AAP Article: “Myth: A Diagnosis of a FASD Does Not Change the Treatment Plan” – John Stirling, MD, FAAP

This article appeared the June edition of the Fetal Alcohol Spectrum Disorders (FASD) Regional Education and Awareness Liaisons (REAL) Champions Network e-newsletter, from the American Academy of Pediatrics (AAP).

Guest Editor’s Desk, John Stirling, MD, FAAP

Myth: A diagnosis of a FASD does not change the treatment plan

At first blush, it might appear that there’s little help in a diagnosis of a FASD. After all, most patients don’t come to the pediatrician with a Chief Complaint of Fetal Alcohol Spectrum Disorder. Instead, they show up with academic issues, or behavioral problems related to poor executive function (impulsiveness, ADHD), or emotional dysregulation (dramatic mood swings, violence). The medical diagnostic workup may reveal early exposure to alcohol, but whatever the etiology, the first priority of the treatment plan will always be to manage the behaviors. Second, prenatal exposure to a teratogen like alcohol results in lifelong impairment of CNS function, so even a firm diagnosis of a FASD won’t provide a cure.

On closer reflection, though, recognizing fetal alcohol exposure’s teratogenic effects can provide very useful information to clinicians attempting to manage behavioral problems like these. Consider:

  • Unlike the neurodevelopmental consequences of early trauma or the functional disruptions caused by acute stress, a teratogen’s effects are fixed and permanent. Alcohol preferentially harms brain structures concerned with moderating stress and regulating emotion. These structural (and thus functional) alterations can impair the child’s ability to adapt after a trauma or to learn coping skills in therapy, and a therapist will necessarily take them into consideration in setting goals and choosing an approach.
  • Caregivers’ expectations play an important role in their own parenting choices. Children affected by an FASDoften present challenging behaviors, from oppositional toddlers to teens who lie and steal. It may appear to unsophisticated adults that the child is simply choosing to misbehave. Many parents or foster parents will take such defiance or disregard personally, with adverse consequences for the family relationships. When a caregiver understands that a behavior doesn’t arise so much from a conscious choice as from an uncontrollable impulse or a cognitive deficit (i.e. brain damage), they may find it easier to be patient. Patience and understanding are much more effective in modifying behavior than are anger and punishment, especially with children who cannot help but be poor learners.
  • A child with a FASD can be expected to have a more dramatic response to postnatal environmental stressors. Even when problem behaviors have other, more proximal causes (as in recent sexual abuse or the death of a loved one), the FASD diagnosis can alert professionals and caregivers that the child might have greater difficulty with resilience.

So, it’s really not much of a question after all. The therapeutic process begins with and depends on the provider’s understanding of the patient. Recognizing the influences of this common teratogen on the brain’s development is an important first step to proving relevant and effective interventions.