DR. BARRY STANLEY MB. CHB, F.R.C.S. [C] FASD The term Fetal Alcohol Spectrum Disorder [FASD] embraces Fetal Alcohol Syndrome [FAS], Partial Fetal Alcohol Syndrome and Alcohol Related Neurodevelopmental Disorder [ARND]. The absence of the FAS facial features does not exclude the diagnosis of brain damage from prenatal exposure to alcohol. Only 10% of those afflicted will have the facial features. Only 15% will have an IQ below 70. 85% will have a normal range IQ or higher than average IQ. However, all those afflicted with FASD have a low Adaptive Quotient as measured by tests such as the Vineland Adaptive Behavior Scales. Those afflicted with FASD demonstrate primary and secondary disabilities to varying degrees depending on the quantity of alcohol taken, the manner it is drunk eg binge drinking, the time in the pregnancy and the health and nutrition of the mother. Primary disabilities are the inevitable consequences of prenatal exposure to alcohol. -Impaired spatial learning -confabulation - often interpreted as lying -attention disorders, easily distracted and perseveration perseveration/transition problems -sensory problems- self mutilation -impaired executive functioning i.e forming, planning and achieving goal directed task -learning disabilities -low I.Q. [15% only ]] -co-morbid psychiatric illnesses [previously considered to be a secondary disability] -memory problems, short term memory for verbal and visual recall. [ when the verbal processing is good and visual poor it is known as a non-verbal learning disability ] These primary disabilities lead -to difficulty communicating-giving and receiving information takes everything literally - concrete thinking -problems with planning and organizing -impulsiveness, poor judgment, easily lead
-failure to learn from experience -difficulty with abstractions, idioms, humor, sarcasm -difficulty relating cause and effect, anticipating consequences -difficulty appreciating others point of view -problems expressing remorse or taking responsibility for behavior -frustration. -bowel and micturition control problems FASD is not just a central nervous condition. It also effects the peripheral nervous system. Those afflicted with FASD have sensory abnormalities. They may be over sensitive or under sensitive. Under sensory means that they are less sensitive to external stimuli. They are less sensitive to cold or physical pain. They have a need for sensory stimulation resulting in inappropriate hugging and touching. Repetitive scratching, pulling hair out, and more severe kinds of self mutilation [often interpreted as OCD or attention seeking] provides comfort, especially in times of stress, that others obtain from more normal sensory stimulation. It is my observation that those with FASD exist in two states, 1 -a mind of chaotic, uncontrolled and uncomfortable thoughts, usually described as being bored. 2- a mind perseverating [ super focused ], with or without physical activity. They seek the second to escape the first. What they perseverate on is determined by their particular set of cognitive, emotional, information processing, memory, expressive and sensory disabilities; as well as their early childhood experience and their immediate environment, including how others relate to them. What they may perseverate on to soothe themselves extends from cutting, provoking others, to more acceptable behaviors, such as playing video games, reading and sports. Alcohol and hard drugs are used to obliterate the 1st state of mind. Those with FASD can often stop using them providing they have an alternative focus of perseveration. This is not true of Marijuana and Tobacco, which generally appear to have a specific action that reduces their multiple chaotic thoughts and allows them to focus on one process.
The “medicinal” use of pot is lost if it is used to excess, in which case it assumes the harmful role of other street drugs. The secondary disabilities are -disrupted school experience trouble with the law -confinement -inappropriate sexual behavior -alcohol and drug problems -dependent living -problems with employment -problems parenting Previously mental health problems were considered to be a secondary disability. It is now apparent that they are primary disability. 94% of those with FASD will develop more than one psychiatric illness [co-morbidity] as defined in the Diagnostic and Statistical Manual of Mental Disorders [DSM]. Secondary disabilities are mitigated by a stable, nurturing home environment and an early diagnosis. It is important to note however, that serious secondary disabilities may still occur in spite of these positive conditions being met. The diagnosis is ideally made by a team of professionals using the Canadian Guidelines. The FASD Clinic at St. Michael’s Hospital, Toronto uses this method. A history of maternal drinking is required unless the FAS facial features are present. Psychometric evaluation, including tests such as the Vineland Adaptive Behavior Scale is required. Early childhood development and subsequent school and social progress are reviewed. B. Stanley REFERENCES 1- The Stream of Consciousness. William James. Psychology, Chapter XI, 1892. 2- W.C. Sullivan, Stewart Scholar. A Note on the Influence of Maternal Inebriety on the Offspring. Journal of Mental Science. 1899. 3- Pattern Of Malformations in Offspring Of Chronic Alcoholic Mothers, Jones et.al. The Lancet: Saturday 9 June 1973. 4- The Effects of Drinking on Offspring; An Historical Survey of American British Literature. Rebecca Warner, Henry L. Rosett. The Journal of Alcohol Studies. 1975. 5- Understanding the Occurrence of Secondary Disabilities in
Clients with Fetal Alcohol Syndrome [FAS] and Fetal Alcohol Effects [FAE]. Final Report, August 1996., Streissguth et.al., Fetal Alcohol and Drug Unit, University of Washington, Seattle, U.S.A. 6- Incidence of Fetal Alcohol Syndrome and Prevalence of Alcohol - P.D.Sampson et.al., Teratology 56:317-326  7- Mental Illness in Adults With Fetal Alcohol Syndrome or Fetal Alcohol Effects. Chris. Famy et.al., Am. J. Psychiatry 1998; 155: 552-554 8- Fetal Alcohol Syndrome: Implications For Correctional Service. F.J. Bolland et.al. Research Report, Research Branch, Correctional Service Canada. 1998. 9-. Comparison of Social Abilities of Children with FAS to Those Children with Similar IQ Scores and Normal Controls. Alcoholism; Thomas et al Clinical and Experimental Research, 22, 1998 10- Developing Clinical Practice Guidelines for Pharmacological Interventions With Alcohol - Affected Children., 1999. Kieran D. O’Malley, University of Washington Fetal Alcohol and Drug Unit. Randi Hagerman, University of Colorado, Health Sciences Centre, Children’s Hospital, Denver. 11- Diagnosing The Full Spectrum of Fetal Alcohol-Exposed Individuals: Introducing The 4-digit Diagnostic Code. Susan J. Astley and Sterling K. Clarren. Alcohol and Alcoholism. Vol. 35, No. 4, 2000. 12- Estimating the Prevalence of Fetal Alcohol Syndrome. P.A. May et.al., Alcohol, Research & Health., Vo. 25, No 3, 2001 13- An Introduction to the Problem of Alcohol Related Birth Defects. www.med.unc.edu/alcohol/ed/fas/slides Fetal Toxicology Division, Bowles Centre for Alcohol Studies, University of North Carolina. 14- Teratogenic Effects of Alcohol on Brain and Behavior. Sarah N. Mattson et.al. Alcohol Research and Health. Vol 25 No 3, 2001 15- Fetal Alcohol Exposure and Attention: Moving beyond ADHD. Coles et.al., Alcohol Research and Health, Vol, 25. No 3, 2001. 16- Comparison of the Adaptive Functioning of Children Prenatally Exposed to Alcohol to a Nonexposed Clinical Sample. Whaley et al. 25, July 2001. 17- Prenatal alcohol exposure and childhood behavior at age 6 to 7 years: 1, dose -response effect, B.Sood et.al., Pediatrics,
2001 Aug;108; E34. 18- Clinical Implications of a Link Between Fetal Alcohol Spectrum Disorder and Attention-Deficit Hyperactivity Disorder. Kieran D O’Mally, Jo Nanson, Can. J Psychiatry, Vol.47, No4, May 2002. 19- Fetal alcohol spectrum disorder and ADHD: diagnostic implications and therapeutic consequences, Kieran O’Mally and Linda Storoz. Expert Review. Neurotherapeutics 3, 477-489  20- Youth with Comorbid Disorders, Kieran D. O’Mally, The Handbook of Child and Adolescent Systems of Care, Chapter Thirteen, 2003 21- Fetal Alcohol Spectrum Disorder [FASD]: A Need for Closer Examination by the Criminal Justice System. Timothy E. Moore, Melvyn Green. Criminal Reports, Vol 19 Part 1, July 2004 22- FASD 4-Digit Diagnostic Code , FAS Diagnostic and Prevention Network, University of Washington, Seattle, U.S.A. 23 Fetal Alcohol Spectrum Disorder [ FASD ], Public Health Agency of Canada, Cat.No. H124-4/2004, ISBN 0-662-68619-5, Publication No. 4200 24- Report on Prenatal Exposure to Alcohol. Professor Peter Hepper, Belfast, N. Ireland, 1998. Maternal alcohol consumption during pregnancy may delay the development of spontaneous fetal startle behavior. Peter G. Hepper et.a., Physiology and Behavior, 83 , 711-714. 25- Fetal Alcohol Spectrum Disorder Canadian Guidlines for Diagnosis. Albert E. Chudley et. a.l., C.M.A.J.- March 1st., 2005. 26- Binge Drinking During Pregnancy as a Predictor of Psychiatric Disorders on the Sructured Clinical Interview for DSM-IV in Yourng Adult Offspring., Helen M. Barr et.a.l., American Journal of Psychiatry, 2006: 161: 1061- 1065 Chudley et al Appendix 3: FASD Canadian Guidlines for diagnosis. Examples of tests that are most widely used to assess the domains * Psychologists, speech-language pathologists and occupational therapists were consulted regarding their widely used tests. Tests for brain function are regularly updated and the most current versions should be used where appropriate Hard and soft neurologic signs (including sensorymotor .
Hard neurologic signs are assessed by the physician according to usual standards. Soft neurologic signs include motor signs that can be elicited on the physical examination, with referral for occupational therapy assessment where appropriate. Tests of motor functioning include: Movement Assessment Battery for Children BrunuinksOseretsky Scales of Motor Development Alberta Infant Motor Scale Peabody Developmental Motor Scales Quick Neurological Screening Test-II Tests for visual-motor functioning include: Developmental Test of Visual-Motor Integration or Bender Gestalt (simple) Rey Complex Figure Test and Recognition Trial (complex) Tests of perception include: Gardner Test of Visual Perceptual Skills Gardner Test of Auditory Perceptual Skills Tests of sensory function include: Dunn Sensory Profile University of Washington Sensori-motor Checklist Congenital sensory-neural hearing loss as evaluated by audiologist Congenital vision anomalies as evaluated by an ophthalmologist Tests and observations of articulation, phonology and motor speech if indicated: Goldman-Fristoe –2 Test of Articulation Phonological Awareness Test Brain structure Documented measurements of the head circumference (occipital-frontal circumference below the 3rd percentile) adjusted for age and gender(during the physical examination at any age including head circumference at birth) and other evidence of functional or structural CNS dysfunction based on a neurologic examination or findings on imaging techniques (computed tomography scan, magnetic resonance imaging, electroencephalogram). Neurologic problems may include seizures not due to a postnatal insult or other signs such as impaired motor skills, neuro-sensory hearing loss, memory loss or poor eye–hand coordination. Cognition Tests of intellectual functioning include:
Wechsler Intelligence Scale for Children-III (WISC-IV not yet tested for usefulness with the FASD population) Stanford-Binet- Fourth Edition (SB5 not yet tested for usefulness with the FASD population) Wechsler Preschool and Primary Scale of Intelligence-III Differential Ability Scales Bayley Scales of Infant Development Communication Test batteries of language functioning usually combine both receptive and expressive language functions, as well as single-word and complex functions (sentences and paragraphs). Elicited versus recognition ability (multiplechoice) should be distinguished. Peabody Picture Vocabulary Test-III Expressive Vocabulary Test Preschool Language Scale (3 or 4) Reynell Developmental Language Scales Test of the Auditory Comprehension of Language-3 Token Test Listening Test Test of Word Knowledge Clinical Evaluation of Language Fundamentals (Preschool, CELF-3, CELF- These measures are complemented by a language sample analysis that includes: length of utterance, use of complex sentences and word retrieval. Social Language Observations Narrative skill (PLS-E story retell); Renfrew Bus Story, Frog Where are You (Note: Language pragmatics are considered in the domain of social/adaptive skills.) Academic achievement Tests commonly used include: Wechsler Individual Achievement Test-II (most widely used) Gray Oral Reading Test Woodcock Johnson Achievement Battery Wide Range Achievement Test-3 (note: needs to be supplemented by a test that includes reading comprehension) Note: Avoid relying on group administered achievement test data. Preschool children present a challenge in this domain; however, concept knowledge as assessed by the Preschool Language Scale, Bracken Test of Basic Concepts and Boehm Basic Concept Scale can be used.
Memory Assessment should include comparisons between visual and auditory memory; short-term memory, delayed recall, and working memory. Tests commonly used include: Children’s Memory Scale-III Wechsler Memory Scale-III Wide Range Assessment of Memory and Learning Rey Complex Figure Test (recall) Developmental Neuropsychological Assessment (NEPSY) memory subtests Stanford-Binet Fourth Edition memory subtests California Verbal Learning Test Working memory composites from Wechsler scales Executive functioning and abstract reasoning Delis-Kaplan Executive Function System Behaviour Rating Inventory of Executive Function (BRIEF): parent and teacher versions Verbal Abstract Reasoning and Problem Solving Test of Problem Solving (Elementary and Adolescent) Semantic Relationships (CELF-3) and Similarities and Differences (LPT-R, TLC-expanded) Observation (e.g., answering how and why questions, explanations, inferences) (Note: observations made on the IQ test may also apply here) Visual Abstract Reasoning and Problem Solving Executive function subtests on the NEPSY Wisconsin Card Sorting Test Attention deficit/hyperactivity Tests commonly used include: Observation Conners’ Rating Scale Child Behaviour Checklist Continuous Performance Test-2 Adaptive behaviour, social skills, social communication Assessment of social and adaptive skills is considered most important, but the available standardized instruments do not adequately tap the unusual adaptive problems found in FASD. Observation and interview, school reports and previous assessments Vineland Adaptive Behaviour Scale: often used, but inadequate at higher ages Adaptive Behaviour Assessment System: easier to administer and seems to correlate well with other measures and
observation Informal assessment of language pragmatics (not standardized), social communication