Fetal Alcohol Exposure Often Mistaken as Behavioral Issues

Neil Osterweil

January 12, 2015

Children referred to a specialist because of behavioral problems may have undiagnosed fetal alcohol spectrum disorders (FASD), suggest results of a new study.

Among 547 foster or adopted children referred to a children's mental health center for behavioral issues, 156 met criteria for FASD, but 125 (80.1%) had never been diagnosed with prenatal exposure to alcohol, report Ira J. Chasnoff, MD; Anne M. Wells, PhD; and Lauren King, MA, from Children's Research Triangle in Chicago, Illinois.

Of 31 children who had been diagnosed with prenatal alcohol exposure before referral, 10 had a change in their diagnosis to a different disorder within the fetal alcohol spectrum, which represents a 6.4% misdiagnosis rate, the investigators said.

"Although FASD have long been recognized as a leading cause of intellectual disabilities, behavior problems, learning disabilities, and cooccurring mental health disorders, children and adolescents who have been affected by prenatal alcohol exposure often go undiagnosed or are misdiagnosed," Dr Chasnoff and colleagues write in an article published online January 12 in Pediatrics.

The researchers collected data on a sample of 547 children referred to their center for multidisciplinary diagnostic evaluation. They used current diagnostic criteria to identify whether the children should have been diagnosed with FAS, partial FAS, alcohol-related neurodevelopmental disorder, or alcohol-related birth defects.

The investigators note that although children with FAS are usually correctly diagnosed on the basis of growth criteria, central nervous system impairment, and characteristic facial features, other, more common disorders related to prenatal alcohol exposure may be missed.

"Unfortunately, many children and adolescents with FASD go unrecognized and untreated; this is due to multiple factors, including unknown maternal history of alcohol use during pregnancy, lack of consistent facial dysmorphology and growth impairment across all diagnoses within the fetal alcohol spectrum, and the high rate of cooccurring mental health disorders," the authors write.

They hypothesize that in addition to these factors, "the historically confusing language and diagnostic terminology applied to alcohol-affected children, and the perceived stigma against addressing alcohol use by pregnant women most likely contributed to the majority of affected children and adolescents in the current study having been misdiagnosed or missed completely."

The authors point out that only half of American Academy of Pediatrics members surveyed reported being confident in their ability to make a FASD diagnosis and cited evidence that behavioral issues associated with prenatal alcohol exposure are often mistaken for attention-deficit hyperactivity disorder.

Other studies have shown that compared with children without FASD, children with prenatal alcohol exposure tend to have greater verbal and reasoning difficulties and exhibit higher levels of sociopathic behaviors such as stealing or lying, they explain.

Children and adolescents with FASD require "more intense forms of mental health therapy addressing attachment difficulties, behavioral difficulties, and sensory processing deficits," the investigators write.

The study was supported in part by a grant from the US Department of Health and Human Services. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online January 12, 2015.

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