Deborah Brauser

November 4, 2009 (Honolulu, Hawaii) “Psychiatric training in fetal alcohol spectrum disorders (FASDs) is “inaccurate and inadequate,” a national survey of psychiatric trainees reveals.

Presented here at the American Academy of Child & Adolescent Psychiatry 56th Annual Meeting, the survey showed although 40% of respondents reported receiving supervision with a patient with suspected or confirmed FASDs, 70% reported never diagnosing a patient with an FASD, and 51% reported they had never treated a patient with the condition.

In addition, a total of 83% reported they had never used any standardized diagnostic schema at all.

Dr Roy Eyal

“Results from our study show that FASDs are under-recognized by psychiatry trainees, representing missed opportunities for prevention and intervention,” lead investigator Roy Eyal, MD, from the Semel Institute for Neuroscience & Human Behavior at the University of California–Los Angeles, told Medscape Psychiatry.

“While respondents reported seeing hundreds of patients in clinical settings, the majority reported never diagnosing an FASD. With the high prevalence of this disorder, trainees are obviously treating those who have it, they just aren’t recognizing it,” he added.

In addition, only 10% of respondents felt that they were “very much” or well-prepared to diagnose or treat FASDs, with 70% responding that that they are “not at all” or not well-prepared.

Impairing Illness

Past studies have shown that alcohol can affect the development of the human fetus and can cause fetal alcohol syndrome (FAS), which is defined by 4 diagnostic criteria: alcohol exposure, growth retardation, facial features, and central nervous system impairment. It is estimated that FAS affects 1 to 2 of every 1000 live births in the United States.

FASD is a more broadly defined disorder and does not require the facial features or growth problems from FAS, but it does require alcohol exposure and central nervous system impairment. It affects 1 in every 100 live births in the United States. However, significant effects of FASD can occur throughout life and do not differ from FAS.

“About a quarter of the adults with this disorder have made suicide attempts, 94% have a mental illness, almost half have been incarcerated at least once, 80% do not live independently, and almost half of women with children no longer have the children in their care. It’s just a really impairing spectrum of illness that affects a lot of people,” Dr. Eyal explained.

The most important protective factor for individuals with FASDs is early diagnosis, said Dr. Eyal, so the investigators designed the current study to evaluate the quality of FASDs education for psychiatric residents and fellows.

Using a Web-based questionnaire, the researchers collected data from psychiatry trainees across the United States from October 2008 to January 2009. A representative sample of those who responded (n = 308; 64% women, 59% white) was then evaluated. It consisted of trainees from the Northeast (29%), South (26%), West (24%), and Midwest (21%).

Troubling Finding

Most troubling, said Dr. Eyal, was the fact that so many respondents mistakenly reported that “it is safe to drink some alcohol” during the first (6%), second (15%), and third trimesters (30%).

“For the first trimester, almost everyone understood that it is unsafe to drink alcohol. But regarding the third trimester, the ideology is obviously misunderstood.”

“Alcohol is a teratogen throughout pregnancy, especially the third trimester,” said Dr. Eyal. “This is the period of fetal brain development considered to be the most sensitive to the damaging effects of alcohol.”

Finally, only 31% of respondents correctly reported that those with FASDs are at equal risk for adverse outcomes as those with full FAS.

“Even though [FASDs] are 100% preventable, 10% to 15% of women drink regularly while pregnant, and over 3% drink heavily,” reported Dr. Eyal.

National Problem

“Overall, the results revealed that training for psychiatry trainees is inconsistent and inadequate, and they poorly understand the importance of alcohol abstinence throughout pregnancy,” said Dr. Eyal. “In addition, profound underrecognition of FASDs is a national problem.”

He added that the trainees reported making diagnoses of FASDs much more frequently when receiving supervision specifically addressing the disorder. There is also a need for an increased focus on broader education, national recognition, and prevention efforts.

“While it is vital to increase awareness of FASDs in the community, we must first educate our clinicians and continue to expand our knowledge of pathophysiology and evidence-based treatment of this spectrum of debilitating but preventable disorders,” concluded Dr. Eyal.

Accurate Picture

Asked by Medscape Psychiatry to comment on the survey findings, Elise M. Fallucco, MD, clinical instructor in psychiatry, Washington University School of Medicine, St. Louis, Missouri, said she believes they accurately reflect current FASD training.

“Having just gone through psychiatry training myself, I’d say that this is pretty realistic,” she said. Dr. Fallucco was not involved with the study.

She supported Dr. Eyal’s conclusion that there is a need for increased awareness that these are common disorders that are often underidentified and undertreated.

Dr. Fallucco said she would be interested to see what percentage of those with FAS or FASDs “were being picked out by psychiatrists in practice. This poster told us about residents, but I’d like to hear how psychiatrists in the community are doing.”

“I’d also be interested in learning more about the next steps,” said Dr. Fallucco. “Now that we know that this is underidentified, what do we do to get the word out to improve the education of psychiatry residents and make sure that more kids are getting screened and identified? We’ve recognized that there is a problem, now I’m looking forward to hearing possible solutions.”

Dr. Eyal and Dr. Fallucco have disclosed no relevant financial relationships.

American Academy of Child & Adolescent Psychiatry 56th Annual Meeting: Abstract 2.20. Presented October 29, 2009.