"Your daughter needs to be smarter."
For Tiffany Morgan, the elementary school teacher's words stung like acid on a festering wound.
In 2013, Morgan's 9-year-old daughter Ny'Ana was diagnosed with fetal alcohol spectrum disorder (FASD), a range of intellectual and physical impairments caused by a mother's drinking during pregnancy. The diagnosis was devastating: It meant that Ny'Ana would face a lifetime of learning difficulties. She would never read, write or behave like other children, no matter how hard she tried.
"I have to explain, over and over again, that my daughter has brain damage," said Morgan, who lives in St. Paul and works to educate mothers about the dangers of drinking during pregnancy. "Ny'Ana does not have the ability to be smarter."
Prenatal alcohol exposure affects about 7,000 newborns in Minnesota each year, and its effects remain deeply misunderstood. Children who suffer from FASD are frequently labeled as "hyperactive" and inattentive. Their symptoms are often hidden, or confused with a variety of behavioral disorders, resulting in misdiagnoses and wrong treatment. Teachers may expect children with FASD to perform like their peers, not recognizing that their brains function differently.
But researchers at the University of Minnesota are starting to deploy powerful brain imaging technology to unlock the mystery of how fetal brains react to alcohol.
This month, they began conducting MRI brain scans of 90 Minnesota children between ages 8 and 16 who were exposed to alcohol in the womb. Their scans will be compared with those of healthy children to identify abnormalities in the way the children's brains have developed. Then, a year and a half later, researchers will conduct another round of brain scans on the same group.
The study, funded with a $1.7 million grant from the National Institute for Alcohol Abuse and Alcoholism, is unusual in its ambition and scope. Researchers at the U aim to map hundreds of regions of the brain and analyze how connections between them are impaired by alcohol. It is considered among the first longitudinal studies gauging how alcohol changes a developing brain over time.
The findings should help clinicians better identify and treat the condition, while bringing renewed attention to the devastating effects that even small amounts of alcohol can have on a fetus.
"The imaging technology will go a long way toward raising awareness that FASD is a brain-based disability," said Sara Messelt, executive director of the Minnesota Organization on Fetal Alcohol Syndrome (MOFAS), an advocacy group. "We can show people ... that this is not about poor behavior, poor parenting or a kid that just won't sit still. More people will see ... that the brains of these children are wired in a fundamentally different way."
Jeffrey Wozniak, who is leading the study, is well aware of the lasting damage caused by alcohol on developing brains. The U psychiatrist has researched the problem for the past 14 years, publishing a series of groundbreaking studies while also working with patients. Each year, Wozniak and his colleagues diagnose and treat about 300 children at the fetal alcohol clinic near the U's West Bank campus.
Missing wiring
On a recent afternoon, Wozniak pulled up a series of brain images on dual computer screens in his office. He pointed to a C-shaped mass of nerve fibers deep in the brain. Known as the corpus callosum, the structure connects the right and left halves of the brain, and plays a vital role in processing information. When compared to a typical child's brain, the structure in the brain of a child who has FASD looked small and malformed, as if it had stopped growing.
Wozniak then highlighted a separate series of brain images showing the microscopic nerve fibers that crisscross the brain like a mesh of wires. Again, the nerve fibers in the child with alcohol exposure looked fewer in number and visibly underdeveloped, as if they had been clipped by scissors.
Taken together, such brain abnormalities help to explain why children with FASD have memory problems and trouble processing information. Tasks that involve multiple steps, or "sequential thinking," can be difficult, Wozniak said. Without regular reminding, children with FASD have trouble following daily routines, such as doing homework after school or bathing before bed. They can struggle with low self esteem and isolation because they have trouble keeping up with conversations.
"Some of the wiring that normally connects different parts of the brain is missing and is abnormal," Wozniak said, pointing at the screen. "If you miswire those pathways, it becomes a lot harder to do basic tasks."
Researchers hope that such images will help early diagnosis of FASD, which is notoriously difficult to detect from physical or behavioral symptoms.
Only about 10 percent of children affected by prenatal alcohol exposure exhibit outward, physical anomalies, studies have found. And these features, such as a smooth upper lip, smaller head and narrow eyes, can be subtle and difficult to detect. The mental effects, too, are frequently confused with other disorders, such as attention deficit hyperactivity disorder (ADHD) and post-traumatic stress disorder. As a result, affected children are often prescribed behavioral medications with serious side effects that fail to address their unique challenges, researchers say.
A 2015 study by a group of Chicago-based researchers found that 86.5 percent of youths in foster care with FASD had never been diagnosed with the disorder or had been misdiagnosed.
A major barrier to diagnosis, researchers found, was the stigma that surrounds drinking and pregnancy: Many mothers were reluctant to come forward and admit they drank while pregnant.
The challenge of diagnosing and treating FASD is particularly acute in Minnesota, which has among the highest rate of alcohol abuse among women of childbearing age. In 2015, nearly one out of five Minnesota women between age 18 and 44 reported "binge drinking," defined as having four or more drinks in a row within the past 30 days, according to data from the U.S. Centers for Disease Control and Prevention.
Only eight states report a higher rate of binge drinking, a significant risk factor for fetal alcohol exposure.
"It's not an easy question for a doctor to ask a mom, 'Was your child exposed to alcohol?' " Messelt said. "All too often, it's ignored or diagnosed as something else, because the question is never asked."
Hard to come clean
Morgan hopes the U's research will change that.
A recovering alcoholic, Morgan said she initially panicked and lied when a pediatrician identified developmental delays in her daughter and asked if she had been exposed to alcohol in the womb.
"I got scared and said, 'No,' because I was terrified they would take my baby," she said. Morgan finally decided to come clean when the pediatrician suggested that Ny'Ana be prescribed a heavy dose of Concerta, a drug used to treat ADHD that has serious side effects.
Since her diagnosis, Ny'Ana has received extra one-on-one support in the classroom, as well as special therapy to help her develop social skills. Even so, the girl's disability still goes unnoticed by many of her peers and teachers. Her occasional tantrums are sometimes misinterpreted as acts of defiance instead of symptoms of her underlying brain damage, Morgan said.
"Already these children come into life horribly, horribly hurt," Morgan said. "We shouldn't hurt them more by ignoring the severity of this disability and pretending it's something else."
chris.serres@startribune.com 612-673-4308 • Twitter: @chrisserres
