exposure.
Researchers and clinicians have developed effective learning and behavioral interventions to help people with FASD. For example, school-based interventions can help children with FASD learn more easily. School-based interventions may include specialized teaching strategies that provide a consistent routine and allow children to practice new skills over and over again.10 Other promising interventions include:
- Family support groups and classes to help parents better care for a child with FASD.10
- Nutritional supplements for pregnant women and postnatal supplements for their children.11
- Behavioral interventions for affected children, including training in social skills, problem solving, and personal safety.10
For more information, please visit: www.niaaa.nih.gov.
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2 Hamilton, D.A., Barto, D., Rodriguez, C.I., Magcalas, C.M., Fink, B.C., Rice, J.P., Bird, C.W., Davies, S., and Savage, D.D. Effects of moderate prenatal alcohol exposure and age on social behavior, spatial response perseveration errors and motor behavior. Behavioral Brain Research 269: 44–54, 2014.
3 Day N.L., Helsel, A., Sonon, K., and Goldschmidt, L. The association between prenatal alcohol exposure and behavior at 22 years of age. Alcoholism: Clinical and Experimental Research 37(7):1171–1178, 2013.
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5 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. (pp. 86, 798–801). Washington, DC: American Psychiatric Association, 2013.
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7 Mattson, S. N., Crocker, N., and Nguyen, T.T. Fetal alcohol spectrum disorders: Neuropsychological and behavioral features. Neuropsychology Review 21(2), 81–100, 2011.
8 O’Connor, M.J. Mental health outcomes associated with prenatal alcohol exposure: Genetic and environmental factors. Current Developmental Disorders Reports 1(3):181–188, 2014.
9 May, P.A., and Gossage, J.P. Maternal risk factors for fetal alcohol spectrum disorders. Alcohol Research & Health 34(1):16–23, 2011.
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12 Ethen, M.K., Ramadhani, T.A., Scheuerle, A.E., Canfield, M.A., Wyszynski, D.F., Druschel, C.M., and Romitti, P.A., National Birth Defects Prevention Study. Alcohol consumption by women before and during pregnancy. Maternal and Child Health Journal. 13(2), 274–285, 2009.
13 Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H–48, HHS Publication No. (SMA) 14–4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.