Welcome to FASD training

•Please complete the

following in your packet:

•Pretest

•Values Clarification Activity

FOUNDATIONS

OF FASD

Susan Montague LCP, LCAC

Cheryl Rathbun LSCSW

40th Annual Governor’s Conference for the Prevention of Child Abuse and Neglect

October 4th, 2016

Saint Francis Community Services

785-825-0541

Adapted from the CDC

Competency-Based

Curriculum

Development Guide for

Medical and Allied

Health Education and

Practice, 2009, 2015

Learning Objective

• To provide a framework to understand

the historical, biomedical, and clinical

significance of fetal alcohol syndrome

(FAS) and other fetal alcohol spectrum

disorders (FASDs).

Unless otherwise noted, content information contained in this PowerPoint presentation is

referenced in the Fetal Alcohol Spectrum Disorders Competency-Based Curriculum Development

Guide for Medical and Allied Health Education and Practice, Centers for Disease Control and

Prevention, 2009 available at www.cdc.gov

Learning Goal A

• Describe the basic biomedical foundation

of fetal alcohol spectrum disorders

(FASDs):

• Recognition of the Issues

• Effects of Alcohol on the Developing Embryo/Fetus

• Characteristics of FASDs

• Intervening with Individuals affected by FASD

Learning Goal B

• Explain basic clinical implications relevant to

alcohol and pregnancy:

• Preconceptional Counseling

• Prevention of Alcohol-Exposed Pregnancies

• Counseling Pregnant Women who Use(d) Alcohol

• Framework for FAS Identification, Diagnosis and

Treatment/Intervention

Learning Goal C

• Provide an overview of the epidemiological,

psychosocial, and cultural issues related to

fetal alcohol spectrum disorders (FASDs):

• Scope of the Issues

• Monitoring Prenatal Alcohol Exposure

• Prevalence of FASDs

• Costs of FASDs

• Psychosocial and Cultural Issues

Learning Goal D

• How stigma and bias may affect women

who use alcohol and other drugs, and

individuals with fetal alcohol spectrum

disorders (FASD)

AN OVERVIEW OF FETAL

ALCOHOL SPECTRUM

DISORDERS (FASD)

• Individuals affected by

prenatal alcohol exposure can

have a range of serious,

lifelong problems including

physical,

cognitive, behavioral,

and social deficits.

Photo (used with permission): Children with FAS

Terminology

• Fetal Alcohol Spectrum Disorders (FASD): an

umbrella term describing the range of effects that

can result from prenatal alcohol exposure—but is

not a diagnostic term

• Fetal Alcohol Syndrome (FAS): medical

diagnosis, usually made by a dysmorphologist,

clinical geneticist, or developmental pediatrician,

but other medical professionals can make this

diagnosis

FASD:

Relevance to Clinical Practice

High Prevalence

• Prevalence in a Midwestern city (May, 2014)

• FAS: 6- 9/1000 children

• All FASD: 24-48/1000 children (2.4% to 4.8%)

• Increased prevalence among children in child

welfare (Lange, 2013)

• FAS: 60/1000 children (6%)

• All FASD: 169/1000 children (16.9%)

FASD:

Perspectives on Prevalence• Down syndrome 1.2/1000 births

• Cleft lip+/-palate 1.2/1000 births

• Spina bifida 1/1000 births

• Autism: 12.5-14/1000

• FAS: 6- 9/1000

• All FASDs: 24 -48/1000

(May 2014)

FASD Awareness Strategies

• Universal Prevention: education and awareness for

everyone

• Selective Prevention: intervention for those at risk

• Indicated Prevention: targeted intervention for those at

greatest risk

Free awareness and education materials available from the

CDC at: www.cdc.gov/ncbddd/fasd/freematerials.html

No known amount

of alcohol is safe

during pregnancy

Public Health Messages

• Alcohol use during pregnancy increases risk of alcohol related birth defects

• No amount of alcohol consumption can be considered safe during

pregnancy

• Alcohol-related birth defects are preventable

• Pregnant women who have already consumed alcohol during pregnancy

should stop in order to minimize further risk

• Recognizing that nearly half of all births in the United States are unplanned,

women of child-bearing age should consult their physician and take steps

to reduce the possibility of prenatal alcohol exposure

• Health professionals should routinely inquire about alcohol consumption by

women of childbearing age, inform them of the risks, and advise them not

to drink during pregnancy

2005 Surgeon General’s Advisory on Alcohol Use in Pregnancy (www.cdc.gov/ncbddd/fas/fasprev.htm)

Best Public Health Message

• According to the Centers for Disease Control and

Prevention (CDC), the following is an ideal prevention

message related to alcohol consumption by women of

childbearing age:

• Women who are pregnant or could become

pregnant should not consume alcohol

Experiential Exercise

•Value Clarification Activity

CLINICAL IMPLICATIONS

How can I identify and help

children and parents with

alcohol use/abuse problems

leading to FASD?

Interventions to Prevent Alcohol-Exposed Pregnancies

• Provide all clients with information about alcohol,

contraception, and FASDs

• Provide alcohol screening to women of childbearing

age

• Provide brief alcohol intervention for women at risk

• Provide targeted alcohol treatment and promote

contraception use for women at highest risk:

• Women who have a child with an FASD

• Women with a history of alcohol abuse and/or

dependence

Standard Drink

Source: National Institute on Alcohol Abuse and Alcoholism. (2005a). Helping patients who drink too much: A clinician’s guide,

Updated 2005 Edition. NIH Pub. No. 07-3769. Bethesda, MD: U.S. Department of Health and Human Services.

Risky Drinking Definitions• Low Risk Drinking Limits

• Men:

• No more than 4 per day

• No more than 14 per week

• Women:

• No more than 3 per day

• No more than 7 per week

• Heavy or At-Risk Drinking• Drinking above low-risk levels

Binge Drinking• “…Drinking so much within about 2 hours

that blood alcohol concentration (BAC)

levels reach 0.08 grams per deciliter…”

Typically…

Women (and men > 65): > 4 drinks

Men: > 5 drinks

Women and Alcohol• 50% of non-pregnant women aged 18-44 years report

alcohol use

• 10% of non-pregnant women aged 18-44 years report

frequent or binge drinking

• An episode of “binge” drinking for

women of childbearing age is

defined as more than 3 drinks in

about a two hour period

Alcohol and Pregnancy• Women who binge drink are at increased

risk of an unintended pregnancy and an

alcohol-exposed pregnancy

• About 7.6% of pregnant women used

alcohol

• Centers for Disease Control and Prevention. Alcohol use

and binge drinking among women of childbearing age –

United States, 2006-2010. MMWR 2012;61:534-538.

IMPACT OF ALCOHOL ON PREGNANCY OUTCOMES

Potential Effects• Premature Birth

• Pre- and Postnatal Growth Retardation

• Physical Malformations

• Microcephaly

• Cognitive and Behavioral Problems

Impact of Alcohol on the Developing Embryo/Fetus

• Alcohol readily crosses the placenta:

• Fetal liver/organs unable to fully metabolize alcohol

• Embryo/fetus exposed to similar BAC (blood alcohol concentrations)

levels as mother

• Specific manifestations of prenatal alcohol exposure are

affected by timing, dose, and other fetal/maternal factors

• Some “catch-up” in fetal growth and development may

be possible if drinking stops at any time during

pregnancy

Critical Period

• Scientific studies have shown that

prenatal alcohol exposure can

effect the development of the fetus

at any point during gestation.

Timing of an Exposure• There are multiple critical periods associated

with prenatal alcohol exposure:

• 1st Trimester Drinking: risk for major morphological

abnormalities, characteristic facial features, growth

retardation, and neurological effects

• 2nd Trimester Drinking: risk for spontaneous abortion,

growth retardation, and neurological effects

• 3rd Trimester Drinking: risk for growth

retardation and neurological effects

Dose(amount of an exposure)

• Threshold Effect: There is no known

safe level of alcohol use during

pregnancy

• Dose-Response Rate: The higher the

BAC level and the longer the exposure,

the greater the risk alcohol poses to

developing embryo/fetus

Who Drinks During Pregnancy?

• Among pregnant women, the highest

prevalence of reported alcohol use was

among those who were:

• Aged 35-44 years (18.6%)

• College graduates (13.0%)

• Unmarried (4.6x married)

Tan, Denny, Cheal, Sniezek & Kanny,

2015

FAS Diagnostic Criteria• Pre- and/or Postnatal Growth Retardation

• Height and/or weight at or below 10th percentile

• Specific Facial Anomalies

• Small palpebral fissures (eye openings)

• Thin upper lip (vermillion)

• Smooth philtrum (ridge between nose and mouth)

• Central Nervous System Impairments

* Corrected for racial norms if possible.

Facial Anomalies

© Family Empowerment Network UW Medical School

Related Conditions• Partial FAS (pFAS)

• Alcohol-Related Birth Defects (ARBD)

• Alcohol-Related Neurodevelopmental

Disorder (ARND)

• Neurodevelopmental Disorder Associated

with Prenatal Alcohol Exposure (ND-PAE

DSM-5)

Partial FAS• With or without confirmed prenatal alcohol

exposure

• Two or more facial features

• One or more of following:

• Pre and/or postnatal growth retardation

• Evidence of deficient brain growth (OFC at or below 10th

percentile) or structural abnormalities

• Evidence of cognitive/behavioral abnormalities, inconsistent with

developmental level that can’t be explained by

genetics/family/environment alone

Alcohol Related Birth Defects

• Confirmed prenatal alcohol exposure

• Two or more facial features

• At least one associated congenital

structural deficit

Alcohol-Related Neurodevelopmental Disorder

• Confirmed prenatal alcohol exposure

• At least one of the following:

• Evidence of deficient brain growth (OFC-Occipitofrontal head

circumference- at or below 10th percentile) or structural

abnormalities

• Evidence of cognitive/behavioral abnormalities, inconsistent

with developmental level that can’t be explained by

genetics/family/environment alone

ND-PAE: DSM-5• Section II

• Neurodevelopmental disorder associated with

prenatal alcohol exposure (p. 86)

• 315.8 (F88)

• Section III: Conditions for Further Study

• Neurobehavioral disorder associated with

prenatal alcohol exposure (p. 798)

Spectrum of FASD

+/- OR OR

OR

As Defined in DSM-5

FAS w/out confirmed

maternal exposure

FAS

Partial FAS with or w/o confirmed exposure

FAS with confirmed

maternal exposure

Alcohol-related birth

defects (ARBD)Alcohol-related neurodevelopmental disorder (ARND)

PFAS

ARBD

ARND

ND-PAENeurodevelopmental disorder associated with prenatal alcohol exposure (ND-PAE)

Adapted from Neuroscience and Biobehavioral Reviews (2007); 31:230-238PEDIATRICS Vol. 106 No. 2 August 2000

AConfirmed

Exposure to Alcohol

BFacial

Anomalies

CGrowth

Retardation

DCNS

Abnormalities

ECognitive

Abnormalities

FBirth

Defects

Differential Diagnosis• No feature of FAS is unique to prenatal alcohol exposure

• Many genetic conditions include growth retardation and/or

CNS impairments

• Many environmental factors can lead to growth deficiencies

and/or CNS deficits (e.g. poor nutrition, abuse, neglect,

depression, lead exposure)

• Other syndromes include constellation of facial features

similar to FAS, including:

• Williams Syndrome

• Noonan Syndrome

• Dubowitz Syndrome

• Fetal Dilantin Syndrome

FAS Diagnostic Framework

Child presents for

office visit

Triggers emerge:

1. Developmental

problems

2. Facial

abnormalities

associated with

FAS

3. Growth delays

4. Prenatal alcohol

exposure

Provider

Completes initial

evaluation

1. Facial

malformations

2. Growth

abnormalities

3. Neuro-

developmental

concerns

4. Prenatal

alcohol exposure

Referral

to

Specialist

Continue to

monitor

changes in

child’s

health over

time

FAS Diagnosis

confirmed using

dysmorphic and

anthropometric

procedures along

with appropriate

neuro-

developmental

evaluation data

Multidisciplinary

intervention plan

developed

Intervention plan

is communicated

to frontline

providers,

caregivers, and

child with ongoing

exchange with the

intervention team

Case

management plan

is initiated at the

community level

based on

recommendations

Yes

No

Referral

Criteria

Met?

Provider Contact Diagnosis Services

Impact of FASDs

• The following problems are associated

with fetal alcohol spectrum disorders:

• Delayed development

• Hyperactivity

• Learning disabilities

• Behavioral problems

Photo courtesy of the University of Louisville Fetal Alcohol Spectrum Disorders (FASD) Clinic - Weisskopf Child Evaluation Center, and

the FASD Southeast Regional Training Center at Meharry Medical College Department of Family and Community

Medicine: FASDsoutheast.org. Any use of this photo requires written permission from the University of Louisville FASD Clinic -

Weisskopf Child Evaluation Center and the proper acknowledgement as written in this caption.

Impact of FASDs

• Physical Issues

• Low birth weight and growth

• Sleep and sucking problems as a baby

• Vision or hearing problems

• Problems with heart, kidneys, or bones

• Damage to part of the brain

• Speech and language delays

Impact of FASDs

• Behavioral and Intellectual Disabilities

• Poor reasoning and judgement skills

• Learning disability or low IQ (typically 79

or less)

• Hyperactivity

• Difficulty with attention

• Poor Coordination

• Difficulty in School (especially with math)

Impact of FASDs cont.

• Poor memory

• Poor ability to communicate in social

situations

• Trouble keeping a job

• Trouble with the law

• Difficulty with parenting

• Struggles with independent living

Central Nervous System Impairments

• Poor Fine and Gross Motor Coordination

• Potential Range of Cognitive Disabilities:

• Mental retardation and/or learning disabilities

(I.Q. range 30-130+)

• Developmental delays

• Speech and language deficits

• Memory and processing problems

• Attention problems and hyperactivity

Impact on Cognition

• Specific Learning Disabilities

• Poor Academic Achievement

• Discrepancy Between Verbal and

Nonverbal Skills

• Slowed Movements or Reaction to People

and Stimuli

• Poor Organization and Planning Skills

• Concrete Thinking

• Lack of Inhibition

• Poor Judgment

Impact on Executive Functioning

Impact on Motor Functioning

• Delayed Motor Milestones

• Clumsiness

• Balance Problems

• Tremors

• Poor Dexterity

Impact on Attention and Hyperactivity

• Distractibility

• Overactivity

• Difficulty Completing Tasks

• Trouble with Transitions

Impact on Social Skills• Lack of stranger fear

• Vulnerability to being taken advantage of

• Immaturity

• Superficial interactions

• Inappropriate choice of

friends

• Poor social cognition

Physical Issues•Low birth weight and growth

•Sleep and sucking problems as a baby

•Vision or hearing problems

•Problems with the heart, kidneys, or

bones

•Damage to part of the brain

•Speech and language delays

Life Long Issues• School and Social Skills Deficits

• 1 in 20 US School Children may have FASD

• Experienced by 60% of individual over age 12

• Difficulty living independently

• Mental health issues

• Substance use

• Trouble keeping a job

• Difficulty with parenting

• Trouble with the law• Experienced by 60% of individuals

Interventions for People with FASD• Diagnostic services are part of a continuum of

needed services for individuals and their families,

including:

• Medical (physician, PA, nurse, nurse practitioner)

• Mental Health (psychologist, counselor)

• Case Management (social worker, case worker)

• Education/Special Education

• Occupational, Physical, Speech/Language

Therapy

• Other Health and Allied Health Services

• Family Support and Respite

Photo: Adult with FAS (used with permission of Teresa Kellerman/ www.come-over.to/FASCRC)

Clinical Recommendations

I. Educate about FASDs

II. Conduct alcohol screening for all

women of childbearing age (e.g.

discuss quantity-frequency

questions); OR refer women for

screening

III. Conduct brief alcohol intervention for

women at risk (e.g. assess drinking

patterns, risks, symptoms); OR refer

women for intervention

IV. Refer patients/clients for alcohol

treatment, as indicated

Clinical Recommendations cont.

V. Identify individuals with possible

FASDs

VI. Screen and as appropriate diagnosis

individuals with FAS or other

FASDs; OR refer patients/clients for

FASD screening/diagnosis

VII. Manage/coordinate treatment for

individuals with FASDs

VIII. As needed, refer patients/clients with

FASDs (or suspected FASDs) to

appropriate services

Podcast Summary• Check out our short podcast for a summary of Competency I of the

CDC Competency-Based Curriculum Development Guide for Medical and Allied Health Education and Practice http://www.youtube.com/watch?v=ARPgT26dg24

Intervening with Individuals

Affected by FASD

Addressing the Needs

•Physical

•Environment/Educational

•Counseling/Therapy

•Psychopharmacologic

•Complementary Therapies

Physical• Safe living environment

• Basic protective factors

• Adequate Nutrition

• Overall Good nurtrition

• Some indication of protective properties of

nutrients

• i.e. Vitamins

• Activity/Exercise

• Adequate Sleep

Environmental & Educational Strategies

•Structure

•Predictability

•Monitored level of stimulation

•Recognized retention difficulties

•Multi-modality instruction

•Repetition

•Support

Structure• Organized, safe physical environment

• Home, work environment, school, recreational

environment

• Well defined areas that remain constant

• Small number of people

• Excess "clutter” well hidden

• Including cluttered walls

• Balance between “minimalist environment” and

some stimulation

Predictability• Staff, family members, professionals

consistent presence

• Assigned seating

• Remember those memory problems…

• Consistent routines

• School, work, home & community

schedules

• Alert in advance of activity change

• Consistent consequences

Monitored Level of Stimulation

• Protect from over-stimulation

• Supervise T.V.

• Monitor Internet use

• Monitor cell phone, electronic devices

• Monitor extraneous activities

• Learn and anticipate “danger signs”

• Give frequent, short breaks

• Re-direct behavior

Recognize Retention Difficulties

•Short sentences

•Teach 1 concept at a time

•May need to break concepts into

small steps

•Have individual repeat

information just heard

Recognize Retention Difficulties

• Teach memory strategies for daily living

skills

Meal time

Medications

School time

Sleep time

Work schedules

Appointments

• Concrete Language

Communications

•Abstract vs. Concrete

100 Adults were Surveyed…

•What word does every dog

know?

•And the Top 5 answers are…

Abstract ConceptsFAS/FAE/FDE: Educational Implication Susan Doctor, Ph.D.

Why Consequences

Wait Get Started

Listen Clean it up

Watch Do it right

Get in line Respond

Do you understand? Join

Later Ask for help

Be responsible Choose

What are you feeling? Predict, plan ahead, set

a goal

Concrete LanguageDiane Malbin, www.fascets.org

Show me Come with me

What’s easy? Now

What’s hard? Go to…

What does it make Let’s start here

you want to DO? (demonstrate)

Is there a story It’s time to go

Tell me when…

Can you draw it? What works?

Think about ‘Idioms’As easy as pie When pigs fly

Beat around the bush Pull the plug

Be up and running Pulling your leg

In the red Put a sock in it

Keep your fingers crossed No dice

Elvis has left the building Pay the piper

Timeframes•Modify timeframes

• Increased time to complete objectives

• Homework, chores, daily living activities

• Increased time for transitions and

changes

• Increased time to process and respond to

requirements

Multi-Modality Instruction

•Pictorial cues of tasks/routines

•Use of songs, music, or rhythm cues

•Use of lists

•Sign language to supplement verbal

language

•Use tape recorders and earphones

•Model behavior

Repetition

Repeat

Repeat

Repeat

Repeat

Repeat

Caution: What to Watch For

•Don’t Assume if an individual can

repeat rules that they understand them

and are capable of following them• Information processing

• Expressive vs. Receptive language

• “Masking”• i.e., waiting for others to go first

• Clue gathering

Caution: What to Watch for

• Idioms

• Watch for reactions to loud or unexpected

noises

• Behavior may be related to (or exacerbated

by) other needs

• Sleep

• Sensory

• Consider a ‘sensory diet’

• i.e.,1 hour before bedtime turn off video/computer

Counseling/Therapy

• Start counseling early

• Don’t wait for psychological or behavioral

issues to present themselves

• Focus on social skills

• Area where many people with FASD

stumble—and get into trouble

• Improvement in social skills has broad

effect on other aspects of life

Counseling/Therapy, cont.

• Modify counseling to accommodate

cognitive disability:

• Decrease stimulation in environment

• Individual vs. group counseling

• Plan session time

• Time of day

• Length of session

• Number of sessions per week

Counseling/Therapy, cont.

• Consider insight of client vs. actual

behavior• Concrete vs. Insight-oriented counseling

• Choose practical language to help client

identify issues of importance• Increase ‘concrete’ language

• Specific to the individual with FASD

• Don’t expect generalization: teach in real environments

• May require field-trips to home, work, community

Counseling/Therapy, cont.

•AA Twelve Step Facilitation

• Re-word to make more concrete

•Community Reinforcement Approach

•Contingency Management

•**Motivational Interviewing (MI) may

not be as effective in this

population

Complementary Therapies (CDC 2009)

• Biofeedback

• Relaxation therapy

• Medication

• Yoga

• Acupuncture/acupressure

• Reiki/engergy healing

• Vitamin/herbal supplements

Medication (CDC 2009)

• Stimulants

• Not a treatment for FAS(D) itself

• Address over activity, inattention, impulsivity

and some secondary condition

• Antidepressants

• Address depressive symptoms, sleep problems

• Secondary effects include school disruption,

negativity, irritability, aggression, anit-social

behavior

Medication, cont.

• Neuroleptics

• Psychotic symptoms not associated with FASD

• Can address aggression, anxiety, or behavior

regulation

• Anti-Anxiety

• Anxiety more common

• Maybe basis for underlying cause in some

psychiatric conditions

Stigma and FASD

3 main categories of stigma that exist within FASD

• Personal responsibility and blame toward biological mothers• Oversimplification, drinking culture in America

• Felt and enacted stigma experienced by childrenand families• Child is “troublemaker” or “not trying hard enough”

• Anticipated life trajectories for individuals with FASD• Destined for conflict with the law

Stigma and FASD

Alcohol, Pregnancy and Stigma

• Pregnant women who drink alcohol often

experience:

Judgmental attitudes from service providers

Feeling of shame

Depression

Low self-esteem

Fear of losing their children(Green et al., 2014)

Stigma and FASD

Caregivers and Stigma

• When parents experience persistent chronic

stress, the case is related to the perceptions

that people with disabilities are stigmatized in

the community, rather than the severity of their

child's disability

(Green et al., 2014)

Stigma and FASD

• Individuals with FASD and Stigma

• Stigma is a clinical risk factor

• Delays treatment seeking

• Worsens course and outcome of treatment

• Reduces compliance

• Increases the risk of relapse

• These risk factors can lead to:• Further disability

• Discrimination

• Isolations (Green et al., 2014)

Experiential Exercise

• The Wright Family Story

• Please get into groups of 6 to 10

• Stand in a circle shoulder to shoulder

• Each person will be given an item

• A story will be read and every time you hear any word that

sounds like “right” pass the object in your hands to the

person on your right. Every time you hear the word “left”

pass the object to the person on your left.

Exercise Questions

• How much of the story can you remember?

• What does this activity tell us about communication?

• What does this activity tell us about teamwork?

• What does this activity tell us about listening skills?

• How might a person who has been affected by prenatal substance exposer struggle?

• How might others struggle with working with someone who might have been prenatally exposed?

Tips for Providers to Reduce Stigma

• Move away from the behavior of the birth mother and onto the substance of Alcohol

Define FASD as “The range of effects that can occur when a developing baby is exposed to alcohol” vs. FASD occurs when a pregnant women drinks alcohol” (National Organization of Fetal Alcohol Syndrome)

• Continue to educate teachers, employers, service provider and families about FASD with attention to respect, inclusivity and acceptance (Green et al., 2014)

Tips for Providers to Reduce Stigma

• Support evidence-based approaches to

enable pregnant women in addressing their

alcohol use

• Keep in mind that alcohol dependence is a

chronic disease that should be treated as

any other chronic disease

(Green et al., 2014)

Tips for Providers to Reduce Stigma

• The stigma of drinking during pregnancy prevents women from speaking openly with their health care providers or their child’s pediatrician

• Stigma can also increase relapse and higher levels of alcohol exposure

(NOFAS)

Summary

• “Stigmatization is linked to depression,

anxiety disorders, aggressive behavior and

lower quality of life. Stigma marks certain

individuals as less worthy than others,

marginalizes them, and impedes their

access to needed educational and health

services.”(American Academy of Pediatrics)

Summary

• “Negative public attitudes and social beliefs

towards women who drink during

pregnancy foster a cycle of fear, blame and

shame that have far-reaching impacts on

FASD prevention, diagnosis, and treatment

across the lifespan.”

(FASD 101 Curriculum, Unpublished, 2016)

Closing•Questions

•Complete the Post Survey

Select Websites• Federal Government Sites

• CDC’s Fetal Alcohol Spectrum Disorders website: www.cdc.gov/ncbddd/fas/

• National Institute on Alcohol Abuse and Alcoholism: www.niaaa.nih.gov/

• National Institute on Drug Abuse: www.nida.nih.gov/

• Substance Abuse and Mental Health Services Administration: www.samhsa.gov/

• SAMHSA’s FASD Center for Excellence: www.fasdcenter.samhsa.gov

• Organizations

• FASD Education and Outreach Projects: www.FASDeducationl.org

• Minnesota Organization on Fetal Alcohol Syndrome (MOFAS): www.mofas.org

• The Arc of the United States: www.thearc.org

• University Sites

• Fetal Alcohol and Drug Unit of the University of Washington: depts.washington.edu/fadu/

• Fetal Alcohol Syndrome Diagnostic & Prevention Network, University of Washington:

depts.washington.edu/fasdpn/

References• Astley, S. J., Stachowiak, J., Clarren, S. K., & Clausen, C. (2002). Application of the fetal alcohol

syndrome facial photographic screening tool in a foster care population. Journal of Pediatrics,

141(5),712–717.

• Babor, T. (2003). Alcohol: No ordinary commodity. New York: Oxford University.

• Bertrand, J., Floyd, R. L., Weber, M. K., O’Connor, M., Riley, E. P., Johnson, K. A., et al. (2004). Fetal

alcohol syndrome: Guidelines for referral and diagnosis. Atlanta, GA: Centers for Disease Control and

Prevention.

• Centers for Disease Control and Prevention. (1995). Sociodemographic and behavioral characteristics

associated with alcohol consumption during pregnancy—United States, 1988. Morbidity and Mortality

Weekly Report, 44(13),261–264.

• Centers for Disease Control and Prevention. (2002a). Alcohol use among women of childbearing age—

United States, 1991-1999. Morbidity and Mortality Weekly Report, 51(13), 273–276.

• Centers for Disease Control and Prevention. (2002b). Fetal alcohol syndrome—Alaska, Arizona,

Colorado, and New York, 1995-1997. Morbidity and Mortality Weekly Report, 51, 433–435.

• Department of Agriculture & U.S. Department of Health and Human Services. (2000). Nutrition and your

health: Dietary guidelines for Americans (5th ed.). Home and Garden Bulletin No. 232.

• Dorris, M. (1989). The broken cord. New York: HarperCollins Publishers.

• Fast, D. K., Conry, J., & Loock, C. A. (1999). Identifying fetal alcohol syndrome among youth in the

criminal justice system. Journal of Developmental & Behavioral Pediatrics, 20(5), 370–372.

• Floyd, R. L., Sobell, M., Velasquez, M. M., Ingersoll, K., Nettleman, M., Sobell, L., et al. (2007).

Preventing alcohol-exposed pregnancies: A randomized controlled trial. American Journal of Preventive

Medicine, 32(1), 1–10.

• Food and Drug Administration. (1981). Surgeon General’s advisory on alcohol and pregnancy. FDA Drug

Bulletin, 11(2), 9–10.

References• Goddard, H. H. (1912). The Kallikak family: A study in the heredity of feeble-mindedness. New York:

Macmillan.

• Goodlett, C. R. & West, J. R. (1992). Fetal alcohol effects: Rat model of alcohol exposure during the

brain growth spurt. In I. S. Zagon & T. A. Slotkin (Eds.) Maternal substance abuse and the developing

nervous system (pp. 45-75). San Diego: Academic Press.

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