Understanding the Similarities and Differences between Fetal Alcohol Spectrum Disorder and Mental Health Disorders
The profound effects of prenatal alcohol exposure were first described in France in 1968 (Lemoine et al. 1968) and in North America in 1973 (Jones et al. 1973; Jones and Smith 1973). The first identified children were born to alcoholic mothers who had consumed significant amounts of alcohol during the pregnancy. The children had clear patterns of physical anomalies (growth deficiency and characteristic facial features) and neurocognitive deficits. Jones and Smith (1973) called this disorder Fetal Alcohol Syndrome (FAS). Later research found that some individuals who had prenatal exposure to significant amounts of alcohol do not show all of the facial features and growth deficiency of full FAS, but they do have significant cognitive deficits, behavioural problems, and mental health concerns This is due to differences in drinking patterns, the timing of exposure in the pregnancy, the quantity of alcohol consumed and other maternal factors such as genetics and nutrition. The full range of outcomes due to prenatal alcohol exposure is called Fetal Alcohol Spectrum Disorder (FASD). FASD includes three medical diagnoses: FAS, partial FAS and Alcohol Related Neurodevelopmental Disorder.
The prevalence of full FAS in the United States is estimated to be 2-7 per 1,000 and that of all the diagnoses under FASD to be 2-5 per 100 (May et al. 2009). However, the prevalence of people with FASD in the criminal justice system (CJS) appears to be disproportionately higher, with estimates of 10% to 23% of youth and adult in correctional facilities (Canadian Institute for Health Information 2008; Fast et al. 1999; MacPherson and Chudley 2007). The effects of significant prenatal exposure to alcohol are life-long and can increase susceptibility to criminal activity, victimization, and mental health problems for youth and adults. In the CJS there is an over-representation of people with FASD, individuals with mental health disorders, and those with both FASD and mental health disorders (Burd et al. 2010; Conry and Fast 2000; Fast et al. 1999; MacPherson and Chudley 2007). In one longitudinal study of adolescents and adults with FASD, 60% had had some contact with the legal system. Those that did appeared to have additional risk factors such as mental illness (Streissguth et al. 1996).
Many individuals, who are not necessarily known to have FASD, have mental health disorders which may contribute to their difficulties in the legal system and trouble with the law. Examples of these disorders are Attention Deficit Hyperactivity Disorder (ADHD), Anxiety Disorders, Bipolar Disorder, Conduct Disorder, Depression, Oppositional Defiant Disorder, Personality Disorders, Psychotic Disorders, and Substance Use Disorders. According to the Correctional Service Canada (CSC) (2010), in the past fifteen years there has been a considerable increase in the number of both male and female offenders with mental health problems presenting to the system and requiring mental health care.
This discussion paper examines the similarities and differences between individuals having a diagnosis of FASD and those having a diagnosis of a mental health disorder. First, the diagnostic process for FASD and for mental health disorders is described. In order to understand the implications of these diagnoses, the behaviours that result from FASD need to be understood. What is less well understood is the overlap between FASD and mental health disorders, that is, the high proportion of those with FASD who also have a mental health disorder and the unknown number of individuals with mental health disorders who may have an undiagnosed FASD. In addition to the primary disability, the FASD or mental health disorder, the interaction with genetics and post-natal environmental factors confounds the diagnostic profile.
2. Diagnosing FASD and Mental Disorders
People can be diagnosed as having full FAS with a confirmed or unconfirmed history of prenatal alcohol exposure because of the three distinctive features (growth deficiency, facial anomalies, and central nervous system dysfunction) which do not co-occur in other disorders. Using the current Canadian Diagnostic Guidelines, people who have only some of the facial features and significant neurocognitive dysfunction are diagnosed as having partial FAS (pFAS), and those with no significant facial features but with significant neurocognitive dysfunction are diagnosed as having Alcohol Related Neurodevelopmental Disorder (ARND) (Chudley et al. 2005). For a diagnosis of pFAS or ARND there must be a confirmed history of prenatal alcohol exposure. Obtaining a history of prenatal alcohol exposure can be extremely challenging, especially for adults being evaluated for FASD. In the past, the term Fetal Alcohol Effects (FAE) was used to describe individuals with pFAS and ARND and appears in the earlier literature.
FASD is the umbrella term used to encompass the range of outcomes caused by prenatal exposure to alcohol; it is not a diagnosis. For convenience, the collective term FASD rather than the specific diagnoses is used in the remainder of this article to describe the effects of this disability.
Assessing for FASD requires both physical and cognitive evaluations. Therefore, it is recommended that it be made by a multidisciplinary team comprised of specialists such as pediatricians/physicians, psychiatrists, psychologists, speech-language pathologists, and occupational therapists, all of whom should be specifically trained in making FASD diagnoses. The physician/pediatrician looks mainly at the physical characteristics and the other members of the team primarily assess brain function and mental health disorders. It is critical to consider other syndromes which may resemble FASD, and consider post-natal factors which can compound the effects of prenatal alcohol exposure and affect brain function (e.g. substance abuse, traumatic brain injury, physical and emotional abuse, or an unstable environment). Individuals with a mental handicap or a traumatic brain injury may have symptoms which can be confused with those from prenatal alcohol exposure.
A diagnosis made at later ages is complicated due to physical features that may change as the child grows into an adult. In follow-up studies by Spohr and colleagues (Spohr et al. 1993; Spohr et al. 1994) only 10% of their original diagnosed group continued to have clearly recognizable features of FAS. People with ARND, who do not have the distinguishing physical features, can be overlooked and misdiagnosed. As individuals become older, it is often more difficult to obtain a reliable history of prenatal alcohol exposure. Because of these factors, making a diagnosis of an FASD is more difficult in adults. Along with these challenges, the capacity for making FASD diagnoses in Canada is limited due to the limited number of health professionals experienced in making assessments.
Evidence of brain damage is an essential criterion in making a diagnosis of any FASD. By definition, all individuals with FASD have significant deficits in multiple areas of brain function. It is now known that people who do not meet the criteria for full FAS (i.e., partial FAS or ARND) can be more severely impaired in brain function than those with full FAS (Streissguth et al. 2004).
People with FASD can show a wide range of intellectual ability (IQ), from mentally handicapped to average or higher (Conry et al. 1997; Streissguth et al. 1996), although the mean IQ for groups studied is in the below average range. Deficits in intellectual ability alone do not explain the challenges of a person with FASD. Some individuals with FASD may present as more competent than they are because of their average IQ, but struggle in their day-to-day functioning because of their deficits in adaptive function, executive function, language, and memory. In order to make a diagnosis of an FASD, a neuropsychological assessment is done using standardized tests to assess these areas of brain function (Chudley et al. 2005).
The implications of the brain damage for day to day functioning have been described using the acronym “ALARM”: Adaptive Behaviour, Learning, Attention, Reasoning, and Memory (ALARM) (Conry and Fast 2000). People with FASD can show poor judgment, may be easily led by others, may not learn from previous mistakes, and can be impulsive. In the legal system, their problems with language and memory may jeopardize them receiving fair treatment. Individuals with FASD might recite the differences between right and wrong, but in the circumstances react impulsively with no regard for consequences. Their superficial talkativeness can lead others to overestimate their competence and level of understanding. Since people with FASD often have trouble learning from experience and planning for the future, they may not be deterred by traditional consequences in the CJS.
Perske (1994; 2010) studied why the responses and behaviour of individuals with intellectual disabilities may be misunderstood, and his findings can apply to people with FASD. Some of his relevant results include: desiring to please people in authority, watching for clues from the interrogator (guessing what the person wants to hear or simply agreeing without understanding what is being asked), having problems with language and memory, bluffing greater competence than one possesses, taking blame quickly without understanding the consequences, and having a too-pleasant façade (which may be interpreted as lack of remorse). If overwhelmed, the person may “shut down” and this could be seen as defiance. Most of these characteristics would not be typical of the person with only a mental health disorder.
How do we know that the brain deficits identified on the neuropsychological evaluations of people with suspected FASD actually represent brain damage? Brain imaging studies, which have shown structural abnormalities in various brain regions, correlate with these functional brain deficits (learning and behaviour) and may help explain why individuals with FASD develop behaviour difficulties (Astley et al. 2009; Riley et al., 2004). Some of the effects of alcohol on the brain might help explain the impairments in learning, memory, and social skills in people with FASD (Schonfeld et al. 2006).
In contrast to the diagnosis of FASD which is made by a multidisciplinary team, diagnoses of mental health disorders are made by psychiatrists or psychologists, who may or may not be part of a mental health team. The Diagnostic and Statistical Manual IV-TR (DSM-IV-TR) from the American Psychiatric Association (2000) or the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) from the World Health Organization (2007), are the current standards used by psychiatrists in making mental health diagnoses. The DSM-IV-TR provides clinical definitions of mental health disorders based on clusters of symptoms or behaviours while the ICD-10 provides classifications of all medical conditions. The psychiatrist gathers information from the patient, family, and other professionals who have worked with the patient. The psychiatrist uses the guidelines and, informed by experience and clinical judgment, makes the mental health diagnoses.
The DSM-IV-TR is currently under revision. According to the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) Task Force, no definition precisely specifies the concept of a mental/psychiatric disorder (American Psychiatric Association 2010). A proposed definition includes key features as follows: (1) a behavioural or psychological syndrome (2) that reflects an underlying psychobiological dysfunction (3) which results in significant distress or disability. The DSM classification of mental disorders reflects a consensus of current knowledge and does not imply that the condition meets legal criteria for mental disorder.
Currently, the diagnoses under FASD are not clearly evident in the DSM-IV-TR. FAS is listed with “other congenital malformations”. The defining characteristics or criteria for FASD are not described. Therefore, individuals with FASD may be given diagnoses based on subsets of their symptoms found in existing classifications such as “mental retardation”, “attention deficit/hyperactivity disorder” or “learning disorders” and which may not capture the complete profile. Similarly, the ICD-9 or 10 has only FAS in a category: “noxious influences affecting the fetus or newborn” or “congenital malformation syndromes due to known exogenous causes, not elsewhere classified.” The complexity of making a FASD-related diagnosis and the current classification systems familiar to psychiatrists make it unlikely that a FASD diagnosis will be considered or made as part of a forensic psychiatric assessment.
For both general psychiatric and forensic psychiatric assessments, it may be more difficult to obtain the information needed to make a mental health diagnosis when the patient/client is an adult, as that person’s consent is usually needed before contacting other sources of information. In addition, the collateral sources for information may be impossible to locate. Information may be unknown or reported inaccurately, and may be inaccurate in previous reports. If information is available only from the patient/client, and that person is someone with a disability such as FASD, this information could be unreliable (Conry and Fast 2000) and the diagnosis is inaccurate or incomplete. The psychiatrist may not make a diagnosis of FASD if not trained or experienced in that area, if a multi-disciplinary team for FASD is not available, or if information from previous assessments is missing. Nevertheless, even if FASD is not mentioned in a psychiatric report, there is still a possibility that FASD has not been considered or eliminated as a diagnosis.
Forensic evaluations typically do not include assessments of the full range of brain function, as the primary interest or referral question is the query of mental disorder. Psychiatrists have long been interested in the confounding effects of cognitive function on psychiatric disorders. Of particular interest has been the significant difference in IQ levels between those with schizophrenia and healthy controls. Those with schizophrenia demonstrate slightly lower IQs initially compared to healthy controls, and decline with the onset of psychosis (Woodberry et al. 2008). While significantly lower than the controls, the mean IQ was in the average range. Lower IQ has also been associated with increased risk for severe depression, but not bipolar disorder (Zammit et al. 2004). IQ, therefore, is an important finding but not a discriminating feature separating those with FASD from those with a mental health disorder.
When a diagnosis of substance use disorder is made, the possibility of neuropsychological impairment after a long history of substance use needs to be recognized and assessed. Impairments in areas such as memory, attention, learning, and cognitive flexibility are well known. These deficits may or may not be irreversible but predicting the effects is complicated by a host of other factors. Cerebral atrophy has been seen on CT and MRI scans in over half of those with chronic alcohol problems. The use of other drugs can also lead to cognitive deficits (Toneatto 2004). In this regard, those with a long standing substance use disorder may present with similar deficits to those with FASD.
In animal studies, prenatal alcohol exposure was found to have adverse effects on neuroendocrine function, particularly the hypothalamic-pituitary-adrenal axis which plays a key role in response to stress, and that these adverse effects are life-long. The researchers postulated that individuals with FASD may be permanently hyperreactive to stress (Weinberg et al. 2008). Uban et al. (2011) characterized prenatal alcohol exposure as an adverse early life experience that programs neurobiological mechanisms and increases vulnerability to subsequent life stressors, which can then increase vulnerability to mental health disorders such as anxiety and depression.
Thus, there is a similarity between those with mental illnesses and those with FASD with regard to the presence of underlying neuro-psycho-biological dysfunction in both groups contributing to their disorders. There is now scientific research showing that major psychiatric illnesses are caused by the combined influences of genetic and environmental factors (Peay and Austin 2011).The difference is that those with FASD have brain damage from birth and a predisposition to mental health disorders due to genetics and the prenatal alcohol exposure.
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