Children of alcoholism

Robert (a pseudonym) was removed from the care of his biological mother and stepfather at age nine, following multiple reports to social services of what an adoption officer later described as the worst case of child neglect they had ever seen. Dangerously underweight, dirty and badly clothed, at age nine Robert had not been properly toilet trained, had underdeveloped speech and communication, and seemed to have had more interaction with the family's dogs than with his own parents. He was regularly locked in a cupboard, forced to scavenge for food in bins and sleep on a soiled mattress, and may have been sexually abused. His mother had documented long-term alcohol misuse issues and had continued to drink heavily through pregnancy, resulting in Robert's fetal alcohol spectrum disorder (FASD; the name given to a range of conditions that can result from prenatal exposure to alcohol). Although this was mentioned to Robert's adoptive family at placement, the implications were not carefully spelled out.

Years later, during Robert's teenage years, his adoptive parents took him to see Dr Raja Mukherjee, the consultant psychiatrist who now runs the National Clinic for Fetal Alcohol Spectrum Disorders in Surrey – the only specialist FASD clinic in the UK. After a thorough assessment, Robert was diagnosed with alcohol-related neurodevelopmental disorder (ARND). One of the more common diagnoses in the fetal alcohol spectrum, ARND is characterised by the same learning difficulties, speech and language delays and behavioural problems as the more widely recognised fetal alcohol syndrome (FAS), but without a distinctive set of craniofacial abnormalities, making ARND an 'invisible' disorder. This can lead to a further risk of adverse development, as it can be more difficult for caregivers to effectively advocate for the educational needs of a child who appears to be physically healthy (Streissguth et al., 2004). Due to a reluctance to diagnose or seek diagnosis through fear of stigma, the difficulty of obtaining an accurate history, and a lack of knowledge amongst professionals (Mukherjee et al., 2015), FASD is thought to be significantly under-diagnosed, not least in the UK (Morleo et al., 2011). A recent meta-analysis by Roozen and colleagues concluded that around 2 per cent of all newborn babies worldwide are probably affected by FASD, and that in countries where women regularly consume alcohol the rate is likely to be higher.

As a teenager, despite having been looked after by a caring family for many years, Robert seemed unable to grasp the importance of personal hygiene, and still struggled with bedwetting and many related behavioural issues. He would still go to bins to look for food, despite having access to a well-stocked kitchen and having surpassed his healthy weight to become a strapping young man. His intelligence, speech and language, executive function and social cognition were all seriously delayed, but his meek, submissive attitude endeared him to teachers, who were reluctant to move him on to a special educational needs unit. Outside the classroom, however, Robert was an easy target for bullies, and was almost involved in a serious accident having been persuaded into the middle of a busy road by boys he called friends. Robert was eventually transferred to a special school where he began to develop his interests in football and horse riding.

FASD and early traumatic experiences

The wide range of social and behavioural difficulties suffered by young people like Robert are the result of learning difficulties and other cognitive deficits, particularly in speech and language, memory, attention and impulsivity (Mattson et al., 2011) that can result from prenatal exposure to alcohol. Deficits in these basic skills can lead to frustration, hyperactivity and a lack of empathy. These cognitive deficits can occur due to the organic brain damage sustained by prenatal exposure to alcohol. Illicit drugs are often a factor, and there is evidence that poly-drug use can lead to a compounding impact on brain damage (Rivkin et al., 2008).

The brain damage, cognitive deficits, and social and behavioural problems that characterise FASD have been described as strikingly similar to those caused by early traumatic experiences such as neglect and abuse. This can occur through a number of mechanisms, including the extended stress response. Human infants are not capable of regulating their own emotions, and so rely on a recognisable caregiver to calm them in times of stress. If an infant is denied the attention of a loving parent, either in cases of neglect where they are absent, or in cases of abuse where the caregiver is the source of stress, the infant will experience extended periods of anxiety. This can lead to chemicals such as cortisol being released in dangerously large quantities in the infant's developing brain, leading to abnormal or stunted growth, and permanent brain damage. This is just one example of how early trauma can lead to brain damage, but just as in cases of prenatal exposure to alcohol, the impact on cognitive faculties can be wide-ranging and significant, and these deficits invariably lead to behavioural problems, inattention, a lack of social awareness, and ultimately social exclusion.

In a 2011 NSPCC survey, over a quarter of British 18- to 24-year-olds reported being the victim of some form of severe maltreatment during their lives, the majority of which having been inflicted by a parent or guardian. Among young people who have histories of traumatic experiences, the rate of FASD is thought to be much higher. This is especially true of children in care in the UK, where figures from Adoption UK suggest 61 per cent have a history of traumatic experiences, and around 30 per cent are thought to suffer from FASD (Selwyn & Wijedesa, 2011).

All this points to a close relationship between FASD and traumatic experiences, but very few studies have sought to investigate this interaction. Young people who suffer both exposures will presumably be worse off in the long-term than children with either one exposure, but is there a predictable pattern? For children like Robert and his adoptive family, a thorough picture of how these two exposures interact is crucial for understanding and predicting difficulties, particularly as the child approaches adolescence, when social and behavioural problems can become more harmful. These are understudied and often overlooked disorders, each of which receives some level of research attention independently, but surprisingly little as an interrelated pair of exposures.

New research

In October 2016 I began a three-year PhD research project at the University of Salford, to investigate the impact of traumatic experiences on children with FASD. The first step of any research project is to identify what is already known. A systematic review revealed only five published studies that had sought to investigate the combined effects of prenatal exposure to alcohol and early traumatic experiences. The review showed that children with both exposures are more likely to have deficits in speech and language, intelligence, attention, memory, and a wide range of emotional and behavioural issues than children with only one exposure. The methods used in these studies, their quality, and their results varied widely, but the overall conclusion of the review was that a child like Robert, who is exposed to alcohol prenatally, and to traumatic experiences during his early years, can expect to suffer compounding effects to their cognitive, social and behavioural development compared to a child with either one exposure.

This may seem obvious, and indeed this result was expected, but it is the details that matter to prospective caregivers and professionals. Clinics like the National Clinic for Fetal Alcohol Spectrum Disorders provide invaluable support and advice as well as diagnoses to the caregivers of young people like Robert. The aim of this project is to provide more accurate information to these kinds of professionals and families, since almost all research has assessed either young people with FASD or young people with a history of traumatic experiences, rather than the interaction of exposures.

Over the next two years, I will investigate the impact that traumatic experiences have on empathy, executive functioning, behavioural development and intelligence in children with FASD. I will also explore the use of brain imaging technology, and the impact that raising children with these kinds of histories can have on families. I hope that this can go some way to improving the support available to young people like Robert and their families, and perhaps encourage other students and prospective researchers to take an interest in what is a worryingly overlooked field.

'As a parent myself, it can be upsetting to hear about the lives of some of the children involved in my research. People who have a traumatic start to life can often present some of the greatest challenges to those who look after them. The families of children like Robert are some of the most amazing, talented and hard-working people I've met… it's an honour to work alongside them.'

- Alan Price is a PhD Researcher in the School of Health Sciences at the University of Salford [email protected]

Image: Ben Harley

Key sources

Mattson, S.N., Crocker, N. & Nguyen, T.T. (2011). Fetal alcohol spectrum disorders. Neuropsychology Review, 21(2), 81–101.
Morleo, M., Woolfall, K., Dedman, D. et al. (2011). Under reporting of foetal alcohol spectrum disorders. BMC    Pediatrics, 11(1), 1.
Mukherjee, R., Wray, E., Curfs, L. & Hollins, S. (2015). Knowledge and opinions of professional    groups concerning FASD in the UK. Adoption & Fostering, 39(3), 212–224.    
Rivkin, M.J., Davis, P.E., Lemaster, J.L. et al. (2008). Volumetric MRI study of brain in children with intrauterine exposure to cocaine, alcohol, tobacco, and marijuana. Pediatrics, 121, 741–750.
Roozen, S., Peters, G.J.Y., Kok, G. et al. (2016). Worldwide prevalence of fetal alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research, 40(1), 18–32.
Selwyn, J. & Wijedesa, D. (2011). Pathways to adoption for minority ethnic children in England: Reasons for entry to care. Child & Family Social Work, 16(3), 276–286.
Streissguth, A.P., Bookstein, F.L., Barr, H.M. et al. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Journal of Developmental & Behavioral Pediatrics, 25(4), 228–238.