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ALCOHOLISM: zyxwvutsrqponm
CLINICAL
AND EXPERIMENTAL
RESEARCH
Val. zy
22, No. 2
April 1998
A Fetal Alcohol Behavior Scale zy
Ann P. Streissguth, Fred L. Bookstein, Helen zyxwvu
M. Barr, Shoshanna Press, and Paul D. Sampson zy
This research aimed to develop a Fetal Alcohol Behavior Scale
(FABS) that describesthe behavioralessence of fetal alcohol syn-
drome (FAS) and fetal alcohol effects (FAE),regardlessof age, race,
sex, and1
0
.Usinga referencesampleof 472diagnosedpatientswith
FASor FAE, ages2 to 51,five studies are described.The FABSdem-
onstrates high item-to-scale reliability (Cronbach's (Y = 0.91) and
good test-retest reliability(r = 0.69) over an average interval of 5
years. It identifies many of the subjects with known or presumed
prenatalalcoholexposureindetectionstudies usingbothprisonand
generalsamples. FABSscoresalso predictdependentliving among
adult patientswith FASIFAE.The FABSis uncorrelatedwith 1
0
,sex,
age, race, and diagnosis (FAS versus FAE). We outline areas of fur-
ther work to definethe specificity and utility of this FABS.
Key Words: Fetal alcohol syndrome (FAS), Fetal alcohol effects,
Behavioralteratology,Alcohol-relatedneurodevelopmental
disorder
(ARND), Behaviorscale.
ETAL ALCOHOL syndrome (FAS) and fetal alcohol
Feffects (FAE) are important causes of developmental
disabilities in children and adults.'-7 However, because of
the subtle and variable nature of the defining physical and
central nervous system (CNS) characteristics and their
changes with age,879
many children and adults with this
disability are never diagnosed and so are cut off from the
services and interventions that might help them. The goal
of this research is to construct a short, easy-to-administer
scale that will capture the behavioral essence of FAS and
FAE, regardless of age, race, sex, or IQ, and thus have
utility across various populations and across the life span.
The diagnosis of FAS has traditionally been based on
three types of criteria: growth deficiency apparent at birth;
a pattern of dysmorphic features primarily recognizable in
the face; and some manifestations of CNS dysfunc-
tion.1,8,10-15 As growth deficiency and CNS dysfunction
have many causes, the facial dysmorphologyhas historically
been the distinguishingfeature linkingthis birth defect with
its prenatal alcohol etiology. The CNS dysfunction associ-
From the Department of Psychiatiy zyxwvutsrq
and Behavioral Sciences (A.P.S.,
H.M.B., S.P.), University of WashingtonSchool of Medicine, Seattle, Wash-
ington;Institute of Gerontology(F.L.B.), Universityof Michigan,Ann Arbor,
Michigan;and the Department of Statistics (P.D.S.), University of Washing-
ton School of Arts and Sciences, Seattle, Washington.
Presented at the 1996Borchard Foundation Symposium on the Behavioral
Effects zyxwvutsrqp
in Childrenfollowing Prenatal Alcohol Exposure, Missillac, France,
This study was funded by the Centersfor Disease Control (Grant R041
CCROO8515-01-04)and by the National Institute on Alcohol Abuse and
Alcoholism (GrantROI-AA01455-01-22).
Reprint requests:Ann P. Streissguth, Ph.D., Department of Psychiatry and
Behavioral Sciences, University of Washington, School of Medicine, Box
359112, Seattle, WA 98195. zyxwvutsrqpo
July 28-30, 1996.
Copyright zyxwvutsrq
01998 by The Research Society on Alcoholism.
Alcohol Clin Exp Res, Val 22, No 2, 1998: pp 325-333
ated with FAS, while more prevalent as a prenatal alcohol
effect, has not been considered as specific or unique as the
facial dysmorphology. Since the mid-l970s, it has been
clear that the range of intellectual disabilities associated
with the FAS diagnosis was very broad16 and that no spe-
cific level of intellectual functioning could ever reasonably
serve as the distinguishingCNS characteristic for defining
FAS. Some children with FAS are mentally retarded, but
many are not. On the other hand, confining the concept of
alcohol-related birth defects to just those produced during
the specific phase of prenatal exposure necessary for pro-
ducing facial dysmorphology seems overly restrictive in
light of recent
The term FAE (as well as PFAS and PFAE, terms used
for probable or possible FAS or FAE) has been used
historically for patients who have a history of prenatal
alcohol exposure and have some but not all of the charac-
teristics of FAS.',22Partial manifestations of a birth defects
syndrome are not unusual and, in the case of alcohol, a
large number of CNS characteristics have been linked to
prenatal alcohol exposure, both in animal studies and hu-
man st~dies.'~-'~
The Institute of Medicine's report on
FAS9 addressed this issue by suggesting a new term, alco-
hol-related neurodevelopmental disorder (ARND), to re-
flect the CNS component of fetal alcohol effects. The
ARND criteria include structural brain anomalies, de-
creased cranial size at birth, neurological hard and soft
signs, and/or evidence of a complex pattern of behavior or
cognitive abnormalities that are inconsistent with develop-
mental level and cannot be explained by familial back-
ground or environment alone. Although general categories
of cognitive abnormalities (i.e., learning difficulties,prob-
lems with memory) and behavioral abnormality (i.e., poor
impulse control, poor judgment) were listed, no specific
criteria were suggested. Research from our laboratory has
revealed a wide variety of cognitive, neuropsychological,
and learning disabilities associated with prenatal alcohol
exposure in a long-term prospective epidemiological
~ t u d y . ~ ~ - * ~
We have recently clustered these into a perfor-
mance-based neurodevelopmental framework for estimat-
ing the prevalence of FAE, including FAS and ARND.27
The studies described in the present paper are an attempt
to quantify the behavioral phenotype of fetal alcohol.
Clinically, individuals identified as either FAS or FAE
often share a similar behavioral profile.5328
Despite the
wide range of primary disabilitiesthat people with FAS and
FAE may manifest, their parents and caretakers often de-
scribe them in terms of some relatively characteristic be- z
325

2. 16zyxwvutsrqponmlkj
STREISSGUTH zy
ET AL.
Table 1. zyxwvutsrqp
Demographic Characteristicsof the Five Study Samples
Demographic Referencesample study sample Normative sample sample sample
characteristic (n = 472) (n = 81) (n = 186) (n = 37) (n = 70)
Detection Test-retest Prediction study
Age at evaluation
2-6 165 - 52 8’ 0
7-1 1 96 - 20 8 0
12-17 124 1 28 14 7
18-51 87 80 86 7 63
Male 271 81 96 21 36
Female 201 0 85 16 34
White 273 76 125 24 45
Black 31 3 17 2 4
Native American 129 2 4 11 20
Other 37 0 34 0 1
Alcohol-related
diagnosis
FAS 169 -
FAE 303 -
Sex
Ethnicity
- 27 43
- 10 27
* Age at initial administration of the PBC
haviors. For example, “Talks a lot but says little; is chatty
but with shallow content.” “Makes ‘off the wall’ comments;
sometimes says things that seem completely out of con-
text.” “Overreacts to situations; emotional responses are
often stronger than you would expect.” “Often demands
attention or monopolizes a conversation.” Such behavioral
descriptors by parents, which predated popular writings
about zyxwvutsrq
FAS, refer to characteristics that transcend scores on
performance tests, and as a group, do not seem character-
istic of other childhood disorders.
Over the years, these behavioral descriptors were tran-
scribed by Streissguth as they were used by parents and
caretakers to describe their children with FAS and FAE.
Those most frequently encountered were assembled into a
list of 68 short descriptors, which we called a “Personal
Behaviors Checklist” (PBC), that could be answered in a
yesho format by someone familiar with the child’s behav-
ior. For many years, parents and caretakers of patients with
FASFAE associatedwith our Fetal Alcohol and Drug Unit
routinely filled out PBCs.
The purpose of this paper is to report a series of studies
conducted over a period of several years that used these
data more formally.First, we performed a Derivation Study
to condense this checklist into a scale that we called the
Fetal Alcohol Behavior Scale (FABS). Then, we conducted
a Detection Study to see whether this scale could be used to
detect people with FAS or FAE from among a deviant
subgroup of the population (i.e., those in prison). Then we
did a Normative Study to determine the sensitivity of this
scale for identifying children of mothers with alcohol prob-
lems from within a nonclient sample of parents. Next, we
performed a Test-Retest Study to evaluate the stability of
these items in describingan individual’sbehavior over time.
Finally,we conducted a Prediction Studyto see whether the
scale could have anyvalue in predicting to dependent living
as an adult. Standard demographic descriptors for each of
these five samples are collected in Table 1. The five studies
are described herein.
METHODS
A PBC was developed by Streissguth in the 1970s comprised of items
used by parents and caretakers to describe their children with FASPAE.
Items represented the following categories: communication and speech,
personal manner, emotions, motor skills and activities, social skills and
interactions, academic/work performance, and bodily and physiological
functions. A total of 472 patients who had previously been diagnosed as
FAS, PFAS, FAE, or PFAE by experienceddysmorphologists,were ulti-
mately rated on the PBC by their parents or caretakers (see Table 1,
column 1, for demographic characteristics).These comprised the FAS/
FAE reference sample. Subsetsof this reference samplewere used for the
Derivation Study, the Test-Retest Study, and the Prediction Study. zy
The Derivation Study
By 1994,PBCswere availableon 134patients under the age of 35years.
These data were used for principal components analyses based on covari-
ance matrices for each of the four age groups defined in Table 1. Indi-
viduals scoring high on the first principal component are considered to
reflect the behavioral essence of FAS and/or FAE. To define a scale less
than half the length of the PBC, we selected those PBC items having high
item-to-scale correlation for each of the four age groups. We defined a
26-item FABS by requiring minimum item-to-scale correlation of 0.32 or
better across the four age groups. By 1995, a larger, more representative
sample of PBCs for patients under the age of 35 years zyx
(n = 322) was
available, and a second principal components analysis was conducted,
resulting in a second scale with high item-to-scale validity (also 0.32).
These two scales correlated 0.92. The 36 items representing the union of
the items selected by these two analyses is referred to as the FABS.
The Detection Study
The Detection Study was conducted in late 1994, after the first princi-
pal componentsanalysis of the DerivationStudy had been performed.The
Detection Study was conducted in a special unit for developmentally
disabled, emotionally disturbed (nonpsychotic) male inmates within the
Washington State Prisons System. Eighty-one of these inmates met the
study criterion of having been known to the prison staff for at least 3
months and consented to participate. They are described in Table 1
(column 2). The respondents,two correctionsofficers, and a prison coun-
selor filled out a singleFABS on each of the 81 men by group consensus.

3. FETAL ALCOHOL BEHAVIOR SCALE
impulsive
stubborn
unawareconseq
poorattention
cutel ixie ish
can’t Eke hint
incompltasks
tantrums
too easily led
overreacts
moodsw)ngs
Sensitive
interrupts
poorjudgement
center of attn
fearless
loosesthings
peopleoriented
overstimulated
very active
likeA%ZX
demandsattentn
tries hard,but...
opinionated
out of context
overly friend1
sleeping prx
itemattracted
superf.friends
hygiene prb
lovesto climb zyxwvutsrqponmlk
321
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A
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A
A
V
V
A
A
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A
V
A
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A
A
A
A
V
A
messy
touches freq
indistinct speech
chats,no content
poor manners
talksfast
not capable
canfhp;y?$?
dif’ty performing
seems brighter
dif‘ty learning
unusualtopic
low self-esteem
toilettraining
inappro lhome
inappropkutside
repeats often
noisesensitive
enjoys fixing
freq phrases
feeding prb
ioud,unusvoice
vision prb
light sensitive
prb sex funct
flirts
stomach aches
hearingprb)
I
dry skin
unusualsmell
bangs head
rocks
poor sch attnd
A ;
V
V
V
A zyxwvutsrqpon
V
i Patientswith FAS/FAE
v (FAS/FAk referencesample, n=472)
V ! 36 items chosenfor FABSA
32iitems not chosen for FABSv
V
A
V
V
V
V
V
V zyxwvutsrqp
0% 25% 50% zyxwvu
75%
percent ‘yes’
Informationon whether or not each inmate had a biological mother with
alcohol problems was obtained independently from questionnaires filled
out by the inmates themselves. zyxwvutsrqp
The Normative Study
The Normative Study of the FABS was conducted among parents in a
general practice waiting room at the University of Washington Medical
Center in 1995 after the second principal components analysis was com-
pleted.” While waitingto be called for their appointments,all consenting
adults who had children of any age zyxwvutsr
(n = 186) were asked to fill out a
questionnaireregarding one of their children selected randomly by Shos-
honna Press (see Table 1, column 3). Average time to complete the
questionnaire (the FABS and a few demographicquestions)was approx-
imately 5 min. In this normative sample, Cronbach’s coefficient a was
equal to 0.89,indicatingsatisfactorilyhigh item-to-scalereliabilit~.~’
If one
were to divide the FABS scale into two subscalesin all possible ways, this
value of 0.89 is a weighted average of all the correlations between the
scores on the two halves.
Fig. 1. The 68 items on the PBC ranked according to
percent “yes“ responses by parenWinformantson 472
patients with FAS/FAE. For full text of the items, contact
the senior author.
100%
The Test-RetestReliability Study
There were 41 patients in the FAS/FAE reference sample of 472 who
had had two PBCs filled out at two differentagesby the same respondent.
The 37 patients with at least a 1-year interval between the two FABS
scores comprised the sample for the Test-Retest Study. Mean age at the
firstPBCwas 13.4years; at the second, 18.7years (see Table 1,column 4).
The Prediction Study
The Prediction Studyconducted in 1997included a subset of 70 adults
with FASFAE from the FASPAE reference sample who had previously
had a PBC and later had a Life History Interview (LHI) administered to
a caretaker, spouse, or informant in 1996at least 1year after the PBC?l
Of particularinterest to this FABS studywas a summalyscore on the LHI
called Dependent Living, indicating that the adult with FASPAE was
unable to live independentl~.~~
Mean age o
f patients in the Prediction
Studyat the time of evaluation for Dependent Living on the LHI was 28.1
years.

4. 328 zyxwvutsrqponml
overreacts
chats.no content
unusualtopic
demands attentn
unaware conseq
incompletetasks
inapproploutside
likes to talk
interrupts
center of attn
touches freq
can’t ia team
canfta{e hint
sleeping prb
poor manners
overstimulated
out of context
hygiene prg
phys loving
repeats often
messy
talks fast
inapgrophome
supe icial friend
fidgety
poorjud ement
dif’ty per8orming
loud,unus voice
overly friendly
loses things
noise sensitv
mood swings
poor attention
prb sex funct
tries hardbut...
freq phases
fearless
itemattracted
flirts
too easily led
indistinctspeech
tantrums
opinionated
stomach aches
light sensitive
impulsive
low self-esteem
klutz
STREISSGUTH ET AL.
...
toilettraining
not capable
ve active
gubborn
people oriented
seems b
:
;
&
loves to climb
unusual smell
dif‘ty learning
rocks
hearingprb
dry skin
cutelpixyjsh
sensitive
bangs head
poor sch attnd
vision prb
enjoys fixin
feeding prg zyxwvutsrqpo
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V
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V Patientswith FASIFAE
V
V (two derivationsamples, n=l34/322)
V
V
V
V
V
V
36 items chosen for FABS A
32 items not chosenfor FABS v zyxwv
0 0.2 0.4
item-to-scalecorrelation
RESULTS zyxwvutsrq
Deriving the zyxwvutsrq
FABS from the PBC Items
Figure 1ranks the frequency with which each of the 68
items in the PBC was endorsed by the 472 parentdcaretak-
ers in describing an individualwith FASFM. “Impulsive”
and “stubborn” at the top are the two most frequently
endorsed items at over 85%. “Poor school attendance” and
“rocks rhythmically” are the least frequently endorsed
items at under 20%. But, we did not specificallyselect items
for the FABS because of having a high frequency. In fact,
those selected have frequencies between 29% and 79%.
The black triangles in Figs. 1and 2 represent those items
selected for the FABS from the PBC according to their
item-to-scale correlations in the principal components for
each of the four age blocks examined. Figure 2 presents the
same 68 items as Fig. 1,but here they are ordered accord-
Fig. 2. The same 68 items on the PBC as in Fig. 1,
ranked according to their item-to-scale correlations.
The correlationplotted isthe maximum (across the two
derivation analyses, zyxw
n = 134 and 322, respectively) of
the minimum item-to-scale correlation over the four
age groups of Table 1.zyx
0.6
ing to their item-to-scale correlations. These range from
“Overreacts ...,”with an item-to-scale correlation of 0.58,
down to “Tries hard, but ...,” with an item-to-scale corre-
lation of 0.32.Items in Figs. 1and 2 with open triangles did
not meet this criterion. Cronbach’s coefficient ly30 was
equal to 0.91 in the Derivation Study sample of 322, indi-
cating high item-to-scale reliability in the FABS.
“Scree plots” (not shown) indicate that there is only one
main principal component of the items contributing to the
FABS in any of the four age groups. The item frequencies
are sufficiently close to 50% that we can replace the score
on this first principal component by a simple sum of “yes’
responses to the FABS items, which yields the FABS sum-
mary score.
Figure 3 showsthat the FABS score computed in thisway
is independent of not only the patients’ ages, but also IQ,

5. FETAL ALCOHOL BEHAVIOR SCALE zyxwvutsrqp
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329
Relationshipof FABS
to other common
determinants of outcome
(data from FASlFAE reference sample)
age at FABS evaluation (years)
male female
Sex of Client Total
36
v) zyxwvutsrq
324
c
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$ 1 2
.-
0
n= 273 129 31 39 472
Wh NAm BI 0th
Race Total
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40 60 80 100 120 140
FullScale IQ
FAS FAE
Alc-related Diagnosis Total
Fig. 3. Relationshipof the FABS to age, IQ, sex, race, and FAS versus FAE. The box in a boxplotspans the middle half of the FABS scores from the 25th to 75th
percentiles. The dark horizontal line within a box indicates the median FABS score. The whiskers extending vertically from each box reach to the lowest and highest
FABS.The open boxes on the lower and upper whiskers indicate the 10th and 90th percentiles respectively.Wh, White; NAm, NativeAmerican; El, Black oth, other:
Alc, alcohol.
sex, race, and diagnosis (FAS or FAE). Thus, no adjust-
ments of the FABS summary score are needed for any of
these potential confounds. In the FAS/FAE reference sam-
ple, individual patients' FABS scores ranged from 0 to 36
(Fig. 4). The mean FABS score in this sample of 472
patients with FAS/FAE is 20.3; the median 21.0. Seven
percent of the sample had a score of 6 or less.
In the Detection Study and the Normative Study (see
herein), the FABS scores of this reference sample of 472
patientswith FASFAE are compared with other populations
to see whether individualswith heavy prenatal alcohol expo-
sure can be detected among them. Because of the historical
development of the FABS, there are different numbers of
items in the FABS for the 1994Detection Study (Fig. zyxwvut
5) and
the 1995Normative Study (Fig. 6).
Using the FABS to Detect Men with Alcoholic Mothers
from Among Prison Inmates
The boxplots in Fig. 5 show fairly impressive separation
of the FABS scores on the reference sample of 472 patients
with FASFAE from the FABS scores of the inmates in the
Detection Study. We find that 85% of the inmates have
FABS scores below 6 or 7, whereas 85% of the FASFAE
patients have FABS scores above 6 or 7 (on the 1994
26-item FABS). Three of the four highest FABS scores as
filled out by the corrections officersin the Detection Study
were on inmates who themselves had independently re-
ported having mothers with alcohol problems.
Using the FABS to Detect Children with Alcoholic Mothers
fiom Among a Group of Parents
The boxplots in Fig. 6 show fairly impressive separation
of the FABS scoresof the FASFAE reference sample from
the FABS scores of the Normative Study sample.The mean
FABS score in the Normative Study sample is 6.6 (on the
199535-itemFABS). About 80% of the FABS scoresof the
reference sample fall below a score of 11or 12, whereas
about 80% of the FASFAE patients in the FASFAE
reference sample have a FABS score above 11or 12. Only
about one-third as many items are endorsed in the Norma-
tive Study,compared with those in the Derivation Study.As
Fig. 6 shows,having a father with alcohol problems did not
affect FABS scores in the Normative Study.However, hav-
ing a mother with alcohol problems raised the FABS scores
to a range substantially overlapping that of the Derivation
Study patients with FAS/FAE.
Demonstrating the Reliability of the FABS Score Over Time
For the 37 patients in the Test-Retest Study, FABS
scores were correlated at 0.69 over an average duration of
5.0years (range: 1.5to 9.4).The mean discrepancybetween

6. 330 zyxwvutsrqpon
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12 21 24
(median)
The 1996 zyxwvuts
36-item FABS
(datafrom FAS/FAE referencesample, N=472)
STREISSGUTH ET AL.
Fig. 4
. Cumulative frequency distribution of FABS scores for the
FAS/FAE reference sample (n = 472). Determination of the median
score'' is indicated by the dashed lines from this plot.
36
than 9 points higher (on the 1996 36-item FABS). The
correlation of 0.69 is a more appropriate estimate of reli-
ability than the Cronbach zyxw
a, because it incorporates insta-
bility over time in the implicit criteria being used by the
caretaker and in the patient's own behavioral lability. Ex-
amination of a scatterplot showing the change in FABS
score by duration of testhetest interval revealed no system-
atic trends over time.
n= 472 81 13 44 24
Yes no unkn
BiologicMother HadAlcohol Problems
Total
F A S / F A E
sample
reference D e t e c t i o n S t u d y S a m p l e
Fig. 5. Boxplots comparing the FAS/FAE FABS scores from the FAS/FAE
reference sample (n = 472) with the FABS scores of prlson inmates in the
Detection Study (n = 81). Additional boxplots break out the inmate sample
accordingto inmate's report of whether or not the inmate thought his biological
motherhad an alcohol problem. Individualscores are represented by dots to the
right of the boxplot,for offspringwhose biologicalmothers hadalcoholproblems.
Note that the boxplot data for the FAS/FAE reference sample are based on the
same 26 items used with the inmates for the DetectionStudy.
FABS 1and FABS 2 was only about 1.5 points. A
s Fig. 7
shows, only three patients had scores more than 9 points
lower on retest, whereas only two patients had FABS more zyxwvu
Usingthe FABS Scores to Predict Dependent Living in
Adults with FASIFAE
Patients with high FABS scores are much more likely to
still be living dependently as adults (Fig. 8). The median
score on the 1996 36-item FABS for the 60 adults with
FAS/FAE livingdependently is 21.5, compared with 8.5 for
those not livingdependently (n = 10).The mean age of the
Prediction Study sample at the administration of the FABS
was 24.8 years (range: 12.6to 43.0 years). The mean age at
the LHI administration was 28.1 years (range: 21 to 50
years). The mean duration between FABS and LHI was 3.3
years (range: 1.1 year to 12.3 years). The mean duration
between the FABS and the LHI was not different for
patients who were and were not classified as living depen-

7. FETAL ALCOHOL BEHAVIOR SCALE zyxwvutsrqpo
331
35
30
(
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Fig. 6. Boxplotscomparing the FABSscores of the FAS/FAE
referencesample zyxw
(n = 472) with the FABSscores on children in
the Normative Study (fl = 186). Additional boxplots show the
0
I
n 15 Normative Study sample brokenout accordingto respondent’s
m
m report of alcohol problemsfor the target child’s biological par-
ents. The individual scores for the two smallest groups (“moth-
er” and “no info” are shown with dots. Note that the boxplot
c
data for the FAS/FAE reference sample are based on the same
35 items used with the parents for the Normative Study. The
35-item FABS differs from the 36-item FABS because of a
clerical omission.
;10
I-
5
0
n= 472 186 13 27 138 8
mother father neither no
only parent info
Biologic Parents Had Alcohol Problems
Total
F A S I F A E
sample
reference N o r m a t i v e S t u d y S a m p l e
mean FABS at older age = 20.0 k 8.6
mean FABS at younger age = 21.5 f 9.3
correlation zyxwvutsrqpon
r = 0.69
/*
9 18 27 36
The 1996 36-item FABS at younger age (Test 1)
Fig. 7. FABS scores at two different ages for the 37 patients
who had PBCs filled out by the same respondent after at least
a 1-year interval. These data are from the 1996 36-item FABS.
unkn, Unknown.
dently as adults. Dependent living as an adult is one of the
severe long-term consequences of FAS.31,32
the patient well or by the consensus of a group who collec-
tively know the patient’s behavior well, each from different
standpoints. The FABS score has adequate test-retest reli-
ability and is uncorrelated with age, sex, race, IQ, and
alcohol-related diagnosis, so has maximum usefulness
across various groups from age 2 up through age 35. Be-
cause FASwas only identified as such in 1973,there are not
presently enough geriatric patients available for study.
The behavioral phenotype reflected in the FABS score is
DISCUSSION
The FABS emerging from this series of studies is a
36-item scale in a yes/no format. The FABS score is a
simple count of yes responses. It is not self-administered,
but rather is filled out by a person or caretaker who knows

8. 332 zyxwvutsrqponml
STREISSGUTH zy
ET AL.
n= 10 60
no yes
Dependent Living zyxwvutsrq
Fig. zyxwvutsrqpon
8. Boxplots comparing FABS scores for adults with FAS/FAE who are
living dependently(n = 60)or not living dependently(n = 10).Thesedata arefrom
the 1996 36-item FABS.
not characteristic of the normative sample as rated by their
parents nor of the group of prison inmates as rated by the
corrections staff. In both groups, those individualsthought
to have had a biological mother with alcohol problems had
scores more often in the range of FAS/FAE patients.
FABS scores appear to be correlated with maternal al-
cohol problems, but not with paternal alcohol problems
(Fig. 6). Thus, the FABS appears to reflect the behavioral
phenotype of fetal alcohol fairly specificallyrather than the
behavioral consequences of being raised in an alcoholic
family.This does not appear to be a “children of alcoholics”
finding.
In the FASiFAE reference sample (Table S), additional
psychometric data were available for approximately 400
subjects. The FABS is almost perfectly uncorrelated with
IQ (Verbal IQ X FABS, zyxwvutsr
r = -0.03; Performance IQ X
FABS, r = zyxwvutsr
-0.05), as well as uncorrelated with age, sex,
and race (Fig. 3). The FABS correlates negligibly with
achievement scores (Wide Range Achievement Test-Re-
vised; Reading: X FABS, r = -0.05; Spelling:r = -0.15;
and Arithmetic: r = -0.16). The FABS correlates moder-
ately (r = -0.36) with the Vineland Adaptive Behavior
Composite (VABS) and at magnitudes near 0.6 with cer-
tain subscales of the Child Behavior Checklist (CBCL),
namely, Social (r = -0.61), Attention (Y = -0.63), and
Total Problems (r = -0.63). These latter findings are not
surprising, because previous studies have shown that pa-
tients with FAS/FAE have elevated scores on the CBCL
and depressed scores on the VABS:,32,33 scores reflecting
the general level of behavioral problems and adaptive living
problems characteristic of individualswith FAS/FAE. One
advantage of the FABS is its brief administration time.
All of the respondents in these five studies filled out the
FABS in a research context. Further study is needed to
clarify its utility in a clinical or screening context. Instru-
ments like the FABS should not be used clinically (i.e., for
diagnostic purposes) without additional evidence of prena-
tal alcohol exposure. Additional studies are needed to de-
termine the specificity of this behavioral phenotype to al-
cohol teratogenesis, to evaluate contemporaneous
interrater reliability, and to ascertain the conditions under
which it would be a useful tool. Studies comparing FABS
scores of individualswith FAS/FAE compared with patient
groups with other developmental disabilities (e.g., Down’s
syndrome), to those with high behavioral problems scores
on the CBCL, and to more children of alcoholic fathers
versus alcoholicmothers will further elucidate the extent to
which the FABS succeeds in capturing the specificbehav-
ioral essence of FAE and alcohol-related neurodevelop-
mental disabilities.
ACKNOWLEDGMENTS
The authors thank Sterling K. Clarren, M.D., John M. Graham,
M.D., James H. Hanson, M.D., David F. Smith, M.D., Kenneth
Lyons Jones, M.D., and the late David W. Smith, M.D., for
diagnostic assessments of patients; Robert Jones, Ph.D., for facil-
itating the Detection Study; and Alan Ellsworth, Pharm.D, for
facilitating the Normative Study. The technical assistance of
Karen Kopera-Frye, Julia Kogan, and Kaylin Anderson, and the
assistance of John Anzinger and Kristi Cove11 in manuscript prep-
aration are gratefully acknowledged.
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