ARE MOTHERS WHO DRINK HEAVILY IN PREGNANCY VICTIMS OF FAS? Maud Rouleau,BSc, Zina Levichek, MD, Gideon Koren, MD, FRCPC ABSTRACT Background Consumption of large amounts of alcohol in pregnancy adversely affects the fetus and may result in Fetal Alcohol Spectrum Disorder. Because of the familial trend of problem drinking, it is possible that women drinking heavily in pregnancy were also victims of FAS through their mother s drinking. Objective To examine the possibility that women drinking in pregnancy were also affected by alcohol use in their mothers. Method A cohort study was conducted at Breaking the Cycle program in Toronto, where mothers of young children or expecting mothers with problem drinking and drug abuse, and their children are followed and treated. Women s alcohol use, depression, alcohol use in pregnancy, as well as learning difficulties, and their mother s alcohol consumption were assessed and compared to the general population. Results All 173 women who passed the first contact stage and were followed by the program were included in this study. One hundred and sixty-five women reported problem drinking, and 64 of them reported being raised by a mother with problem drinking. Rates of depression, learning difficulties, suicide attempts, drinking in pregnancy and criminality were 6-fold higher than in the general population, and their educational levels substantially lower than the Canadian average. Conclusions A substantial proportion of women drinking heavily in pregnancy were born to women who drank heavily. Their characteristics, including rates of learning, disability, criminality and psychiatric morbidity, suggest that a substantial proportion of them are afflicted by ethanol embyropathy. Further studies should examine these women directly for the diagnosis of FAS. From the Motherisk Program, Division of Clinical Pharmacology/Toxicology, The Hospital for Sick Children and the University of Toronto. Supported by grants from the Canadian Institute for Health Research. INTRODUCTION Fetal alcohol syndrome (FAS) is characterized by complex physical and neurodevelopmental abnormalities resulting from maternal alcohol consumption during pregnancy. Adverse alcohol effects on the fetus typically include prenatal and/ or postnatal growth, central nervous system and craniofacial anomalies of the child 2. Craniofacial abnormalities include characteristics such as small palpebral fissure, an indistinct philtrum, an elongated thin upper lip, a low nasal bridge and microcephaly 3. FAS falters the child s normal growth and usually holds a devastating impact on the central nervous system, which may result in
irrevocable and permanent brain damage, mental retardation, memory and attention deficits, learning difficulties, hyperactivity, behavioural disorders, speech impairment, faulty coordination, and much more 3-4. It has been shown that genetics are involved in the development of alcoholism in both men and women 5. In addition, heavydrinking patterns may be due to familial and environmental exposure to drinking behaviour. Hence, the problem drinking evolves from a combination of both genetic and environmental factors as seen in twin studies, which fail to demonstrate 100% agreement rate of alcoholism in identical twins 6. Gender-related differences in alcoholism suggest that genetics are more prevalent among men, whereas more environmental influence is seen in women 7. For example, the differential inheritance patterns for alcoholism were illustrated among Swedish adoptees, where genetic influence was evident in men, whereas environmental factors affected both sexes 8. A maternal inheritance of alcohol consumption has been demonstrated in a study including 913 Swedish adopted women, in which daughters of drinking mothers had a four-fold increase in the rate of alcohol abuse when compared to rates of alcoholism in daughters of drinking fathers 5. However, the alcohol abuse in these adopted women was considerably less prevalent than in their biological mothers, illustrating the importance of environmental factors in the development of alcoholism in women. Breaking the Cycle (BTC) is a diagnosis and treatment program in Toronto for substance abusing or recovering women who are either pregnant or have at least one child under the age of six. The goals of this program are to support the recovery and improve parenting skills of these women through different programs. BTC offers the services of psychologists, addiction and child development counsellors, parent-child therapists, mental health counsellors, public 2 health nurses, paediatricians, and pregnancy outreach counsellors to assure that all possible health services are made available for the women and their children. BTC also offers basic needs support such as clothing exchange for the mother and child, daily lunch, and transportation. The participation of the women in BTC program is 100% voluntary. While women attend support groups, supervision of their children is made available. We hypothesized that many alcoholic women giving birth to a child, had been afflicted by FAS due to alcoholism in their mothers. As a first step in addressing this hypothesis, we characterized these women and their biological mothers in areas relevant to FAS. METHODS Study Population The study population was composed of all women managed by BTC since its inception in 1995 and until July 2001. All 252 files were reviewed, and 173 contained a mother s intake form, which, for the purpose of this study, included sufficient information about the women participating in BTC. The rest of the women did not continue in BTC beyond the initial contact. The intake forms were reviewed and relevant data were extracted, including mother s age, mother s alcohol and other drug use in pregnancy, highest school grades completed, post-secondary education, learning difficulties, mother s alcohol and drug abuse history, medical and psychological problems, rehabilitation and detoxification treatment history, family history including alcohol and other drug abuse, as well as significant medical and psychological problems such as suicide attempts and mother s criminal record. The information recorded in the intake forms had all been collected by a one-to-one interview of the woman by a staff counsellor at BTC upon the woman s first few visits to the program.
Data Analysis Characteristics of women attending BTC were compared to those in the general population by chi-square analysis. RESULTS Of the 173 mother s intake forms, 170 contained information about women s alcohol and / or substance abuse, as well as their family history of alcohol and / or substance abuse. Of these 170, 165 (97%) reported different degrees of alcohol use and 115 (69.7%) of them had at least one parent with a problem drinking. Of 170 women, there were 64 cases (37.7%) where the mother of the patient was a problem drinker. Out of 167 women, 38 (22.8%) reported experiencing learning difficulties in school. Of the 173 intake forms including information about the women s health and psychiatric morbidity, 80 (46.2%) of women reported experiencing depression at some point of life. Of those 80 cases where depression was reported, 12(15%) had a mother with depression. environmental factors 5,6. Our study aimed at examining whether problem-drinking mothers exposing their fetuses to the risk of FAS were also likely victims of alcohol embryopathy. At least one-third of our patients were reared by problem drinking mothers. It is likely that the true figure is higher, due to poor recall, and the fact that some of these women were adopted. When compared to the general population, our patients had very high rates of learning disabilities, criminality, depression, suicide attempts and shorter education. These characteristics are very typical of alcohol related neurodevelopmental disabilities (ARND). Various degrees of learning disability are hallmarks of Fetal Alcohol Spectrum Disorder (FASD), resulting in substantially shorter education. High rates of criminality have been repeatedly described in FAS, and it is estimated that a large number of prison inmates in Canada are victims of FAS. Psychiatric morbidity, including depression and suicide attempts occur in the vast majority of FASD cases. The proportions of women in the study groups with alcohol consumption (97.1%), depression (46.2%), criminal activities (55.9%) were significantly higher when compared with the female population in Canada 1 (Table 1). The suicide attempt rate of the studied group (46.4%) was compared to the American suicide attempt rate 9-10 for the general population, since Canadian data were not located. The education level of the BTC patients was significantly lower than the general population, with only half of the expected rate of post-secondary education. Figure 1 also shows the differences in rates of problem drinking (defined as 7 or more drinks per week), in the BTC group (64 cases, 37.65%) and the general population (6.38%). All differences were highly significant (P< 0.001). DISCUSSION There is convincing evidence that alcoholism in women involves genetic as well as These figures strongly support the hypothesis that many of the mothers giving birth to children with FAS are themselves victims of the same condition, due to the genetics of maternal alcoholism. Any strategy to diagnose and manage FAS should include assessment of the natural mother for the same diagnosis. Such diagnosis is important to address the serious problems of the mother, as pre-requisite to ensure optimal management of the baby by the mother with fetal alcohol damage. REFERENCES 1. Statistics Canada. (2000). Women in Canada 2000: A gender-based statistical report. Catalogue no. 89-503-XPE. Ottawa: Ministry of Industry. 2. Goodstadt MS, Caleekal A: Alcohol Education programs for University Students. A Review of their Effectiveness. International Journal of Addictions 1984;19(7)v. 3
3. FAS link. Fetal Alcohol Syndrome: Information, Support & Communication Link. Accessed July 28, 2001. URL: www.acbr.com/fas/index.htm#sites. 4. American Academy of Pediatrics. Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorders. Pediatrics. 2000;106(2):358-360. 5. Bohman M, Sigvardsson S, Cloninger R: Maternal Inheritance of Alcohol Abuse: Cross- Fostering Analysis of Adopted Women. Arch Gen Psychiatry.1981;38:965-9. 6. Blume SB: Gender Differences in Alcohol- Related Disorders. Harvard Rev Psychiatry.1994;2(1):7-14. 7. Pickens RW, Svikis DS, McGue M, Lykken DT, Heston LL, Clayton PJ: Heterogeneity in the inheritance of alcoholism: a study of male and female twins. Arch Gen Psychiatry.1991;48:19-28. 8. Cloninger CR: Neurogenetic adaptive mechanisms in alcoholism. Science. 1987;236:410-6. 9. Sadock BJ, Sadock VA: Kaplan & Sadock s (2000). Comprehensive Textbook of Psychiatry (7 th ed.) (Vol.1, p.501). Philadelphia: Lippincott Williams & Wilkins. 10. Sadock BJ, Sadock VA: Kaplan & Sadock s (2000). Comprehensive Textbook of Psychiatry(7 th ed.) (Vol.2, pp.2038-9). Philadelphia: Lippincott Williams& Wilkins. Table 1: Comparison between BTC group and general population in alcohol consumption, criminal activity, depression, suicide attempt rate, alcohol abuse and education. BTC Gen. Population P values Alcohol Consumption 165 1,893,437 5 4,943,063 Criminal Activity 71 100,746 56 15,287,154 Depression 80 498,665 93 6,337,835 Suicide attempt rate 64 372 74 7,726 Alcohol abuse 64 502,872 106 7,379,128 Education Less than grade 9 23 200,501 9+ but no post secondary 104 1,781,801 post-secondary 43 3,688,414 4
Fig. 1 Comparison of BTC group with General Population 120 97.06 100 Percentages 80 60 40 27.70 55.90 46.24 46.38 37.65 20 7.29 4.60 6.38 0 0.65 alcohol abuse w omen as offenders depression Suicide attempt rate problem drinking Categories 5