fetal alcohol syndrome essay example

Fetal Alcohol Syndrome: Causes and Consequences Essay

Introduction, causes of fetal alcohol syndrome, effects of fetus alcohol syndrome on the born child.

In many countries of the world alcohol and dug abuse during pregnancy has been one of the major threats to child health and welfare. Although this fact is well known across many social divides, many expectant mothers across the globe still indulge in excessive drinking of alcohol during pregnancy. These women do this without knowledge that their unsuspecting unborn babies can develop a disorder known as fetal alcohol syndrome after birth (Hans-Ludwig, p. 13).

Fetal alcohol syndrome is a disorder which causes lasting birth defects in a newborn baby. It is associated with expectant mothers who overdrink alcohol during pregnancy. Scientists have not yet found out, if the volume of alcohol taken, the frequency of taking, or the time the alcohol is taken during pregnancy, is connected to a variation in the degree of injury done to the unborn baby. Hence it is advised that expectant mothers should completely abstain from the habit of drinking (Elizabeth, p. 8).

The main cause of fetal alcohol syndrome is the abuse of alcohol during pregnancy by pregnant mothers. When an expectant woman drinks alcohol it easily penetrates the placenta into the fetus body. Any amount of alcohol she drinks potentially exposes the unborn baby to definite risk of contracting fetal alcohol syndrome. Heavy drinking of alcohol can predispose the fetus to the disorder more than small doses of alcohol. The timing of alcohol consumption is also a very vital aspect in preventing the possibilities of an infant developing the disorder, since alcohol consumption in the first three month of pregnancy offers more risk to the infant than the following period of pregnancy. Although drinking alcohol at any other time can still predispose fetal alcohol syndrome. The primary disabilities an infant suffers from after birth as a result of fetal alcohol syndrome is usually caused by the central system damage damages before birth which had resulted from prenatal alcohol exposure. Most commonly the resultant primary disabilities in the newborn babies are usually confused with a child having behavioral problems although the central nervous distortion is the underlying cause of this problem. The functional disabilities which are the main feature in fetal alcoholism syndrome are caused by the central nervous system damages which occur in more than one way. The damage to the CNS by alcohol is still under research to establish the mechanism in which this phenomenon occurs (Hans-Ludwig, p. 3).

The effects of ethanol on the fetus might be determined by the amount consumed by the pregnant mother and the time during pregnancy the alcohol was consumed. As mentioned earlier the first three month of pregnancy is more crucial as far as this disorder is concerned. The effect of Fetal alcohol syndrome varies from one child to the next, depending on a variety of factors such as, the amount of alcohol consumed by the mother during pregnancy and the physiological condition of the mother and the fetus before birth. One of the effects of Fetal alcohol syndrome includes development of a characteristic facial appearance, which always consists of small upturned nose, sagging eyelids, emaciated upper lip, inflamed forehead and thin chin. The children having this syndrome are usually characteristically thin and short in stature.

Babies suffering from fetal alcohol syndrome normally develop physical difficulties and deformities such as hearing difficulties, dental disfiguration, coronary problems, kidney problems, muscles and joint problems. There is also a manifestation of central nervous system problems such as affecting the cognitive and adaptive function ability of a child.

Fetal alcohol syndrome is one of the major causes of psychological retardation in children in the modern world. Hence sensitization and education of pregnant women about the cause, effects and prevention of fetal alcohol syndrome is imperative.

Hans-Ludwig Spohr, Hans-Christoph, Alcohol: Pregnancy and the Developing Child, Cambridge University Press, 1996.
Elizabeth M. A., Pregnancy Risk: Fetal Alcohol Syndrome and the Diagnosis of Moral Disorder, JHU Press, 2003.
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Epidemiology, fasd diagnosis, medical, behavioral, and cognitive problems, secondary and co-occurring conditions, economic effects, the role of the pediatrician and the medical home, selected public domain resources, lead authors, committee on substance abuse, 2014–2015, former committee member, contributors, council on children with disabilities, fetal alcohol spectrum disorders expert panel – aap/cdc cooperative agreement, 2021 reference update acknowledgment, abbreviations, fetal alcohol spectrum disorders.

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Janet F. Williams , Vincent C. Smith , the COMMITTEE ON SUBSTANCE ABUSE; Fetal Alcohol Spectrum Disorders. Pediatrics November 2015; 136 (5): e20153113. 10.1542/peds.2015-3113

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Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use.

Neurocognitive and behavioral problems resulting from prenatal alcohol exposure are lifelong.

Early recognition, diagnosis, and therapy for any condition along the FASD continuum can result in improved outcomes.

○ no amount of alcohol intake should be considered safe;

○ there is no safe trimester to drink alcohol;

○ all forms of alcohol, such as beer, wine, and liquor, pose similar risk; and

○ binge drinking poses dose-related risk to the developing fetus.

This clinical report has been reaffirmed with reference and data updates. New or updated references or datapoints are indicated in bold typeface. No other changes have been made to the text or content.

The AAP would like to acknowledge Carol Cohen Weitzman, MD, FAAP, for these updates.

Fetal alcohol spectrum disorders (FASDs) is an overarching phrase that encompasses a range of possible diagnoses, including fetal alcohol syndrome (FAS), partial fetal alcohol syndrome, alcohol-related birth defects (ARBD), alcohol-related neurodevelopmental disorder (ARND), and neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE). FAS refers to a clinical diagnosis based on a specific constellation of physical, behavioral, and cognitive abnormalities resulting from prenatal alcohol exposure (PAE). 1 By 1973, sufficient research evidence had accrued to devise basic diagnostic criteria such that FAS became established as a diagnostic entity. 1 The US Surgeon General issued the first public health advisory in 1981 (reissued in 2005) that alcohol during pregnancy was a cause of birth defects. 2 , 3 In 1989, Congress mandated that alcohol product labels include a warning about potential birth defects. Nineteen states and the District of Columbia have now enacted laws requiring these warnings at the point of sale, including bars and restaurants. 4

As it became evident that PAE resulted in a spectrum of lifelong manifestations, varying from mild to severe and encompassing a broad variety of physical defects and cognitive, behavioral, emotional, and adaptive functioning deficits, the term “fetal alcohol effects” was adopted to describe children who had PAE manifestations yet did not meet the FAS diagnostic criteria, primarily by lacking physical abnormalities associated with FAS. Because the term was too broad and vague for practical clinical or epidemiologic use, it was retired from use in 1996 and replaced with 2 pathophysiologically based diagnostic categories: ARBD and ARND. 5 , – 7

Despite greater public awareness, improved terminology, and an accruing body of research, the lack of uniformly accepted diagnostic criteria for FAS and other related disorders has critically limited efforts to determine accurate prevalence figures, expand awareness and prevention campaigns, actuate early identification and intervention programs, and delineate the full continuum of alcohol-related conditions. As part of the fiscal year 2002 appropriations legislation, Congress mandated that the Centers for Disease Control and Prevention (CDC) develop diagnostic guidelines for FAS and related disorders and integrate them broadly across medical and allied health professions’ training curricula. Under the auspices of the CDC, acting through the National Center on Birth Defects and Developmental Disabilities FAS Prevention Team, in conjunction with the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effects, a multidisciplinary scientific working group of key national experts engaged in an intensive collaborative effort to draw conclusions about PAE effects. This collaborative conducted a comprehensive review of scientific and clinical evidence and extensively consulted with clinicians, experts, and families to delineate clear diagnostic criteria for FAS on the basis of a combination of 3 cardinal facial features, growth problems, and central nervous system abnormalities qualified by confirmed or unknown PAE ( Fig 1 ). 8 Through this effort, practical clinical approaches were endorsed so that those children with PAE could be more readily identified, the condition could be diagnosed with greater accuracy, and children could be referred for appropriate services. 9 , 10

Child presenting with the 3 diagnostic facial features of FAS: (1) short palpebral fissure lengths, (2) smooth philtrum (Rank 4 or 5 on the Lip-Philtrum Guide), and (3) thin upper lip (Rank 4 or 5 on the Lip-Philtrum Guide). Legend written by Susan Astley, PhD. © 2015, Susan Astley PhD, University of Washington.

In April 2004, the National Institutes of Health, CDC, and the Substance Abuse and Mental Health Services Administration, along with additional experts in the field, were convened by the National Organization on Fetal Alcohol Syndrome to develop the following consensus definition of FASD: “FASD is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term FASD encompasses all other diagnostic terms, such as FAS, and is not intended for use as a clinical diagnosis.” 11

Research continued to accrue about ARND, that is, individuals with PAE-associated neurodevelopmental and behavioral abnormalities yet without the FAS facial phenotype, so that in late 2011, the Interagency Coordinating Committee on Fetal Alcohol Spectrum Disorders organized a consensus conference to define ARND diagnostic criteria and related screening and referral needs. 7 As an outgrowth of this conference, a subcommittee collaborated with the American Psychiatric Association in preparing the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , reorganized on a neurologic disorders framework. The manual includes FASD under the term “FAS (ND-PAE).” 12 , 13 FASD terminology continues to evolve, and research evidence suggests that ARBD may be declining in use while ARND/ND-PAE terminology remains incompletely defined. ND-PAE may become the accepted diagnostic term for moderate PAE findings, and “static encephalopathy” associated with PAE is a suggested diagnostic term for severe PAE effects. 14

FASDs remain among the most commonly identifiable causes of developmental delay and intellectual disability yet are generally accepted to be vastly underrecognized. FAS, ARBD, and ARND prevalence rates and occurrence patterns have been the subject of many studies since the late 1970s. The wide variance in reported rates reflects the specific diagnoses studied and the different research methodologies used, the 3 most common methodologies being clinic-based studies, passive surveillance of existing records often limited to a geographic area, and active case ascertainment studies. 15 , 16 Although the prevalence of FAS in the United States during the 1980s and 1990s was reported as 0.5 to 2 cases per 1000 live births, recent studies aggressively diagnosing FASD have reported FAS rates and FASD estimates of 6 to 9 cases and 24 to 48 cases per 1000 children (or up to 5%), respectively, while continuing to consider these rates underestimates. 15 , – 18 Rates as high as 9 cases per 1000 live births have long been documented among vulnerable populations, usually related to isolation and socioeconomic impoverishment, such as can be more often found among certain American Indian and other racial/ethnic minority populations. 19 , – 21 An FAS prevalence of 1.0% to 1.5% has been reported among children in foster care. 22 A recent study among a population of foster and adopted youth referred to a children’s mental health center reported a FASD misdiagnosis rate of 6.4% and a missed diagnoses rate of 80.1%. 23 FAS is the FASD with the most explicit diagnostic criteria, so it only represents a fraction of individuals affected by PAE. FASDs other than FAS are more challenging to diagnose, so the true FASD prevalence remains unknown and the actual impact underappreciated. 15 , – 18

Approximately half of all US women of childbearing age have reported past month alcohol consumption, and use ranged from sporadic intake to 15% reporting binge drinking. 24 Binge drinking is a pattern of drinking that raises a person’s blood alcohol concentration to 0.08% or greater and was originally defined as 5 or more standard drinks per occasion (generally within 2 hours). 25 A “standard drink” contains approximately 0.5 fluid oz of pure ethanol, which is the amount found in a 1.5-oz shot of distilled spirits, 5 oz of wine, or 12 oz of beer. In 2004, the National Institute on Alcohol Abuse and Alcoholism changed the binge drinking definition for women to “the ingestion of 4 or more drinks per occasion” to account for known physiologic gender-related differences affecting alcohol absorption. 26 Setting this lower threshold for binge drinking among women also served to increase prevalence. 27 Binge drinking in the preconception period is associated with unintended pregnancy and a higher likelihood of risky behaviors, including drinking during pregnancy. 28 Often, PAE is unintentional, occurring before the woman knows that she is pregnant. Women continue to drink alcohol and binge drink during pregnancy despite the US Surgeon General’s warnings and their awareness that risk for potential harm exists. 29 , – 31 Although most women report cutting down or abstaining from alcohol use during pregnancy, 7.6% of pregnant women report continued alcohol use, and 1.4% report binge drinking. 24

FASD as such is not heritable, and having an FASD does not increase a woman’s risk of having a child with FASD. No genetic factors are known to be predictive of which particular children with PAE will have FASDs or the extent of effects. Multiple studies and meta-analyses have focused on how various patterns of drinking during pregnancy might affect fetal and child development. 32 , – 43 Mills et al prospectively studied approximately 31 000 pregnancies to determine how much alcohol pregnant women could safely consume and found increased risk of infant growth retardation even when consumption was limited to 1 standard drink daily. 32 Although a consensus is still lacking about the effects of low levels of PAE, harmful effects are well documented related to moderate or greater PAE and to binge drinking. 34 , – 42 The potential for fetal harm increases as maternal alcohol consumption rises. 34 , 42 Despite methodologic differences, potentially confounding factors, and variable sensitivity among the detection methods applied, these studies support advising that the healthiest choice regarding alcohol use during pregnancy is to abstain.

Ongoing work seeks to define specific diagnostic criteria for each of the FASD conditions along the continuum, such as has been possible for FAS. The FAS diagnosis is made only when an individual meets all 3 diagnostic criteria: prenatal and/or postnatal growth deficiency, the 3 cardinal facial features (reduced palpebral fissure length, smooth philtrum, and thin upper vermillion lip border [ Figs 2 , 3 , 4A , 4B and 5 ]), and any of a range of recognized structural, neurologic, and/or functional central nervous system deficits. 8 , – 10 , 44 Confirmed PAE strengthens the evidence, but FAS can be diagnosed without this history when all of the specific FAS diagnostic criteria have been met. Diagnosing FAS also means a comprehensive history has documented any other in utero substance exposures, including tobacco, medications, or illicit substances of abuse, and that other possible genetic and environmental etiologies have been excluded, specifically Williams, Noonan, 22q deletion syndromes, trisomy 21, and fetal toluene embryopathy, because some dysmorphological features are shared with FAS. 45

The palpebral fissure length is defined by the distance between the endocanthion (en) and exocanthion (ex) landmarks. Legend written by Susan Astley, PhD. © 2015, Susan Astley PhD, University of Washington.

The palpebral fissure length (the distance from the inner corner to outer corner of the eye) being measured with a small plastic ruler. Legend written by Susan Astley, PhD. © 2015, Susan Astley PhD, University of Washington.

Lip-Philtrum Guide 1 is one of two Guides (see Fig 4B ) used to rank upper lip thinness and philtrum smoothness. The philtrum is the vertical groove between the nose and upper lip. The guide reflects the full range of lip thickness and philtrum depth observed among Caucasians with Rank 3 representing the population mean. Ranks 4 and 5 reflect the thin lip and smooth philtrum that characterize the FAS facial phenotype. Guide 1 is used for Caucasians and all other races with lips like Caucasians. This guide is available from fasdpn.org as a free digital image for use on smartphones. © 2015 Susan Astley, PhD, University of Washington. Legend written by Susan Astley, PhD.

Lip-Philtrum Guide 2 is one of two Guides (see Fig 4A ) used to rank upper lip thinness and philtrum smoothness. The philtrum is the vertical groove between the nose and upper lip. The guide reflects the full range of lip thickness and philtrum depth observed among African Americans with Rank 3 representing the population mean. Ranks 4 and 5 reflect the thin lip and smooth philtrum that characterize the FAS facial phenotype. Guide 2 is used for African Americans and all other races with thicker lips like African Americans. This guide is available from fasdpn.org as a free digital image for use on smartphones. © 2015 Susan Astley, PhD, University of Washington. Legend written by Susan Astley, PhD.

All other FASD conditions have a range of PAE-associated findings that meet only some of the FAS diagnostic criteria. A computer-based 3-dimensional facial image analysis is showing promise in identifying PAE-affected children who have cognitive impairments but lack the FAS diagnostic facial features. 46 ARBD refers to children with confirmed PAE and certain physical findings related to congenital structural malformations and dysplasias affecting organ systems and/or specific minor anomalies but normal neurodevelopment. 10 , 14 , 33 A confirmed history of PAE should also prompt careful developmental screening and assessment for ARND/ND-PAE, which is among the possible diagnoses when there are no physical stigmata of FAS, yet evidence of brain abnormalities, and either structural or functional neurocognitive disabilities manifest as problems with neurodevelopment, behavior, adaptive skills, and/or self-regulation. 7 , 9 , 10 Other individuals whose features meet most but not all of the diagnostic criteria for FAS are described as having partial fetal alcohol syndrome. Fetal exposure to alcohol and to one or more additional substances complicates the causal explanation of clinical findings because the potential teratogenic, fetal growth, and neurobehavioral effects might be attributable to exposure to the other drug(s) alone, to multiple different exposures, or to drug combinations, including alcohol.

Although a classic FAS diagnostic triad has long been identified, other findings, including microcephaly, behavioral abnormalities, and “noncardinal” abnormal facial features, such as maxillary hypoplasia, cleft palate, or micrognathia, are also well recognized to co-occur with PAE. 1 , 45 , 47 A wide range of developmental and/or medical problems can accompany FAS as a result of alcohol’s structural and/or functional effects on the brain and various other organs or systems, particularly the cardiovascular, renal, musculoskeletal, ocular, and auditory systems. 1 , 45 , 48 A growing body of FASD research has focused on delineating how various brain volume deficits are related to neurocognitive function and facial dysmorphology, and close correlations with alcohol use in the first trimester of pregnancy have been found. 49 , 50 Fetal death is the most extreme PAE outcome, and PAE is also associated with sudden infant death syndrome ( Fig 5 ). 35 , 51

Young man presenting with the 3 facial features of FAS (small eyes, smooth philtrum, and thin upperlip) at 2 years of age and 20 years of age. Legend written by Susan Astley, PhD. © 2015, Susan Astley PhD, University of Washington.

Children and adolescents with known PAE experience a variety of behavioral and cognitive difficulties, ranging from subtle learning and/or behavioral problems to significant intellectual disability. 10 , 49 , 52 , – 56 PAE is associated with a higher incidence of attention-deficit/hyperactivity disorder (ADHD) and specific learning disabilities, such as mathematics difficulties. 52 , 54 , – 58 The neurocognitive profile associated with FASDs results from deficits in visual-spatial and executive functioning, including impaired impulse control, memory skills, and problem-solving, but also difficulties with abstract reasoning, auditory comprehension, and pragmatic language use. 49 , 58 PAE-associated executive dysfunction is evident as slow information processing and integration, and children with FASD show deficits in cognitive planning, concept formation, set shifting, verbal and nonverbal fluency, social interaction skills, and peer relationships. 49 , 58 Because attention deficits are considered a common characteristic of people with FASD, these skills have been extensively investigated. Children with FASD have demonstrated attention deficiencies with their capacity to hold information temporarily in memory while coding it or performing a mental operation on it and with the ability to shift attention flexibly compared with those with ADHD, who display greater difficulty with focus, concentration, and staying on task. 57 , – 59 Children and adolescents with PAE have difficulty rapidly processing relatively complex information and perform worse on visual than on auditory sustained attention tasks. 60 Although a few case reports have associated extreme PAE with autism spectrum disorders, most reports have delineated qualitative differences in the social difficulties experienced by those with FAS compared with individuals with autism spectrum disorders. 61 , 62

Compared with the general population, although similar to those with other intellectual disability, individuals with FASD have a higher incidence of concurrent psychiatric, emotional, and behavioral problems. 13 , 49 , 54 , 56 , 63 , – 65 Children and adolescents with FASD have a 95% lifetime likelihood to experience mental health issues, and among the most prevalent are anxiety and mood disorders, particularly depression, as well as ADHD, substance use, addiction, and suicide. Individuals with PAE have greater rates of school disruptions, trouble with the law, and under- or unemployment. 54 , 64 , 65 Failure to achieve age-appropriate socialization and communication skills results in maladaptive and impaired social functioning. Substance use; inappropriate sexual behaviors, such as inappropriate exposure, improper touching, and promiscuity; and consequent legal problems have been reported in adults diagnosed with FAS. 54 , 65 , 66 Delayed diagnosis and misdiagnosis contribute to the higher risk for secondary and co-occurring conditions.

An integrated multifactorial FASD model that includes genetic, PAE, and environmental factors, among others, provides an approach to understanding and assisting this complex and diverse high-risk population. FASDs have no cure, but affected individuals experience improved medical, psychological, and vocational outcomes through longitudinal intervention and treatment that maximize protective factors and build capacity in identified strengths. 67 , – 71 Multimodal symptom treatments that improve long-term outcomes include optimizing environmental modifications, parenting strategies, social support, and developmental and educational interventions that address the neurologically based problems related to FASDs. 67 , – 72 Children with FASDs prescribed neuroleptic medication have shown improved outcomes, but stimulant medication either failed to improve or worsened ADHD symptoms. 73 The heterogeneity of FASD manifestations calls for tailoring treatments to meet individual needs and addressing these constellations of lifelong disabilities across the life span.

Washington State continues to be a national and international leader in FASD diagnostic, prevention, and intervention practices through a long-standing coordinated effort of diverse programs focused on their collective FASD-associated needs and building a strong FASD research and evidence basis. The 2014 recommendations from the Washington State Fetal Alcohol Spectrum Disorders Interagency Work Group highlight evidence-based practices that include identifying risk and protective factors, engaging early intervention, addressing the high FASD risk for substance abuse problems, and applying screening-informed treatment planning, including neuropsychological assessment-guided treatment plans. 74

Children with FASD are not explicitly designated to receive special education services in the Individuals with Disabilities Education Act; however, some school districts serve affected children through the “Other Health Impaired” category. PAE is not specifically listed in this category but does qualify a child as “at risk” and eligible for early intervention services (Part C). The developmental and behavior difficulties in young children with FASDs qualify for special education services (Part C and Part B). Various school-based educational accommodations have been effective in helping children with FASDs reach their developmental and educational potential, but the transition to the posteducational setting and adulthood poses additional challenges where support services such as vocational training and life skills development are needed. 54 , 69 , 71 , 72 , 74

The constellation of medical, surgical, behavioral, educational, custodial, judicial, and other services required to care for an individual with FASD results in a large economic burden to the individual, the family, and society. 75 In the 1980s, the estimated annual FAS-related expenses for the United States increased from $75 million to $4 billion, with the lifetime cost of care approaching $1.4 million. 54 , 75 , 76 Cost estimates are similarly high in Canada but also vary widely depending on the methodologies used. 77 During 2005, children with FAS incurred average medical expenditures 9 times higher than those without FAS. 78 When FAS with intellectual disability was considered in making these calculations, average expenditures increased an additional 2.8 times the costs for FAS alone. 79 Because FAS is only 1 subset of FASD, the true economic effect of FASD is much larger. It has been documented in Canada that an FASD evaluation requires 32 to 47 hours for 1 individual to be screened, referred, evaluated, and given the diagnosis of an FASD, resulting in a total cost of $3110 to $4570 per person. 79 On the basis of the cost of a comprehensive multidisciplinary FASD assessment in Canada, the total cost estimate of all FASD screening and diagnosis ranges from $3.6 to $7.3 million per year, excluding treatment costs. 79 The estimated lifetime cost of care, including social and health care services, for each child born with FASD is up to $2.44 million. 75 , 80 The calculated expense of raising a child with FASD is 30 times the cost of preventing the FASD. 81 In 2005, the annual Medicaid cost to care for a child with FASD was 9 times that of a child without FASD. 78

The main role of a pediatrician and the medical home regarding FASD is to be knowledgeable about the disorder to guide prevention, to suspect and screen for FASD, and to recognize, manage, and refer patients. Pediatricians, medical home team members, and other health professionals are in prime position to provide both primary and secondary FASD prevention education and counseling because young women of childbearing age are among their patient population. 82 Pediatricians build trusted relationships with their adolescent and young adult patients and the parents of these patients, and a routine and expected part of medical home care is to discuss personal health responsibilities, including preventing pregnancy, alcohol, and other substance use and abstaining from sexual activity. Many women have misconceptions about the “safety” of alcohol use and as a result continue to consume alcohol during pregnancy despite the Surgeon General’s warnings. 24 Refraining from alcohol use during pregnancy is an important message to be delivered by health care providers as a part of prenatal care and other health visits during pregnancy. Clear guidance to correct misunderstandings about the risks of alcohol use during pregnancy and educate people about the importance of abstaining from alcohol during pregnancy may prevent further PAE and related outcomes. Earlier termination of alcohol use in pregnancy is associated with fewer alcohol-related complications for the mother and her baby. Specifically, first trimester drinking (vs no drinking) produces 12 times the odds of giving birth to a child with FASD, first and second trimester drinking increases FASD odds 61 times, and drinking in all trimesters increases FASD odds 65 times. 83

Adolescent patient care standards include providing consistent patient and family education and anticipatory guidance about alcohol use risks, screening for alcohol use and addiction, and intervention to address use and refer patients to treatment. Because adolescents who drink alcohol while pregnant could have a child with a FASD, policies from the American Academy of Pediatrics (AAP) and public domain tools are available to promote pediatrician skills and practices related to alcohol and other drug use screening, brief intervention, and referral to treatment. 84 , – 86

Given the prevalence in the United States of alcohol use by women who are sexually active or pregnant, pediatricians, through the medical home, should maintain a high level of suspicion for FASD, become familiar with FASD features, and conduct screening to detect PAE and FASD patients as early as possible. Maternal markers that increase the likelihood of a child having had PAE include the mother’s past history of alcohol or drug use problems, such as addiction, multiple drug use, a previous alcohol-exposed pregnancy, little or no prenatal care, unemployment, a transient lifestyle, incarceration, and/or a heavily drinking partner or family member. 66 Primary care providers should consider the possibility for FASD whenever a child has suggestive physical stigmata and/or is being assessed for poor growth, developmental delays, or behavioral concerns, including attention deficit or school failure. Any history of adoption, especially from an environment of socioeconomic impoverishment, whether domestic or international, and any history of involvement with a US child social services system can indicate a higher likelihood of having had PAE and a need for careful screening for FASD. 23 , 53 , 87 A history of involvement with child protective services related to parental substance use or to child neglect, abuse, or abandonment is a strong marker for risk, as is a history of any out-of-home or foster care placement, including kinship care. 87 Many people are not aware of the requirement for health care providers to report FASD to child protective service systems. 88 The 2010 reauthorization of the federal Child Abuse Prevention and Treatment Act legislation included specific policy revisions and mandates about FASD, including “a requirement that health care providers involved in the delivery or care of such infants notify the child protective service system,” make appropriate referrals to this system and other services, and develop a plan of safe care. 88

Medical home care relevant to FASD patients includes documenting a PAE and other substance exposure history and other historical details as well as physical examination findings, diagnosing FAS in patients when possible, and/or referring for comprehensive FASD assessment and diagnostic evaluation for intervention. 10 , 13 , 72 Effective medical home practices include optimizing the electronic health record use to facilitate documentation of PAE screening as a practice routine and integrating checklists or other tools to facilitate coordinated collaborative care, follow-up connections, and care transitions. Similar to other patients with complex conditions, those with FASDs are best served through periodic well-child care surveillance and coordinated collaborative patient management through referral to medical subspecialists and other health professionals to diagnose and/or manage comorbidities, facilitating access to and enrollment in developmental and educational services, consultation with social work risk assessment services, and coordination with legal and other community resources for the child and family. Partnering with the patient and family helps medical home physicians understand this lifelong diagnosis and how to manage any stigma and emotional responses, such as anger, shame, or blame that may arise from many sources, including themselves. 62 , 89 Working closely with families to engage their child in appropriate developmental and educational services is an ongoing role, and it is important to anticipate and coordinate the eventual transition of individuals with an FASD from pediatric to adult care services. Pediatricians may also refer FASD-diagnosed patients to the Supplemental Security Income (SSI) system so they can obtain income assistance and medical insurance. Many infants and children with FASD may be eligible for SSI. Furthermore, SSI can help adolescents and young adults with income support and medical insurance beyond 26 years of age, if not available through their parents. Early referral to the SSI system is important.

Assessment of physician training needs has shown that although pediatricians are knowledgeable about FASD and PAE risks, they inconsistently provide anticipatory guidance for FASD prevention with adolescent patients and lack confidence about integrating into routine practice the care management and treatment coordination needed by patients affected by FASDs. 90 , 91 To address these gaps, the CDC-funded FASD Regional Training Centers have published a curriculum development guide to create trainings for medical and allied health students and providers. 92 Other educational modalities and practice tools to enhance practitioner confidence with providing FASD care have been cooperatively developed by the CDC and the AAP. 92 Available through the AAP Web site, the FASD Toolkit and clinical algorithm are among the modalities developed to guide FASD screening, diagnosis, and management in the medical home.

There is no known absolutely safe quantity, frequency, type, or timing of alcohol consumption during pregnancy, but having no PAE translates into no FASD. Despite research evidence clearly documenting the spectrum of detrimental consequences of PAE, too many women continue to drink alcohol during pregnancy. Progress continues to be made in understanding the mechanisms of alcohol’s deleterious effects and identifying the most efficacious intervention strategies for preventing and ameliorating deficits associated with FASDs, but each discovery also reveals new challenges. From an economic, societal, educational, family, or health or medical home perspective, FASDs represent a major public health burden. 93 The pediatrician and the medical home as well as cooperative care with practitioners such as obstetricians and family medicine providers play important roles in the success of FASD prevention, intervention and treatment modalities but also in the research progress needed to discover additional means to address the lifelong consequences of FASDs.

AAP FASD Toolkit. www.aap.org/fasd

Astley SJ, Grant T. Recommendations From the Washington State Fetal Alcohol Spectrum Disorders Interagency Work Group, December 2014. Seattle, WA: Washington State Fetal Alcohol Spectrum Disorders Interagency Work Group. http://depts.washington.edu/fasdpn/pdfs/FASD-IAWG-Dec2014-Report.pdf

American College of Obstetricians and Gynecologists. At-Risk Drinking and Alcohol Dependence: Obstetric and Gynecological Implications. www.acog.org/Resources-And- Publications/Committee-Opinions/ Committee-on-Health-Care-for- Underserved-Women/At-Risk- Drinking-and-Alcohol-Dependence- Obstetric-and-Gynecologic- Implications

Centers for Disease Control and Prevention. www.cdc.gov/fasd

FAS Diagnostic and Prevention Network. FAS Facial Photography and Measurement Instruction (using images and animations to teach accurate measurement of FAS facial features). http://depts.washington.edu/fasdpn/htmls/photo-face.htm

National Dissemination Center for Children with Disabilities. www.parentcenterhub.org/nichcy- resources (All About the IEP— Individualized Educational Program: www.parentcenterhub.org/repository/iep/ )

NIAAA Collaborative Initiative on Fetal Alcohol Spectrum Disorders: www.cifasd.org

NOFAS National and State Resource Directory: www.nofas.org/resource-directory

Substance Abuse and Mental Health Services Administration (SAMHSA), Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence: www.fascenter.samhsa.gov

Substance Abuse and Mental Health Services Administration. Addressing Fetal Alcohol Spectrum Disorders (FASD). Treatment Improvement Protocol (TIP) Series 58. HHS Publication No. (SMA) 13-4803. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014. http://store.samhsa.gov/product/TIP-58- Addressing-Fetal-Alcohol-Spectrum- Disorders-FASD-/SMA13-4803

SAMHSA Treatment Locator: www.samhsa.gov/treatment/index.aspx

Janet F. Williams, MD, FAAP Vincent C. Smith, MD, MPH, FAAP

Sharon Levy, MD, MPH, FAAP, Chairperson Seth D. Ammerman, MD, FAAP Pamela K. Gonzalez, MD, FAAP Sheryl A. Ryan, MD, FAAP Lorena M. Siqueira, MD, MSPH, FAAP Vincent C. Smith, MD, MPH, FAAP

Janet F. Williams, MD, FAAP

Vivian B. Faden, PhD – National Institute of Alcohol Abuse and Alcoholism Gregory Tau, MD, PhD – American Academy of Child and Adolescent Psychiatry

Renee Jarrett, MPH

Sandra L. Friedman, MD, MPH, FAAP

Philip John Matthias, MD, FAAP Paul Seale, MD Yasmin Suzanne Nable Senturias, MD, FAAP Vincent C. Smith, MD, MPH, FAAP Renee M. Turchi, MD, MPH, FAAP David Wargowski, MD Janet F. Williams, MD, FAAP

Jacquelyn Bertrand, PhD – Centers for Disease Control and Prevention Elizabeth Parra Dang, MPH – Centers for Disease Control and Prevention Jeanne Mahoney – American College of Obstetricians and Gynecologists

Rachel Daskalov, MHA Faiza Khan, MPH

Carol Cohen Weitzman, MD, FAAP

American Academy of Pediatrics

attention-deficit/hyperactivity disorder

alcohol-related birth defect

alcohol-related neurodevelopmental disorder

Centers for Disease Control and Prevention

fetal alcohol syndrome

fetal alcohol spectrum disorder

neurobehavioral disorder associated with prenatal alcohol exposure

prenatal alcohol exposure

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Essay: Fetal Alcohol Syndrome (FAS)

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Fetal Alcohol Syndrome (FAS) refers to a series of birth defects that result from maternal consumption of alcohol during pregnancy. These include physical, mental, learning, and behavioral disabilities that have lifelong implications. FAS affects people from all socioeconomic, racial, and ethnic backgrounds. Despite numerous efforts made to create awareness and educate women about the harmful effects of alcohol on the developing fetus, a report from the Centers for Disease Control and Prevention suggests that between 50 and 60 percent of women continue to drink alcohol in the year of their pregnancy. Women are unwilling to give up their alcohol craving habits for the nine- month period because they simply do not care, or they do not really believe alcohol can be so detrimental. In many parts of the world, alcohol use is acceptable and even seen as a major component of family festivities and social gatherings. It is imperative that healthcare workers, especially nurses who are at the bedside most of the time, religiously undertake to instill knowledge and redirect such poor choices made by pregnant mothers. Although teaching is best done during the preconception period, it is never too late. Many children would have been spared the harm done to them only if someone would have cared enough to intervene when it was necessary. Every pregnancy should be afforded a happy and healthy outcome. Everything a pregnant woman eats, her unborn child eats as well. Hence, the fetus of a drinking woman would have had its first drink long before it was born. Science has proven that alcohol easily crosses the placenta to the developing fetus, whose alcohol level is usually the same as its mother (Pilletteri, 2014, p. 740). A woman who drinks alcohol during pregnancy is also at risk for spontaneous preterm labor, giving birth to a low birth weight or small for gestational age baby (Bird, 2013, p. 41). Saying no to alcohol during pregnancy should become a public outcry. Every woman who decides to become pregnant needs to abstain totally from alcohol use. There should be regular screenings and information sessions during prenatal visits so that parents-to-be who may be overwhelmed by their pregnancy, know and feel that they have the support of others. This is especially important among young mothers, those with unintentional pregnancies, and school drop-outs who may tend to place the blame on the fetus. A pregnancy that just ‘happens’ to a woman should not be allowed to reach age of viability if that woman shows not desire to dedicate those nine months toward the healthy nurturing of the fetus inside of her. Group sessions for pregnant women should be conducted by every major prenatal and childbirth facility. Positive role modelling and knowing that she is not alone can significantly change a woman’s perception of her pregnancy. Many who have experienced it live to tell stories of fear, neglect, hate, hunger, intimate partner violence, and suicide attempts. Group sessions can build strength and confidence so much so that a woman does not feel the need to ‘drown’ herself in alcohol to forget her troubles. An otherwise unwanted pregnancy can really become a bundle of joy. There are both prenatal and postnatal abnormalities associated with FAS, ranging from mild developmental delays to severe brain damage. Common features include microcephaly, small for gestational age, facial dysmorphology, poor motor coordination, hyperactivity, learning disabilities, poor reasoning and judgment skills (Thomas, Warren, and Hewitt, 2010, pp. 120-121). Several studies done on mice, rats, and dogs have confirmed that prenatal alcohol exposure produces these effects. The amount of alcohol consumed and the period during fetal development when it is consumed are directly linked to the severity of effects. Although dangerous at every stage, alcohol use during the first trimester produces most of the facial abnormalities associated with fetal alcohol syndrome. These can be the earliest signs that a child has FAS ‘ epicanthal folds, low nasal bridge, thin upper lip, narrow palpebral fissures, flat mid face, short nose, and indistinct philtrum (Thomas, Warren, and Hewitt, 2010, p. 119). Children exposed to alcohol prenatally can also suffer from brain abnormalities without exhibiting these facial features.

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Fetal Alcohol Syndrome

According to the research study conducted by Mcgee et al. (2009), classroom behavior between children diagnosed with Fetal Alcohol Syndrome (FAS) and those growing typically normal revealed a marked difference in the social communication profiles of the two groups. A total of 24 children clustered into 12 pairs took part in empirical study.

The classroom observation proceeded for a period of two weeks, 20 minutes each day. Handheld computers were used to record performance based on the Social Communication Coding System. There are six behavioral dimensions measured by the system. For instance, the children were examined in terms of their tendencies towards being pro-social or engaged, assertiveness, passiveness, hostility, coerciveness and orientation towards adult-seeking (Mcgee et al., 2009).

Results from this study indicated that the tendency towards being passive or being disengaged was more pronounced in children with Fetal Alcohol Disorder (FAS) than their corresponding peers. In addition, irrelevant behavior prevailed for a long time among children with FAS than those without. Besides, pro-social and engage behavior was more dominant in children with FAS.

Nonetheless, the proportion and mean time spent by these children as pro-social characters was relatively shorter than in children without FAS diagnosis. From these findings, it is evident that Fetal Alcohol Syndrome can indeed impart long term behavioral patterns in children and adolescents.

The ability to interact or socialize with age-mates is usually a daunting task for school-age children with this condition. This can be noted easily especially when they are observed in a classroom environment.

Moreover, such difficulty with social communication can also be a common concern for parents and teachers under the care of the affected children. The exact nature of their problems is often cumbersome to establish bearing in mind that inability to interact smoothly with their peers transcends into poor academic performance (Mcgee et al., 2009).

The prevalence of teratogen and its subsequent disruption of fetus growth has been an issue under deliberation for the last four decades or so. As Thomas, Warren & Hewitt (2010) note, prenatal exposure of fetus to alcohol can lead to the development of negative chronic impacts on the behavioral, psychological (neurological) and physical wellbeing of children even as they grow to maturity. The authors further clarify that the long term effects of FAS can be classified into three.

First, facial dysmorphology is a common chronic impact in children diagnosed with FAS. Second, there are myriad deficiencies that arise during the prenatal period that equally affect the postnatal stages of development.

Lastly, exposure of the fetus in an alcoholic environment during pregnancy has a long term effect on the central nervous system since the latter may end up malfunctioning with time. However, there are instances when earl y exposure to alcohol may not necessarily lead to all of these effects even if the affected child attains the full-blown stage of the syndrome.

Early research studies conducted on FAS indicated that prenatal exposure to alcohol was a major pathway to the development of small brain, a condition known as microencephaly (Thomas, Warren & Hewitt, 2010). Besides, FAS has also been associated with neuroglial heterotopias whereby cells located within the nervous system reposition themselves to wrong locations. Moreover, the growth of corpus callosum is significantly interfered with among children who were exposed to alcohol during the prenatal stage.

Subsequent research carried out on the likely impacts of FAS in children and adolescents also gave unanimous results when the noninvasive imaging of the brain structure was done (Thomas, Warren & Hewitt, 2010). Results obtained from structural imaging showed that there was appreciable shrinking of brain size. Participation as well as occupational performance is dully affected among children affected with FAS.

For instance, their cognition ability may be impaired as they grow up, poor learning capabilities as well as deficits in sensory-motor abilities (Jirikowic, Kartin & Olson, 2008). These children also develop near-permanent adaptive challenges alongside behavioral and social difficulties. Later in life, the impacts of FAS on children often replicates themselves on day-to-day activities such as engaging in drug abuse, poor performance in school and reduced ability to live independently.

As Jirikowic, Kartin and Olson (2008) recommend, occupational therapists should endeavor to promote participation and social interaction among people with this disorder as part and parcel of reverting their physical and neurobehavioral patterns to normalcy. Furthermore, early diagnosis and onset of therapeutic treatment has been suggested as an important ingredient in treating patients identified with this disorder.

As already mentioned, this population is adversely affected by deficiency in adaptive skills. Quite often, they have lower adaptive skills that do not match either their age or intellectual level. According to this context, adaptive behavior primarily addresses how individuals perform their daily tasks and chores in order to meet their social and individual needs.

Children with Fetal Alcohol Syndrome (FAS) have also been identified to be at a higher risk of developing a disorder called Attention-Deficit/Hyperactivity Disorder (ADHD). An empirical research study conducted by Doig, McLennan and Gibbard (2008) confirms the correlation between ADHD and prenatal exposure to alcohol. Nonetheless, the researchers have expressed fears that there is inadequate information regarding the successful treatment of ADHD among this group of people.

On the long term impacts of FAS on children, the study hypothesized and later concluded that this syndrome has the potential to restrict growth as well as enhance neuropsychologic deficiencies. Worse still, the syndrome is a major precipitator of craniofacial abnormalities as depicted in the research outcome (Doig, McLennan & Gibbard, 2008). Moreover, cormobid mental health complication has also been identified in children suffering from FAS.

in a separate but related research by lswang, Svensson and Astley (2010), it has been adequately documented that children diagnosed with FAS often face difficult times in resolving disputes as they keenly anticipate the effects of their behaviors. In this research study, nine children who had gone through prenatal exposure to alcohol were investigated. These individuals were also found to have difficulties in expressing themselves in comparison to their peers who had grown in an alcohol-free prenatal environment.

In recap, it is vital to note that Fetal Alcohol Syndrome (FAS) is one of the many syndromes that fall under the umbrella of Fetal Alcohol Spectrum Disorder (FASD) occasioned by early exposure of fetus to an alcoholic environment by a pregnant mother. Although other syndromes exist, the discussion on FAS cannot be ignored due to myriad long term effects of the condition on children and adolescents.

For instance, school-age children identified with FAS have been found to have difficulties in expressing themselves through language, inability to solve conflicts, among other neuropsychological and physical deficits such as reduction in brain size and higher prevalence of Attention-deficit/hyperactivity disorder (ADHD).

Nevertheless, further research on this subject is highly recommended in order to examine other latent and most precarious effects of FAS on children as well as enhanced drug and therapeutic treatment options that can be used to manage, revert or completely cure this disorder.

Doig, J., McLennan, J., & Gibbard, W. (2008). Medication Effects on Symptoms of Attention-Deficit/Hyperactivity Disorder in Children with Fetal Alcohol Spectrum Disorder. Journal of Child and Adolescent Psychopharmacology, 18 (4), 365-71.

lswang, L., Svensson, L., & Astley, S. (2010). Observation of Classroom Social Communication: Do Children With Fetal Alcohol Spectrum Disorders Spend Their Time Differently Than Their Typically Developing Peers? Journal of Speech, Language and Hearing Research, 53 (6), 1687-1703A.

Jirikowic, T., Kartin, D., & Olson, H. (2008). Children with fetal alcohol spectrum disorders: A descriptive profile of adaptive function. The Canadian Journal of Occupational Therapy, 75 (4), 238-48.

Mcgee, C. et al. (2009). Social Information Processing Skills in Children with Histories of Heavy Prenatal Alcohol Exposure. Journal of Abnormal Child Psychology, 37 (6), 817-30.

Thomas, J., Warren, K., & Hewitt, B. (2010). Fetal Alcohol Spectrum Disorders: From Research to Policy. Alcohol Research and Health, 33 (1/2), 118-126.

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Patient Care & Health Information
Diseases & Conditions
Fetal alcohol syndrome

Fetal alcohol syndrome is a condition in a child that results from alcohol exposure during the mother's pregnancy. Fetal alcohol syndrome causes brain damage and growth problems. The problems caused by fetal alcohol syndrome vary from child to child, but defects caused by fetal alcohol syndrome are not reversible.

There is no amount of alcohol that's known to be safe to consume during pregnancy. If you drink during pregnancy, you place your baby at risk of fetal alcohol syndrome.

If you suspect your child has fetal alcohol syndrome, talk to your doctor as soon as possible. Early diagnosis may help to reduce problems such as learning difficulties and behavioral issues.

The severity of fetal alcohol syndrome symptoms varies, with some children experiencing them to a far greater degree than others. Signs and symptoms of fetal alcohol syndrome may include any mix of physical defects, intellectual or cognitive disabilities, and problems functioning and coping with daily life.

Physical defects

Distinctive facial features, including small eyes, an exceptionally thin upper lip, a short, upturned nose, and a smooth skin surface between the nose and upper lip
Deformities of joints, limbs and fingers
Slow physical growth before and after birth
Vision difficulties or hearing problems
Small head circumference and brain size
Heart defects and problems with kidneys and bones

Brain and central nervous system problems

Problems with the brain and central nervous system may include:

Poor coordination or balance
Intellectual disability, learning disorders and delayed development
Poor memory
Trouble with attention and with processing information
Difficulty with reasoning and problem-solving
Difficulty identifying consequences of choices
Poor judgment skills
Jitteriness or hyperactivity
Rapidly changing moods

Social and behavioral issues

Problems in functioning, coping and interacting with others may include:

Difficulty in school
Trouble getting along with others
Poor social skills
Trouble adapting to change or switching from one task to another
Problems with behavior and impulse control
Poor concept of time
Problems staying on task
Difficulty planning or working toward a goal

When to see a doctor

If you're pregnant and can't stop drinking, ask your obstetrician, primary care doctor or mental health professional for help.

Because early diagnosis may help reduce the risk of long-term problems for children with fetal alcohol syndrome, let your child's doctor know if you drank alcohol while you were pregnant. Don't wait for problems to arise before seeking help.

If you have adopted a child or are providing foster care, you may not know if the biological mother drank alcohol while pregnant — and it may not initially occur to you that your child may have fetal alcohol syndrome. However, if your child has problems with learning and behavior, talk with his or her doctor so that the underlying cause might be identified.

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When you're pregnant and you drink alcohol:

Alcohol enters your bloodstream and reaches your developing fetus by crossing the placenta
Alcohol causes higher blood alcohol concentrations in your developing baby than in your body because a fetus metabolizes alcohol slower than an adult does
Alcohol interferes with the delivery of oxygen and optimal nutrition to your developing baby
Exposure to alcohol before birth can harm the development of tissues and organs and cause permanent brain damage in your baby

The more you drink while pregnant, the greater the risk to your unborn baby. However, any amount of alcohol puts your baby at risk. Your baby's brain, heart and blood vessels begin to develop in the early weeks of pregnancy, before you may know you're pregnant.

Impairment of facial features, the heart and other organs, including the bones, and the central nervous system may occur as a result of drinking alcohol during the first trimester. That's when these parts of the fetus are in key stages of development. However, the risk is present at any time during pregnancy.

Risk factors

The more alcohol you drink during pregnancy, the greater the chance of problems in your baby. There's no known safe amount of alcohol consumption during pregnancy.

You could put your baby at risk even before you realize you're pregnant. Don't drink alcohol if:

You're pregnant
You think you might be pregnant
You're trying to become pregnant

Complications

Problem behaviors not present at birth that can result from having fetal alcohol syndrome (secondary disabilities) may include:

Attention deficit/hyperactivity disorder (ADHD)
Aggression, inappropriate social conduct, and breaking rules and laws
Alcohol or drug misuse
Mental health disorders, such as depression, anxiety or eating disorders
Problems staying in or completing school
Problems with independent living and with employment
Inappropriate sexual behaviors
Early death by accident, homicide or suicide

Experts know that fetal alcohol syndrome is completely preventable if women don't drink alcohol at all during pregnancy.

These guidelines can help prevent fetal alcohol syndrome:

Don't drink alcohol if you're trying to get pregnant. If you haven't already stopped drinking, stop as soon as you know you're pregnant or if you even think you might be pregnant. It's never too late to stop drinking during your pregnancy, but the sooner you stop, the better it is for your baby.
Continue to avoid alcohol throughout your pregnancy. Fetal alcohol syndrome is completely preventable in children whose mothers don't drink during pregnancy.
Consider giving up alcohol during your childbearing years if you're sexually active and you're having unprotected sex. Many pregnancies are unplanned, and damage can occur in the earliest weeks of pregnancy.
If you have an alcohol problem, get help before you get pregnant. Get professional help to determine your level of dependence on alcohol and to develop a treatment plan.
AskMayoExpert. Fetal alcohol syndrome. Rochester, Minn.: Mayo Foundation for Medical Education and Research; 2016.
Fetal alcohol spectrum disorders (FASDs): Facts about FASDs. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/fasd/facts.html. Accessed March 13, 2017.
Fetal alcohol spectrum disorders (FASDs): Alcohol use in pregnancy. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/fasd/alcohol-use.html. Accessed March 13, 2017.
Fetal alcohol spectrum disorders (FASDs): Secondary conditions. Centers for Disease Control and Prevention. https://www.cdc.gov/ncbddd/fasd/secondary-conditions.html. Accessed March 13, 2017.
Fetal alcohol syndrome. American Academy of Family Physicians. https://familydoctor.org/condition/fetal-alcohol-syndrome/#questions. Accessed March 13, 2017.
Williams JF, et al. Fetal alcohol spectrum disorders. Pediatrics. 2015;136:e1395.
Effects of alcohol on a fetus. Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/shin/content/SMA07-4275/SMA07-4275.pdf. Accessed March 13, 2017.
Weitzman C, et al. Fetal alcohol spectrum disorder: Overview of management and prognosis. http://www.uptodate.com/home. Accessed March 13, 2017.
Wilhoit LF, et al. Fetal alcohol spectrum disorders: Characteristics, complications, and treatment. Community Mental Health Journal. In press. Accessed March 13, 2017.
Weitzman C, et al. Fetal alcohol spectrum disorder: Clinical features and diagnosis. http://www.uptodate.com/home. Accessed March 13, 2017.
Hoecker JL (expert opinion). Mayo Clinic, Rochester, Minn. March 25, 2017.
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Understanding the Facts around Fetal Alcohol Syndrome

Cases engaging the connection of maternal use of alcohol and the results that this particular attitude have towards the unborn infants even towards their growth and development have been given attention to due to the rising number of individuals being diagnosed with health, physical and mental problems suspected to be related to the said matter. Jennifer Havens (et al, 2008) tries to examine the situation in the study Factors associated with substance use during pregnancy: Results from a national sample. Here, Havens and her colleagues try to point out the prevalence of the situation growing among pregnant mothers and how their attitude on alcohol use actually affect the development of their unborn infants. Considerably, this article is concentrated on examining the situation being strongly implicative on the health of unborn children from the United States.

To make sure that the data would be accurate enough and relatively connected to the current situations that the world is dealing with at present especially in connection to points of pregnancy among women, the researchers decided to contact participants from ages 15 to 44 who are pregnant and have participated accordingly with the National Survey on Drug Use and Health between the years 2002 and 2003. In this study, it was acknowledged by the researchers that expectant mothers often experience particular points of psychological issues due to their worries. Mothers who may not have supportive husbands, or at some point are being stressed out by their own families or their own selves may build up personal anxieties that cannot be easily addressed. Hence, as a result, they resort to drinking, thinking that they may not be damaging their young infants growing inside them [compared to instances when they actually take illegal drugs]. This belief, however, has been strongly disregarded by the fact that there have been recent evaluations on cases being reported to have been associated with being exposed to alcohol drinks at an early stage of development which could directly be defined through the distinct course of development taken into account when unborn infants are developing inside their mother’s womb. In the end, the results of this study points out that whether the mother specifically drank light alcohol or drank heavily, the effects are the same with the chances of young infants actually at the receiving end of the said intake.

On the other hand, while Havens’ (et al) study actually define the distinct emergence of problematic issues on children brought up by mothers who have had the chance of drinking neither hardly or lightly, Kelly’s (et al, 2009) study says something else about the case. In the research entitled Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age?; Kelly and her colleagues tried to examine how the amount of alcohol actually makes a distinct impact on an unborn child. Like the study of Havens and her colleagues, this research also recognizes the pathopsychological issues that expectant mothers actually need to deal with and the resort they usually take into consideration. Unlike the first study though, this one explores another aspect of the environment which is located in UK. Utilizing data from personal interviews and home visits, the researchers cross referenced the data they have collected with that of the data that has already been archived in relation to the surveys handled during a particular nation-wide scaling operation on the same issue. In the end, the cross referenced details all account to specific points that define the underlying facts that are specifically essential in determining the facts about mother’s attitude and knowledge with that of the conditions of developmental issues that their children develop alongside with. In the end, the study concluded on the distinction of the case regarding the issue on relatively pointing out how light drinking do not cause any specific issue on unborn children or even as they grow up. This study basically outruns the research handled by Havens and her colleagues. Considerably, such findings alter the relative results of the consequences presented by Havens [et al] in the research.

It could be understood that somehow, with these contrasting research results, the way the results turned out to be could be related to the accuracy of the reports presented in each case of investigating on the topic involved. Haven’s research resulted to such consistency due to the fact that it did not intend to compare the situation based on the rate of alcohol intake that each mother takes into account; while the other research was concentrated on examining the drinking behavior of the mothers based on the rate of alcoholic beverages they take into account. Most likely, it is the generality of Havens’ (et al) report that made it examine the general condition than actually concentrating on particular elements of the matter.

Distinctively, both studies, even though they may have slight differences especially when it comes to defining the importance of seeing through the issue of developing interventions that are necessary to make sure that expectant mothers, although they may be experiencing high rates of anxiety, need not be overly consumed about their condition and put the lives and later development of their children at risk. Relatively, both studies tend to remind mothers of the great responsibility they are given especially in relation to taking care even that of their unborn children. With the data collected through the referenced factors in these particular researches, the authorities in the field of medicine and psychology could actually get vital information that they could use in helping out mothers who might be in great danger of putting their unborn children into high risks of development issues. Addressing the problem on its earliest stage is always a better choice especially when it comes to emerging health issues like that of the Fetal Alcohol Syndrome.

Havens JR, Simmons LA, Shannon LM, Hansen WF (September 2008). “ Factors associated with substance use during pregnancy: Results from a national sample”. Drug and alcohol dependence 99 (1–3): 89–95. http://www.sciencedirect.com/science/article/pii/S037687160800255X. (Retrieved on March 3, 2014).

Kelly Y, Sacker A, Gray R, Kelly J, Wolke D, Quigley MA (February 2009). “Light drinking in pregnancy, a risk for behavioural problems and cognitive deficits at 3 years of age? “. Int J Epidemiol 38 (1): 129–40.http://ije.oxfordjournals.org/content/38/1/129.abstract. (Retrieved on March 3, 2014).

Clarren, S.K. (2005). A thirty year journey from tragedy to hope. Foreword to Buxton, B. (2005). Damaged Angels: An Adoptive Mother Discovers the Tragic Toll of Alcohol in Pregnancy . New York: Carroll & Graf.

Chudley A, Conry J, Cook J et al. (2005). “ Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis”. CMAJ 172 (5 Suppl): S1–S21.

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Fetal alcohol syndrome is a patter of physical or mental illness, mostly deformities that is developed due to excessive use of alcohol by mothers during pregnancy. It is however not always the case that ingestion of alcohol would always cause a baby to develop fetal alcohol syndrome.

Fetal alcohol syndrome hinders the development of a child in many ways due to the varied birth defects that manifests themselves in victims. The most common physical aspect that is hindered in children with this condition is growth. This could occur on any parts of the body but mostly the head and height of the child is greatly diminished, ( Malbine 1996). This condition of having a small head (micro cephalic) is mainly due to failure of the brain to grow normally, which could also vary from a mild level to moderate.

The face could also have an abnormal growth of features on it, such as a sunken nasal bridge, having short eye openings as well as having a short nose. It is also very common for skeleton defects such as the child having abnormal positions for joints as well as problems with their functions. Heart defects have also been reported due to this syndrome whereby a child could have a murmur, which is a hole between the right and left hand side of the heart between the ventricles.

Another physical defect on children is that of having cleft lips as well as hydrocephalus which is a condition where one has an increased flow of fluid in the brain leading to an increased pressure on it. Lastly it is true to say that this excessive drinking by pregnant women could lead to many defects even some involving internal organs such as the liver and kidneys that may not be very easy to detect until it is very late. The development of the nervous system, which works in tandem with the body skeleton e.g. spine and cranium are also greatly compromised.

Emotionally, as the child grows emotional lapses are also very likely. To start with, children with this condition are mostly vey slow learners. This may cause them to have very unpredictable mood swings as it is very difficult to communicate with them and know exactly how they are feeling and any problems they are facing. These children are also very impulsive in their behavior and are usually likely to act without any foresight or care about the effects of some of their actions. This is because they do mostly feel depressed inside and have no real connection to a parental figure that can help counsel them.

Children with this condition often cut a forlorn figure in the society and tend to have a feeling of being disliked hence are more likely to experience outbursts and temperaments to people around them, (C. Margaret, 1995). Some would even cry for long hours, especially small children for any reasons including loneliness or even pain caused by any of the aforementioned defects. They therefore are generally not very in the society as compared to the others.

There are also social implications of the fetal alcohol syndrome. Some could stem out of the initial birth defects obtained at birth while others are developed with time as the child grows. An example is a kid with cleft lips who could be traumatized for looking very different from the other children or having trouble interacting with other children in case they may poke fun at him about the same. A child with joint problems is also not likely to participate in games activities therefore making them feel isolated and ostracized from the rest of the children.

The children involved also demonstrate poor attention and concentration skills due to mostly thinking about their own problems. They are very often hyperactive and could involve themselves in many delinquent activities such as stealing and even lying. They may also not have a proper response to social cues and therefore seem so different and even isolated figures in the society. In some cases, people with history of alcohol from their families could also have problems making new friends as they are not easily likely to reciprocate friendship once initiated. This may lead the victims to lead a life of social withdrawal where despite encountering many people, they would tend not to associate with very few people.

This life of utter sullenness could go on and on as the victim tends to resent the people around them as they perceive themselves as very different from the rest. It is also possible that the victims might develop an inferiority complex in the social setting they are in given the fact that families with drinking problems are seen to be very disorganized and with many problems. An example is having their learning in school disrupted mostly due to the issues with the family or even just by being stubborn and feeling like it. This might lead the victim to lag behind and by not having a good educational background they would jeopardize their chances of getting good jobs and being successful and settling in life.

Statistics have also shown that children who suffer from this condition are very likely to engage in alcohol use in their lives. This is especially very unfortunate when they do start at a very early age as it leads to a dominoes effect of very many other problems to the victim. In addition to using alcohol, the chance of using drugs is very high. Substances such as cocaine, Cannabis and many more are being used every day by children with problems with alcohol. Again the negative effects this has on the individual cannot be overemphasized.

Children with the fetal alcohol syndrome are much more likely to participate in crime more than any other child. This is mostly due to the negative image that is portrayed by the parents as most drunk people behave in an uncouth manner. They cause problems to the society and have no particular willingness to act any different than they learnt from their parents. Subsequently, these individuals are not likely to get jobs thereafter as most employers do not hire people with criminal backgrounds.

In general, we can say that all these negative social effects are due to an 'attachment disorder' which can be termed as the lack of trusting and true relationship to an adult, therefore denying them the chance for the parental care and chance to learn from them.

The final aspect is about the cognitive development inhibition of the fetal alcohol syndrome. Cognitive development has to do with the instincts to learn, perceive and understand in human beings. It should be noted first that fetal alcohol syndrome is likely to cause an individual to have a poor memory. This therefore becomes a platform for many other memory related problems to come in. This includes lacking a specific mathematical deficiency as well as having problems with abstraction i.e. time and time.

Lack of a good comprehension of what is around them and having an impaired judgment are also common effects of this condition. Many would make decisions hurriedly without so much care on how these would affect them in future. This could also be partly be explained by the poor development of the brain which hinders its function of reasoning and critical thinking.

It is therefore true to say that fetal alcohol syndrome is very dangerous and injurious to its victims and pregnant mothers should be warned to steer away from alcohol as it might have profound negative effects to the baby and the child it would grow into. It is also true that the defects caused by the alcohol to the baby are very many and very unique to every victim.

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Fetal Alcohol Spectrum Disorders: A Case Study

This grand rounds manuscript reviews important considerations in developing case conceptualizations for individuals with a history of prenatal alcohol exposure. This case study provides an introduction to fetal alcohol spectrum disorders, diagnostic issues, a detailed description of the individual's history, presenting symptoms, neuropsychological test results, and an integrated summary. We describe a 9-year old girl diagnosed with a fetal alcohol spectrum disorder (FASD): Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). This patient is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility.

Review of Fetal Alcohol Spectrum Disorders

The estimated prevalence of fetal alcohol spectrum disorders (FASD) is conservatively around 1%; however, a recent study in North America found rates as high as 4.8% of the school-age population is affected by prenatal alcohol exposure, indicating a significant public health concern ( May et al., 2014 ; May et al., 2015 ). While there have been considerable efforts in the public health sector to reduce drinking during pregnancy ( Grant et al., 2004 ), there has not be a meaningful decrease in prenatal alcohol exposure over the past decade ( Thomas, Gonneau, Poole, & Cook, 2014 ). Approximately half of all pregnancies are unplanned and the rates of drinking during childbearing age are substantial; thus, there is ongoing risk of having children born who are affected by prenatal exposure to alcohol ( Finer & Zolna, 2011 ; Green, McKnight-Eily, Tan, Mejia, & Denny, 2016 ).

Prenatal alcohol exposure results in a heterogeneous clinical presentation, which varies greatly in terms of cognitive and behavioral abilities. Prenatal alcohol exposure remains the leading preventable cause of birth defects, developmental disorders, and intellectual disability ( American Academy of Pediatrics, 2000 ). While fetal alcohol syndrome (FAS) has been recognized since the early 1970s ( Jones & Smith, 1973 ), there continues to be difficulty in identifying children affected by prenatal alcohol exposure who do not meet full criteria for FAS. An accepted diagnostic schema to identify children affected by prenatal alcohol exposure has yet to be fully codified in the Diagnostic and Statistical Manual of Mental Disorders - 5 th edition ( DSM-5 ; American Psychiatric Association, 2013 ) or other medical diagnostic system, although positive steps have been made. Unfortunately, a majority of children with FASD are undiagnosed or misdiagnosed due to a lack of characteristic physical features and overlapping symptomology with other disorders ( Chasnoff, Wells, & King, 2015 ).

Overview of Clinical Presentation

Prenatal alcohol exposure results in a wide range of central nervous system dysfunction that is apparent neurologically, structurally, and functionally ( Bertrand et al., 2005 ). Underlying changes in the brain have been shown to relate to increased neurological issues including increased rates of seizures, sleep abnormalities, and sensory processing impairments ( Bell et al., 2010 ; Church & Kaltenbach, 1997 ; Coffman et al., 2012 ; Jan et al., 2010 ; Simmons, Madra, Levy, Riley, & Mattson, 2011 ; Simmons, Thomas, Levy, & Riley, 2010 ; Steinhausen & Spohr, 1998 ; Wengel, Hanlon-Dearman, & Fjeldsted, 2011 ). In addition to neurological signs and symptoms, central nervous system dysfunction can also be evident through the presence of structural brain differences (e.g., microcephaly, structural abnormalities) or functional impairment (e.g., intellectual disability, cognitive deficits).

In some cases, children will meet criteria for a diagnosis of fetal alcohol syndrome (FAS). An FAS diagnosis is characterized by the presence of two or more key facial features (short palpebral fissures, smooth philtrum, thin vermillion border), growth deficits, and evidence of central nervous system abnormalities (e.g., microcephaly, abnormal morphogensis) ( Hoyme et al., 2005 ). For additional detail, please see Figure 1 . It is important to note that the majority of children who are affected by prenatal alcohol exposure do not meet full criteria for an FAS diagnosis and partial phenotypes are important to recognize.

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Facial characteristics associated with fetal alcohol exposure. Figure from Warren KR, Hewitt BG, Thomas JD (2011) Fetal alcohol spectrum disorders: Research challenges and opportunities. Alcohol Research and Health 34: 4-14. Figure in the public domain. See Table 1 for more information.

Alcohol is one of the most investigated behavioral teratogens, with decades of research demonstrating the broad behavioral and cognitive effects of prenatal exposure ( Glass, Ware, & Mattson, 2014 ; Mattson, Crocker, & Nguyen, 2011 ). There are a variety of factors that may affect the neurobehavioral consequences of prenatal exposure including genetics, environment, rate and volume of exposure, and other variables related to the pregnancy and development. The timing and dosage of teratogenic exposure to alcohol to the fetus in utero may directly correlate with impairment in specific areas. For example, exposure to alcohol during the first trimester may lead to cerebellar damage related to movement or habit learning whereas second trimester exposure may relate to behavioral or emotional dysregulation as the amygdala development may be atypical. As of now, there is no safe dosage or timing in which to drink and pregnant women are recommended by the Surgeon General to not drink throughout pregnancy. Further, the exact relations between dosage and timing of exposure and behavioral effects is still largely unknown and likely varies dramatically based on other characteristics such as speed of metabolism of alcohol, other genetic factors, other potential comorbidities, and environmental effects. Often alcohol is not the only teratogen and there may be concerns related to nutritional status and other factors that affect both the pregnancy and long term behavioral outcomes of the child. Understanding the relation between neurological insult and behavioral presentation can help inform intervention. However, there have been consistent findings across studies that point to an emerging neurobehavioral profile associated with prenatal alcohol exposure ( Mattson & Riley, 2011 ; Mattson et al., 2013 ).

Behavioral Deficits/Self-Regulation

Behavioral deficits are often the impetus to seek clinical care for individuals affected by prenatal alcohol exposure. Across studies, there has been repeated confirmation of behavioral concerns related to self-regulation and externalizing problems such as impulsivity and rule-breaking, in addition to inattention, anxiety, depression, and poor social functioning ( Glass et al., 2014 ; Mattson et al., 2011 ; Streissguth et al., 2004 ). Children with prenatal alcohol exposure have higher rates of concomitant psychopathology, including increased rates of psychopathology, negative affect, and overall mood lability ( Burd, Klug, Martsolf, & Kerbeshian, 2003 ; Sood et al., 2001 ; Streissguth et al., 2004 ). Further, studies consistently support the presence of attention deficits in children who have histories of prenatal exposure to alcohol, with rates of attention-deficit/hyperactivity disorder (ADHD) diagnoses estimated between 40-90% ( Bhatara, Loudenberg, & Ellis, 2006 ; Burd et al., 2003 ; Fryer, McGee, Matt, Riley & Mattson, 2007 ).

Adaptive Functioning

Another core feature of the clinical presentation associated with prenatal alcohol exposure is the presence of impaired adaptive behavior. Adaptive behavior deficits have been noted across all domains of adaptive function (i.e., communication, socialization, motor skills, and daily living skills) and appear to worsen with age ( Carr, Agnihotri, & Keightley, 2010 ; Crocker, Vaurio, Riley, & Mattson, 2009 ; Jirikowic, Carmichael Olson, & Kartin, 2008 ). In terms of communication, many children with prenatal alcohol exposure demonstrate deficits in aspects of language including phonological processing, speech production, and social communication ( Doyle & Mattson, 2015 ). Social skills are complex and often considered the most severely affected domain of adaptive functioning in children with prenatal alcohol exposure. Alcohol-exposed children have routinely been found to demonstrate poor social interactions and struggle with socially inappropriate behavior ( Greenbaum, Stevens, Nash, Koren, & Rovet, 2009 ; McGee, Fryer, Bjorkquist, Mattson, & Riley, 2008 ). Children with prenatal alcohol exposure also have difficulty with motor control ( Kalberg et al., 2006 ; Simmons, Thomas, Levy, & Riley, 2006 ). Daily living skills are often impaired or delayed in children with prenatal alcohol exposure and are apparent both in delayed reaching of developmental milestones (e.g., toileting, following rules, bathing, feeding) and overall difficulty with living independently, although there is minimal research conducted within adult samples ( Moore & Riley, 2015 ). Difficulties in adaptive function often appear to persist into adulthood, although there are anecdotal reports of both improved and worsening behavioral concerns. As prenatal alcohol exposure results in damage to the brain, it is likely that deficits in this area are related to the prenatal neurological striatal insult that can result in poor habit learning requiring instructions to be repeated more often and not learning effective strategies for functioning in social and practical situations as quickly as typically developing youth. These issues seen in childhood may be exacerbated in adulthood as the gap between what is expected of the individual and what the individual is able to do may grow. Further, as adults individuals often have more freedom and access to situations that may lead to more high risk behavior and negative outcomes. These adaptive behavior problems often lead to secondary disabilities, including high rates of interaction with the justice system, lower rates of independent living, and high rates of substance abuse ( Streissguth, Barr, Kogan, & Bookstein, 1996 ).

Neurocognitive Functioning

In addition to behavioral deficits, cognitive effects of prenatal alcohol exposure are well documented and have been reviewed in depth (see Glass et al., 2014 ; Mattson et al., 2011 for review). Overall, prenatal alcohol exposure results in cognitive deficits across various domains, including general intellectual function, executive function, learning, memory, and visual spatial reasoning. The literature on impairments in these domains is the basis for the proposed criteria of Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE), which is in the appendix of the DSM-5 as a condition for further review ( Doyle & Mattson, 2015 ; Kable et al., 2016 ).

One of the most robust findings in children with prenatal exposure to alcohol is overall diminished general cognitive function. Average intelligence estimate scores among children exposed to alcohol prenatally fall approximately 1 standard deviation lower than the average non-exposed individual ( Glass et al., 2013 ; Streissguth et al., 2004 ), although individuals can range from severe impairment to unimpaired (e.g., full scale IQ scores of 40-112; Mattson et al., 2011 ). Executive dysfunction is often considered a core feature of prenatal alcohol exposure and poor performance on these higher-order domains is seen across parent report and objective standardized assessments ( Glass et al., 2014 ; Mattson et al., 2011 ; Nguyen et al., 2014 ). Deficits exist across aspects of executive function including planning, set-shifting, cognitive flexibility, response inhibition, and working memory.

Alcohol-exposed children also struggle with poor performance in learning new material, both in visual and verbal domains, with stronger support for the latter ( Mattson et al., 2011 ; Pei, Rinaldi, Rasmussen, Massey, & Massey, 2008 ; Willford, Richardson, Leech, & Day, 2004 ; Willoughby, Sheard, Nash, & Rovet, 2008 ). Learning deficits are also apparent in the presence of decreased academic performance across domains, with particular weaknesses seen in areas of mathematical functioning ( Glass, Graham, Akshoomoff, & Mattson, 2015 ; Goldschmidt, Richardson, Stoffer, Geva, & Day, 1996 ; Howell et al., 2006 ). Memory deficits are also seen across domains (verbal, visual, auditory), and often appear to be associated with initial encoding difficulties with relatively spared retention ( Kaemingk, Mulvaney, & Halverson, 2003 ; Willoughby et al., 2008 ). Children with prenatal alcohol exposure also have difficulties processing visual information ( Mattson et al., 2011 ; Mattson, Gramling, Delis, Jones, & Riley, 1996 ; Paolozza et al., 2014 ), which can relate to poor performance in several areas of functioning ( Crocker, Riley, & Mattson, 2015 ).

Diagnostic Issues

While it appears that training pediatricians on recognizing dysmorphology is effective in increasing awareness and identification of children with FAS ( Jones et al., 2006 ), the vast majority of children affected by prenatal alcohol exposure do not meet criteria for the diagnosis and are at high risk of not receiving necessary services in spite of significant cognitive and behavioral challenges. There are various factors that hinder clinical identification of alcohol-exposed children including high rates of symptoms that overlap with other clinical disorders (e.g., ADHD), no biomarker to date, lack of prenatal exposure information, and often no obvious facial dysmorphology. Objective screening tools, including neonatal testing and the development of potential biomarkers, can assist in the identification of alcohol-exposed children at birth ( Koren et al., 2014 ; Zelner et al., 2010 ; Zelner et al., 2012 ); however, these tools have not been introduced as best practice guidelines at this point and remain in a research phase. Ongoing study is needed to determine the accuracy and reduce the risk of disproportionately targeting specific groups, inaccurate screening, and address the concern of stigma and judgment associated with maternal drinking during pregnancy ( Drabble, Thomas, O'Connor, & Roberts, 2014 ; Yan, Bell, & Racine, 2014 ). A common concern in development of identification tools for alcohol exposure at birth is that even if it is possible to accurately determine prenatal alcohol exposure with adequate sensitivity and specificity, it is not certain that an individual will be negatively affected later in life. As such, tools targeted at identifying affected individuals (vs. exposed individuals) may be most beneficial in assuring proper allocation of interventions and resources.

Further complicating access to services, many children with histories of prenatal alcohol exposure are placed in foster or adoptive care and, unfortunately, documentation of concerns or discussion of the potential effects of prenatal alcohol exposure are often unavailable or unclear. Many reasons exist for the lack of accurate or comprehensive prenatal exposure information such as biological mothers not disclosing for any reason, including stigma related to drinking during pregnancy, and medical professionals not routinely asking about substance use during pregnancy. It is important for clinicians to ask about alcohol exposure (and other teratogenic exposures) both in the preventative context for all women of childbearing age, during pregnancy specifically inquiring about drinking habits pre- and post-pregnancy recognition, as well as in child-visits to ask the parent about prenatal exposure during pregnancy. Conducting a comprehensive interview to understand a woman's baseline alcohol-use pattern can be pertinent in determining rates or risk of alcohol-exposure. Parents may not wish to disclose drinking during pregnancy (affecting both biological and foster care placements) and often it is not until a child develops a significant issue in school that this issue comes to light, at which time records may or may not be reviewed and followed up. Therefore, many affected children may have no information regarding prenatal exposure causing the etiology of behavioral or cognitive dysfunction to never be fully elucidated. Lastly, as there has not been a unanimous agreement for a codified system of diagnostic criteria for alcohol-related diagnoses beyond fetal alcohol syndrome, there is a history of various criteria being used to define or categorize effects of prenatal alcohol exposure. Most recently, the DSM-5 has proposed the following criteria after consulting with experts in the field. As the DSM-5 is the most utilized diagnostic manual for mental health disorders in the U.S., is commonly used in access to services at schools, and informs insurance reimbursement, we have focused on these criteria for the current manuscript. Further, the criteria generally map on to the most recently released updated clinical guidelines related to prenatal alcohol exposure ( Hoyme, et al., 2016 ).

Proposed Diagnostic Scheme

A proposed diagnostic system to identify the effects of prenatal alcohol exposure has been incorporated into the DSM-5 as a condition requiring further study, referred to as ND-PAE ( American Psychiatric Association, 2013 ). A similar term, Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, is listed as a prototypical example under Other Specified Neurodevelopmental Disorder (315.8, F88). The criteria for ND-PAE require indication that the individual was exposed to alcohol at some point during gestation (including prior to pregnancy recognition) and that the exposure was more than “minimal.” The precise dosage is not specific and relies on clinical judgment, although a suggested estimate for minimal exposure is defined as 1–13 drinks per month during pregnancy (and never more than 2 drinks on any one drinking occasion ( American Psychiatric Association, 2013 ). In addition to exceeding a minimal level of prenatal alcohol exposure, the individual must also display impaired neurocognition, self-regulation, and adaptive functioning. As the location of the disorder in the appendix of DSM-5 (“conditions for further study”) suggests ongoing research is required to determine the feasibility, sensitivity, and specificity of the proposed criteria to accurately identify those affected by prenatal alcohol exposure ( Kable et al., 2016 ).

A common clinical situation occurs when a child presents to an outpatient clinic with myriad other diagnoses – ADHD, adjustment disorder, reactive attachment disorder, mood disorder not otherwise specified, post-traumatic stress disorder (PTSD), and a learning disability – for which a diagnosis of ND-PAE may more parsimoniously encapsulate and holistically conceptualize the case. Pediatricians or mental health professionals may not be adequately trained on how to integrate information regarding prenatal alcohol exposure into their practice or the information regarding prenatal exposure may not readily available ( Gahagan et al., 2006 ; Rojmahamongkol, Cheema-Hasan, & Weitzman, 2015 ). Further, the diagnosis may be stigmatizing and thus providers may be hesitant to discuss it with the family ( Zizzo et al., 2013 ).

Support for Assessment

Given the heterogeneous neurobehavioral profile associated with prenatal alcohol exposure, a comprehensive neuropsychological examination is recommended. The assessment ideally covers the criteria associated with a diagnosis of ND-PAE (see Figure 2 ; American Psychiatric Association, 2013 ). Doyle and Mattson (2015) have reviewed variety of valid, reliable neuropsychological and parent-report measures that assess neurocognitive functioning, behavioral self-regulation, and adaptive functioning. Once a full assessment is conducted, a comprehensive case conceptualization requires a significant records review. Often the diagnosis, as discussed, is difficult as there may be a variety of distinct diagnostic categories that are met for each child. There is a strong emphasis on clinical judgment to determine the most parsimonious and accurate diagnoses, while also considering access to needed services.

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Core symptoms for Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE). For complete criteria see American Psychiatric Association, 2013 , Diagnostic and statistical manual of mental disorders, DSM-5 (5th ed.), pp. 798-799.

Once a diagnosis is given, advocacy for the child becomes a priority both at school and at home ( Boys et al., 2016 ), ideally with collaboration across various settings and providers. A behavioral analysis to understand what factors are contributing to poor performance is beneficial in order to develop effective treatment recommendations. Clinicians and researchers have advocated for the importance of specific modifications in teaching strategies and classroom environments to aid children with histories of prenatal alcohol exposure ( Green, 2007 ; Kalberg & Buckley, 2006 ; Kodituwakku & Kodituwakku, 2011 ; Premji, Benzies, Serrett, & Hayden, 2007 ). Despite advances in understanding the precise neuropsychological deficits associated with FASD, very few empirically supported interventions are available ( Burd et al., 2003 ; Kodituwakku & Kodituwakku, 2011 ). Targeted interventions ( Adnams et al., 2007 ; Kable, Taddeo, Strickland, & Coles, 2015 ; Kable, Coles, & Taddeo, 2007 ; Peadon, Rhys-Jones, Bower, & Elliott, 2009 ) and patient advocacy ( Boys et al., 2016 ; Duquette, Stodel, Fullarton, & Hagglund, 2006 ) can facilitate outcomes, although this is a significant area of need both in terms of development and dissemination. Early identification and effective treatments for alcohol-exposed children could result in better outcomes; however, both are currently limited in terms of access to services and the generation of effective interventions ( Bertrand et al., 2005 ; Kodituwakku & Kodituwakku, 2011 ; Premji et al., 2007 ).

School systems and other providers may or may not be familiar with the effects of prenatal alcohol exposure and may benefit from additional psychoeducation. Support for the child in the development of an individualized education plan or special services, as indicated by the effect of prenatal alcohol exposure on learning, may be necessary. Additional considerations could include repurposing interventions targeted within other populations for children with alcohol-exposure, although they may need to substantially modified to be successful in this population.. Often, alcohol-exposed individuals are complex and require evaluating the situation from a holistic, multifaceted bio-psychosocial perspective, including collaboration between various settings and providers and implementing interventions in a number of systems and environments (e.g., school, home, parent-training, outside support, physical therapy, occupational therapy, speech and language pathology, vocational training). Additional information regarding interventions and treatment recommendations will be discussed at the end of the case study.

REASON FOR REFERRAL AND BACKGROUND HISTORY

The case presented here, referred to as Jane, is a composite of cases seen in a research project at the Center for Behavioral Teratology who were then subsequently seen at an outpatient child psychiatry facility. Thus, the data represents a prototypical child seen at the facility. Jane is a 9-year-old, right-handed, monolingual English speaking girl in the 3 rd grade. She was referred by her primary care physician for a neuropsychological evaluation to assess her current level of neurocognitive functioning due to parent reported behavioral problems, emotional concerns, and poor school performance. The following background history was obtained from an interview with Jane and her adoptive mother, Mrs. Smith. Mrs. Smith expressed significant concerns regarding fears of Jane being held back at school and inability to “control Jane” at home and around other children.

Per clinical interview with Mrs. Smith and review of records, Jane has had significant behavioral concerns since she was a toddler. These include explosive tantrums, aggressive behavior, and difficulty with emotional regulation and self-soothing. Jane had been in three different residential/foster care placements and was most recently transitioned to a foster-to-adopt placement in first grade with Mr. and Mrs. Smith. She has adapted well to this placement and was officially adopted by Mr. and Mrs. Smith in the beginning of this year, prior to starting 3 rd grade. Jane has been engaged in family therapy, which has focused on attachment issues and evidence based treatment and parent-training for behavioral concerns; however, she still shows significant deficits that require “round the clock care” according to Mrs. Smith. While social skills training has been recommended, they have not been able to fit it into their schedules at this time.

Mrs. Smith noted that Jane has had significant tantrums and difficulties with self-control. She often provokes fights with other children and can have significant tantrums that last for over an hour, which include crying, screaming, destroying property, and hurting others. This in part led to the frequent changes in placement early in her life as other foster parents “could not handle her behavior.” Behavioral concerns also included impulsivity, difficulties with maintaining attention on specific tasks, difficulty following directions, and some aggressive behaviors including hitting and kicking her peers and parents. As she grew older, her behaviors continued and became more sophisticated: she began lying (for example, she broke several toys and then blamed it on another foster child in the home), and stealing items from others in the household. The new placement, engagement in therapy, and utilization of parent-training has successfully reduced the frequency of tantrums to approximately once a week, although they maintain similar severity, which is not developmentally appropriate. These behaviors most often occur at home, although she repeatedly needs to be redirected to on-task behavior at school as well. Her teachers express concern regarding her ability to stay on task and complete work, though have not witnesses the same frequency or severity of behavioral outbursts that are reported at home.

Jane has been seen by several different mental health professionals and continues to be engaged in both behavioral therapy and psychopharmacological intervention. She has a current clinical diagnosis of Attention-Deficit/Hyperactivity Disorder (ADHD), combined presentation, that was originally diagnosed at age 6. Due to difficulties in social interactions, she was assessed for an autism spectrum disorder at the age of 3, which was ruled out at that time. Jane was able to perform adequately in elementary school through second grade, with some difficulties surrounding the transition to a new school in first grade. However, since beginning third grade, she has had difficulty with increasing cognitive, behavioral, and social demands and is currently at risk of not transitioning to fourth grade with her peers. She has been suspended twice from this elementary school due to inappropriate behavior (i.e., inappropriately touching another peer, throwing her chair, not following directions, and breaking a computer).

The potential for Jane to be assessed for and potentially qualify for an individual education plan (IEP) had been brought up by her parents and teachers in 2 nd grade, though the school district decided that at that time she has yet to meet criteria for significant services as she was not significantly behind in her academic achievement. She currently has a 504 plan that provides minimal behavioral accommodations. Her parents are currently in process of requesting another IEP evaluation at the school. Jane was assessed by a school psychologist at the age of 7 upon entering first grade and was not found to meet criteria for intellectual disability (IQ = 78, no evidence of specific learning disability), though had significant difficulty with aspects of adaptive functioning. In that evaluation she also received a diagnosis of ADHD and a prescription of a non-stimulant medication (Straterra). Her mother reports that this medication has been minimally effective though expressed concern regarding additional medications or stimulant medication due to potential side effects. For example, there has been concern regarding maintaining weight gain, given that she has a relatively low body mass index. She was assessed for services by the school under the other health impairment (OHI) criterion and a 504 plan was initiated at that time in which she received several accommodations including preferential seating at the front of the task and extra time on assignments.

In many cases regarding prenatal exposure, a comprehensive review of records is imperative as there are often complex biopsychosocial risk factors that may impact functioning. Many children with histories of prenatal alcohol exposure have backgrounds remarkable for social service involvement and potential foster/adoption care. In this case, Jane was born after 32 weeks gestation. Per the hospital records and adoption telling, her biological mother reported drinking before and during pregnancy (several drinks during the day and generally in a binge drinking pattern, 4-5 drinks a day on weekends, “sometimes that much on a weekday”). Per these records, the biological mother and father also reported occasionally using methamphetamine and marijuana. The biological mother reported pregnancy recognition at 5.5 months, at which time she attempted to cut down on her alcohol and substance use. She reported only binge drinking “occasionally” since knowing she was pregnant, though continued to drink greater than four drinks per occasion on several weekends during her third trimester. This pattern of reducing drinking later during pregnancy appears to be common based on our clinical and research interviews, therefore detailed maternal screening for alcohol exposure to the fetus both pre and post pregnancy recognition is imperative. Conducting a detailed interview of baseline substance use and lifestyle factors prior to the pregnancy can also provide important information on drinking patterns that may be underreported during pregnancy. Further, patterns of drinking may change during a pregnancy, as in this case, which is be important to note and investigate. In this case, Jane's biological mother reported minimal prenatal care and her nutritional status was unclear throughout the pregnancy.

Child protective services removed Jane from her biological mother's care at the hospital when she had a positive toxicology screen at birth for methamphetamine and Jane's biological mother relinquished her rights at that time. Jane was placed in a foster care home after discharge. At the one year well-child pediatric appointment Jane was referred to a dysmorphologist after the foster parent disclosed Jane's prenatal history based on her records. Jane was evaluated by a dysmorphologist with expertise in FAS (See Table 1 , Figure 1 ). Jane was in the 7 th percentile for height and 4 th percentile for weight, consistent with FAS criteria for growth deficiency, though she did not meet full facial dysmorphology criteria for FAS. She met all developmental milestones, generally on the later end. Per the foster care records, she did not crawl until she was 17 months and had received “on and off” occupational and physical therapy between the ages of 1 and 4. Her adoptive mother noted that when Jane was placed with them, there were no developmental delays for speech or language, though noted she is still quite “clumsy”.

Summary and Comparison of the Various Diagnostic Schemas for Prenatal Alcohol Related Disorders. Table adapted and updated from Warren KR, Hewitt BG, Thomas JD (2011) Fetal alcohol spectrum disorders: Research challenges and opportunities. Alcohol Research and Health 34: 4-14. In the public domain.

Psychosocial History

Jane currently lives with her adoptive mother and father along with two other children, who are also adopted. Of note, Jane frequently steals her sibling's toys and will hide broken toys and lie about how they were broken. When confronted, Jane often has tantrums resulting in tears and acting aggressively towards her mother (e.g., kicking, hitting). In these situations, her mother views her as “acting much younger age than she really is.” Jane reported to the examiner that she has many friends; however, her mother reports that she does not get invited to friend's houses and her teachers report repeated difficulty with peer interactions. Generally, Jane gets along better with peers and neighbors who are two to three years younger than she is. As a younger child, Jane's mother reported that Jane had difficulty interacting in peer situations, often talking over others in conversations or invading other's personal space.

Academic History

Jane's educational history is complicated by her frequent placement changes and she switched schools several times before her current stable placement. She attended preschool between the ages of 3-5 and had a series of behavioral concerns including reports of hiding under her desk, attachment difficulties with foster parents, not following directions, not completing assignments, yelling during class, often getting up from her seat, interrupting peers and the teacher, and not responding or listening to consequences. She has previously been assessed for additional services and has an active 504 plan (she sits near the front of the class, gets extra time on assignments, written reminders and a calendar to help with homework). Jane is currently performing poorly in third grade. She often fails to complete assignments (often crumpled at the bottom of her backpack). Further, she almost two grades behind in math, and one grade behind in reading and spelling. Per her teachers she has particular difficulty with complex math word problems and reading comprehension. She is not pulled out of class for any additional help and receives no tutoring.

Psychiatric History

Currently, Jane is being treated for irritability, mood symptoms and diagnosis of ADHD with a combination of outpatient therapy and medications. Despite the earlier concern regarding weight gain and side effects of medications, since the original evaluation at the age of 7 she has moved to a new psychiatrist and currently takes Prozac (10 mg daily), Clonidine (0.1 mg in the morning and 0.2 mg in the evening), Adderall XR (20 mg daily), and Risperdal (0.25 mg), as prescribed. Of note, there is very little research on medication dosage or efficacy in this population. Further, similar to the various diagnoses that a child with this profile may receive, medications prescribed may also be compounded. Jane's prescribed medications are not uncommon for this population as many children with fetal alcohol spectrum disorders are treated psychopharmacologically using multiple medications. There is preliminary evidence that alcohol-exposed children may respond differently to medication ( Doig et al., 2008 ). Currently psychiatrists familiar with prenatal alcohol exposure may tend to start at lower doses and increase at a slower rate to help effectively treat behavioral symptoms. To date, there has not been case-control studies to inform published guidelines on psychiatric medication for alcohol-exposed children.

Medical History

As previously discussed, Jane's biological parents have a history of substance abuse problems. Per review of records, Jane's birth was unremarkable with the exception of prenatal exposure to alcohol and drugs and lack of prenatal care. Within her first year, records indicate that she exhibited “failure to thrive.” Growth failure has continued and Jane will occasionally refuse to eat or, at other times, not monitor her eating and overeat to the point of vomiting. Other information regarding her biological parents or family history is unknown. She has no history of seizures or traumatic brain injury, and has never been in any serious accidents. Jane, fortunately, does not have a significant medical history or neurological concerns that would further complicate her cognitive profile. If there were cause for concern regarding a neurological insult or injury, a consult with a neurologist or other medical professionals may be recommended. At this point, neuroimaging studies have primarily been conducted in research settings rather than as part of a clinical protocol. While there is a substantial literature on brain injury and imaging findings in this population, the field is not yet at the point where imaging would necessarily lead to meaningful clinical implications in most cases. Potential consults with other disciplines (i.e., occupational therapy, speech therapy, physical therapy, educational specialist, feeding specialist, pediatrician, neurologist, and psychiatrist) may be indicated as well. Please see Figure 3 for general referral process.

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Framework for FAS Diagnosis and Services. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. National Center on Birth Defects and Developmental Disabilities, Center for Disease Control and Prevention, Department of Health and Human Services in coordination with National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect. 2004. http://www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf . In the public domain.

Current Testing

Testing was completed across two days. Jane reportedly took all of her medications as prescribed. Jane had been previously examined by a pediatric dysmorphologist and was recently re-assessed as part of her continuing general care. While Jane's height and weight remained below the 10 th percentile for her age and sex, indicating a growth deficiency, she did not meet criteria for microcephaly or display facial dysmorphology required for a medical ICD code, and thus would not qualify for an alcohol related diagnosis of FAS or partial FAS (see Table 1 , Figure 1 ).

Neuropsychological Assessment Results

The purpose of this evaluation was to identify any learning or cognitive difficulties, determine whether any observed deficits are consistent with a specific etiology, and provide this information to her family, teachers, and physicians to help formulate a possible diagnosis and treatment plan. Of note, as mentioned this case is a composite of a prototypical child who participated as part of a research project at the Center for Behavioral Teratology who was subsequently seen at an outpatient child psychiatry facility. Depending on the assessment setting, there may be a variations in the amount of neuropsychological testing that is feasible, for example in a general outpatient assessment center, a child may be able to receive a comprehensive neuropsychological battery conducted over several days or if a child is seen within a pediatrician's office, they may only receive very brief assessment or screening. This case attempts to balance a more comprehensive assessment with feasibility concerns as this battery could be completed during one day (for example, only giving certain subtests of the WIAT-III, not giving additional parent report measures). For additional information on ND-PAE and appropriate assessment protocols, please refer to Kable et al., 2016 and Doyle and Mattson, 2015 .

Current Functioning Based on Self-Report

Jane reported that her current mood is “okay.” She did not endorse any difficulties with sleep or appetite. She reported no pain (0/10), though showed the examiner a Band-Aid from a fall the previous week. She reported no weakness or numbness and her gait/balance was grossly within normal limits.

Behavioral Observations

Jane arrived on time accompanied by her mother. She was cooperative and felt comfortable with testing, noting once that some measures appeared familiar. She had adequate frustration tolerance, though repeatedly asked for breaks and “when it would be over.” She understood all test questions and had adequate vision and hearing. She did not wear corrective lenses or a hearing aid. Her levels of attention and concentration were adequate to complete the testing. She was able to understand the test instructions and only occasionally required repetitions. She required redirection to task when given individual subtests without direct interaction with the examiner (i.e., WIAT-III numerical operations, CPT-3). Her speech was at a normal volume, with a normal rate and rhythm. She often asked the examiner questions about her background and had to be redirected to the task at hand.

Jane appeared to be alert and oriented throughout the testing process. She appeared well groomed, with generally good hygiene, casual dress, and appeared her stated age. Jane maintained euthymic affect throughout most of the interview and testing and spontaneously participated in conversation with the examiner. During assessment, she exhibited appropriate eye contact, although was consistently hyperactive and fidgety throughout the testing. Her thought process was logical and goal-directed, and her thought content was normal and appropriate to the situation. She consistently demonstrated effort to perform well on the various subtests administered and performed at expectation on objective measures of validity; thus, these results appear to be a valid indication of her cognitive and behavioral abilities at the time. Jane took her medications as prescribed on the days of the assessment; therefore, her cognitive and behavioral abilities reflected in the results of this assessment are not representative of her abilities without these medications.

Results of Testing

The neuropsychological assessment included measures of global intellectual performance, executive functioning, learning, memory, and visual-spatial reasoning to evaluate neurocognitive functioning as defined by ND-PAE (see Figure 2 ). The behavioral questionnaires and parent interviews captured information regarding Jane's self-regulation, behavioral functioning, and adaptive behavior. The table below provides information on the scores and descriptions of performance.

Tests Administered

Child Behavior Checklist (CBCL) ( Achenbach & Rescorla, 2001 )

California Verbal Learning Test, Children's Version (CVLT-C) ( Delis et al., 1994 )

Conners Continuous Performance Test, Third Edition (CPT-3) ( Conners, 2014 )

Delis-Kaplan Executive Function System (D-KEFS) ( Delis, Kaplan & Kramer, 2001 )

Finger Tapping Test, Grooved Pegboard (Norms: Strauss, Sherman & Spreen, 2006 ).

NIMH Diagnostic Interview Schedule for Children Version IV, Computerized Version (C-DISC-4.0) ( Shaffer et al., 2000 )

NEPSY, 2 nd edition ( Korkman, Kirk & Kemp, 2007 )

Wechsler Intelligence Test for Children, Fifth Edition (WISC-V) ( Wechsler, 2015 )

Wechsler Individual Achievement Test, Third Edition (WIAT-III) ( Wechsler, 2009 )

Vineland Adaptive Behavior Scale, Second Edition (VABS-II) ( Sparrow, Cicchetti & Balla, 2005 )

NEUROCOGNITIVE FUNCTIONING

Self-regulation, adaptive behavior, integrated evaluation and diagnostic interpretation.

Jane is a 9-year-old, right-handed girl referred by her primary care physician for a neuropsychological evaluation to assess her current level of neurocognitive functioning due to behavioral concerns and poor school performance. Overall, the current neuropsychological evaluation revealed a variety of weaknesses and several strengths on the domains tested. Jane demonstrated low average cognitive abilities, as her full scale IQ estimate, which is a combination of all index scores, was approximately one and a half deviations below the mean (WISC-V, FSIQ=79, 8 th percentile). This is in line with research on children with heavy prenatal alcohol exposure with IQ estimates generally between one and two standard deviations below the mean. In her case, this global estimate of functioning should be interpreted with caution as there was significant variability between the index scores with relative strengths seen in verbal comprehension (WISC-V VCI, SS=92, 30 th percentile) and relative weaknesses seen on working memory and fluid reasoning (WISC-V WMI, SS= 74, 4 th percentile; FRI SS=74, 4 th percentile) There was also significant spread within domains, for example on processing, She was in the average range for a task requiring her to have rapidly scan and match a target to a sample of items but was in the borderline range when asked to associate symbols and numbers in a rapid fashion.

In terms of academic functioning, Jane performed below her current grade level (3 rd grade) on all achievement measures (reading, writing, math). She demonstrated relative strengths in reading (WIAT-III Basic Reading, SS=90, 25 th percentile) and spelling (WIAT-III Spelling, SS=88, 21 st percentile) and relative weaknesses in math, evident on both a written math worksheet (WIAT-III Numerical Operations, SS=73, 4 th percentile) and math problem solving (WIAT-III Math Problem Solving, SS=69, 2 nd percentile). On spelling measures she made errors that were phonemically consistent. In terms of math, she had difficulty completing even simple problems and she often tried to rush through questions if she did not know how to do them or would become upset. When asked to try, she would make mistakes that demonstrated she had no automaticity in regards to number facts..

Taken together, this pattern is emblematic of a specific learning disability in mathematical functioning. Jane has experienced difficulties learning and using academic skills, in particular within the domain of math, for several years based on her parent reports and standardized assessments. She demonstrated low average to low performance on her ability to master calculation, math word problems and number facts. Her mother and teachers note that Jane gets lost in the middle of math problems, forgets the rule she was supposed to follow, and often becomes upset and does not want to continue further. This was consistent with our assessment and an examination of her homework. Jane also had difficulty with mathematical reasoning and applying mathematical concepts to solve problems. She has been able to compensate to some extent with her other cognitive strengths, though continues to struggle in this domain. Her math skills were substantially and quantifiably below those expected for her age and cause significant interference for her academic performance, especially when considered in the context of standardized testing.

Jane's performance on measures of executive function was also below expectation. She demonstrated impairment on a measure of selective auditory attention and vigilance (NEPSY-II Auditory Attention, SS=3, 1 st percentile), and was borderline range in her ability to cognitive shift and inhibit her responses (NEPSY-II Response Set, 2 nd percentile). She had average verbal fluency, visual scanning, and motor speed, although demonstrated difficulties on tasks involving inhibitory control or cognitive flexibility, such as in switching tasks (D-KEFS Color Word Interference Inhibition, SS=6, 9 th percentile; Color Word Interference Inhibition/Switching, SS=5, 5 th percentile; Trail Making Test Number-Letter Switching, SS=2, <1 st percentile). She also demonstrated an isolated difficulty in number sequencing (D-KEFS Trail Making Test-Number Sequencing, SS=3, <2 nd percentile), which was not seen on letter sequencing. Overall, Jane demonstrates particular difficulty with higher order executive function tasks and selective attention, while basic fluency, color naming, and reading abilities remain intact.

In terms of memory, Jane demonstrated impairment on both verbal and visual memory at immediate and delayed conditions. She had difficulty in learning a list of words, after hearing the list five times she was able to remember only 7 of the 15 words (CVLT-C total list A, T=20, <1 st percentile), however a delay she was able to remember all of the words she learned initially illustrating poor encoding, but intact retention. She demonstrated intact performance on some aspects of memory, including memory for faces and memory for names, though had more difficulty with remembering verbal information even when given context (NEPSY-II Narrative Memory, SS=5, 5 th percentile) and more complex visual information both immediately and after a delay (NEPSY-II Memory for Designs, SS=5, 5 th percentile). Regarding visual-spatial processing, she demonstrated low average ability on the WISC-V visual spatial tasks (Block Design, Matrix Reasoning) and on a measure where she had to copy designs though had intact performance on a separate visual puzzle task and on a measure of visuomotor integration. Jane also completed a computerized measure of attention difficulties and demonstrated elevated omission scores (CPT-3 Omissions, T=67, 97 th percentile) and average commission scores (CPT-3 Commissions, T=57, 75 th percentile), which indicates the presence of inattention though not hyperactivity. It is important to note that she was on medication for ADHD at the time of testing.

Regarding her emotional functioning, Jane's mother reported clinically significant elevations on several scales, including: anxious/depressed, social problems, and attention problems. Withdrawn/depressed, somatic complaints, thought problems, and rule-breaking behavior were within the borderline range. According to the clinician-assisted interview, she met positive criteria for ADHD, oppositional defiant disorder (ODD), conduct disorder (CD), and separation anxiety. In terms of adaptive behavior, Jane's parents indicated that her communication (VABS-II Communication, SS=75, 5 th percentile), socialization (VABS-II Social Skills, SS=78, 7 th percentile), daily living (VABS-II Daily Living Skills, SS=73, 4 th percentile) and overall adaptive function (VABS-II, Total, SS=74, 4 th percentile) were all moderately low for her age. In terms of motor skills, her gross motor abilities were intact bilaterally. She demonstrated a relative weakness on fine motor skills on her dominant hand (R), though her non-dominant fine motor skills were intact.

Taken together, Jane's neuropsychological profile is characterized by weaknesses in executive function (working memory, cognitive flexibility, inhibitory control), learning, memory (visual and verbal), and academic achievement, in particular concerns with math. She has mixed performance on visual-spatial reasoning, and intact performance on language measures, gross motor skills, hyperactivity, aspects of memory (faces, names), fluency, and motor speed. Per parent and collateral reports with her therapist and teacher, significant mood regulation and adaptive behavior concerns are evident, particularly in externalizing behaviors.

While her math difficulties are potentially related to prenatal alcohol exposure, it is impossible to determine that they would be fully due to an alcohol-related condition and therefore Jane meets criteria for a diagnosis of a specific learning disorder with impairment is math. Likely her math performance is related to her lower working memory and perceptual reasoning abilities, which affected her calculation and problem solving abilities.

Her parents were given a standardized, semi-structured clinical interview, the Computerized Diagnostic Interview Schedule for Children Version IV (C-DISC-4.0) ( Shaffer et al., 2000 ). In other clinical contexts, there are various other published structured clinical schedules or other comprhensive clinical interviews can be utilized. For Jane, while the C-DISC-4.0 illustrates several diagnoses in which she meets DSM - IV criteria, her profile of functioning may be most parsimoniously conceptualized as meeting criteria for the Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure diagnosis, which is listed as a condition for further study in DSM-5. Therefore, her symptomology would be best captured by the Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, under the Other Specified Neurodevelopmental Disorder DSM Code (315.8, ICD F88). She also continues to meet criteria for ADHD, combined presentation, per clinician, teacher, and parent-reports, as well as behavioral performance based on objective testing. Both poor math performance and symptoms of ADHD are also criteria in ND-PAE. These diagnoses are given in addition to ND-PAE as she qualifies for all three independently. A similar pattern is seen with children who meet criteria for ADHD and depressive disorders or ADHD and ODD, while there are shared characteristics, one may qualify for both independently.

While Jane also demonstrates a clinical phenotype similar to autism spectrum disorders, previous testing has ruled out this diagnosis and she does not demonstrate the communication deficits or repetitive behaviors necessary to meet criteria. Since Jane does not display the necessary facial dysmorphology for a diagnosis of FAS, documentation of more than minimal prenatal alcohol exposure is required, which is apparent from review of social services records.

Often, documentation of more than minimal prenatal alcohol exposure is not present, hindering the ability to potentially give the ND-PAE diagnosis. A decision tree for identification of children affected by prenatal alcohol exposure was recently described by Goh et al. (2016) . This decision tree requires a small number of clinically-obtained variables to determine whether an individual is likely to be affected by prenatal alcohol exposure. As part of the current testing, this decision tree is presented in Figure 4 with a highlighted path to indicate data from Jane's case. In her case, there was clear documentation of heavy alcohol exposure in utero, and application of the decision tree yielded an outcome consistent with this documentation. In many cases, where exposure information is not available, application of the decision tree may be useful to rule in or rule out the possibility of alcohol effects.

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Decision tree for identification of children affected by prenatal alcohol exposure. Data from the current case are indicated are highlighted in red. Figure adapted from Goh et al. (2016) .

Note: AE = alcohol-exposed, CBCL = Child Behavior Checklist - domains included Somatic Complaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior, and Aggressive Behavior. Physical exam for FAS includes measuring whether key facial features are present (palpebral fissure length ≤10 th percentile; philtrum lipometer Score=4 or 5; vermilion border lipometer score=4 or 5). Criteria for FAS diagnoses requires at least two of three KEY facial features (palpebral fissure length ≤10 th percentile; philtrum lipometer Score=4 or 5; vermilion border lipometer score=4 or 5), and presence of head circumference ≤10 th percentile OR height and/or weight ≤10 th percentile. VABS = Vineland Adaptive Behavior Scale, domains included Communication, Socialization, and Daily Living Skills. Physical Exam (extended features) are specified as ptosis and incomplete extension of one or more digits.

DSM-5 Diagnoses

Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure, Other Specified Neurodevelopmental Disorder (315.8, F88) Attention-Deficit/Hyperactivity-Disorder, combined presentation (314.01, F90.0) Specific Learning Disorder with Impairment in Mathematics (315.1, F81.2)

Rule Out: Conduct Disorder, Oppositional Defiant Disorder, Separation Anxiety. These diagnoses are better captured by the alcohol related neurodevelopmental diagnosis, though continued monitoring and targeted intervention is recommended.

Discussion of treatment recommendations

Treatment recommendations with an evidence base for children with heavy prenatal alcohol exposure are scarce; however, this population may respond well to interventions developed for other developmental disorders. Previous efforts have been successful in creating evidence-based interventions in other areas of functioning for children with FASD by modifying existing programs, such as social skills ( O'Connor et al., 2006 ) and math ( Kable et al., 2015 ; Kable et al., 2007 ), which supports the feasibility of adapting interventions to suit the specific needs of affected children. The development of evidence-based interventions for FASD is a critical research need that has been repeatedly documented ( Kalberg & Buckley, 2006 , 2007 ; Premji et al., 2007 ).

Preliminary studies have demonstrated that children with FASD can make significant gains with effective instruction ( Kable et al., 2015 ; Kerns, Macoun, MacSween, Pei, & Hutchison, 2016 ). For example, children with FASD were able to learn a verbal rehearsal strategy that improved their digit span performance ( Loomes, Rasmussen, Pei, Manji, & Andrew, 2008 ). Further, recent studies have found that self-regulation and executive function trainings result in improved parent-reports, inhibitory control, and storytelling ( Nash et al., 2015 ; Wells, Chasnoff, Schmidt, Telford, & Schwartz, 2012 ). Computerized and attention focused interventions have also been moderately efficacious ( Kerns, Macsween, Vander Wekken, & Gruppuso, 2010 ; Pei, Flannigan, Walls, & Rasmussen, 2016 ). Math intervention studies that were developed in concert with the neuropsychological profile associated with prenatal alcohol exposure (Math Interactive Learning Experience, MILE) have demonstrated significant gains in both pilot studies and community-based intervention ( Kable et al., 2015 ; Kable et al., 2007 ). In Jane's case we would recommend this program, given her circumscribed deficits in this area. The MILE intervention focuses on improving math performance within the context of other issues that influence an alcohol-exposed child's ability to learn including emphasizing learning readiness (preparing the environment for optimal performance), individualized pace of instruction, physical and visual aids, active feedback, and meta-cognitive control (encouraging greater reflection in problem solving).

Children with heavy prenatal alcohol exposure are likely to have an especially complex set of factors contributing to educational attainment including higher likelihoods of history of abuse, foster care or adoptive care, and a distinct, yet heterogeneous neurobehavioral profile. As the majority of children with FASD are enrolled in general education classrooms ( Boys et al., 2016 ; Howell et al., 2006 ), it is recommended that these children receive a thorough and comprehensive evaluation to uncover potentially ‘invisible’ special needs that may be missed or misinterpreted to be incorporated into an effective educational plan. A recent study found that approximately 50% of alcohol-exposed children had difficulty in academic functioning ( Boys et al., 2016 ), demonstrating minimal improvement in over 25 years from previous studies ( Streissguth et al., 1991 ; Streissguth et al., 1994 ; Streissguth, Barr, Kogan, & Bookstein, 1997 ).

The heterogeneity of academic, behavioral, and cognitive function in children with FASD makes it exceedingly difficult to create a “one size fits all” academic curriculum. For instance, the range of intellectual function among these children is quite broad, and therefore effective interventions must cater to a wide range of abilities. In addition, programs must understand and address the interplay between cognitive, academic, social, emotional, and behavioral challenges. For example, poor performance may be due to behavioral impulsivity or executive dysfunction, both of which are common deficits in FASD. Other predictors are correlated with inattentive/overactive behaviors in internationally adopted children (which are overrepresented in the sample used in this study) that indicate older age at adoption, longer time in the adoptive home, and smaller family size are associated with greater parent-rated difficulties. Further, these difficulties were associated with poorer reading performance, expressive language, and adoptive family functioning ( Helder, Brooker, Kapitula, Goalen, & Gunnoe, 2016 ).

Assessment of school-based services for children with FASD is a burgeoning area of research. In the classroom, a combination of evidence-based interventions may be the most efficacious, as they can target various areas simultaneously. Since 60–95% of alcohol-exposed children are diagnosed with ADHD ( Fryer, McGee, Matt, Riley, & Mattson, 2007 ; Mattson et al., 2011 ), it may be worthwhile to investigate the feasibility of repurposing existing, empirically supported ADHD interventions or interventions for other populations for use in children with FASD. There are several interventions in which utilizing treatment approaches for other populations (such as ADHD or ASD) have been effectively used for prenatal alcohol exposure, although they generally require considerable modification and individual tailoring based on the unique neurobehavioral profile of alcohol-exposed children. Unfortunately, the availability of interventions has fallen far below the needs of alcohol-exposed children, and many of these programs are still being studied to assess generalizability, feasibility, and efficacy.

Access to Services

Currently, the most common and feasible method of receiving services for an alcohol-related neurodevelopmental disorder is to qualify for services under a different diagnosis, such as intellectual disability or ADHD, or to qualify under a specific catch-all category based on functioning and symptomology. Legal precedents providing services for individuals with intellectual disability, or those requiring similar services, have facilitated access to services. Section 504 plans can help with classroom accommodations, yet fall short of creating an individualized plan and addressing unique needs of the individual ( Senturias, 2014 ).

Individuals with FASD may require services from numerous providers, including primary care, specialist centers, occupational therapy, psychosocial skills training, and educational specialists ( Rogers-Adkinson & Stuart, 2007 ). In general, the coordination between providers, disciplines, and agencies, requires a case manager or social worker to facilitate care. Often these systems of care are referred to as wraparound services that help increase communication and coordination between all parties involved in care (e.g., parents, teachers, mental health professionals, physical/occupational therapists, behavioral therapists, assessment teams, physicians, speech/language, adoption services, foster care services). Wraparound services are not specific to prenatal alcohol exposure and can be utilized for a variety of complex medical or behavioral presentations. In particular for prenatal alcohol exposure, there are several FASD service centers ( McFarlane & Rajani, 2007 ) that provide models for the continued development of resources. However, there is no easy or practical way to standardize the service needs for children, as each child will have unique patterns of deficits and may require a more individualized approach. One study using semi-structured interviews revealed that there were no standardized special education classes that were appropriate for all alcohol-affected children, as each child required individual supports based on their own pattern of functioning ( Autti-Ramo, 2000 ).

It is important to note that prenatal alcohol exposure results in neurological dysfunction and often behavioral and cognitive effects. As is the case with neurodevelopmental disorders, the course of care is not solely focused on full remediation or is curative in nature, but rather emphasizes supports and intervention to build on the strengths of the child, while considering the weaknesses to improve overall function. As the individual grows there are additional concerns and considerations that must be addressed including potential supports for transition to independence, additional contact with high-risk situations, and a widening gap of performance and age-based expectations. A continued holistic approach to consider all aspects of functioning and environment is important to inform effective intervention and high likelihood of positive outcomes.

Summary of the Case

Given Jane's profile of functioning, she was given diagnoses of Neurodevelopmental Disorders Associated with Prenatal Alcohol Exposure (Other Specified Neurodevelopmental Disorder), a specific learning disorder with impairment in math, and ADHD combined presentation, as discussed above. The clinician who provided the assessment also attended the IEP meeting at her school to provide additional support for Jane's parent's request for an IEP and share specific strategies that may be especially beneficial for Jane's behavioral and cognitive outcomes. The IEP meeting consisted of the principal, representatives from special education, current teacher, adoptive mother, and adoption advocate. As is often the case, the clinician provided psychoeducation to the team regarding the effects of prenatal alcohol exposure, as most members had very little training to work with this population. The clinician was able to educate the team and empower the parent in sharing pertinent information regarding Jane's case. This discussion led to the development of a specific and targeted IEP that included particular focus on providing additional time and training on new concepts (repeating new lessons until competency was achieved) and a new behavioral reinforcement schedule (tying the positive reinforcement directly and immediately to a behavior, for example getting a sticker immediately after turning in an assignment). Jane also received specific targeting intervention at home and at school focused on improving her math abilities including tutoring, online math programs, the use of the MILE program as discussed above, and modified assignments to improve her math facts skills before introducing more complex information. Further, she was also given recommendations for ADHD including creating a work environment to reduce distractions, using a reward system, encouraging ongoing collaboration between all parties involved (e.g., teachers, parents, psychiatrists, therapists, tutors, and other providers).

Understanding Jane's full neurobehavioral profile from a comprehensive neuropsychological assessment led to a parsimonious diagnosis and actionable treatment recommendations. Further, this assessment assisted in less punishment and more support for areas in which she struggles (e.g., instead of getting a grade reduction for not turning in homework, creating a new system for keeping track of homework and additional scaffolding for supporting homework completion by breaking assignments into steps). This level of involvement is not often feasible; however, understanding the full profile of functioning and providing additional support to parents and schools results in improved outcomes.

Parent-training with a focus on antecedent-based strategies (rather than consequence based strategies) may be a more effective approach as it has been successful in other neurodevelopmental disabilities. Further, this strategy directly focuses on compensating for weaknesses observed in ND-PAE, for example difficulty with learning from prior experience and self-regulation. Both parent training, in-home behavioral consultation, or other aspects of wraparound services can be helpful for both the teaching of new skills and generalization of progress. Psychoeducation for all parties involved in care, from parents to teachers to mental and medical health providers, is imperative in effective cross discipline communication and overall improved outcomes while considering the holistic nature of factors that can affect functioning (e.g., environment, social stress, other system level issues).

An interagency collaboration suggested several areas for improving outcomes, including: FASD awareness and education in schools, understanding FASD as a comorbid disorder ideally in the context of a medical diagnosis similar to acquired brain injury, FASD specific interventions including collaboration between clinicians and school psychologists, advocacy for children with FASD, conducting a full neuropsychological assessment, and continuing interagency collaboration ( Boys et al., 2016 ). This case study corroborates these findings and provides additional support for continuing assessment and advocacy for this population.

Acknowledgements

Preparation of this paper was supported by the National Institute on Alcohol Abuse and Alcoholism grants U01 AA014834 (Mattson) and F31 AA022261 (Glass). We thank the families and children affected by prenatal alcohol exposure for graciously participating in studies at the Center for Behavioral Teratology at San Diego State University.

Compliance with ethical standards: This article does not contain any studies with human participants or animals performed by the author. The case study is a composite of cases seen by the first author.

Conflict of Interest: The authors declare they have no conflict of interest.

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Causes And Effects Of Fetal Alcohol Syndrome Essay Example

Type of paper: Essay

Topic: Psychology , Disorders , Alcoholism , Development , Autism , Alcohol , Pregnancy , Brain

Published: 01/30/2020

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Fetal Alcohol Syndrome is a collective name given to physical and mental birth defects that are as a result of alcohol intake during pregnancy (Pytkowicz 32). Pregnancy is taken as an immensely precarious time for both the mother and the child. Although not harmful when taken in reasonable amounts, alcohol consumption is not advised during pregnancy. This depressant is taken for various beneficial reasons including relaxation and more importantly digestion. Nonetheless, alcohol has very damaging effects if abused, and these effects are exacerbated during pregnancy. The main cause of Fetal alcohol syndrome is alcohol consumption. Apparently, alcohol travels to the foetus through the placenta. An adult’s body is able to metabolise and get rid of alcohol in a fairly short time (West117). However, the foetus takes a longer time to metabolise and get rid of alcohol. Research done on this subject over the years suggests that a foetus takes triple the time to metabolise the same amount of alcohol as an adult. The risk is proportional to the amount taken. The toxicity of alcohol is thus more inherent in a foetus than it is in an adult. Research also suggests that alcohol affects the delivery of oxygen and nutrients to the foetus. The chemistry behind this is based on alcohol binding with the free molecules of oxygen, and destruction of nutrients such as proteins. It should be noted that these are imperative requirements for proper development of the foetus. Optimal nutrition is necessary for Fetal growth, cell division, and development of the nervous system (Abel 121). Oxygen contributes to metabolic activities and respiration which also contributes to general body development. Alcohol interferes with this proper progress, leading to a myriad of symptoms designated as Fetal Alcohol Syndrome. As a depressant, alcohol affects the psychological and brain cell development of the foetus.

Effects of Fetal Alcohol Syndrome

The main and most dangerous effect of Fetal Alcohol Syndrome is brought about by the fact that alcohol is a depressant. This suppresses the activity of the central nervous system which controls all other activities in the foetus. One of the resultant factors is the slow development of the brain cells (Pytkowicz 193). This in turn affects all the processes in the foetus such as; memory, attention, behaviour and reasoning. Mental disability is inevitable in this case. Secondary disabilities are then created as a result of the above. It should be noted that cessation of brain activity leads to negative development in the pregnancy. This implies that there is no pregnancy as the foetus is metabolically dead. Alcohol is thus one of the main causes of still births (Abel 220). In case the brain activity slows down due to brain cell damage, then the foetus will develop much slower. As such, the baby is born prematurely and has a lower rate of survival. The survivors exhibit both the mental and physical characteristics of infants suffering from this syndrome. Destruction of the central nervous system affects the development of neurones throughout the body. This is especially so during the first trimester where the pregnancy is developing at a great speed. Apparently, the neurones migrate abnormally and later fail to function. This effect is what is seen in the peripheral nervous system. As such, the infants suffer from neurological problems like epilepsy and seizures. They lack motor skills, gait, coordination and neuro- sensory capabilities such as hearing, talking and seeing. The cognitive and psychological abilities are part of the effects of brain damage. These are largely as a result of first trimester damage resulting from alcohol intake. Communication, learning, social perception and impulse control become impossible. In other words, children with Fetal Alcohol Syndrome cannot socialise or be with normal people. They do not perform normally. They need help to be able to perform their daily life activities. A very evident secondary effect of Fetal Alcohol Syndrome is the physical malformations. First, there is the stunted Fetal growth. Infants suffering from this syndrome are usually shorter and of less weight than their healthy counterparts. Another physical manifestation is designated as craniofacial features. Apparently, this is a better term for the description of gross deformed features caused by skull damage as a result of improper development. These include; flattened nose groove, thinning of upper lip and a decrease in eye width. The head becomes significantly smaller otherwise known as a micro- cephally. This is associated with mental retardation because the brain does not get enough oxygen due to the minimised space (West 265). This also affects the self esteem of that child. Alcohol being one of the legal drugs, it is ever present in our lives. It is readily available and thus easily acquired. However, it seems to play a nefarious role in an unborn foetus. It is thus imperative that every expectant woman should stay away from alcohol during pregnancy. This will lead to proper development of the foetus and thus a healthy baby.

Works Cited

Abel, Earnest. Fetal Alcohol Syndrome: From Mechanism to Prevention. New York: CRC Press, 2006. Pytcowicz, Ann. Fetal Alcohol Syndrome: A Guide for Families and Communities. New York: Paul Brooks Publishing Company. West, James. Alcohol and Brain Development. London: oxford UP, 2007.

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Fetal Alcohol Syndrome - Paper Example

Fetal Alcohol syndrome is a combination of both physical as well as mental birth deficiencies that occur as a result of women consuming alcohol during pregnancy. Taking alcohol such as wine, beer or both by a pregnant woman means that the baby is also taking. After consuming alcohol, the alcohol passes through the placenta of the pregnant woman and goes into the developing fetus. Therefore, the result may lead to the baby suffering from lifelong complications and damages. Fetal Alcohol syndrome is characterized by facial deformities, growth defects as well as brain damage. Additionally, liver, kidney, hearing problem and heart defects are also associated with FAS (May et al., 2014). Children suffering from FAS have challenges with learning, problem-solving, attention and memories. Fetal Alcohol Spectrum Disorders is a general term that describes various effects that can happen to individuals whose parents especially mothers consume alcohol when pregnant. The effects include FAS, Alcohol-related neurodevelopment disorders (ARND) and Fetal alcohol effects (FAE)

According to the recent research, in every 100 live birth, there is always one child affected by the FAS. Moreover, the research reveals that in every year, there are cases of 40, 000 infants who are affected by the disease. Various research claims that individual who suffers from FAS can spend a whopping $800,000 health cost. In 2013, FAS cost the United States of America $ 5.4 billion with a direct cost of $ 3.9 billion while the indirect cost mounted to $ 1.5 billion. The recent studies reveal that physical, as well as behavioral changes, cannot be outgrown by children hence a lifetime disorder.

Background information and research on FAS

1456115766A brief description of the Fetal Alcohol Spectrum Disorders (FASD)

A fetal Alcohol Spectrum Disorder (FASD) is the combination or range of problems that result when a fetus get exposed to alcohol by a pregnant mother. The disease occurred when a mother addicted to alcohol take it during the pregnancy and some alcohol content crosses the placenta hence mixing with the bloodstream of the baby. The alcohol, therefore, harms the development of the baby's nervous system which includes the brain. Additionally, the growing baby may become under-nourished which trigger changes in the development of the face of the baby, a condition known as FASD facial disorder.

Baby's that are severely damaged by FASD most of the time die before being born. Various conducted on FASD as reveal that there is no cure for the disease. Therefore, World Health Organization encourages pregnant women to avoid taking alcohol. The same sentiments are recommended by the NHMRC to be the safest way of preventing FASD. However, individual suffering from FASD can be assisted to learn and develop positive behavior that can help them become independent and achieve their goals in life. Pregnant women who are addicted to alcohol can be accurately diagnosed of FASD so that appropriate care can be provided to the unborn child. Moreover, the diagnosis can prevent the FASD from occurring during other pregnancies (Landgraf et al., 2013).

A brief description of the Fetal Alcohol Spectrum Disorders (FASD)

-240915766The language development of children with a Fetal Alcohol Spectrum Disorders (FASD)

Children begin to learn the various languages the day they are born. While they are growing and developing, their speech, as well as language, increasingly becomes more complex. The children learn to have clear understanding language they are speaking and used it to express their feeling, ideas, and thoughts. The early stages of language and speech development play a fundamental role for children to know how to read and write. However, children suffering from Fetal Alcohol Spectrum (FASD) have the problem with language development (Blankenship et al., 2013) FASD have effects on the central nervous system thereby affecting brain development as well as the behavior disorders. Due to poor brain development, children tend to lack concentration, poor judgment, and impulsiveness. Therefore, children suffering from the FASD always have difficulty with the development of effective language. Most of the children communicate poorly with others, and the problem sometimes persists up to the old ages. Moreover, the problem of poor language development among children suffering from the FASD may also be as a result of inability recognized physical feature like written words as well as letters. Therefore, such children are not able to practice reading and writing that can help in boosting their language development. Consequently, a lot of efforts both in at home or in school should be put in place to assists children suffering from the disorder effective language development.

The language development of children with a Fetal Alcohol Spectrum Disorders (FASD)

763051031531Reference

Landgraf, M. N., Nothacker, M., Kopp, I. B., & Heinen, F. (2013). The diagnosis of fetal alcohol syndrome. Deutsches Arzteblatt International, 110(42), 703.Mattson, S. N., Roesch, S. C., Glass, L., Deweese, B. N., Coles, C. D., Kable, J. A., & Jones, K. L. (2013). Further development of a neurobehavioral profile of fetal alcohol spectrum disorders. Alcoholism: Clinical and Experimental Research, 37(3), 517-528.

May, P. A., Baete, A., Russo, J., Elliott, A. J., Blankenship, J., Kalberg, W. O., & Adam, M. P. (2014). Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics, 134(5), 855-866.

May, P. A., Blankenship, J., Marais, A. S., Gossage, J. P., Kalberg, W. O., Joubert, B., ... & Robinson, L. K. (2013). Maternal alcohol consumption producing fetal alcohol spectrum disorders (FASD): quantity, frequency, and timing of drinking. Drug and alcohol dependence, 133(2), 502-512.Reference

Promoting language and literacy development

Earlier literacy instruction

Literacy instruction during the preschool times can be beneficial because the problem of literacy and language development start to affect kids when they are admitted in preschool and if they are not assisted, it can affect the children throughout the entire life. Teachers together with the older children with proper language and literacy know-how may help the children with t...

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Fetal Alcohol Syndrome (FAS) is one of the most common and devastating birth abnormalities among American children. This paper will provide an in-depth look at FAS, using four reliable sources as a basis of this analysis. The sources used are Streissguth, Jacobson & Jacobson, the National Center on Birth Defects and Developmental Disabilities ...
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