What About Fetal Alcohol Exposure?

To the Editor: When we saw the title of the Review and Overview article by O’Donnell and Meaney (1), “Fetal Origins of Mental Health: The Developmental Origins of Health and Disease Hypothesis,” published in the April 2017 issue of the Journal, we were overjoyed because we thought this was indication that our field was finally getting a leg up on prevention. Although the thesis of the review was directionally correct (i.e., the quality of fetal growth and development predicting the risk for a range of noncommunicable, chronic illnesses), the review missed one of the most obvious causes of these problems: fetal alcohol exposure. We appreciated the discussion that fetal growth predicts risk for later psychopathology, such as attention deficit hyperactivity disorder (ADHD), but missing was one of the most common causes of low birth weight and prematurity: fetal alcohol exposure.

Fetal alcohol exposure is one of the leading causes of intellectual disability and is associated with impairment in executive functioning, learning, memory, mood or behavioral regulation, attention, and impulse control. DSM-5 lists the prevalence of the proposed diagnosis of neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) as between 2% and 5% in the United States. The problem has been found at even higher rates in other countries. For example, May et al. (2) found rates of ND-PAE of 18.2%−25.9% in four rural communities in South Africa, and Fitzpatrick et al. (3) found rates of 12% in a rural Australian community. More disturbingly, we have found rates of 39% in a family medicine center on Chicago’s South Side (4), and this research revealed that patients—whose mental health problems had fetal origins—were misdiagnosed as having bipolar disorder, depression, schizophrenia, and ADHD.

To the authors’ credit, they did briefly mention that children born small were likely to be born to mothers with high-risk lifestyles that include increased alcohol consumption. However, our study revealed that the vast majority of mothers who were caring for adult children with ND-PAE engaged only in social drinking before they realized they were pregnant (4). We hope this letter to the editor will place more emphasis on more common problems in life, such as ND-PAE.