Amy Salmon

Medicine, morality and mothering: public health discourses on foetal alcohol exposure, smoking around children and childhood overnutrition

Over the past few decades, three issues have emerged as threats to the health of infants and children in western, industrialised countries: the developmental impact of alcohol use in pregnancy (Foetal Alcohol Spectrum Disorder, or FASD), childrens exposure to second-hand smoke in the home, and childhood overnutrition and obesity. The definitive role of drinking during pregnancy, exposure to second-hand smoke and overnutrition on negative health outcomes in infants and children remains the subject of considerable debate. Nevertheless, all three issues have been medicalised and criminalised: framed as looming health emergencies that require immediate intervention and, increasingly, legislation. However, it is our contention that the alarm these health ‘threats’ currently generate has many of the characteristics of a moral panic. In this paper we unpack the discourses surrounding these three issues, and explore the common focus on maternal responsibility and the ways in which these movements serve to covertly marginalise and stigmatise particular groups of women.

Aboriginal mothering, FASD prevention and the contestations of neoliberal citizenship

Over the past 25 years, Aboriginal leaders, community advocates, childrens and womens health specialists and Canadian government agencies have drawn increasing attention to the perceived need to undertake targeted initiatives to prevent fetal alcohol spectrum disorder (FASD) in indigenous communities. In pursuit of this goal, a range of prevention campaigns have been undertaken – generally with funding from the State – urging pregnant women to abstain from alcohol. Because both risk and protective factors for FASD are intimately connected to the social conditions in which women become pregnant, give birth to and mother their children, FASD prevention campaigns targeting Aboriginal communities suggest possibilities that are both provocative and problematic for advancing movements for social justice, decolonisation and improved maternal and child health. In this essay, I consider how the gendered and racialised legacies of colonisation emerge alongside concerns for improved health and well-being of indigenous children to inform contemporary, state-funded efforts to prevent FASD. In so doing, I examine the ways that neoliberal economic and political trajectories of Canadian state formation intersect with some aspects of decolonisation movements to raise important questions about when, how and under what conditions colonial states support FASD prevention efforts among indigenous peoples.

The international charter on prevention of fetal alcohol spectrum disorder.

The fi rst international conference on prevention of fetal alcohol spectrum disorders was held in Edmonton, AB, Canada, on Sept 23–25, 2013. The conference resulted in the production, endorsement, and adoption of the following international charter on the prevention of fetal alcohol spectrum disorder by more than 700 people from 35 countries worldwide, including senior government offi cials, scholars and policymakers, clinicians and other front-line service providers, parents, families, and indigenous people. It is presented to all concerned in the international community as a call for urgent action to prevent fetal alcohol spectrum disorder. Fetal alcohol spectrum disorder is a serious health and social problem, as well as an educational and legal issue, which aff ects individuals, families, and societies worldwide. The disorder is caused by alcohol use during pregnancy—no known amount of alcohol is safe for a growing embryo and fetus, which can develop extensive brain damage and physical abnormalities from exposure to alcohol. Although early intervention and supportive care can improve outcomes for individuals with fetal alcohol spectrum disorder, the associated cognitive, behavioural, and physical impairments can have devastating implications for the individual, family, and other caregivers. Fetal alcohol spectrum disorder is a lifelong disorder. The cause and consequences of fetal alcohol spectrum disorder have been known for 40 years, yet the disorder continues to affl ict millions of people worldwide—about one in every 100 livebirths. In countries where drinking among women of childbearing age is common, the prevalence of fetal alcohol spectrum disorder can be substantially higher. This disorder is of overwhelming concern in some populations. Fetal alcohol spectrum disorder is preventable. However, one major obstacle to prevention is lack of awareness of the disorder’s existence and of risks associated with women drinking alcohol during pregnancy. Opinionbased advice and confl icting messages from diff erent studies about presumed safe amounts of maternal alcohol consumption cause confusion and contribute to a failure to perceive the risk of fetal alcohol spectrum disorder. Findings from basic research have shown clearly that even low to moderate consumption of alcohol can cross the placenta and interfere with the normal development of the embryo and fetus. Heavy or frequent alcohol use increases the risk of giving birth to a baby with fetal alcohol spectrum disorder. People with fetal alcohol spectrum disorder have additional challenges as a result of their disorder, such as breakdown in family relations, disruption of schooling, unemployment, homelessness, and alcohol and drug misuse. Adolescents and adults with fetal alcohol spectrum disorder are also at high risk of encounters with the criminal justice system, either as off enders or victims. Many individuals go to jail and become repeat off enders and are often victimised themselves. The fi nancial burden of fetal alcohol spectrum disorder on families, communities, and governments is substantial. To address their complex needs, individuals with fetal alcohol spectrum disorder often require additional support in health, social, educational, legal, and correctional services. The associated fi nancial costs are unsustainable for many countries. The cost of people ignoring the problem and not taking action for prevention is going to further increase the strain on scarce societal resources. Although maternal alcohol consumption during pregnancy is the direct cause of fetal alcohol spectrum disorder, many underlying causes exist for drinking during pregnancy. Reasons include women having little information about the risks of drinking while pregnant, drinking before pregnancy is recognised, dependence on alcohol, untreated mental health disorders, and social pressures to drink. The complex biological and social determinants of health, including genetics, poverty, malnutrition, and poor social support networks and personal autonomy, also aff ect drinking behaviour and the severity of its results to the fetus. The risk of alcohol-exposed pregnancy increases with adverse life events, gender-based violence, trauma, stress, and social isolation. Whatever the reasons for women drinking during pregnancy, eff ective prevention strategies need to be identifi ed and addressed within the social, economic, and cultural context of every community. Lancet Glob Health 2014

Developing effective, culturally appropriate avenues to FASD diagnosis and prevention in northern Canada

This article describes 2 research initiatives that are being undertaken by members of the Canada Northwest FASD Research Network, involving collaborations between researchers, clinicians, service providers and community members in the Canadian North. Improving both the diagnosis and prevention of FASD requires evidence-based approaches to clinical and social service delivery that are capable of accounting for the unique contours of the geographic, regional and cultural diversities in which women become pregnant and in which families live. Although FASD has been a priority for communities and governments in northern Canada, research capacity has not been available to support the development of the context-specific knowledge needed to inform policy and practice in this region. Moreover, there have not been adequate mechanisms for transferring practice-based knowledge from the Canadian North to researchers and service providers in the South, who might make use of this knowledge to inform their own practice. Herein, we highlight the ways in which reciprocal knowledge exchange involving CanFASD Northwest researchers at academic health science centres and diverse stakeholder groups is supporting multi-directional capacity building in FASD diagnosis and prevention.

Health profiles of clients in substance abuse treatment: a comparison of clients dependent on alcohol or cocaine with those concurrently dependent

The purpose of this study was to assess whether, among clients receiving substance abuse treatment (n = 616), those dependent on alcohol or cocaine differed significantly from those concurrently dependent on both drugs in terms of physical, mental, social, and economic harms as well as substance use behaviors. Methods: Clients from five substance abuse treatment agencies presenting with a primary problem of cocaine or alcohol were classified into three groups as dependent on: (1) alcohol alone, (2) cocaine alone, or (3) both cocaine and alcohol (i.e. concurrent dependence). Participants completed a self-administered questionnaire that included details of their drug and alcohol use, physical health, mental health, social health, economic health, and demographic characteristics. Results: The concurrent group drank similar amounts of alcohol as those in the alcohol group and used similar amounts of cocaine as the cocaine group. The alcohol group had significantly (p < .05) poorer health profiles than the concurrent group across most variables of the four health domains. An exception was significantly more accidental injuries (p < .05) in the alcohol group. In both bivariate and multivariate analyses, the concurrent group had significantly (p < .05) more accidental injuries, violence, and overdoses than the cocaine group. As well, the concurrent group had significantly (p < .05) higher scores on the anxiety and sexual compulsion scales than the cocaine group, controlling for demographic variables. Conclusion: These findings can aid health care professionals to better respond to issues related to concurrent dependence of cocaine and alcohol.

Good intentions and dangerous assumptions: Research ethics committees and illicit drug use research:

Illicit drug users are frequently identified as a ‘vulnerable population’ requiring ‘special protection’ and ‘additional safeguards’ in research. However, without specific guidance on how to enact these special protections and safeguards, research ethics committee (REC) members sometimes fall back on untested assumptions about the ethics of illicit drug use research. In light of growing calls for ‘evidence-based research ethics’, this commentary examines three common assumptions amongst REC members about what constitutes ethical research with drug users, and whether such assumptions are borne out by a growing body of empirical data. The assumptions that form the focus of this commentary are as follows: (i) drug users do not have the capacity to provide informed consent to research; (ii) it is ethically problematic to provide financial incentives to drug users to participate in research; and (iii) asking drug users about their experiences ‘re-traumatizes’ and ‘re-victimizes’ them.

Prevention of fetal alcohol spectrum disorder FASD : who is responsible?

PREVENTION OF FETAL ALCOHOL SPECTRUM DISORDER FASD: WHO IS RESPONSIBLE? Sterling Clarren, Amy Salmon and Egon Jonsson AN OVERVIEW OF SYSTEMATIC REVIEWS ON PREVENTION, DIAGNOSIS AND TREATMENT OF FETAL ALCOHOL SPECTRUM DISORDER Maria Ospina, Carmen Moga, Liz Dennett and Christa Harstall AN OVERVIEW OF SYSTEMATIC REVIEWS ON PREVENTION, DIAGNOSIS AND TREATMENT OF FETAL ALCOHOL SPECTRUM DISORDER Maria Ospina, Carmen Moga, Liz Dennett and Christa Harstall FIVE PERSPECTIVES ON PREVENTION OF FASD Lola Baydala, Robin Thurmeier, June Bergman, Nancy Whitney and Amy Salmon

Ethical Challenges in Contemporary FASD Research and Practice.

Fetal alcohol spectrum disorder (FASD) is increasingly recognized as a growing public health issue worldwide. Although more research is needed on both the diagnosis and treatment of FASD, and a broader and more culturally diverse range of services are needed to support those who suffer from FASD and their families, both research and practice for FASD raise significant ethical issues. In response, from the point of view of both research and clinical neuroethics, we provide a framework that emphasizes the need to maximize benefits and minimize harm, promote justice, and foster respect for persons within a global context.