Kenneth R. Warren

Fetal Alcohol Spectrum Disorders: An Overview

When fetal alcohol syndrome (FAS) was initially described, diagnosis was based upon physical parameters including facial anomalies and growth retardation, with evidence of developmental delay or mental deficiency. Forty years of research has shown that FAS lies towards the extreme end of what are now termed fetal alcohol spectrum disorders (FASD). The most profound effects of prenatal alcohol exposure are on the developing brain and the cognitive and behavioral effects that ensue. Alcohol exposure affects brain development via numerous pathways at all stages from neurogenesis to myelination. For example, the same processes that give rise to the facial characteristics of FAS also cause abnormal brain development. Behaviors as diverse as executive functioning to motor control are affected. This special issue of Neuropsychology Review addresses these changes in brain and behavior highlighting the relationship between the two. A diagnostic goal is to recognize FAS as a disorder of brain rather than one of physical characteristics.

National Institute on Alcohol Abuse and Alcoholism report on moderate drinking.

In support of the 2005 update of the U.S. Department of Agriculture/U.S. Department of Health and Human Services Dietary Guidelines, the National Institute on Alcohol Abuse and Alcoholism was asked to assess the strength of the evidence related to health risks and potential benefits of moderate alcohol consumption, with particular focus on the areas of cardiovascular disease, breast cancer, obesity, birth defects, breastfeeding, and aging. The findings were reviewed by external researchers with extensive research backgrounds on the consequences and benefits of alcohol consumption. This report now serves as the National Institutes of Healths formal position paper on the health risks and potential benefits of moderate alcohol use.

Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders

The adverse effects of prenatal alcohol exposure constitute a continuum of disabilities (fetal alcohol spectrum disorders [FASD]). In 1996, the Institute of Medicine established diagnostic categories delineating the spectrum but not specifying clinical criteria by which diagnoses could be assigned. In 2005, the authors published practical guidelines operationalizing the Institute of Medicine categories, allowing for standardization of FASD diagnoses in clinical settings. The purpose of the current report is to present updated diagnostic guidelines based on a thorough review of the literature and the authors’ combined expertise based on the evaluation of >10 000 children for potential FASD in clinical settings and in epidemiologic studies in conjunction with National Institute on Alcohol Abuse and Alcoholism–funded studies, the Collaborative Initiative on Fetal Alcohol Spectrum Disorders, and the Collaboration on FASD Prevalence. The guidelines were formulated through conference calls and meetings held at National Institute on Alcohol Abuse and Alcoholism offices in Rockville, MD. Specific areas addressed include the following: precise definition of documented prenatal alcohol exposure; neurobehavioral criteria for diagnosis of fetal alcohol syndrome, partial fetal alcohol syndrome, and alcohol-related neurodevelopmental disorder; revised diagnostic criteria for alcohol-related birth defects; an updated comprehensive research dysmorphology scoring system; and a new lip/philtrum guide for the white population, incorporating a 45-degree view. The guidelines reflect consensus among a large and experienced cadre of FASD investigators in the fields of dysmorphology, epidemiology, neurology, psychology, developmental/behavioral pediatrics, and educational diagnostics. Their improved clarity and specificity will guide clinicians in accurate diagnosis of infants and children prenatally exposed to alcohol.

Fetal alcohol syndrome: Historical perspectives

Fetal alcohol syndrome (FAS), the most severe manifestation of the adverse effects of alcohol on foetal development, was first described in the French medical literature by Lemoine et al. in 1968 [Les Gfants des parents alcholiques: anomalies observes a propos de 127 cas (The children of alchoholic parents: anomalies observed in 127 cases). Quert in Medicine 8, 476-482]. Five years later, Jones et al., 1973. Pattern of malformation in offspring of chronic alcholic mothers. Lancet 1, 1129-1267] were the first to delineate systematically the association between maternal alcohol abuse and a specific pattern of birth defects and to provide diagnostic criteria for this condition. Several diagnostic systems have since been developed with a view to capturing the wide spectrum of physical and behavioral anomalies resulting from prenatal alcohol exposure. The purpose of the current paper is to outline the evolution of FAS as a medical diagnosis.

Alcohol research: past, present, and future.

Created forty years ago, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) has played a major role in the great strides made in the understanding, treatment, prevention, and public acceptance of alcohol‐use disorders. Throughout most of U.S. history “habitual drunkenness” was viewed as a problem of moral degeneracy or character flaw inherent in the individual. However, the wealth of scientific evidence amassed throughout NIAAAs history has established alcoholism as a medical condition, that is, as a disease for which affected individuals should feel no shame or be treated with disdain. We look at the developments in alcohol epidemiology, typology, etiology, prevention, and treatment research over the past 40 years. We also discuss how NIAAA addresses alcohol disorders from a life‐course framework, affecting all stages of the lifespan, from fetus through child, adolescent, and young adult, to midlife/senior adult, with each stage involving different risks, consequences, prevention efforts, and treatment strategies.

Fetal Alcohol Spectrum Disorders: When Science, Medicine, Public Policy, and Laws Collide.

Historically, alcohol has been used for different purposes including as a part of religious observances, as a food, at times as a medicine and its well-known use as a beverage. Until relatively recently these purposes have not changed and have at times been at odds with one another, resulting in collisions among policies and practices in science, medicine, public policy and the law. One area in which this has been particularly true is that of fetal alcohol spectrum disorders (FASD) where the adverse consequences of consumed alcohol on children in the womb and after birth may have been observed since antiquity, but the actions taken based on such observations have been influenced as much by the socio/cultural/political context of the times in which they were made as by evidence of harm. This article provides an overview of the inherent confusion when new scientific findings confront prevailing medical practice, the history involved in this confusion with respect to FASD, including public policy and legal issues that have arisen around alcohol and pregnancy, and the research and clinical challenges still being faced.

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

The conception of the ABCD study: From substance use to a broad NIH collaboration

Adolescence is a time of dramatic changes in brain structure and function, and the adolescent brain is highly susceptible to being altered by experiences like substance use. However, there is much we have yet to learn about how these experiences influence brain development, how they promote or interfere with later health outcomes, or even what healthy brain development looks like. A large longitudinal study beginning in early adolescence could help us understand the normal variability in adolescent brain and cognitive development and tease apart the many factors that influence it. Recent advances in neuroimaging, informatics, and genetics technologies have made it feasible to conduct a study of sufficient size and scope to answer many outstanding questions. At the same time, several Institutes across the NIH recognized the value of collaborating in such a project because of its ability to address the role of biological, environmental, and behavioral factors like gender, pubertal hormones, sports participation, and social/economic disparities on brain development as well as their association with the emergence and progression of substance use and mental illness including suicide risk. Thus, the Adolescent Brain Cognitive Development study was created to answer the most pressing public health questions of our day.

A Review of the History of Attitudes Toward Drinking in Pregnancy.

BACKGROUND It is now well accepted in pediatrics and obstetrics that prenatal alcohol is a teratogenic agent and the primary causative factor underlying fetal alcohol spectrum disorders (FASDs), although for the majority of the 20th century that knowledge was either unknown or ignored. At least 2 factors contributed to the delay in recognizing alcohols role in teratogenicity: the rejection of earlier evidence pertaining to alcohol and pregnancy following the repeal of Prohibition in the United States, Canada, and several European countries; and misinterpretation of earlier research findings in a eugenic rather than toxicological context. The pervasive belief held well into the 1970s that there was no risk to either mother or fetus from prenatal alcohol posed a major challenge to changing physician and public attitudes on alcohol and pregnancy. This review provides insight on key events that occurred in changing physician and public understanding of the risks posed by prenatal alcohol use in pregnancy. METHODS Historical review of events primarily in the U.S. federal government, found in referenced documents. RESULTS The transition in physician and public understanding of the risks posed by prenatal alcohol use was aided by the existence of National Institute on Alcohol Abuse and Alcoholism (NIAAA) which was created in 1971. This government agency was able to support research on alcohol and pregnancy immediately following the 1973 published clinical reports calling attention to a proposed fetal alcohol syndrome (FAS). These early research studies provided the foundation for the first government health advisory on alcohol and pregnancy, issued by NIAAA in 1977. Subsequently, the U.S. Food and Drug Administration (FDA) used this new knowledge on FAS in their effort to add alcoholic beverages to the range of products with ingredient and consumer information labeling. The ensuing hearings and actions resulted in a new health advisory under the auspices of the Surgeon General, encouraging avoidance of alcohol consumption in pregnancy. In subsequent years, Congressional attention to the FAS issue resulted in the Alcoholic Beverage Labeling Law. CONCLUSIONS The pace at which understanding of the risks of prenatal alcohol moved forward from a total misunderstanding to acceptance was aided by both the efforts of the NIAAA in its support of research, and the FDA in its efforts to improve consumer information. Today, many women in the United States as well as other countries continue to ignore advisories on avoiding alcohol consumption in pregnancy, emphasizing the need for persistence in education on these health risks.

Alcoholic liver disease and pancreatitis: Global health problems being addressed by the US National Institute on Alcohol Abuse and Alcoholism

The review article summarizes the mission of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) with focus on the NIAAAs current and future research version for alcoholic liver disease and alcoholic pancreatitis.