Questioning Fetal Alcohol Syndrome: a Case Report of Multiple Etiological Factors

Abstract

A 14-year-old, Caucasian, right-handed male presented for neuropsychological evaluation for diagnostic clarification due to attention-deficit/hyperactivity disorder, bipolar I disorder, and oppositional defiant disorder diagnoses and to rule-out fetal alcohol syndrome (FAS) due to aggression, impulsivity, difficulties with authority, and history of legal issues. Patient was born at 29 weeks gestation without complications. Patient’s adoptive mother reported delays in walking, as well as regression in talking, with suspected prenatal alcohol exposure, neglect, and abuse in first 2 years of life prior to being adopted. Patient is currently in detention setting due to recent homicidal ideation toward family member. Neuropsychological and psychological tests were administered to assess for FAS and clarify previous diagnoses, for which psychostimulant and antipsychotic medications have proven ineffective. Results suggest minimal intellectual impairment beyond low general processing speed abilities, minor academic achievement concerns in only sentence comprehension, executive dysfunction specifically in inhibition, inefficient learning with early plateau, and externalizing behaviors. Adaptive functioning difficulties are limited to self-direction and safety. No evidence of brain atrophy, delayed physical development, or facial dysmorphia in childhood but significant behavioral concerns suggestive of FASDs. A wide range of etiological factors with unconfirmed prenatal alcohol exposure, such as neglect, trauma, and poor school attendance, suggests that FAS may be diagnostically restrictive as it pertains to the broad spectrum of prenatal alcohol effects and common comorbidities. FAS criteria may be revisited as it relates to confirmed alcohol exposure when history does not permit.