FETAL ALCOHOL SYNDROME
DEFINITION
Fetal alcohol syndrome (FAS) is a cluster of irreversible birth
abnormalities that are the direct result of heavy drinking during
pregnancy.
CAUSE
Alcohol, like most other drugs, passes easily through the mother's
placenta and into the fetal bloodstream. In the fetus, the alcohol
depresses the central nervous system and must be metabolized by the
immature liver of the fetus, which cannot effectively process this
toxic substance. The alcohol stays in the fetus's body for a prolonged
time (even after leaving the mother's body) and the unborn child
remains intoxicated, possibly suffering withdrawal symptoms after the
alcohol is no longer present.
DIAGNOSIS
Children born with fetal alcohol syndrome typically are smaller in
size, have smaller heads, and suffer deformities of limbs, joints,
fingers, and face, as well as heart defects. They may also have cleft
palate and poor coordination.
In some children, FAS does not appear until adolescence, when they
exhibit hyperactivity and learning and perceptual difficulties. These
impairments are symptomatic of minimal brain dysfunction (MBD), which
affects between 5 and 19 percent of schoolchildren, according to a
study by the National Institute of Alcohol Abuse and Alcoholism.
Studies of children with FAS who are now teenagers have uncovered new
physical problemsear infections, hearing and vision loss, and
dental problems that were not identified when the children were
first studied at a younger age.
Only a small percentage of the children born to alcoholic women
suffer FAS. The reasons for this are unknown, although it is thought
that some children have an increased genetic sensitivity to alcohol.
Maternal risk factors for this condition include:
- Chronic drinking during pregnancy
- Previous problems with drinking
- Previous children
- Being African-American
Some studies have shown that female light-to-moderate
drinkers (so-called social drinkers) give birth to babies with subtle
alcohol-related neurological and behavioral problems. Although these
problems are less severe than those in children of heavy drinkers,
these findings indicate that lesser amounts of alcohol can also cause
developmental and behavioral abnormalities.
TREATMENT AND PREVENTION
Pregnant women should abstain from all alcoholic beverages. Women
attempting to conceive should also abstain.
MIDDLE STAGES
In the middle stages of alcoholism, the compulsion to begin drinking
manifests itself earlier in the day. The drinker prefers
alcohol-related activities and friends who drink. An increasing
tolerance for alcohol is accompanied by an increasing lack of control,
drunkenness, and blackouts, a type of amnesia that allows functioning
(such as making dinner or driving) but which blots out memory of the
occasion later on. Drinkers in the middle stages of alcoholism may go
in and out of a series of blackouts during one drinking episode.
At this stage of alcoholism, the first drink of the day sets up a
craving for more, and the desire for alcohol overwhelms common sense
or what is socially appropriate. (Alcoholics Anonymous members say,
"It is the first drink that gets you drunk.") Loss of
control while drinking may not inevitably cause drunkenness each time
(that is a function of the unpredictability of the drinker's
behavior), but sooner or later, that "first drink" will lead
to an episode of overindulgence. As the disease progresses, the
certainty of getting drunk increases.
Drinkers in this stage begin to be secretly ashamed and worried
about lack of control. They may try to control their drinking or stop
completely, but these attempts often fail. They may switch brands or
kinds of alcohol and go from hard liquor to beer. They may seek a
"geographic cure," moving to a new city or job in an attempt
to cut down, or they may look fruitlessly for some other external
formula that will successfully alter their drinking behavior.
Eventually the alcoholic exhibits signs of denial, one of the chief
psychological symptoms of alcoholism. By refusing to accept the fact
of alcoholism, denial allows the drinker to keep drinking while
repressing inner conflict. In the midst of the growing problems linked
to alcohol consumption, drinkers blame everything except alcohol for
their plight. Rationalizations for drinking become manifest, and
unhappy relationships, financial difficulties, and work problems are
all blamed for the need to drink. What the drinker fails to comprehend
and denies strenuously is that the heavy drinking is not the result of
these problems but the cause.
Although drinkers claim they drink to relieve fatigue, anxiety, and
depression, alcohol, in large amounts, exacerbates these feelings.
Heavy drinking also brings out feelings of anger, self-loathing, and
lack of selfesteem and may produce rages expressed against family
members and friends.
As drinking progresses, alcoholics experience:
- Stomach upset
- Minor hand tremors
- Increased tolerance for alcohol
- Morning hangover and shaking hands that require tranquilizers or
alcohol to treat.
FINAL STAGES
Persons suffering late-stage alcoholism finally grow obsessed with
alcohol to the exclusion of almost everything else. They drink despite
the pleading of family and the stern advice of doctors. They may begin
round-the-clock drinking despite an inability to keep down the first
drinks in the morning. Although relationships with family and work may
become completely severed, nothing, not even severe health problems,
is enough to deter drinking.
The late-stage alcoholic suffers a host of fears, including fear of
crowds and public places. Constant remorse and guilt is alleviated
with more drinking. On top of mental disturbances, debts, legal
problems, and homelessness may complicate his or her life. Latestage
addiction is characterized by cirrhosis and severe withdrawal symptoms
if alcohol is withheld (shakes, delirium tremens, and convulsions).
Without hospitalization or residency in a therapeutic community,
late-stage alcoholics usually succumb to insanity and death.
People suffering alcoholism do not have to "hit bottom"
and reach the extreme late stages of alcoholism to decide to get help.
Many men and women have recognized their alcohol problems before they
lost their jobs or families, or began drinking in the morning,
suffered DTs, or had to be hospitalized. For them, the labels
"early stage," late stage," "problem
drinker," or "alcoholic" were less important than the
fact that their growing powerlessness over alcohol was causing them
pain.
DIAGNOSIS OF ALCOHOLISM
In some cases, the "diagnosis" of alcoholism is made by the
courts, as when a judge hands down a drunk driving sentence that
includes a requirement to attend Alcoholics Anonymous (AA), or to
enter a rehabilitation program. The emergency rooms of hospitals make
such diagnoses when a man or woman appears suffering from alcohol
poisoning or withdrawal. Some doctors, however, may miss the diagnosis
of alcoholism, in part because patients rarely admit to excessive
consumption; 50 percent of persons with alcoholism seen by doctors are
incorrectly diagnosed.
Families may diagnose alcoholism when a family member is
hospitalized for the disease or when a spouse leaves because of a
drinking problem. However, families may suffer from alcoholism denial
in which they completely or partially deny the problem.
TREATMENT OF ALCOHOLISM
Alcoholism enjoys a good recovery rate once the alcoholic stops
drinking. Treatment takes many forms because there are many kinds of
alcoholics, each with special needs. Treatment sources include
hospitals, alcoholism units within hospitals, private clinics designed
solely for the care of alcoholics, residential alcoholic
rehabilitation facilities, self-help groups such as Alcoholics
Anonymous, and private practitioners such as alcoholism counselors,
psychologists, psychiatric social workers, and psychiatrists.
For a small number of alcoholics, a brief stay of 3 to 10 days in a
detoxification center may be necessary. Candidates for detoxification
are those who suffer withdrawal symptoms because of the alcohol
addiction. At the detox center (hospital unit, nonmedical alcoholism
facility, or other institution) the alcoholic's body can clear itself
of the alcohol's toxic effects. The patient is cared for with rest,
nutritious diet, abstinence from alcohol, and careful medical
attention, which may include medication to reduce anxiety and manage
withdrawal symptoms and psychiatric evaluation to determine the
presence or absence of treatable psychiatric disorders such as
depression or anxiety. Treating these, however, will not treat the
alcoholism, but not treating them is likely to be associated with
failure of the alcoholism treatment.
For long-term care, the alcoholic can recover at a rehabilitation
center or in the inpatient treatment unit of a hospital. These centers
provide alcohol-free environments; continued medical care; group,
individual, and family therapy; classes about alcoholism; and regular
Alcoholics Anonymous meetings.
Alcoholics Anonymous (AA) and its subgroupsAl-Anon for family
members of alcoholics and Alateen for teenage children of
alcoholicsare self-help organizations that provide experienced
advice and support for alcoholics and their families. From 7,000
responses to an informal survey the organization sent to its members
in the United States and Canada, 29 percent indicated they had
remained sober for more than 5 years, 38 percent for 1 to 5 years, and
33 percent for less than 1 year. Sixty percent of the respondents had
sought counseling for alcoholism prior to joining AA. While a
scientific analysis of the sobriety success rate for AA is difficult
(the organization does not keep membership lists and does not promote
itself with sobriety rates), most experts recognize AA as the core of
any alcoholic therapy. The "12-step" approach of AA has been
widely copied in other selfhelp groups.
Outpatient care is also available to patients at rehab centers,
allowing individuals to return to work and home while receiving
therapy. These centers do not "dry out" alcoholics but
provide therapeutic settings in which a bridge back to a normal life
can be built.
Many alcoholics do not require detox centers or rehab programs but
start treatment with a thorough physical exam by a doctor to diagnose
possible alcohol-related conditions. The doctor can ease the
alcoholic's mind by giving him or her a clean bill of health or by
setting up a schedule of continuing care to manage chronic health
problems.
Early recovery from alcohol is marked by:
- Occasional thoughts of drinking, especially at times of stress
or at cocktail hour. Although the compulsion to drink may be
absent, drink desires are a natural reminder of years of drinking
and should gradually diminish and need not be alarming.
- Mood swings. Elation may yield to discouragement and tears.
Gradually these wide shifts of mood should moderate.
To combat the early problems of recovery, the alcoholic
should:
- Receive plenty of patience from friends and family.
- Take adequate rest and a nutritious diet.
- Join a support group such as AA to share experiences with other
people suffering alcoholism.
To help with sobriety, some alcoholics receive Antabuse
(disulfiram), a drug that intervenes in the liver's alcohol
metabolism, preventing the breakdown of acetaldehyde (an intermediate
product of alcohol metabolism). After the administration of Antabuse,
even a small sip of alcohol produces acetaldehyde accumulation and
nausea, vomiting, severe headache, breathing difficulties, blurred
vision, lowered blood pressure, and feelings of impending death.
Antabuse use must be consented to by the recovering alcoholic with
the clear understanding of its effects. The drug neither alters the
alcoholic's mood nor removes urges to drink. Not an instant solution
or complete therapy, this drug deters drinking and can play a useful
part in treatment if it makes recovering alcoholics feel
"protected" from alcohol while learning to stay sober.
Antabuse is administered only until the recovering alcoholic feels
ready to live without it; it is not taken long term.
The narcotic antagonist Naltrexone has recently been approved by
the FDA for use in treating alcoholism. It appears to diminish
alcohol's pleasurable effects and thus helps keep a "lapse"
from becoming a "relapse." Like Antabuse, it is not a
cure-all and should be given in the context of relapse prevention
training and supportive counseling.
Mood-altering drugs such as tranquilizers may occasionally be
administered during recovery to quell anxiety. However, one drug habit
should not be substituted for anothertranquilizers may be
addicting. While some emotional conditions such as manic-depressive
psychosis require pharmacological solutions, sobriety should generally
be drug-free. This should not prevent individuals who need
medications, such as for severe depression, from taking them. While
some AA groups discourage even lithium or antidepressants, the Central
AA Council recognizes the important role such medications can play for
some recovering alcoholics.
LIVING SOBER
Quitting drinking is only the first step in recovering from
alcoholism. Learning to live without alcohol requires adjustment in
attitudes, values, and lifestyles. If serious psychological
disturbances have developed because of drinking, psychiatric
counseling designed for alcohol abusers may be required. Occupational
rehabilitation or vocational guidance also may be necessary.
Abstinence is the absence of alcohol or drugs; sobriety is a way of
life. Recovery begins where formal treatment leaves off, and this
lifelong process never ends. In developing a new way of life, many
factors play a part. Recovering alcoholics should avoid people,
places, and objects associated with their drinking. After being sober
for some time, alcoholics should make new friends and engage in new
activities by going to school, returning to work, learning a new
hobby, doing volunteer work, or renewing a lost association with their
churches or religious groups.
Positive addictions should be substituted for alcohol addiction:
Walking, jogging, sports, or a regular schedule of exercise promotes
well-being and self-esteem and provides a healthy outlet for energy.
Research indicates that exercise releases brain chemicals that
stimulate a natural high. Even a walk after dinner can act as a
tranquilizer that helps alleviate the urge for alcohol.
PREVENTION OF ALCOHOL
ABUSE
The National Institute on Alcohol Abuse and Alcoholism defines
moderate drinking as an average of not more than two drinks per day,
and estimates that 15 million adults (15 percent of the drinkers in
the United States) consume more than that amount. The 15 percent of
men and 3 percent of women who ingest more than four drinks a day risk
a serious drinking problem. Anyone, even safe drinkers, can become a
statistic when one night's overindulgence leads to a drunk driving
incident, a violent family argument, an incapacitating hangover, or
some other mishap.
Efforts at moderation do not have to be prohibitionist or
puritanical. Americans need to view moderation or abstinence as
life-enhancing choices rather than negative self-denial.
In a statement of goals, the U.S. Department of Health and Humans
Services has sought:
- A freeze in the per capita consumption of alcohol
- No increase in the proportion of adolescent drinkers
- A reduction in the cirrhosis death rate and the number of deaths
from alcohol-related accidents
- A reduction in the infants born with fetal alcohol syndrome
- Increased general public and adolescent awareness of the risks
associated with alcohol abuse
Because alcohol use is generally accepted in modern society
and alcohol is constantly available (while treatment for alcoholism is
not always easy to obtain), these goals present a constant challenge.
Most problem drinkers are not presently receiving formal treatment
apart from what AA offers. The available treatments are most effective
for socially stable, middle-class alcoholics and least effective for
the homeless without families.
The need to provide increased services of better quality to those
with alcoholism is urgent. The major burden of coping with this
complex drug problem continues to fall on the individuals and families
most directly affected. A further enlightened public policy on
alcoholism addressing legal drinking ages, liquor labeling, laws
governing drunk drivers, and public education is still necessary.
A variety of sources of information about alcoholism is available.
The Yellow Pages lists resources under "Alcoholism." Local
chapters of the National Council on Alcoholism provide information and
referrals. Alcoholics Anonymous and Al-Anon family groups are listed
in both the white and the Yellow Pages of the telephone directory. For
printed materials, contact the National Clearinghouse of the National
Institute on Alcohol Abuse and Alcoholism. (For more information see
appendix B, Directory of Health Organizations and Resources.)
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