Dr. Carl C. Bell, in memoriam

Welcome to this bonus episode of the MDedge Psychcast. In this episode, as a tribute to the late Carl C. Bell, MD, we would like to replay highlights from the interview that Lorenzo Norris, MD, did with him last year at the annual IPS (Institute on Psychiatric Services) Mental Health Services conference in Chicago.

Dr. Norris, host of the MDedge Psychcast, is assistant professor of psychiatry and behavioral sciences at George Washington University, Washington. Dr. Bell, who died Aug. 1, was a psychiatrist at Jackson Park Hospital in Chicago and an emeritus professor of psychiatry at the University of Illinois at Chicago. He spoke with Dr. Norris in episodes 26 and 27 about identifying and preventing fetal alcohol spectrum disorders.

Conceptualizing intellectual disabilities in children

• In the late 1960s, African American children had twice the rates of mild intellectual disabilities as did white children.
• Some clinicians thought that the intellectual disabilities they were seeing among African American children were the result of social-cultural mental retardation, but that conclusion did not make sense to Dr. Bell.
• Julius B. Richmond, MD, former surgeon general, cocreated Head Start as a way to address some of the educational disadvantages faced by low-income children.
• African American psychologists began to suggest that standardized tests were biased against certain racial and low-income groups.
• Bell thought some African American and low-income children might have knowledge that their counterparts in other communities might not have.

Fetal alcohol exposure emerges as an explanation

• A few years ago, Dr. Bell was talking with a woman patient with three children in the Illinois Department of Children and Family Services. The children had poor tempers, social/emotional skills. And when he looked at their mother, he saw fetal alcohol facies.
• After talking with the patient longer, he learned that she had not gotten far in school. She also had problems with simple subtraction. At that point, he thought that the patient might have had fetal alcohol exposure.
• He then began looking at family medicine patients at Jackson Park Hospital in Chicago. The question at that time was: "Were you drinking while you were pregnant?" That question did not explain why patients had children who could not do basic subtraction and had ADHD, for example.
• Bell realized that the right question was: When did you realize you were pregnant? In many cases, they would say that they had learned they were pregnant at 4-6 weeks.

Choline deficiency and fetal alcohol exposure

• The Institute of Medicine recommended that pregnant women consume 450 mg/day of choline each day.
• Robert Freedman, MD, and his colleagues found that higher amounts of choline as a prenatal supplement are tied to more self-regulation among infants who had common maternal infections during gestation.
• Bell began giving choline to patients. In one example, a patient's ability to relate to others improved dramatically after taking choline over an 18-month period.
• The American Medical Association passed a resolution supporting the addition of adequate amounts of choline to prenatal vitamins.

References

Freedle RO. Correcting the SAT's ethnic and social-class bias: A method for reestimating SAT scores. Harvard Educ Rev. 2003. 73(1):1-42.

Bell CC and J Aujla. Prenatal vitamins deficient in recommended choline intake for pregnant women. J Fam Med Dis Prevent. 2016. 4(2):1-3.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders: A randomized, double-blind, placebo-controlled trial. Am J Clin Nutr. 2015 Nov;102(5):1113-25.

Wozniak JR et al. Choline supplementation in children with fetal alcohol spectrum disorders(FASD) has high feasibility & tolerability. Nutr Res. 2013. Nov;33(11):897-904.

Zeisel SH and KA da Costa. Choline: An essential nutrient for public health. Nutr. Res. 2009. Nov;67(11):615-23.

Freedman R et al. Higher gestational choline levels in maternal infection are protective for infant brain development. J Pediatr. 2019 May. 208:198-206.

Velazquez R et al. Maternal choline supplementation ameliorates Alzheimer's disease pathology by reducing brain homocysteine levels across multiple generations. Mol Psychiatry. 2019 Jan 8. doi: 10.1038/s41380-018-0322-z.

Wilhoit F et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Ment Health J. 2017 Aug;53(6):711-8.

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