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VOLUME 21 NUMBER 3

SEPTEMBER 2004

Alcohol before birth


A woman who drinks while pregnant could be giving her child a poor start in life.
n all likelihood, the environmental toxin that presents the greatest danger to
the greatest number of unborn children today is alcohol. Heavy drinking by a
pregnant woman can have devastating
effects on the unborn childs body and
brain. Despite increasingly wide public understanding of these effects, they are still
too common and difficult to prevent.
For centuries, medical observers noticed
physical and mental defects in children of
alcoholic women without agreeing on a
cause. Many blamed the symptoms on
heredity, or on the dietary deficiencies and
infectious diseases that often accompanied
alcoholism. It was only in the 1960s that
scientists and physicians began to arrive at
a better understanding of the problem and
identified the disorder now known as fetal
alcohol syndrome.

The symptoms
Children with severe fetal alcohol syndrome have a characteristic look. They are
short and thin, with small heads and distinctive facial features, which may include
drooping eyelids, a short upturned nose
with a low bridge, a thin upper lip, a bulging
forehead, and a receding chin. Some also
have heart, kidney, or urinary tract defects,
poor muscle tone or joint articulation, and
other physical disabilities.
But in most cases, their emotional and
intellectual limitations are more serious.
Many are mildly retarded; the average IQ is
about 70, putting them in the lowest 2.5%
of the population. But even those with normal intelligence suffer impaired learning,
memory, judgment, and impulse control.
They may be hyperactive and distractible,
and they have difficulty appreciating the
consequences of their actions or behaving

appropriately in social situations. Because


the source of these deficiencies is not always
obvious, they often seem simply stubborn
and uncooperative. They may eventually
become isolated and depressed adolescents
and adults who are drawn into petty crime,
drug addiction, and alcoholism. Women
with fetal alcohol syndrome often become
alcohol abusers themselves and thus risk
giving birth to children with the syndrome.
There are so many symptoms, and they
vary so much from person to person, that
the description of fetal alcohol syndrome
sometimes resembles an encyclopedia of
childhood (and adult) psychiatric disorders. But the pattern is just uniform enough
to suggest a distinct brain pathology,
which is substantiated by experiments that
show slow learning and hyperactivity in
the offspring of rats given high doses of
alcohol during pregnancy.
Fetal alcohol syndrome in its classic and
visible form is not the only result of drinking during pregnancy. The effects can be
subtler and less disabling, depending on
the amount of drinking, its pattern, and its
timing, as well as heredity and the mothers
diet and other health habits. Some terms
now used for milder forms of the syndrome
are alcohol-related neurodevelopmental
disorder, fetal alcohol spectrum disorder,
and simply fetal alcohol effects.
Fetal alcohol syndrome is almost certainly the most common known cause of mental retardation in the United States, but its
actual prevalence is uncertain. Medical
records are not always accurate, and diagnosis is not always consistent. The symptoms range from almost indiscernible to
nearly incapacitating, and the cause can be
difficult to identify. According to the best
current estimates, nearly 12,000 children

INSIDE
Depression and pain
They go together and must
often be treated together. . . . . . 4
In brief:
Missing mental health services:
Worldwide, the most serious
problems often go without
treatment. . . . . . . . . . . . . . . . . . 6
Smoking and schizophrenia:
Why are people with schizophrenia addicted to nicotine? . . . . . 6
Omitting medications in
schizophrenia: The costs and
consequences of following or
ignoring doctors orders. . . . . . 7
Improving patient communication: A checklist helps schizophrenic patients say what they
need. . . . . . . . . . . . . . . . . . . . . . 7
Q&A:
What is a therapeutic alliance,
and why is it important? . . . . . .8

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Alcohol before birth continued


Michael Craig Miller, MD
James B. Bakalar, JD
Lester Grinspoon, MD
Mary Anne Badaracco, MD
Paul Barreira, MD
Jonathan F. Borus, MD
Barbara Coffey, MD
Steven H. Cooper, PhD
Christopher B. Daly
Frank W. Drislane, MD
Anne K. Fishel, PhD
Donald C. Goff, MD
Alan I. Green, MD
William E. Greenberg, MD
Shelly Greenfield, MD, MPH
Thomas G. Gutheil, MD
Michael Hirsch, MD
J. Allan Hobson, MD
Steven J. Kingsbury, MD, PhD
Michael J. Mufson, MD
Andrew A. Nierenberg, MD
Hester H. Schnipper, LICSW, BCD
Barbara Wolfe, PhD, RN
Editorial Board members are associated with
Harvard Medical School and affiliated institutions.
They review all published articles.

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Founding Editor
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HARVARD MENTAL HEALTH LETTER

are born each year in the United


States
with
fetal
alcohol
syndrome 1 in 500 to 1 in 2,000
live births. At least three or four
times as many babies suffer from
some fetal alcohol effects, so the total
may be as much as 1% of the population. The rate is five times as high
among African Americans and as
much as 10 to 15 times as high
among Native Americans.

Biological mechanisms
Alcohol is what pharmacologists call
a dirty drug, meaning that it acts by
many different mechanisms to produce many different effects. When it
circulates in the bloodstream of a
fetus, it interferes with development
at many points. Heavy drinking can
reduce the amount of food and oxygen carried to the fetus and increase
levels of damaging oxygen free radicals. It upsets the regulation of cell
growth, causing premature cell death,
preventing the generation of new
cells, and altering the structure and
placement of existing ones. In brain
cells, it can prevent the generation of
synapses and the protective cover of
myelin and interfere with the action
of neurotransmitters.

Resources
National Organization on Fetal
Alcohol Syndrome
www.nofas.org
800-66NOFAS
Substance Abuse and Mental
Health Services Administration, Fetal Alcohol Spectrum
Disorders Center for
Excellence
www.fascenter.samhsa.gov
866-STOPFAS (786-7327)
Information about prevention
studies is available from the
Computer Retrieval Information
on Scientific Projects database.
crisp.cit.nih.gov

www.health.harvard.edu

Neuroimaging of children with


fetal alcohol syndrome shows abnormalities in the size and shape of their
brains. The frontal lobes, the seat of
judgment and planning, may be
smaller than normal; the corpus callosum, which joins the brains two
hemispheres, may be damaged. The
brains sensitivity to alcohol is probably greatest in the early stages of
pregnancy, sometimes before a woman knows she is pregnant.
In severe fetal alcohol syndrome,
organic brain damage is often complicated by a difficult family and social situation. Many of these children
have no effective family because of
their parents alcoholism, so they must
go into foster care, group homes, or
institutions. They need the whole
range of services offered to retarded
and emotionally disturbed children.
They must be carefully taught skills
that most children learn almost
automatically, and their self-esteem
is so fragile that they should not be
exposed much to failure. They require
clear and consistent limits, with immediate consequences for breaking
rules. Cognitive behavioral therapy
may teach them how to control their
moods and impulses.
Studies show that most children
and adults with fetal alcohol syndrome and many with fetal alcohol
effects will eventually need mental
health treatment. In one study, nearly a third of the participating adults
had been in a psychiatric hospital at
some time. In another study, most of
the participants (all with IQs above
70) suffered from alcohol or drug
dependence and major depression,
while many also had anxiety disorders and eating disorders.

Prevention
The general population is now informed of these risks through public
service announcements, brochures in
doctors offices and clinics, and the
warning labels on alcoholic beverage
SEPTEMBER 2004

How much drinking is too much?


No one knows for sure. Because of
memory limitations, shame, and guilt,
we lack sufficient information on how
much alcohol women are consuming.
In a 1999 telephone survey, 13% of a
sample of pregnant women admitted
that they had taken at least one drink
in the previous month; 3% admitted having consumed four drinks at a time at
least once. Both numbers may be low.
Children of alcoholic women have
many problems, and it is not always
easy to know which ones to blame on
the alcohol they ingested before birth.
According to one estimate, 30%45%
of women who take six drinks a day or
more throughout pregnancy will give
birth to a child with fetal alcohol syndrome. Another study suggests that
as little as two drinks a day throughout
pregnancy may slightly retard growth
and lower IQ by a few points. But a
recent survey of more than 400,000

women found no risk at the level of


one drink per day. The style of drinking
and its timing may also be important; a
few binges early in pregnancy could be
dangerous even if a woman consumes
almost no alcohol after that.
The Surgeon General, National Council on Alcoholism, American Academy
of Pediatrics, and American College of
Obstetricians and Gynecologists have
taken the official position that no
amount of alcohol is safe during pregnancy. These authorities recommend
that women who are pregnant or intend
to become pregnant should not drink
at all, and women who are drinking and
intend to go on drinking should not
become pregnant. Some regard that
advice as puritanical and too difficult
to follow; others believe that if a child
should not be given alcohol after birth,
the fetus should not be consuming
alcohol before birth.

containers that have been required


since 1989. These warnings may persuade light and social drinkers to abstain during pregnancy, but research
shows that they are usually ignored by
the heavy drinkers and alcoholics who
need help most.
A more effective approach may be
screening pregnant and potentially
pregnant women for alcohol abuse.
Physicians and others providing prenatal care are now urged to use a standard screening questionnaire, sometimes in a modified version. Some
professionals are uncomfortable talking about alcohol abuse and wrongly
suppose that women will be offended
if they mention it. But studies show
that women want information even
when they hesitate to bring up the subject. Women whose answers to a questionnaire suggest a need for help may
be given contraceptive advice, cognitive behavioral therapy, or a motivational interview in which they are
asked to weigh the pleasure of drink-

ing against the risk of birth defects.


The interviewer should emphasize hope
rather than fear and promote pride
rather than guilt.
Heavy drinkers may need more sustained counseling, family support, and
other services, especially if they have
previously abused alcohol while pregnant or have already delivered a child
with fetal alcohol effects. They can be
referred to shelters or alcohol treat-

SEPTEMBER 2004

www.health.harvard.edu

ment centers. Programs have also been


developed in jails and prisons, hospital
emergency departments, and clinics for
sexually transmitted diseases.
Unfortunately, the women with the
most serious drinking problems are
least likely to seek prenatal care or
volunteer for treatment. Several states
classify drinking or drug use during
pregnancy as child abuse and permit
loss of custody for women who refuse
treatment. But this and other forms of
coercion raise serious legal and ethical
issues. Constitutionally, womens privacy is protected unless a compelling state
interest dictates otherwise. Research
has shown that coercion keeps women
attending treatment programs but does
not necessarily stop them from drinking. Many professionals who care for
alcoholic women fear that threats of
prison, loss of welfare benefits, or loss
of custody will only frighten them away
from prenatal clinics.
The need to make the public aware
of fetal alcohol syndrome and educate
health and social service professionals
about how to identify the disorder will
continue. So will the need for basic research on alcohol use and the mechanisms of its destructive effects. Above all,
we have to find new ways to persuade
alcoholic women to seek treatment and
develop a better understanding of which
treatments work for them. They can still
make a new start in life; a child born
with fetal alcohol syndrome cannot.

References
Hankin JR. Fetal Alcohol Syndrome
Prevention Research, National Institute
on Alcohol Abuse and Alcoholism
Publications, August 2002.
www.niaaa.nih.gov
Jacobson JL, et al. Drinking
Moderately and Pregnancy: Effects on
Child Development, Alcohol Research
and Health (1999): Vol. 23, No.1,
pp. 2530.
National Institute on Alcoholism and
Alcohol Abuse. Tenth Special Report
to the United States Congress on

Alcohol and Health. National Institute


on Alcoholism and Alcohol Abuse
Publications, June 2000.
www.niaaa.nih.gov
Sokol RJ, et al. Fetal Alcohol Spectrum
Disorder, Journal of the American
Medical Association (Dec.10, 2003):
Vol. 290, No. 22, pp. 29963000.
Streissguth A. Fetal Alcohol Syndrome:
A Guide for Families and Communities.
Paul H. Brookes, 1997.
For more references, please see
www.health.harvard.edu/mentalextra.

HARVARD MENTAL HEALTH LETTER