A brief description of FASD, including the two states.

1. 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

2. -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.

3. 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
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Publication No. 4200
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Hepper, Belfast, N. Ireland, 1998. Maternal alcohol
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spontaneous fetal startle behavior. Peter G. Hepper et.a.,
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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 .

6. 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 Brunuinks-
Oseretsky 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:

7. 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 (multiple-
choice) 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.

8. 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

9. observation Informal assessment of language pragmatics (not
standardized), social communication