Foetal Alcohol Spectrum Disorder (FASD) is a range of conditions caused by exposure to alcohol in the womb, impacting neurological and physical development. It is estimated to affect 2-3% of children in the UK 7 , and these children are far more likely to encounter the criminal justice system (CJS) than children without FASD 3 . Elaine Coates spoke to Salford research fellow Dr David Junior Gilbert about the research being done at Salford on FASD.
What is FASD?
FASD encompasses a range of closely related brain and body disorders caused by prenatal alcohol exposure (PAE). Alcohol is known to be a teratogen, meaning that it can cause defects in developing cells. If a baby is exposed to alcohol in the womb, irrespective of the trimester when that happens, they may be born with the condition. It can affect any part of the body but particularly affects the brain, with reduced brain volumes and white matter abnormalities in the hippocampus and corpus callosum 8 . Individuals with FASD often have executive function disorder, so they struggle to regulate their own behaviour. They may be impulsive and have difficulty understanding the consequences of their actions. At the far end of the FASD spectrum, children with Fetal Alcohol Syndrome (FES) often have characteristic malformed facial features including small eyes, a thin upper lip and smooth philtrum and may also have damage to visual, auditory and other organ systems 9 .
There is currently no treatment for FASD, but early diagnosis and intervention can help parents access appropriate support. There is some evidence that nutritional supplements during pregnancy can reduce the damage caused by PAE 8 . A recent small study found that FAS impacted children who received choline supplements during early childhood had improved cognitive development and executive function compared to a control group 4 .
Mechanisms of alcohol damage
Alcohol increases free radicals – highly reactive molecules which can react with biological macromolecules, affecting their function. When the balance of free radicals compared to antioxidants is disrupted, this is referred to as oxidative stress. Developing cells can be affected in many different ways and there may be different impacts depending on the amount, duration and timing of the alcohol exposure.
Free radical damage to proteins and lipids can disrupt membrane functions & cell signalling. Critical cell cycle control proteins may be compromised, which can result in cells maturing early or in the cell cycle stalling, or in inappropriate cell differentiation. Alcohol can also affect DNA methylation and histone methylation, resulting in changes in gene expression 1 .
Alcohol directly damages mitochondria, disrupting the electron transport chain and leading to increased cellular apoptosis. In the developing brain, increased apoptosis of glial cells may be the cause of the reduced brain density associated with FASD. Neurotransmitter systems may also be affected, resulting in behavioural impacts throughout life 1 .
How did Dr Gilbert become interested in FASD?
Dr Gilbert initially trained as a biochemist in Nigeria. He worked for a few years for a pharma company, where he worked with physicians and clinicians with a drug portfolio mainly aimed at improving quality of life for people with serious or terminal conditions. He decided to pursue a Masters and obtained a scholarship to the University of Salford to complete a master’s in public health supervised by Professor Penny Cook who leads the Salford FASD research group. The Salford research group is a multi-disciplinary team with expertise on different aspects of FASD research, ranging from prevalence and epidemiology, genetics, trauma, interventions to support those with FASD, to social workers and criminal justice research. The group is regarded as the largest and most expert research group on FASD in Europe.
When Dr Gilbert decided to specialise in FASD, he says he was inspired by three words:
Misdiagnosis – Individuals with FASD are often misdiagnosed with autism, ADHD or personality disorders, because of lack of awareness of FASD.
Missed diagnosis – individuals may not be diagnosed with any condition, and so receive no support
Under diagnosis – due to lack of resources. There is only one specialist clinic in the UK, in Surrey. There has been very little research to establish the extent of FASD.
For his PhD, Dr Gilbert interviewed parents of children with FASD, and the children themselves, about their experiences. Dr Gilbert work provided the first experimental evidence of interrogative suggestibility in adolescents with FASD . Individuals with FASD demonstrated a significantly higher level of suggestibility compared to the control group 2 . Dr Gilbert has now been awarded a 5-year research fellowship to expand on this work, recruiting subjects from the US, Canada, Australia, New Zealand and the Republic of Ireland, to investigate the vulnerabilities of individuals with FASD to and within the justice system.
FASD and the Criminal Justice System
In New Zealand, a teenager with FASD falsely confessed to having been involved in the rape and murder of a woman because he wanted to claim a $20,000 reward and thought he would be immune from prosecution. Over 20 years later the conviction was quashed 6 .
People with FASD are more likely to have high rates of adverse childhood experience, and FASD adds another layer of adversity compounding their vulnerability. Problems with impulse-control and executive function mean these individuals are more likely to encounter the CJS. They are then vulnerable because their higher suggestibility means they are more likely to agree to suggestions put to them, or to say what they think interviewers want to hear. Some parents interviewed by Dr Gilbert reported than their child would “say Yes to anything”. They may struggle to understand complex questions and may be easily manipulated.
In research not yet published, Dr Gilbert has also looked at confabulation. Confabulation is when people make things up to fill in gaps in their memory, and don’t realise they are doing so. People with FASD have poor memory recall and have a higher rate of confabulation.
There is a need for increased awareness of FASD within the CJS, and an understanding of the increased vulnerability of impacted individuals whether as suspects, witnesses, of victims of crimes, in order to avoid false confessions or miscarriages of justice. Dr Gilbert emphatically says that individuals with FASD are not criminals, it is their diagnosis that provides a context to behaviours relevant to the justice system. Also, these individuals have strengths which should be leveraged upon to create custodial, sentencing and rehabilitation plans.
How is Salford making a difference?
Dr Gilbert hopes his research will lead to better understanding of FASD, and for professionals within the justice system to be more aware of the vulnerabilities of FASD impacted individuals and not take things at face value. It is important for example to avoid leading questions in interviews, and for sentencing and rehabilitation plans to provide appropriate support.
Salford researchers have also been working with the Greater Manchester Combined Authority on a major intervention called the Alcohol Exposed Pregnancy programme. No woman wants to harm their baby – they either do not know they are pregnant, are not aware of the harm alcohol can do, or they need help and support to control their alcohol intake. The programme has already trained hundreds of social care staff to equip them to have conversations around the harms of alcohol during pregnancy, and has provided screening, support and early interventions 5 .
Further Information
This short video by the FASD Salford group gives an overview of their research.
More on Dr Gilbert’s research: https://www.salford.ac.uk/our-staff/david-junior-gilbert
References
Abdul-Rahman, O. A., & Petrenko, C. L. M. (2023). Fetal alcohol spectrum disorders : a multidisciplinary approach (1st 2023. ed.). Springer International Publishing. https://doi.org/10.1007/978-3-031-32386-7
Gilbert, D. J., Allely, C. S., Gudjonsson, G., Mukherjee, R. A. S., & Cook, P. A. (2024). Immediate and repeat interrogative suggestibility in a sample of adolescents with fetal alcohol spectrum disorder. Diversity & Inclusion Research , 1 (1), e12007. https://doi.org/https://doi.org/10.1002/dvr2.12007
Gilbert, D. J., Allely, C. S., Mukherjee, R. A. S., & Cook, P. A. (2022). Foetal alcohol spectrum disorder and Investigative interviewing: A systematic review highlighting clinical and legal implications and recommendations. Behavioral Sciences & the Law , 40 (1), 170-185. https://doi.org/https://doi.org/10.1002/bsl.2552
Gimbel, B. A., Anthony, M. E., Ernst, A. M., Roediger, D. J., de Water, E., Eckerle, J. K., Boys, C. J., Radke, J. P., Mueller, B. A., Fuglestad, A. J., Zeisel, S. H., Georgieff, M. K., & Wozniak, J. R. (2022). Long-term follow-up of a randomized controlled trial of choline for neurodevelopment in fetal alcohol spectrum disorder: corpus callosum white matter microstructure and neurocognitive outcomes. Journal of Neurodevelopmental Disorders , 14 (1), 59. https://doi.org/10.1186/s11689-022-09470-w
Greater Manchester Integrated Care Partnership. (2022). “A very positive and rapid influence on change” – reflecting on work to reduce alcohol exposed pregnancies in Greater Manchester . Retrieved 11/09/2024 from https://gmintegratedcare.org.uk/expert-view/a-very-positive-and-rapid-influence-on-change-reflecting-on-work-to-reduce-alcohol-exposed-pregnancies-in-greater-manchester/
Hansen, R. (2016). Report for Minister of Justice on Compensation Claim by Teina Anthony Pora . https://www.justice.govt.nz/assets/pora-teina-compensation-claim-innocence-report.pdf
McCarthy, R., Mukherjee, R. A. S., Fleming, K. M., Green, J., Clayton-Smith, J., Price, A. D., Allely, C. S., & Cook, P. A. (2021). Prevalence of fetal alcohol spectrum disorder in Greater Manchester, UK: An active case ascertainment study. Alcoholism: Clinical and Experimental Research , 45 (11), 2271-2281. https://doi.org/https://doi.org/10.1111/acer.14705
Popova, S., Dozet, D., Shield, K., Rehm, J., & Burd, L. (2021). Alcohol’s impact on the fetus. Nutrients , 13 (10), 3452. https://doi.org/10.3390/nu13103452
Riley, E. P., Infante, M. A., & Warren, K. R. (2011). Fetal Alcohol Spectrum Disorders: An Overview. Neuropsychology Review , 21 (2), 73-80. https://doi.org/10.1007/s11065-011-9166-x