The damage done to the unborn child by the mother’s consumption of alcohol during pregnancy has been long known. In 1725 the Royal College of Physicians of London referred to the consumption of alcohol as “too often the cause of weak, feeble and distempered children.” Since about 1973 the deleterious effects of prenatal alcohol exposure on the unborn child have come to be known as fetal alcohol spectrum disorder (FASD).
FASD is not a diagnostic term, but is best viewed as an umbrella term for the range of physical, cognitive, behavioural and neurodevelopmental disabilities that result from exposure of the fetus to alcohol. FASD can include abnormalities in the formation of the face, intellectual and learning disabilities, deficits in executive functioning, memory problems, speech and language delays, inattention, hyperactivity, internalising and externalising behavioural problems, and social impairments (Commonwealth of Australia, 2014).
The range and severity of FASD symptoms differ from one individual to the next. The pattern and severity of outcomes for an individual are dependent on the timing, frequency and quantity of alcohol exposure in utero. The spectrum effects of FASD range from subtle neurological, cognitive and behavioural deficits at the lower end of the spectrum to the upper end of the spectrum being fetal alcohol syndrome (FAS) – a condition that is identified according to the following specific criteria:
- growth retardation
- characteristic facial features (small eye slits, thin upper lip and diminished groove between nose and upper lip)
- central nervous system anomalies (including abnormal structure and function, such as intellectual impairment).
Individuals along the FASD spectrum will each experience a specific set of symptoms and a specific set of secondary conditions according to the environment they grow up in. It is important to remember that not all people with FASD will have visible facial characteristics, low IQ, mental illness, violent behaviour or substance addiction. The unique pattern of individual differences in the expression of FASD symptoms makes the assessment of FASD particularly difficult. As a result, FASD appears to be under-recognised and under-treated, particularly in vulnerable populations, such as those living in psychiatric settings, the child welfare system, and juvenile detention and correctional facilities (Standing Committee on Social Policy and Legal Affairs, 2012).
Prevalence and contributing factors
The prevalence of FASD within Australian society is unclear. There is some data bearing upon regional and remote communities, but the true extent of the problem remains largely unknown. It is known to occur in both the Indigenous and non-Indigenous populations, but studies have found higher rates among Indigenous Australians. Such findings are consistent with what is currently known about the harmful pattern of alcohol consumption in some Indigenous communities. Although Indigenous Australians are less likely to consume alcohol than non-Indigenous Australians, those Indigenous Australians who do are far more likely to consume alcohol at harmful levels.
It is likely that FASD is more easily recognised in Indigenous populations than in some non-Indigenous populations due to the concentration of the disorder in some Indigenous communities, whereas the occurrence of FASD may be more dispersed across larger populations. A study of the prevalence of FAS in the Fitzroy Valley communities of Western Australia found, for example, that one in eight children born in 2002 or 2003 have Fetal Alcohol Syndrome (Fitzpatrick et al., 2012).
The Australian Indigenous Doctors Association (2012) asserts that FASD among Indigenous people needs to be addressed from a holistic perspective. They note that the causes of excessive drinking extend well beyond the circumstances of the individual and are a product of a complex mix of interrelated socioeconomic and cultural factors, including dispossession and transgenerational grief, isolation, poverty and trauma. Specific risk factors for Indigenous populations include the following:
- Indigenous women are far more likely to fall pregnant at younger ages and to have more children than non-Indigenous women.
- Although a higher proportion of Indigenous than non-Indigenous women abstain from alcohol, a higher proportion of Indigenous women drink at high-risk levels.
- Indigenous women are more likely to self-medicate with alcohol due to their experience of trauma, grief and loss, family violence and chronic socioeconomic disadvantage.
- There is evidence to suggest that Indigenous women are less likely to reduce their consumption of alcohol during pregnancy than non-Indigenous women.
- Access to prenatal and antenatal services are often not readily accessible to, or accessed by, Indigenous women.
- In some Indigenous communities where there are high levels of alcohol consumption and social dysfunction, drinking is the expected and accepted behaviour for both men and women.
- Cultural factors often confound the proper diagnosis of FASD.
Outcomes for individuals with FASD
Early diagnosis is crucial in addressing the needs of children with FASD and supporting their families in managing the condition. There is evidence from long-term studies that indicates that FASD is associated with poor mental health in adulthood and enduring behavioural, cognitive and emotional difficulties including intellectual and learning disabilities, executive dysfunction, memory problems, speech and language delays, and internalising and externalising behaviour problems. There is also a heightened risk for many secondary disabilities, including comorbid psychiatric conditions, school failure, alcohol and substance abuse problems, and delinquency.
It is commonly reported that adolescence is the most challenging time for families who have a child with FASD. It is a time when not only is the teenager dealing with the usual developmental challenges, but a time when secondary disabilities assert even a stronger influence upon the young person’s adjustment. Issues arising at this time often include disengagement from school, poor peer relationships, and difficulties with mental health, substance abuse and juvenile offending. These issues also arise at a time when the young person is most reluctant to accept guidance and direction from parents and carers and is least inclined to engage with therapeutic services.
The combination of FASD and secondary symptoms invariably leads to social and economic problems, further entrenching the individual in a negative life trajectory. Adolescents and adults with FASD have been described as easily victimised and distractible, as having difficulty handling money, problems learning from experience, trouble understanding consequences and perceiving social cues, having poor frustration tolerance, inappropriate sexual behaviours, substance abuse issues, and experiencing trouble with the law. According to the Australian Human Rights Commission (AHRC), international research reports poor long-term outcomes for children with FASD. Ninety per cent will have mental health problems, 80 per cent will remain unemployed, 60 per cent will come into aggravated contact with the law and less than 10 per cent will be able to work independently by the age of 21 (Australian Human Rights Commission, 2012).
In considering the plight of Indigenous Australians and the level of social and economic disadvantage experienced by many, there is ample reason to believe that FASD is a contributing factor to the maladaptive behaviour that leads to escalating rates of family violence, children being admitted to care, adult imprisonment and suicide.
Early detection of FASD-related conditions in babies and young children is crucial to allow for early intervention to improve long-term outcomes and the life trajectory of individuals with FASD and their families. The National Council on Intellectual Disability noted that there are a number of benefits stemming from the diagnosis of FASD (National Council on Intellectual Disability, 2012):
- Early diagnosis is a protective factor associated with fewer secondary disabilities.
- Diagnosis assists families and the person with FASD to understand their behaviours in terms of neurological damage, rather than that they are wilfully misbehaving.
- A diagnosis helps parents and caregivers set realistic and appropriate expectations for their child.
- Diagnosis can be a dual diagnosis of child and birth mother. The birth mother may be able to receive counselling from this point.
- Diagnosis of one child may mean successful intervention with the mother to prevent the birth of another child with FASD.
Diagnosis of FASD, however, presents a number of difficulties for clinicians and others working with individuals and families affected by this condition. These include the stigma attached to acknowledging maternal alcohol consumption as the primary cause of dysfunction, particularly the inherent blame that the mother is likely to experience as a result of such a diagnosis. There is also a reportedly low level of knowledge among health professionals about FASD, and a seeming preference for a diagnosis of attention deficit/hyperactivity disorder, autism spectrum disorder or general developmental delay, even in the case of confirmed prenatal alcohol exposure. The scope and complexity of the FASD spectrum, and until recently the lack of a nationally recognised diagnostic tool have also been factors that have contributed to the under-diagnosis of FASD in Australia (Bower & Elliot, 2016).
Key issues for psychology
It is important that there is a willingness to consider the impact of fetal exposure to alcohol as a primary diagnosis. This involves practitioners being informed and educated in relation to developments in this field, as well as supporting research initiatives that seek to expand and improve our knowledge of this condition and how best to treat and manage it. For practitioners working with Indigenous clients the possible impact of FASD upon individual development should be equally considered along with other environmental and physiological factors that are relevant in the conduct of any assessment. Our knowledge and understanding of FASD is still emerging and there is much to be done to establish an evidence-base that can guide and direct effective intervention with children, young people, adults and their families who struggle with FASD.
- Australian Human Rights Commission. (2012). Inquiry into Foetal Alcohol Spectrum Disorders : Australian Human Rights Commission Submission to the Standing Committee on Social Policy and Legal Affairs. Retrieved from https://www.humanrights.gov.au/sites/default/files/content/legal/submissions/2012/201200207_FASD.pdf
- Australian Indigenous Doctors’ Association. (2012). Australian Indigenous Doctors’ Association (AIDA) Submission in response to the inquiry into Foetal Alcohol Spectrum Disorder (FASD). Retrieved from https://www.aida.org.au/wp-content/uploads/2015/03/Submission_19.pdf
- Bower, C., & Elliott, E. J. (2016). Australian Guide to the diagnosis of Fetal Alcohol Spectrum Disorder (FASD). Retrieved from http://www.apsu.org.au/assets/Uploads/20160505-rep-australian-guide-to-diagnosis-of-fasd.pdf
- Commonwealth of Australia. (2014). Closing the gap Prime Minister’s report. Retrieved from https://www.dpmc.gov.au/sites/default/files/publications/closing_the_gap_2014.pdf
- Fitzpatrick, J. P., Elliott, E. J., Latimer, J., Carter, M., Oscar, J., Ferreira, M., . . . Hand, M. (2012). The Lililwan Project: Study protocol for a population-based active case ascertainment study of the prevalence of fetal alcohol spectrum disorders (FASD) in remote Australian Aboriginal communities. BMJ Open, 2(3). doi: 10.1136/bmjopen-2012-000968
- National Council on Intellectual Disabilities (2012). Submission to the House of Representatives Standing Committee on Social Policy and Legal Affairs inquiry in Foetal Alcohol Spectrum Disorders. Canberra: National Council on Intellectual Disabilities.
- Standing Committee on Social Policy and Legal Affairs. (2012). FASD: The hidden harm: Inquiry into the prevention, diagnosis and management of Fetal Alcohol Spectrum Disorders. Retrieved from http://www.aph.gov.au/Parliamentary_Business/Committees/House_of_representatives_Committees?url=spla/fasd/report.htm