1. Fetal Alcohol Syndrome
Fetal Alcohol Syndrome
Psychopathology 1
Master of Clinical Psychology Program

2. Email – d.canoy@cqu.edu.au
Doreen Canoy –

3. What is Fetal Alcohol Syndrome?
Pattern of anomalies that have resulted due to prenatal exposure to alcohol
Facial anomalies
Growth retardation
Central nervous system dysfunction
Recognised as being at the higher end on a continuum of disorders which can be attributed to prenatal alcohol exposure.

5. Fetal Alcohol Spectrum Disorders (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioural, and/or learning disabilities with possible lifelong implications. The term FASD is not intended for use as a clinical
diagnosis. (Bertrand et al., 2004, pp. 4)

6. How would someone with FASD present?
Small size for age (especially as an infant)
Facial abnormalities such as small eye openings
Poor coordination
Poor suck and sleep disturbances in infancy
Hyperactive behaviour
Learning disabilities
Developmental disabilities (e.g. speech and language delays)

7. Characteristics of FASD Con’t…
Mental retardation or low IQ
Poor reasoning and judgment skills
Inconsistent or spotty memory
Poor abstract thinking
Impulsive and difficulty learning from mistakes
Temper tantrum and difficulty with self control (not appropriate for age)

8. How is a diagnosis of FAS reached?
Patient
General Practitioner
Paediatrician
Psychologist
Social Worker
Psychiatrist
Neurologist
Multidisciplinary Team Approach

9. Framework for FAS Diagnosis and Services
Child presents for office visit – Triggers Emerge
Complete initial evaluation to gather data related to FAS
FAS Criteria NOT met – Continue to monitor changes in health over time.
FAS Criteria Met - Refer to Specialist for further assessment
Intervention plan is developed
FAS Diagnosis confirmed.
Intervention Plan is communicated to frontline providers
Source: Bertrand. J., Floyd, R.L., Weber, M.K., O'Connor, M., Riley, E.P., Johnson, K.A., Cohen, D.E., National Task Force on FAS/FAE. Fetal alcohol syndrome: Guidelines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention; 2004, p.8. ​

10. Diagnostic Schemas 4-digit code / University of Washington
National Task Force / The Centre for Disease Control and Prevention (CDC)
Canadian Guidelines
Revised Institute of Medicine (IOM)

11. All four schemas look to the three distinct areas
Prenatal and/or postnatal growth deficiency
Central nervous system dysfunction
Characteristic pattern of facial anomalies (differ on how many need to be present)
Photo by Sterling Clarren, MD

12. Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code (2004)
Allows for a full assessment to be undertaken by a multi-disciplinary team of professionals
The 4-Digit code of 4444 indicates a diagnosis of FAS, at the most extreme end of the FASD.
Code of 1111 would indicate:
normal development,
no signs of facial deformities,
no CNS concerns and
no prenatal exposure to alcohol.
This therefore allows for 256 Diagnostic Codes which can be logically grouped in 22 Diagnostic Categories

13. Physician
Sections pertaining to growth, structural & neurological measures of the CNS, facial features and other physical findings.
Occupational Therapist, Psychologist, speech language pathologist and/or other team members complete sections pertaining to psychometric measures of CNS function.
All members participate in the derivation of the 4-Digit Code and intervention plan.

14. Lets start at the beginning…
While there is NO safe time to consume alcohol while pregnant this figure shows the critical periods of fetal development.
Red shows the period when major structural abnormalities occur and the yellow shows functional deficits and minor structural abnormalities.
- Russell Family Fetal Alcohol Disorders Association

15. Presenting symptoms of FAS
Documentation of all three facial abnormalities
Smooth philtrum
Thin vermillion
Small palpebral fissures
Documentation of growth deficits
Documentation of Central Nervous System (CNS) abnormality
As mentioned before FAS is seen to be at the higher end of the FASD continuum and to receive a diagnosis of FAS the following must be present..
Smooth philtrum – no groove between the upper lip and nose.
Thin vermillion – thin upper lip
Small palpebral fissures – small eye opening
Pre or postnatal weight or height at or below the 10th percentile
Children with neurodevelopmental disorders don't learn from their mistakes and they don't understand cause and consequence and they can't be disciplined in the normal way.
- Photograph

16. Facial Dysmorphia Based on racial norms
Must exhibit all three characteristic facial features

17. Thin vermillion border
Smooth philtrum
Thin vermillion border
(University of Washington Lip-Philtrum Guide rank 4 or 5)
No groove between the lip and the nose

18. Photo reprinted with permission from Susan Astley, University of Washington: www.fasdpn.org

19. Small palpebral fissures – at or below 10th percentile
Photo reprinted with permission from Susan Astley, University of Washington:

20. Specific measurement tools and instructions are used to guide correct diagnosis

21. Growth Documentation of growth deficits:
Confirmed prenatal or postnatal height or weight, or both, at or below the 10th percentile, documented at any one point in time (adjusted for age, sex, gestational age, and race or ethnicity).
Australasian Paediatric Endocrine Group
Australian and New Zealand Growth Charts
US Growth Charts (Centre for Disease Control)
The WHO Child Growth Standards

22. Central Nervous System
Central Nervous System
Structural
Head circumference at or below the 10th percentile adjusted for age and sex
Clinically significant brain abnormalities observable through imaging.
Neurological
Neurological problems not due to a postnatal insult or fever, or other soft neurological signs outside normal limits.
Functional
Global cognitive or intellectual deficits representing multiple domains of deficit (or significant developmental delay in younger children) – performance below the 3rd percentile
Functional deficits below the 16th percentile (in at least three domains)
See below for a table to assist with identifying Functional CNS deficits.
Source: Adapted from Bertrand,J., Floyd, R. L., Weber, M. K., O'Connor, M., Riley, E. P.,Johnson, K. A., Cohen, D. E., & National Task Force on FAS/FAE. Fetal alcohol syndrome: Guideiines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and Prevention;2004.

23. What does a healthy brain do?

25. Comorbidity
To increase the difficulty in achieving a correct diagnosis, a number of disorders are often comorbid with FAS.
Autism
Conduct Disorder (CD)
Oppositional Defiant Disorder (ODD)
Anxiety Disorders
Adjustment Disorders
Sleep Disorders
Depression

26. Face & Emotion Processing Retrieval Daily Living Skills
Set Shifting
Verbal Fluency
Basic Motor Control IQ
Problem Solving
Complex Motor Skills
Focused Attention
Static Balance
FASD
ADHD
Shifting Attention
Social Skills
Sustained Attention
Verbal Encoding
Communication Skills
Face & Emotion Processing
Retrieval
Daily Living Skills
Parent reports of behaviour
Mattson, Crocker & Nguyen, 2011

27. Fetal Alcohol Syndrome Summary
100% Preventable
0% Curable BUT with early diagnosis and appropriate intervention individuals with FAS do have the potential to do well.
Major Public Health Concern –vs- Moral Panic?
0.2 to 1.5 cases of FAS occur every 1,000 live births in USA.
If FAS and ARND were added together – 9.1 cases for every 1,000 live births in USA. That would be nearly 1 in 100.
ARND – Alcohol Related Neurodevelopmental Disorder
A biomarker is a term used to describe a test such as blood, urine or faeces to identify the severity or presence of a disease.

28. There is no biomarker for the diagnosis of Fetal Alcohol Syndrome.
Summary Con’t….
There is no biomarker for the diagnosis of Fetal Alcohol Syndrome.
The effects of FAS may include physical, behavioural and/or learning difficulties.
Comorbidity with a number of other disorders can complicate diagnosis.
To ensure accurate diagnosis a Multidisciplinary Team approach is best.

29. References
Armstrong, E. M., & Abel, E. L. (2000). Fetal alcohol syndrome: The origins of a moral panic. Alcohol & Alcoholism, 35(3), pp Astley, S. J. P. D. (2004). Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The four digit diagnostic code (Third ed., pp. 123). Seattle, WA: University of Washington. Bertrand, J., Floyd, R. L., Weber, M. K., O'Connor, M., Riley, E. P., Johnson, K. A., & Cohen, D. E. (2004). Fetal Alcohol Syndrome: Guidelines for referral and diagnosis. 62. Retrieved from Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice. (pp. 274). Washington, DC: U.S. Government Printing Office. Mattson, S. N., Crocker, N., & Nguyen, T. T. (2011). Fetal Alcohol Spectrum Disorders: Neuropsychological and Behavioural Features. [Review]. Neuropsychology Review, 21, doi: /s O'Connor, M. J., & Paley, B. (2009). Psychiatric conditions associated with prenatal alcohol exposure. Developmental Disabilities Research Review, 15(3), 10. Paley, B., & O’Connor, M. J. (2011). Behavioral interventions for children and adolescents with fetal alcohol spectrum disorders. Alcohol Research & Health, 34(1),

30. Riley, E. P. , Infante, M. A. , & Warren, K. R. (2011)
Riley, E. P., Infante, M. A., & Warren, K. R. (2011). Fetal Alcohol Spectrum Disorders: An overview. [Overview]. Neuropsychology Review, 21, doi: /s x Stratton, K., Howe, C., & Battaglia, F. C. (1996). Fetal Alcohol Syndrome: Diagnosis, epidemiology, prevention, and treatment (pp. 230). Retrieved from Telethon Institute for Child Health Research. (). Alcohol Pregnancy & FASD. Retrieved from t/fetal-alcohol-spectrum-disorders-(fasd).aspx

31. Helpful Links http://dcanoy.wix.com/fas-disorders
Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code
depts.washington.edu/fasdpn/pdfs/guide2004.pdf
Brief outline of Diagnostic Criteria
Australasian Paediatric Endocrine Group

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