The Amorebieta Psychology team explains in this article the consequences and symptoms of Fetal Alcohol Spectrum Disorder (FASD), its intervention and how they integrate NeuronUP into it.

What is Fetal Alcohol Spectrum Disorder?

Fetal Alcohol Spectrum Disorder (FASD) comprises a group of disorders caused by prenatal exposure to alcohol. This exposure occurs through maternal alcohol consumption during pregnancy. In this way, alcohol enters the bloodstream of the embryo or fetus via the umbilical cord.

Fetal Alcohol Spectrum Disorder (FASD) Today

Currently, it is estimated that approximately 2 to 5% of the world’s population has FASD. This implies that 9 or 10 out of every 10,000 babies are born with this disorder in the world. In Spain this figure could be somewhat lower, with 6 or 10 children out of 10,000 being born with fetal alcohol spectrum disorder. However, in cases of adoptions it is estimated that up to 50% of children from China, South America and Eastern Europe may suffer from this condition.

Despite this, it is believed that all these figures may not represent the true incidence of the disorder. This is because the stigma surrounding alcohol consumption during pregnancy and the lack of training of professionals in FASD, among other factors, may be leading to an under-diagnosed disorder.

Consequences of FASD for the fetus

Predictably, this exposure to alcohol is not harmless for the future baby. Alcohol can lead to a decrease in the amount of blood flow in the placenta and, therefore, the appearance of ischemia, preventing the fetus from receiving the supply of oxygen and nutrients necessary for its proper development.

To all this we should add that alcohol itself, as a teratogenic agent, can generate alterations both in the structure and in the functioning of different systems and organs, with the fetal brain being specifically the main target of alcohol due to its greater metabolic demand.

Consequently, alcohol can generate alterations at the organic, sensory, motor, cognitive, emotional and/or behavioral level. This will inevitably have a negative impact on different areas of the affected person’s life. For example, physical and psychological health, personal autonomy, academic, occupational, social, family, etc. In addition, fetal alcohol spectrum disorder is a chronic disorder and, as such, will stay with the affected person throughout his or her life regardless of his or her stage of development.

The neurobiological basis of Fetal Alcohol Spectrum Disorder (FASD)

The amount of alcohol consumed, the gestational timing of alcohol consumption and the length of time during which the developing brain is exposed to the effects of alcohol will determine how different brain structures will be affected and, consequently, the severity of the associated symptomatology.

Areas affected in Fetal Alcohol Spectrum Disorder (FASD)

Nowadays, thanks to the great advances in neuroimaging techniques, it has been possible to identify the main brain areas and structures that are usually damaged in FASD. These areas are:

Frontal lobe

This brain area is responsible for higher cognitive functions. That is, those functions that in some way differentiate us from other species. These functions include executive functions. Such as reasoning, planning ability, problem solving, cognitive flexibility (ability to adapt to changes or seek different solutions to the same problem), abstract thinking and adaptation to the environment. Also, language and other functions such as motor control are controlled by this lobe.

In general, it could be said that most of the neural circuits of the cerebral cortex and, therefore, of the frontal lobe develop during the third trimester of gestation. Thus, if alcohol exposure occurs during this last trimester, the different functions described above are more likely to be affected than in other periods.

Parietal lobe

This lobe plays an important role in spatial awareness (awareness of our position with respect to the environment and surrounding objects), motor coordination in relation to space and mathematical ability. The development of this lobe, like the development of the frontal lobe, usually occurs in the third trimester of gestation, so that if exposure to alcohol occurs during this last trimester, the different functions described above are more likely to be affected than in other periods.

Corpus callosum

One of the most frequently malformed structures in individuals with FASD is the corpus callosum. The most frequent malformations usually include a reduction of its thickness, an alteration of its shape or in the most extreme cases an agenesis (total absence) of the structure. It is the largest interhemispheric fiber bundle in the human brain, thus connecting brain areas of both cerebral hemispheres. This structure is involved in temporal tasks (tasks involving time management/estimation), motor and coordination tasks (ability to perform efficient movements in a precise, fast and orderly manner).

Hippocampus

This is the brain structure with the greatest responsibility in mnestic processes such as learning and memory. It is also important to note that other structures such as the cerebral cortex are also involved in these processes. Exposure to alcohol before or during the third trimester of gestation can cause damage to this structure and, therefore, to the ability to learn new information and remember it later.

Amygdala

This small almond-sized structure is responsible for regulating our emotional (fear) and behavioral (attack or flight) reactions to the environment. This brain structure is often seen with a smaller size than expected for it due to neuronal death induced by exposure to alcohol during pregnancy. As a result, people with fetal alcohol spectrum disorder have difficulty regulating emotions and often present high anxiety.

Caudate nucleus

This structure is part of the basal ganglia and plays a fundamental role in motor functioning. In addition, it is also involved in cognitive functioning, such as executive functions (planning and performing tasks) and motivation.

Nucleus Accumbens

Links to reward, pleasure, laughter, addiction, aggression and fear. Thanks to this brain structure we are able to learn from positive or negative experiences and events. People with FASD often have difficulty learning from experiences and their consequences. Therefore, reprimands, punishments or rewards do not usually have a great effect in modifying or reinforcing their behaviors.

Cerebellum

This brain structure is involved in both motor functioning (balance and coordination) and cognitive processing (attention, verbal language, mnesic processes, executive functioning, etc.) It is a structure that, like the cerebral cortex, finishes developing in the postnatal period, so that if the fetus is exposed to alcohol at the end of the third trimester, the functions it is responsible for may be affected.

Most common symptoms in FASD

As a consequence of the neurological damage described above, fetal alcohol spectrum disorder is characterized by the presence of different cognitive, emotional and/or behavioral symptoms:

Cognitive symptoms

Among the cognitive symptoms that can be observed in FASD are difficulties in global intellectual performance, so that sometimes there may be a gap between the chronological age and the mental age of the person. However, it is also not uncommon to observe a heterogeneous cognitive profile, involving the impairment of some cognitive functions, while others are preserved. In fact, difficulties in language development are common, with a notable discrepancy between verbal and nonverbal functioning. In addition, fetal alcohol spectrum disorder may also present with specific learning difficulties in reading, writing or mathematics.

Other more generic functions that may also be affected are:

• Attentional capacity.

• Speed with which information is processed.

• Learning and memory.

• Executive functioning.

• Cognitive flexibility.

• Verbal and visuospatial reasoning.

• Decision making.

• Anticipation of consequences of one’s actions.

• Following instructions.

• Generalization of learning to different contexts.

• Comprehension of abstract concepts.

• Social cognition.

• Hyper/hyposensitivities in relation to visual, auditory and tactile stimuli.

Emotional symptoms

At the affective level, self-esteem problems are common, as well as the presence of symptoms or even anxiety and depression disorders. In addition, it is not unusual to find difficulties in understanding, identifying and self-regulating one’s own emotions, which would include a low tolerance to frustration, and as a consequence may show inappropriate behaviors (impulsive or aggressive) as a means to express their discomfort.

During childhood this can lead to the frequent occurrence of tantrums and during adolescence or adulthood to frequent anger and arguments. These are usually associated with a high level of resentment and a tendency to blame and hold others responsible for the different situations that may have occurred or for one’s own behavior.

Behavioral symptoms

On the other hand, at the behavioral level, in some cases, a delay in psychomotor development can be observed, which can affect both gross and fine motor skills. Another behavioral symptom commonly associated with FASD are symptoms of hyperactivity and impulsivity, which is why children with fetal alcohol spectrum disorder are sometimes misdiagnosed as having Attention Deficit Hyperactivity Disorder (ADHD). Also, cognitive and, therefore, behavioral flexibility are often affected, leading to a limited ability to adapt to changes or unforeseen events and the need to follow extremely rigid routines.

In addition, as is easy to predict, given the various difficulties they may present at the cognitive level, limitations in relation to adaptive or autonomous functioning are also common. Also, there may be difficulties in complying with norms and rules, to a lesser or greater extent, with legal problems being more common in people with FASD than in people without this condition. To all this should be added the greater likelihood of psychoactive substance use. Finally, at the social level, difficulties in interacting with others may also be observed due to poor development of social skills.

Likewise, possible cognitive immaturity or difficulties in emotional management. All this can lead to different consequences such as the person losing interest in social relationships and tending to isolation. Also, they may not be able to maintain long-term relationships or be able to identify and assertively express their own needs. As well as establishing relationships with people of a younger age or being easily influenced or manipulated, among others.

Fetal Alcohol Spectrum Disorder (FASD) Intervention

Once the diagnosis of FASD has been confirmed, and the different cognitive, emotional and behavioral areas affected have been identified, an individualized intervention plan adapted to the child, adolescent or adult in question should be established. This individualized plan may therefore require both psychotherapeutic and neuropsychological intervention.

The frequency with which the person should attend one or both types of intervention will be determined on the basis of the severity of the difficulties detected and the impact they are generating in their daily life as well as in their close environment. This frequency may be reduced as the effectiveness of the intervention becomes evident and the interference of fetal alcohol spectrum disorder in the person’s life becomes less.

Neuropsychological intervention

Specifically, the neuropsychological intervention will improve the cognitive and functional performance of the person with FASD through:

• Repetitive stimulation of affected cognitive functions.

• Specific training in those day-to-day activities that are not being performed adequately.

• The use of preserved cognitive functions and external resources (agendas, alarms, augmentative communication systems, etc.) as a way to compensate the affected functions.

In order to provide a more intensive intervention and get more out of the different window periods, from our psychological office we always offer the possibility of combining face-to-face sessions with telerehabilitation sessions. In this way, between one face-to-face session and another, the child, adolescent or adult with fetal alcohol spectrum disorder can continue to stimulate their cognitive functioning, and improvements can be observed in a shorter period of time.

How do we integrate NeuronUP in our FASD interventions?

It is precisely in the neuropsychological intervention where we integrate the use of the cognitive rehabilitation platform NeuronUP in the treatment of people with fetal alcohol spectrum disorder.

NeuronUP, with its multiple activities aimed at stimulating different cognitive functions, is a useful tool in the design of both face-to-face and telerehabilitation sessions.

The first face-to-face sessions allow the neuropsychologist to identify those specific cognitive processes that, when affected, may be hindering the performance of each activity or game. This allows the neuropsychologist to offer more specific feedback to the patient and to continue planning the intervention on an individualized basis.

The second allows the person to continue working from the comfort of their own home. This means less time spent traveling to the center and a considerable reduction in intervention costs.

Finally, the diversity of activities available, their attractive design and the possibility of adapting and gradually increasing their level of difficulty, makes it easy for our children, adolescents and adults with FASD to maintain their motivation throughout the intervention and to entertain themselves while stimulating and improving their cognitive performance.

Bibliography

• Alcantud, F., Alonso, Y., y Jiménez, E. (2012). Trastornos del desarrollo asociados con la exposición al alcohol durante el embarazo y la lactancia. Valencia: Nau Llibres.
• Caputo, C., Wood, E., & Jabbour, L. (2016). Impact of fetal alcohol exposure on body systems: A systematic review. Birth Defects Research Part C: Embryo Today: Reviews, 108(2), 174-180.
• Chandra, D. Zieff, M. Schwartz-Bloom, D. (2008). Understanding Fetal Alcohol Spectrum Disorders (FASD): A comprehensive guide for pre-K 8 educators. The Iceberg.
• Guerri, C. (2010). Nuevos programas de información y prevención en Europa para reducir los riesgos del consumo de alcohol durante el embarazo y la aparición del Síndrome Alcohólico Fetal y sus efectos relacionados. Adicciones, 22(2), 97-100.
• Hoyme, H. E., Kalberg, W. O., Elliott, A. J., Blankenship, J., Buckley, D., Marais, A. S., … y Jewett, T. (2016). Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders. Pediatrics, 138(2), e20154256.
• Maya-Enero, s., Ramis-Fernandez, S., Astals-Vizcaino, M. and Garcia-Algar, O., (20229. Perfil neurocognitivo y conductual del trastorno del espectro alcohólico fetal. Anales de Pediatría, 95, 208.e1-208.e9.
• Wilhoit, L. F., Scott, D. A., y Simecka, B. A. (2017). Fetal alcohol spectrum disorders: characteristics, complications, and treatment. Community mental health journal, 53(6), 711-718.

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