Dr Judith Guedalia

Pinchas Cohen (not his real name), age 14, was referred for a neuropsychological assessment by his tutor. He had been having trouble with schoolwork and social connections since the beginning of elementary school. Mr. and Mrs. Cohen accompanied their son to his appointment. At first blush, Pinchas looked a bit different than his folks. They were tall and he was much shorter and seemed to have a completely different body build. (I glanced at the anamnesis-intake/history form to see if they had noted whether he was adopted; and indeed he was their biologic child). As we sat and talked, I noticed some other differences. His head seemed a bit smaller than his body size would suggest. He was friendly and affable and seemed even more communicative than most adolescents, who can be downright surly when schlepped to a "shrink for yet another test." Also, there was something different about his smile, but I couldn't put my finger on what was bothering me.

As I noted above, he had had difficulties in learning, reading came late and arithmetic never "came". He was socially isolated from his peers though he, according to his mom, was friendly and loyal to a fault. "He just 'doesn't get it' in social situations," she said, in contrast to his much younger siblings who had no problems in this area. Pinchas was very chatty, but as the interview progressed, I was impressed by how superficial and concrete his comments were. Also, he tended to repeat himself often and didn't seem to pay attention to either of his parents' non-verbal (body language) communications, which signaled that he slow down and let someone else speak.

As Pinchas and his parents came from out-of-town, it was decided to do both the interview and the testing in a two-day, marathon session. (Usually, if the commuting distance is under two hours, the assessment process may be anywhere from two to four visits over a period of a month.) So Pinchas went to another room with another psychologist to begin this aspect of the assessment, while I continued the "intake" with his folks.

We had been chatting for close to three quarters of an hour and Mr. Cohen had not said a word. I noticed that he was sitting with arms crossed in front of him, seeming to be both reserved and angry at the same time. I asked some basic questions about their academic background and family history, but I felt that the dad was holding back. "What am I missing?" I asked aloud.

Mrs. Cohen looked at her husband and then at me and candidly said, "You don't recognize my husband, do you? Well you are religious and probably don't go to nightclubs." I nodded in agreement. "He is a well-known comedian, and before we came he was concerned that you would recognize him. Now that you don't," she said with a sardonic smile, "he's 'surprised' too." I apologized for the "slight," he "pooh-poohed" it, and after that, he sheepishly began to relate his feelings. "I am embarrassed to say that Pinchas' behavior in public often causes me to feel uncomfortable. Not only doesn't he 'get' my jokes, but he becomes too friendly with people, even on the bus. He'll begin talking with anyone, and it is not only embarrassing, but I'm also worried about his safety."

They went off to tour Jerusalem, and I observed Pinchas as he was being tested. The hours passed, he was very cooperative and we adjourned until the next morning to finish up. (He and his parents were going to stay at the hospital's "hotel". Shaare Zedek Medical Center has a number of rooms with amenities, a communal kitchenette and a living room set up for patients' families to stay.)

At the end of the second day, I sat with the parents. The written report would follow, but, based on the neuropsychological testing battery results and the clinical observations, I had some more questions because I could supply answers.

Aside from the cognitive and social deficits that the parents described, the data seemed to point up to, what we call in the trade, Non-verbal Learning Disorder. Also seemingly highlighted was a specific pattern of strengths and weaknesses that we see in children with White Matter Disorder (such as those suffering from Williams Syndrome).

White matter is one of the two main solid components of the central nervous system. It is composed of myelinated nerve cell processes, or axons, which connect various grey matter areas (the locations of nerve cell bodies) of the brain to each other and carry nerve impulses between neurons. Cerebral and spinal white matter do not contain dendrites, which can only be found in grey matter along with neural cell bodies and shorter axons.

Generally, white matter can be understood as the parts of the brain and spinal cord responsible for information transmission, whereas grey matter is mainly responsible for information processing. White matter injuries (axonal shearing) may be reversible, while grey matter regeneration is less likely.

White matter forms the bulk of the deep parts of the brain and the superficial parts of the spinal cord.

Grey matter is the major part of the nervous system in which the nerve impulses for all kinds of mental functions are produced and then sent away, to be carried to their target organs by white matter.

Pinchas' developmental/medical history also showed that he had:

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The school history (as well as the testing) noted:

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Clinical observation:

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And I finally figured out what bothered me about his smile:

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I had one question left to the mother. Did she drink alcohol? "No. Well, not really; only socially, and then never a lot." Maybe not recently, but could she recall 15 years ago, when she was pregnant with Pinchas?

She became thoughtful. "When we were first married and when my husband used to perform, I would accompany him to the nightclubs twice a week. I remember having a Piña Colada (Pineapple juice, Rum, Coconut-cream, parve, mixed drink). But only two drinks a week, and after I knew I was pregnant, I stopped even that."

The hypothesized diagnosis was Fetal Alcohol Effects (FAE). I would send them to the geneticist before making a final diagnosis. Fetal Alcohol Syndrome (FAS) and FAE are relatively rare in Israel, though a few cases have been reported, as the drinking habits of Israelis and olim from various populations - where alcohol consumption is more normative - have risen. I had read about it, both in professional literature and also in the seminal novel, The Broken Cord, by Michael Dorris (1989), which was the first book to describe Fetal Alcohol Syndrome and Fetal Alcohol Effects for the general public. The author wrote about his experience in trying to find a diagnosis for Adam, his adopted Native American son, whose behavior and specific facial and body-size anomalies were as yet undiagnosed. I had never seen a case.

There are variables, which help determine whether a teratogen will have an effect upon the fetus. Which teratogen is used - alcohol, crack, heroin, nicotine (smoking), x-rays, etc. - also affects the type of damage one might see in a fetus. The dosage of the exposure is very important. The more minimal the exposure, the better off the fetus will usually be. When, in fetal development, the teratogenic exposure occurs is of vital importance. Is it one short exposure time or was the exposure on a daily or hourly basis?

A mother's nutritional status and physical well-being might also play roles of varying significance in determining whether an infant is affected (and to what degree) by the prenatal exposure to alcohol. A great deal more research is necessary to determine the reason that some developing fetuses are more vulnerable than others to prenatal exposure to alcohol. The knowledge base in this arena needs to be greatly expanded. The individual factors of the mother and child are also vitally important. That is the reason why professionals cannot tell a pregnant woman how much would be safe to drink.

Since these individual factors cannot be determined, the only way to prevent FAS and FAE is for a pregnant woman to abstain from the use of alcoholic beverages during her entire pregnancy. (The USA's surgeon general's warning in this regard states pregnant women, but the crucial time may be before a woman herself knows she is pregnant. Ironically, during childbearing years, women have their niddah schedule, so as to know when the time is "safe" for wine tasting.

This was a very unusual situation. In this case, the mother drank only two alcoholic drinks a week and she stopped as soon as she knew she was pregnant (about eight weeks into her pregnancy). After consulting (by Internet) with an internationally known specialist in the field of FAS and FAE, I learned that there is both a critical time and critical mass of alcohol involved in FAS/FAE. The unfortunate set of circumstances in this situation dealt with the mother's nutritional make-up and the timing (first weeks of pregnancy). The confluence of these factors was more crucial than the relatively small amount of alcohol she consumed.

My point is that FAE and FAS is a completely preventable disorder with lifelong affects. Keep both timing and amount in mind. To paraphrase the words of Kohelet (Ecclesiaties 3:1), "Everything has its season, and there is a time for everything under the heaven."