Health Watch Table
Tao, Temple, Casson and Kirkpatrick 2013
Overview: Fetal Alcohol Spectrum Disorder is an umbrella term for the range of effects that can occur in an individual exposed to alcohol in utero. These effects can include various physical, intellectual and neurobehavioral deficits that vary widely in severity. Fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (pFAS), alcohol-related neurodevelopmental disorder (ARND) and alcohol-related birth defects (ARBD) are now used to refer to each of the four sub-categories subsumed under FASD.1,2 Prenatal alcohol exposure does not always lead to FASD.
Prevalence: The reported incidence of full FAS currently ranges from 0.2 to 2.0 cases per 1,000 live births and up to 43 per 1,000 among “heavy” drinkers (different population surveyed or different methods used). The prevalence of FASD has been estimated to be at 9.1 per 1,000 live births in the United States.3, 4
Etiology: Prenatal alcohol exposure
The range of deficits in FASD is associated with many factors, including the amount, time and frequency of exposure, as well as the state of health/nutrition of the mother and the genetic makeup of the mother and the fetus. There is no time during pregnancy when it is shown to be safe for mothers to consume alcohol. While binge drinking is especially dangerous, no amount of alcohol has been shown to be safe for all women.
Considerations | Recommendations |
1. Diagnosis | |
Children: Diagnosis of FAS is based on a combination of:
Manifestations of FASD may overlap with other disorders of environmental or genetic (e.g., 22q11 deletion syndrome) etiology. It is essential to rule out such differential diagnoses, especially in the absence of confirmed prenatal alcohol exposure.1,6 Experts call for early diagnosis and intervention with families of alcohol-affected children to:
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Adults: Separate criteria for adults do not exist, but diagnosis is more challenging because:
Most individuals with FASD have an ‘invisible’ disorder and <50% meet current definitions of developmental/intellectual disability.11 However, “The diagnosis can lead to a paradigm shift in attitude and perception towards the affected individual from one of a … difficult individual or sociopath to that of an individual who is neurologically impaired and who needs appropriate assistance with specific management and treatment”.11 |
Individuals may exhibit depression, anxiety or psychosis, poor judgment, poor impulse control, sexual promiscuity and victimization, restlessness, poor problem-solving skills, resistance to change, difficulty forming meaningful relationships, gullibility, inability to understand or to conform to social norms.11
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2. Cognitive Function/Communication | |
Children: Intellectual ability may vary by individual from average IQ to severe intellectual disability. Diagnostic category does not necessarily predict cognitive level, (i.e., needs of FAS, pFAS and ARND can all be substantial).14Learning disabilities, language and communication disabilities are common.1Executive functioning skills are often a significant weakness. This can lead to problems with emotional regulation, impulse control, and deficits in planning, organization, and attention.15, 16 |
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Adults: Cognitive skills may increase further or decline during childhood and into adulthood.11Significant deficits in mathematical ability often persist into adulthood.11, 18 It is common to face challenges in transition to adult care; there are often gaps in services from childhood to adulthood.11 |
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3. Adaptive Daily Living Skills | |
Children and Adults: Support and supervision from care providers or family members is necessary to help individuals make and follow through on treatment plans and appointments. Functional daily living skills are often significantly lower than cognitive skills. Individuals with relatively high IQ scores may still struggle with social skills, financial and time management, and organization of daily life.11, 19Structured activities and routines can help with organizational issues. |
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4. Physical Health Issues1 | |
Children and Adults: Conductive and sensorineural hearing loss and vision abnormalities are common in FAS.5 Dental problems, including malformations and caries, are common in FAS.5 Neurological assessment is part of the diagnostic work-up. Typical and atypical seizures may be present.12 Inappropriate sexual behavior may be more common than anticipated.“Virtually every malformation has been described in patients with FAS.”12Growth deficiency is common.Learning difficulties, poor capacity for abstraction, deficits in higher- level receptive or expressive language, problems in memory, attention and judgment may compromise access to health care services. |
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5. Mental Health and Behavioral Issues | |
Children: Attention disorders (e.g., ADHD) occur in many cases.20 Childhood trauma and attachment disorders are common. Many individuals experience multiple home/foster home placements, neglect, and abuse.18 |
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Adults: Psychiatric disorders occur in a large percentage of cases. Mood, anxiety and conduct disorders are common.22Underlying neurological deficits can lead to increased emotional reactivity.15Adolescents and adults with FASD may have difficulty with cognitive-types of therapy, partly due to language processing difficulties.11Addiction problems are common. They can begin in teenage years and continue into adulthood.13 Interactions with the justice system often occur.13 |
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6. Sleep | |
Children and Adults: Sleep disturbance is common with prenatal alcohol exposure, and medical problems related to obstructive sleep apnea may have been overlooked previously.12 Sleep disturbances, including bedtime resistance, shortened sleep duration, increased sleep anxiety and night awakenings, are common.23 |
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7. Sensory Issues | |
Children and Adults: May have sensory processing (integration) disorder, “clumsiness”, or mild neurological or sensorimotor abnormalities. They may present with difficulties in performing activities of daily living, extreme avoidance of activities and/or agitation.24 |
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Professional Resources | |
FASD Screening Tool Kit: Includes resources and screening tools for primary health care professionals. |
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FASD Toolkit: American Academy of Pediatrics |
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MOTHERRISK is an excellent resource for pregnant and breast-feeding mothers, physicians and others about a wide range of potential toxic substances, especially alcohol. |
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Caregiver Issues and Resources | |
Let’s Talk FASD Caregiver guide with recommendations for both children and adults with FASD. |
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Additional Websites of Interest | |
FASD and Child Welfare Community of Practice: Network to inform policy makers, program developers and practitioners about the needs of children with FASD in the care of child welfare jurisdictions and agencies, as well as early intervention practices. |
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Proof Alliance, formerly the Minnesota Organization on Fetal Alcohol Syndrome St. Paul, MN Website offers information and resources to individuals, families and professionals regarding FASD. |
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FASD United; National Organization on Fetal Alcohol Syndrome London, England; Devoted to preventing alcohol use during pregnancy and supporting individuals and families living with FASD. |
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FAS DPN Center on Human Development and Disability University of Washington, Seattle, WA |
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Original tool: © 2013 Surrey Place Centre.
Developed by Tao L, NP; Temple V, psychologist; Casson I, MD; Kirkpatrick SML, MD
Expert Clinician Reviewer
Thanks to the following clinician for review and helpful suggestions.
Albert E. Chudley, MD, FRCPC, FCCMG
Medical Director, Program in Genetics and Metabolism
Professor, Department of Paediatrics and Child Health
Department of Biochemistry and Medical Genetics
University of Manitoba
Winnipeg, MB
Modified with permission of Surrey Place Centre. This tool was reviewed and adapted for U.S. use by physicians on the Toolkit’s Advisory Committee; for list, view here.
References
- Abele-Webster LA, Magill-Evans JE, Pei JR. Sensory processing and ADHD in children with fetal alcohol spectrum disorder. Can J Occup Ther. 2012 Feb;79(1):60-3.
- Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N, et al. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ. 2005 Mar 1:172(5 Suppl):S1-S21. Available from: www.cdc.gov/ncbddd/fasd/data.html Accessed July 2021.
- Chudley AE, Kilgour AR, Cranston M, Edwards M. Challenges of diagnosis in fetal alcohol syndrome and fetal alcohol spectrum disorder in the adult. Am J Med Genet Part C Semin Med Genet. 2007;145(3):261-72.
- Chudley AE, Longstaffe SE. Fetal alcohol syndrome and fetal alcohol spectrum disorder. In: Cassidy SB, Allanson JE, editors. Management of genetic syndromes. 3rd ed. Hoboken, N.J.: Wiley-Blackwell; 2010. p. 363-80.
- Davis K, Desrocher M, Moore T. Fetal alcohol spectrum disorder: A review of neurodevelopmental findings and interventions. J Dev Phys Disabil. 2011;23(2):143-67.
- Davis KM, Gagnier KR, Moore TE, Todorow M. Cognitive aspects of fetal alcohol spectrum disorder. Wiley Interdiscip Rev Cogn Sci. 2013;4(1):81-92.
- Douzgou S, Breen C, Crow YJ, Chandler K, Metcalfe K, Jones E, et al. Diagnosing fetal alcohol syndrome: New insights from newer genetic technologies. Arch Dis Child. 2012 Sep;97(9):812-7.
- Koren G, Nulman I, Chudley AE, Loocke C. Fetal alcohol spectrum disorder. CMAJ. 2003 Nov 25;169(11):1181-5.
- Koren G, Todorow M, editors. Understanding fetal alcohol spectrum disorder: A resource for education practitioners in Ontario. Toronto, ON, Canada: The Hospital for Sick Children; 2010.
- O’Connor MJ, Paley B. Psychiatric conditions associated with prenatal alcohol exposure. Dev Disabil Res Rev. 2009;15(3):225-34.
- Rasmussen C, Andrew G, Zwaigenbaum L, Tough S. Neurobehavioural outcomes of children with fetal alcohol spectrum disorders: A Canadian perspective. Paediatr Child Health (CAN). 2008 [cited 1 Oct 2012];13(3):185-91.
- Rasmussen C, McAuley R, Andrew G. Parental ratings of children with fetal alcohol spectrum disorder on the behavior rating inventory of executive function (brief). J FAS Int. 2007 [cited 1 Oct 2012];5(e2):1-7.
- Stratton KR, Howe CJ, Battaglia FC, Institute of Medicine. Division of Biobehavioral Sciences and Mental Disorders. Committee to Study Fetal Alcohol Syndrome, National Institute on Alcohol Abuse and Alcoholism. Fetal alcohol syndrome: Diagnosis, epidemiology, prevention, and treatment. Washington, D.C.: National Academy Press; 1996.
- Streissguth A. Offspring effects of prenatal alcohol exposure from birth to 25 years: The Seattle prospective longitudinal study. J Clin Psychol Med Settings. 2007;14(2):81-101.
- Streissguth AP, Aase JM, Clarren SK, Randels SP, LaDue RA, Smith DF. Fetal alcohol syndrome in adolescents and adults. JAMA. 1991 Apr 17;265(15):1961-7.
- Streissguth AP, Bookstein FL, Barr HM, Sampson PD, O’Malley K, Young JK. Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. J Dev Behav Pediatr. 2004 Aug;25(4):228-38.
- Temple V, Shewfelt L, Tao L, Casati J, Klevnick L. Comparing daily living skills in adults with fetal alcohol spectrum disorders (FASD) to and IQ matched clinical sample. J Popul Ther Clin Pharmacol. 2011 [cited 1 Oct 2012];18(2):e397-402.
- Wattendorf DJ, Muenke M. Fetal alcohol spectrum disorders. Am Fam Physician. 2005 Jul 15 [cited 1 Oct 2012];72(2):279,82, 285.
- Wengel T, Hanlon-Dearman AC, Fjeldsted B. Sleep and sensory characteristics in young children with fetal alcohol spectrum disorder. J Dev Behav Pediatr. 2011 Jun;32(5):384-92.
- Fetal alcohol spectrum disorder. Ottawa, ON: Health Canada. 2009. Available from: www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/fasd-etcaf-eng.php Accessed July 2021.
- Fetal alcohol spectrum disorders (FASDs) – data and statistics – United States. Atlanta, GA: Centers for Disease Control and Prevention. 2012. Available from: www.cdc.gov/ncbddd/fasd/data.html Accessed July 2021.
- Fetal alcohol syndrome: Guidelines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention. 2004. Available from: www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf Accessed July 2021.
- National screening tool kit for children and youth identified and potentially affected by FASD. Ottawa, ON: Public Health Agency of Canada (PHAC). 2012. Available from: http://ken.caphc.org/xwiki/bin/view/FASDScreeningToolkit/National+Screening+Tool+Kit+for+Children+and+Youth+Identified+and+Potentially+Affected+by+FASD
Accessed July 2021. - National thematic workshop on FASD: Summary report. Ottawa, ON: Health Canada. 2006. Available from: http://publications.gc.ca/pub?id=284794&sl=0 Accessed July 2021.
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