Pharmacologic Interventions in Fetal Alcohol Spectrum Disorders

Alcohol is a known teratogen that, when a prenatal exposure occurs, can alter the brain structure and function. The neurocognitive, self-regulatory, and adaptive skill delays that are seen in Fetal Alcohol Spectrum Disorders are clinical features seen in ADHD, anxiety, depression, aggression, mood dysregulation/emotional lability/bipolar disorder, and attachment disorders. While there are no pharmacological interventions approved with FASD as an indication, some of the clinical features previously described are amenable to pharmacologic interventions. 

Therapeutic Approach to Pharmacologic Interventions

Through a medical home, pharmacologic interventions can be integrated into a comprehensive management plan that includes behavioral interventions, the patient’s home, school, and/or work environment, as well as other social determinants of health.

Sometimes, despite optimization of behavioral interventions, some individuals will need pharmacological interventions to manage their symptoms.  The list below contains some classes of medication that may be helpful for symptom management for individuals with an FASD:

• Stimulants
  Stimulants (methylphenidate and amphetamine derivatives) are first-line medications primarily used to target symptoms of ADHD common in children with an FASD including but not limited to hyperactivity, inattentiveness, and impulsivity. Given the organic brain injury nature of an FASD, stimulants have variable efficacy when used to treat these symptoms in individuals with an FASD.
• Alpha-2-adrenergic agonists
  Alpha-2-adrenergic agonists(e.g. clonidine and guanfacine) are non-stimulant treatments for ADHD which may help reduce the “fight or flight” response to anxiety in disinhibited children. Alpha-2-adrenergic agonists may also help to address associated problems in attention, hyperactivity, and impulsivity as well as helping decrease tics. Because alpha-2-adrenergic agonists can cause sedation, their daytime use may be limited, but they can be helpful for children who struggle with sleep.
• Selective norepinephrine reuptake inhibitors
  Selective norepinephrine reuptake inhibitors (atomoxetine) are non-stimulant treatments that can be used to treat symptoms of ADHD when stimulants are not effective.
• Anxiolytics
  Anxiolytics (e.g. buspirone) can treat symptoms of anxiety commonly seen in children with an FASD.
• Antidepressant medications
  Antidepressant medications (e.g. sertraline, fluoxetine) can treat depressive symptoms such as sad mood, loss of interest, sleep problems, and anxiety.
• Neuroleptics
  Neuroleptics (e.g. risperidone or aripiprazole) may be used to treat severe symptoms such as aggression, anxiety, disruptive behavior, tics, and impulsivity. The most common side effect of neuroleptic use is significant weight gain and rarely, the medication may cause extra pyramidal crises.
• Melatonin
  Melatonin (a hormone made by the pineal gland) supplementation may help with disturbances in sleep initiation. Children with an FASD can have abnormal sleep patterns (parasomnias and insomnias) as well as an abnormal melatonin profile. Therefore, some children with an FASD and sleep difficulties may respond positively to melatonin supplementation to help with sleep initiation.  Prior to prescribing melatonin supplementation, pediatricians should first emphasize the need for established bedtime routines and environment, including comfortable bedding, temperature, and clothing as well as having a familiar, secure, and consistent sleep environment.
• Choline
  Choline may be a potential neurodevelopmental intervention for a child with an FASD. The scientific evidence for the beneficial effect of choline on the nonverbal intelligence, visual spatial skills, verbal memory and working memory, was found by Wozniak, et al, in a randomized, double-blind, placebo-controlled trial in children 2-5 years with an FASD. The study also reported fewer symptoms of ADHD in the choline-treated versus the placebo group. The authors concluded that choline could be a good adjunct to the comprehensive treatment of a child with an FASD.

Additional considerations when prescribing medications for an FASD include:

• Set appropriate expectations with family members about the effects of medications. There may be symptoms that relate to structural brain abnormalities that cannot be treated with medications.
• Work with a psychiatrist or a developmental and behavioral pediatrician to prescribe or adjust medications.
• Consider that standard medication dosing may not apply but start low and titrate upwards slowly.
• Monitor and be attentive to medication side effects that an individual may experience.
• Periodically review the medications for efficacy, side effects, and interactions.
• Review medications prescribed by all consulting physicians to evaluate issues of overmedications and conflicting medications.