With New Years Even right around the corner, it seems like a good time to take a look at the most recent information about the dangers of drinking while pregnant. The effects of alcohol consumption often appear to be a modern-day issue. However, this phenomenon has actually been studied for the past several centuries. It is an interesting fact of social history that women who consume alcohol have been admonished as far back as far as the 18th century.
A lithograph by the artist, William Hogarth entitled Gin Lane depicts a woman who is obviously intoxicated dropping the baby she is holding in her arms (Randall 2001). While Hogarth may have simply created an artistic commentary on the gin epidemic ravaging England at the time, he may also inadvertently provide us with a portent for the future of research in this field.
It was approximately one century later that the first research into the effects of alcohol on unborn children appeared in the scientific literature. “The most compelling evidence for the earliest suspicion of the teratogenic effects of alcohol comes from Sullivan (1899). He reported that the infant mortality and stillborn rates for children born to alcoholic mothers were more than two times that for nonalcoholic mothers.”
However, it was not until the late 1960’s that serious research was published on this topic. Dr. Lemoine of Belgium and his colleagues published a paper on this subject which was noted in Europe but not in the US (Ibid). Culturally, alcohol consumption was (and often still is) considered to be an integral aspect of socializing with others. The 1960’s was also a time of great political upheaval in the United States and it is just possible that other cultural, political and economic factors prevented this research from gaining any serious attention. Irrespective of these possibilities, Lemoine’s research proved to be extremely important in the development of this field.
The authors described a pattern of symptoms that included craniofacial, limb and cardiovascular defects associated with prenatal growth deficiency and developmental delay. Their next article, published in the same year, is considered the seminal article because it coined the term fetal alcohol syndrome (FAS), thus providing a label for the constellation of defects (Ibid).
The term fetal alcohol syndrome is often thought to be a ‘catch-all phrase’ for this rather complex medical condition. Pre-natal alcohol exposure can lead to FAS but the effects of this exposure exist on a continuum rather than leading to one finite result. Schonfeld, Mattson, Lang, Delis & Riley (2001) note that exposing a fetus to alcohol can lead to fetal alcohol effects. This is not simply a semantic distinction but a medical one. The effects of alcohol on unborn children may be determined, in part, to how much alcohol the unborn fetus was exposed to. “However, there is no doubt that prolonged exposure of alcohol on the unborn fetus will result in significant deficits of various kinds. Currently, the full syndrome of FAS is diagnosed if symptoms are observed in all three areas aforementioned and if a positive history of maternal alcohol use during pregnancy is established. Individuals with only subsets of these symptoms and a positive history of PAE may be diagnosed with fetal alcohol effects” (Kaemingk & Paquette 1999).
The fact of this distinction is important given the severity of symptoms that have been noted in children who were exposed to alcohol in the womb. These symptoms range widely and include neurological deficits, behavioral disorders, lower base intelligence, learning difficulties and some physical disfigurement. As noted by Schonfeld, Mattson, Lang, Delis & Riley (2001) the effects of full-blown FAS are described as “pre- and/or postnatal growth deficiency; a unique pattern of facial characteristics (e.g., smooth philtrum, short palpebral fissures, flat midface and thin upper lip); and central nervous system (CNS) dysfunction (e.g., intellectual deficiency and/or attentional deficit).”
Other authors and studies have noted similar characteristics and traits. “Children with severe FAS have a characteristic look” (“Alcohol Before Birth” 2004).
They have distinctive facial features, that include drooping eyelids, short upturned nose, thin upper lip, bulging forehead and receding chin, they are short and thin in stature” (Jacobs, et al 2000). In fact, as far back as the research conducted by Dr. Lemoine and his colleagues, these unusual physical and developmental characteristics were noted in his research. “The authors described a pattern of symptoms that included craniofacial, limb and cardiovascular defects associated with prenatal growth deficiency and developmental delay” (Randall Ibid).
The clinical information on the effects of alcohol on the unborn child range quite widely. However there is a definite consensus that drinking, even in moderate amounts can affect the fetus. In fact back in 1900, Dr. Nicloux (Ibid) “observed that the placenta was not a barrier to alcohol and that maternal ingestion of alcohol passed to the fetus.” Some researchers attribute an extremely wide range of characteristics attributed to the consumption of pregnant women, while others note a more defined set of symptoms and difficulties. The primary consensus is those pregnant women who consume alcohol do so at risk to their unborn child.
According to Nevitt (1998), FAS babies have physical problems including hearing defects, teeth growing in wrong, defects of the heart, kidneys, muscles and joints. There is also the possibility of damage to the central nervous system. Kaemingk & Paquette (1999) go even further in their analysis. “Prenatal alcohol exposure (PAE) can have devastating effects on cognitive and adaptive function. Fetal alcohol syndrome (FAS) is one of the leading causes of mental retardation in the Western world. Studies focusing on the cognitive and adaptive function of individuals with FAS.” Alters (2001) is another researcher who is concerned about the effects of alcohol on the body especially on our cognitive abilities. In her research she indicates that alcohol can damage brain tissue and the areas of the brain that control memory, emotion and thinking.
The issue of cognition is a key one as it raises a wide range of concerns including the ability to learn new information (and the consequences of functioning in a learning environment), the ability to adapt over time (raising the specter of problems throughout one’s lifetime), the capacity to function in a variety of work environments and any other situation which requires good learning skills. From a practical perspective, the fact is, we are constantly learning today. We live in a challenging society which is continually raising the bar on the kinds of technologies we must learn to use and adapt to. Computer-related learning is now an integral aspect of education from the elementary level on up. There are very few careers which don’t require us to use some form of technology and learn a wide range of skills. For example, even the job of a cashier at a small local store seems like a fairly simple task on the surface. However, when the tasks are broken down into their components, a cashier must have skills in mathematics, customer relations, using the computerized cash register, the ability to demonstrate good judgment and so forth. What appears to be a simple job can actually be more complex when the individual tasks are analyzed.
The issue of learning difficulties was noted by Jacobson and Jacobson (2002) as well: “Two studies have found that children exposed prenatally to alcohol were rated by their teachers as less socially competent and more aggressive in the classroom (Brown et al. 1991; Jacobson et al. 1998b).”
These same authors (Ibid) noted the following: “FAS children are frequently characterized as talkative, affectionate, and outgoing, and with the findings by Steinhausen and colleagues (1993) that behavior problems which become evident during childhood do not improve as the FAS patient reaches adulthood.” This conclusion is a rather serious one. It provides us with a possible snapshot of someone who suffers from these difficulties not only in childhood and teenage years but on into adulthood as well. Thus, it can be reported that at least one research study in this literature review postulates that perhaps the most serious effect of FAS is that this is a syndrome which will likely plague those who have it throughout their lifetime
“Frequently reported maladaptive behaviors included poor concentration and attention, and impulsivity. One of the most striking findings was that adults with FAS or FAE who had IQ scores within the normal range were unable to live independently. Adolescents and adults who were not retarded were described as failing to consider consequences of their actions, lacking appropriate initiative, and being unresponsive to subtle social cues” (Kaemingk & Paquette Ibid).
The issue of poor concentration, attention and impulsivity indicate once again the fact that one of the effects of alcohol on unborn children is not just learning difficulties but serious neuropsychological deficits. If we analyze the previous quote, we can see that the consequences of alcohol on unborn children are severe. The frontal lobe is the part of the brain that houses impulse control and judgment. Therefore, this research is at least one indication that children with FAS suffer serious brain damage as a result of exposure to alcohol.
Another problem worth mentioning is that of ‘social cues’. While it perhaps sounds minor in comparison to other difficulties, it is not. The ways in which we interact with others are governed by our ability to send and receive social signals. These signals are both verbal and non-verbal in nature. When an individual experiences difficulties understanding and/or sending these cues it has the capacity to cause havoc in their life. The fact is, we rely on social cues to behave appropriately in any number of given situations every day — from buying our coffee in the morning, to meetings at work, to socializing with friends and colleagues and even establishing intimate friendships and relationships. Social cues provide us with the information we require to understand a broad range of personal and professional encounters. People with underdeveloped abilities in this area often find themselves misunderstanding conversations, work-related directions and a whole host of verbal and non-verbal information. One very practical example is the job interview. We often receive both obvious and subtle cues in the job interview, from the way the employer looks at us, to the tone in his/her voice, the way they sit in their chair, how they make eye contact (or do not) to the specific things they say to us. A person who misinterprets these cues might find it difficult to handle the job interview and even get employed on a regular basis. It is an essential skill we often take for granted.
Another serious set of problems are those related to behavior as noted in the research by Lynch, et al (2003). She reported that adolescents who had been exposed to alcohol as unborn children were observed to display “numerous developmental and behavioral problems.” The teenage years are well-known to be difficult and often disruptive as young people begin to experience physical (growth spurts, hormonal changes) and emotional changes. As they attempt to cope with these ever-changing aspects of their lives, the presence of a condition such FAS would only prove to be even more disruptive more them.
Olson, et al (1997) also noted the serious effects on infants, pre-school and school-age children. Her research revealed that these infants and children suffered from “hyperactivity, emotional disorders, speech disorders, and even autism.” Another possible effect of alcohol on unborn children may be their proclivity to develop Attention Deficit Hyperactivity Disorder — ADHD. In order to determine whether there is in fact a connection between the two, first there must be a definitive diagnosis of ADHD and then it must be determined that there is a relationship between the exposure of the individual to alcohol in utero. Coles (2001) conducted a study to try and determine whether or not there is a connection between the two. Citing Mirsky, et al (1991), she states:
The clinical diagnosis of ADHD, although usually reliable, is not based on neurocognitive tests of attention but relies, instead, on clinical observation and on parent and teacher reports. The behaviors measured, therefore, reflect deficits in attention only by inference. In contrast, the methods of neuropsychology and cognitive development use experimental procedures to examine behaviors that reflect the fundamental processes of attention.
It is therefore implicit that the diagnosis of ADHD must be made and in a reliable setting. However, Coles admits in her research that even if the diagnosis can be considered reliable it is still a controversial one. The fact is that a plethora of young people are being diagnosed with ADD and ADHD today which may bring this diagnosis into some question. Yet, Coles also adds that the clinical description of FAS often adds the diagnosis of ADHD as one the primary behavioral characteristics. Her goal was to study the veracity of this claim.
At the conclusion of her study, she came to the following conclusion:
These results call into question the assumption that behavior seen in children with FAS results from the same neurocognitive deficits as those seen in children diagnosed with ADHD. Our comparison of these groups of children showed that even though their impairment on rests of global intelligence was similar, little similarity existed in their pattern of responses. Furthermore, their behavior problems also differed (Ibid).
Therefore, it may be that while specific neuropsychological difficulties in children with FAS are similar to those ADHD, they may not be reflective of the condition itself but rather additional aspects of FAS.
One of the threads in the literature on this topic is the issue of why alcohol has such a profound effect on unborn children. This is an area of research that is actually still in its infancy. However, some of the theories are that alcohol affects specific parts of the brain but possibly not others. If that is the case, then one possibility might be for additional research to determine whether or not any of these effects can be ameliorated and if so, how that could be accomplished. As Randall (2002) states: “The paradox of alcohol is that, although its effects on the developing organism are fairly specific (i.e., heavy prenatal alcohol exposure produces an identifiable syndrome, and certain brain regions are affected whereas others are not), it is also a ubiquitous drug that affects many physiologic systems.”
Another theoretical premise regarding FAS is that of the effect of environmental factors. It is highly likely that many people (women and men) who have become chronic users of alcohol either do not seek out the help they need, or they may not have access to the appropriate services. Some individuals may also experience a strong shame factor, and rather than seek out help they try and go it alone. This leads to a destructive cycle of drinking, trying to stop and drinking again. Practically speaking, there are probably many reasons why they have become alcoholics but they may not feel comfortable accessing the help they need.
According to Kaemingk and Paquette (1999), their research has demonstrated that children with FAS and FAE often have parents (at least one) who are chronic alcoholics. This, in turn, leads to a pattern of instability in the home which may, or may not be a factor in their development. “Although there is no dearth of evidence that children with FAS or FAE have intellectual deficits and problems with adaptive function, determination of the origin of the problems is difficult. Many mothers of children with FAS or FAE are chronic alcoholics.” However, they also go on to state: “It has been suggested that better emotional and social development may be related to more stable home environments (e.g., Streissguth et al., 1985), and one study found that FAS and FAE patients had remarkably unstable family environments with patients living in an average of five homes ( Streissguth, et al., 1991).”
Authors Jacobson and Jacobson (2002) agree with the other authors cited in this review that the initial effects of FAS are not in doubt. As such, they agree that the consumption of alcohol by pregnant women has deleterious effects on their unborn children. Yet, they also believe that other factors are important in terms of the overall development of children with FAS and that the syndrome itself does not necessarily tell the entire story. Their research focused on the subject of child development. One of their conclusions was “ […] the hyperactivity reported in studies of clinic-referred patients may have been caused by social and environmental factors, such as co-occurring attachment disorders, anxiety, and post-traumatic stress disorder.”
This finding supports the research of Kaemingk and Paquette (1999, cited above) that children with FAS may be more likely to have been born into a family that is already maladaptive (to some degree) and have at least one parent who is a chronic alcoholic.
Certainly, one aspect of the issue here is the socio-environmental one. We have known for some time that alcohol consumption certainly does affect the unborn child. One of the questions we must ask is why do some women continue to drink during pregnancy when they have every reason to believe that their behavior will harm their unborn child? The possibility is that some women are not receiving this information/education and if they do, they don’t fully understand it. They may also live in a social/economic setting where other women drink while pregnant and therefore they do as well. Hill, Lowers, Locke-Wellman and Shen (2000) postulate the following:
However, the offspring of mothers who smoke during pregnancy may be those who are most likely to inherit genotypes for antisocial behavior from their mothers. It might be argued that, because of public health campaigns, women are usually informed regarding the risks to unborn children due to smoking and other drug or alcohol use; therefore, those who continue to smoke may be the most behaviorally disinhibited and prone to develop externalizing behavior problems including antisocial and criminal behaviors.
Given the range of difficulties noted in this paper, one must consider that another effect of FAS will be the need for highly specialized services. Indeed, Schonfeld, Mattson, Lang, Delis & Riley (2001) state this outright in their research. “ […] many more children than previously thought could be in need of special services. Evaluation and special service placement of alcohol-exposed children should consider not only those with the FAS diagnosis but all children with heavy prenatal alcohol exposure, including those with average intellectual ability.”
In addition to the obvious need for services, there is a definite need for continued education on the dangers of alcohol on unborn children.
There are also research opportunities in the clinical realm, specifically in the prevention of alcohol abuse by pregnant women, although this endeavor is likely the most challenging of all. More realistic for the immediate future is the investigation of ways to identify heavy-drinking women so that intervention can be made as early as possible in pregnancy or, preferably, before conception (Randall 2001).
The primary information that emanates from all of this research is the fact that children with FAS and FAE suffer from a wide range of neurological, cognitive, behavioral and emotional difficulties. Indeed, as the above quote indicates, one of the greatest hopes we have in dealing with this syndrome is perhaps in the preventive stage. That is, it is additional education is obviously warranted among populations of women who continue to engage in drinking even while pregnant. However, I think it is reasonable to ask just how successful such an education program will be? It is already a widely known fact that alcohol affects the unborn child. Irrespective of this fact, many women continue to drink while pregnant. It is just possible that these behaviors exist among women who already know the risk, but other facts impede their adherence to a healthier regimen. Perhaps not only health education is required but education that addresses a multiplicity of other factors that cause women to continue drinking while pregnant. However, as stated above, it is possible that the women who choose to drink while pregnant may be cognizant of the dangers but other psychological, social and emotional factors impact on their life. For example, if a woman is also coping with clinical depression and living in a poor socio-economic situation, she may not be in an emotional or physical state to deal with her pregnancy in a healthy way. This is only one scenario in a long continuum of possibilities.
There is one final effect of alcohol on unborn children that has recently emerged. It is the notion of fetal abuse. As Bryony Gagan (2002) reports, the subject of FAS became highly political when Cryatal Ferguson, a South Carolina woman, was charged with fetal abuse after authorities decided she had failed to comply with court-ordered treatments. But she wasn’t the only one. After authorities were finished with a high-profile program to arrest women who they felt had failed to comply with appropriate court orders, forty-two woman were arrested. Gagan (Ibid) reports that some were chained to the hospital bed during delivery and “Some of those arrested after birth were dragged away from the delivery room in shackles, still bleeding.”
The facts of this case sparked a national debate as much for the issue of FAS as the politics that causes these arrests to begin with. In an era when Roe V. Wade is under serious threat by conservative minded individuals and politicians, fetal rights in many ways is being used as an adjunct to the abortion debate. As Gagan (Ibid) notes this is only part of the scenario. “Most critically for Ferguson and her fellow plaintiffs, the late 1980s and early 1990s marked both the height of America’s “War on Drugs” and the beginning of the conservative pro-life movement’s shift in strategy from a focus on opposing abortion to an embrace of fetal rights.” This scenarios creates the notion of “intended crime” by arresting women who drink while pregnant and branding them as women who intend to harm their unborn children.
Thus, FAS moves into the political arena. It is no longer only a medical diagnosis or a condition to treat but a possible crime. Women who drink while pregnant may no longer be thought of only as irresponsible but also (possibly by some) as criminals.
The issue of the effects of alcohol on the unborn child offer a multiplicity of difficulties to address and analyze. Within the scope of this paper, I have offered some of the opinions the literature has to offer. Perhaps the strongest message from this review is that education for pregnant women is absolutely imperative. At the same time, we must balance this with the needs of those living with FAS and the diversity of difficulties they face every day. However, as this last article demonstrates, FAS is no longer only a medical issue but a social and political one as well.
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