Drinking it in

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Drinking it in
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2. Mother’s ruin
Dealing with the devastating
effects of fetal alcohol
spectrum disorders
Aspies on
the edge
The pain of growing
up with Asperger’s
The
outsider
Spotting the signs
of dyspraxia
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September • October 2012
Issue 60

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F
etalalcoholspectrumdisorders
(FASD) is an educational
term which recognises the
range of effects resulting
from maternal alcohol consumption.
The medical diagnoses within the
spectrum include the most recognised
part of the spectrum, fetal alcohol
syndrome (FAS), as well as problems
with behaviour and the brain with no
obvious external signs, when alcohol
related neurodevelopmental disorders
(ARND) may be diagnosed (British
Medical Association, 2007). Also
included in the spectrum are alcohol
related birth defects (ARBD) and partial
fetal alcohol syndrome (pFAS).
Prenatal exposure to alcohol can
lead to intellectual and developmental
delays and differences which impact
on children's learning in all areas of
the curriculum and require a particular
teaching approach and learning
environment. Possible physical
disabilities include facial differences
(see figure 1), growth deficiencies,
major organ damage, and skeletal
damage, as well as hearing and vision
impairments. Damage to the brain
(central nervous system damage) results
in developmental disabilities, which can
include general learning difficulties,
communication delays/disorders,
behavioural, social and emotional
difficulties, and sensory difficulties
(Mattson and Riley, 1997). The severity
and type of fetal damage caused by
maternal alcohol use depends on a
variety of factors including:
• level and duration of drinking
• pattern of drinking
• timing of alcohol used (stage of
fetal development)
• blood alcohol level
• genetic influences
• maternal age and health –
physiological effects
• use of other teratogens (poly-
substance use and abuse)
• postnatal factors (such as
caregiver/child interactions and
home environment).
There is no period during pregnancy
at which alcohol can be drunk without
risk to the developing foetus, although
there are sensitive periods for particular
organs. The central nervous system
(brain and spinal cord) are vulnerable
throughout pregnancy (see figure 2).
Diagnosis and prevalence
Children and young people with FASD
may account for as many as one
in 100 children (Autti-Ramo, 2002)
with difficulties ranging from mild
to profound. This means that some
children with FASD will have needs that
are evident at birth, easily diagnosed
and recognisable by educators as
in need of support. However, other
children with FASD will have hidden
needs, making the educator’s role
more challenging. In addition, under-
diagnosis (sometimes referred to as
misdiagnosis), when conditions such
Drinking it in
What are fetal alcohol spectrum disorders and how can educators help combat the potentially
devastating effects they can have on a child’s life? Carolyn Blackburn explains all
fetal alcohol spectrum disorders
Prenatal exposure
to alcohol can lead
to intellectual and
developmental delays
Figure 1. Characteristic facial features in a child with fetal alcohol syndrome. These includes a
smooth philtrum, thin upper lip, and small palpebral fissures. Other associated features may include
an upturned nose, underdeveloped ears, flat nasal bridge and midface, epicanthal folds and small
head circumference (source: Darryl Leja, www.nih.gov).

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SENISSUE60www.senmaGAZINE.co.uk
as autistic spectrum disorder or ADHD
are diagnosed instead of FASD, can
mean that children are presented with
a curriculum or intervention which is
only partially suitable for their needs. In
some cases, children are misunderstood
and labelled as wilful, non-compliant
and oppositional. It is not uncommon
for children to be diagnosed with
oppositional defiant disorder (ODD) as
a result of this misunderstanding, when
in fact children lack either the ability to
understand instructions and requests
or remember them for sufficiently long
periods to complete them.
Implications for development
The impact of FASD on children’s
development changes over time
as children mature. If FASD is not
recognised in early childhood, difficulties
for children increase as they progress
through the education system, resulting
in so called secondary disabilities such
as poor mental health, disrupted school
and ultimately criminal activity. Primary
difficulties are as follows:
Developmental difficulties:
• significant delays in achieving
developmental milestones such as
toileting and hygiene skills, in some
cases beyond the primary years.
Medical difficulties:
• medical and health related
difficulties, including organ
damage, poor sleep patterns,
eating and dietary difficulties,
small stature, vision and
hearing impairments.
Learning difficulties:
• understanding cause and effect
• speech language and
communication delays/
disorders including verbosity,
poor understanding, poor social
cognition and communication
skills and a difficulty using
sophisticated language in
social contexts
• cognitive difficulties, including
poor short-term memory, and
poor concentration
• difficulties in understanding
mathematical concepts, such as
time, and understanding money
• frontal lobe damage to the
brain which is associated with
FASD. This results in impaired
executive functioning leading to
deficits, such as impaired ability
to organise, plan, understand
consequences, maintain and
shift attention, and process and
memorise data. This has an
impact on independence in a
range of situations. Executive
functioning impacts on daily
living skills.
Behavioural difficulties:
• behavioural difficulties, including
hyperactivity, inattention,
aggression, obsessions with
people and objects, and agitation,
can cause anxiety and frustration
for children and young people as
well as parents and educators.
These difficulties, whilst often
seen as behavioural issues,
can also be related to sensory
processing disorders requiring
occupational therapy input.
Social difficulties:
• difficulties acquiring appropriate
social and emotional skills,
which impact on relationships,
friendships, and any activity
which requires an understanding
of the state of mind of others and
predicting how this might affect
their actions
• understanding boundaries.
Children and young people
can be frustrated by their
own behaviour, but seemingly
unable to control it, leading to
challenges in self-esteem and
peer relationships.
>>
fetal alcohol spectrum disorders
Figure 2. Critical periods of fetal development (source: Blackburn, Carpenter and Egerton, 2012).

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Emotional difficulties:
• the need to rely on external
prompts from adults can result in
low self-esteem and frustration
• children and young people can
begin to identify the differences
between themselves and peers
even in special school settings,
again resulting in low self-esteem.
• As stated above, secondary
disabilities, such as mental health
problems, disrupted school
experience, trouble with the
law, confinement, inappropriate
sexual behaviour, problems
with independent living and
employment can result from a
lack of identification and support
when children are at primary age.
Implications for learning
It is a necessity for these children and
young people that there is extrinsic
motivation to learn or complete skills
and tasks such as life skills and hygiene
routines and school based tasks,
particularly in secondary aged children.
This requires repetitive reminders and
re-focussing from adults. The amount
of time children spend engaged in
learning tasks within the classroom in
secondary-aged students can be as
low as 40 per cent. In addition, social
communication difficulties mean that
inappropriate interactions with others
can leave children with FASD vulnerable
to bullying and other forms of abuse,
or they may intimidate others with their
over friendly or over-powering behaviour.
Challenges and
opportunities for inclusion
In a typical classroom, children with
FASD present educators with the
following challenges: hyperactivity, short
attention span, erratic mood swings,
poor memory, lack of social skills,
auditory/vocal processing difficulties,
visual sequencing problems, sensory
integration difficulties (particularly lack
of coordination), poor retention of task
instruction, and numeracy/mathematical
difficulties (Carpenter, 2011).
Children and young people with FASD
have particular strengths of a practical
nature. Many are articulate and have
engaging personalities. They enjoy being
with other people. Although they have
working/short-term memory difficulties,
rote learning and long-term memory
can be strengths. Many children with
FASD have learning strengths around
literacy and practical subjects, such
as art, performing arts, sport and ICT,
although they often have difficulties with
comprehension.
These strengths will become the
foundations on which to develop
personalised curricula, to encourage
and develop further strengths, and to
build emotional resilience. However,
the difficulties described above persist
throughout life and impact on daily living
skills, peer and family relationships and
employment prospects. Children with
FASD benefit from a particular learning
environment and teaching strategies
which are now evidence-based both
internationally and in the UK (see
Clarren, 2004; Kleinfeld and Westcott,
1993; Carpenter, 2011; Blackburn et
al., 2012).
As discussed above, children with
FASD can be hyperactive and inattentive,
resulting in low levels of engagement
with school-based tasks and activities.
Often this can be associated with
sensory processing difficulties and can
be supported by a number of strategies
(see boxed out section on the right).
Children with FASD will benefit from
consistency of language between home
and school, emphasising the need for
schools to collaborate closely with
families to ensure children’s wellbeing
and ability to predict outcomes resulting
from their behaviour. Attention to
friendships and peer relationships
is important to improve children’s
emotional resilience; nurture groups
have been found to be particularly
successful in this respect.
Figure 3. The developmental and learning profile of a 13-year-old diagnosed with FASD (based on
data from a child assessment by Dr R. Mukherjee, Surrey and Borders NHS Trust, National Specialist
FASD Behavioural Clinic, 2010). Previous diagnoses from other professionals include: reactive
attachment disorder, ASD, ADHD, anxiety disorder and ODD.
Some children with FASD
will have hidden needs,
making the educator’s
role more challenging
fetal alcohol spectrum disorders

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Many children with
FASD have learning
strengths around literacy
and practical subjects
Inappropriate interaction with other
(sometimes younger) children can result
in police custody and some children
may need one to one supervision to
keep themselves and others safe.
Extreme impulsivity may imply two to
one adult supervision and ongoing risk
assessment in lessons such as science
where equipment has the potential
for harm when the risks are not well
understood by students.
Support into adulthood
Those with FASD will continue to need
provision and support throughout their
adult life, which ideally would include:
• ongoing multi-disciplinary
assessment leading to
appropriate and sensitive support
packages
• a commitment to maximising
appropriate levels of
independence
• the provision of supported/
sheltered living accommodation
with access to assistance with
daily living skills
• supported work and leisure
opportunities.
Conclusion
Without appropriate diagnosis and
effective and appropriate support
and education, children with FASD
will experience social and emotional
vulnerability leaving them at risk from
developing secondary disabilities.
Educators are ideal advocates for
children and families with FASD. It is
crucial, therefore, that they familiarise
themselves with the nature of the
condition and understand the diverse
and complex needs which are a feature
of the spectrum of effects resulting from
prenatal exposure to alcohol.
Further information
Carolyn Blackburn is a member
of the early childhood research
group at Birmingham City
University. She was the project
lead for projects investigating
the educational implications of
FASD in the UK and she is co-
author, with Barry Carpenter and
Jo Egerton, of the first UK text
on the education of children and
young people with FASD (see
References).
Resources to assist educators
with inquiry based reflective
approaches to teaching, including
observation and engagement
focussed intervention tools, can
be found at:
http://complexld.ssatrust.org.uk
Symptoms of FASD and
resulting behaviour:
• inattentiveness/hyperactivity
• sensory processing difficulties
• emotional outbursts/
aggression
• poor memory/organisation
skills
• dysfunctional social skills
(overfriendly/overpowering)
• information processing
difficulties
• poor understanding and
retention of task instruction
• difficulty with sequencing
events
• difficulty with abstract
concepts
• receptive language difficulties
• poor understanding of cause
and effect.
Reducing behaviour
issues in the classroom
By applying the following to the
learning environment and teaching
approaches, behaviour problems
can be reduced:
• provide a calm ordered
learning environment
• ensure frequent breaks with
physical movement to aid
sensory seeking and calming
behaviour
• ensure predictability and
routine to avoid anxiety
• support social and emotional
development with social
stories, scripting and role-play
• break instructions down into
small steps
• provide visual support to
reinforce auditory input
• demonstrate tasks and
reinforce with concrete
resources
• allow more processing and
thinking time and expect to
have to repeat instructions,
tasks and learning objectives
• plan for strengths, which tend
to be practical.
References
Autti-Ramo, I. (2002) Fetal alcohol syndrome: a
multifaceted condition, Developmental Medicine
& Child Neurology, 44: 141–144.
Blackburn, C., Carpenter, B., and Egerton, J.
(2012) Educating children and young people with
Fetal Alcohol Spectrum Disorders: Constructing
Personalised Pathways to Learning. London:
Routledge.
Blackburn, C. (2010) Facing the Challenge and
Shaping the Future for Primary and Secondary Aged
Students with Fetal Alcohol Spectrum Disorders
(FAS-eD Project). London: National Organisation
on Fetal Alcohol Syndrome (UK).
BMA (British Medical Association) (2007) Fetal
Alcohol Spectrum Disorders: A Guide for Healthcare
Professionals. London: British Medical Association.
Carpenter, B. (2011) Pedagogically bereft! Improving
learning outcomes for children with Fetal Alcohol
Spectrum Disorders, British Journal of Special
Education, 38 (1): 37-43.
Carpenter, B., Egerton, J., Brooks, T., Cockbill,
B., Fotheringham, J., and Rawson, H. (2011) The
Complex Learning Difficulties and Disabilities
Research Project: Developing Meaningful Pathways
to Personalised Learning Final Report. London:
Specialist Schools and Academies Trust (SSAT).
Clarren, S.G.B. (2004) Teaching Students with Fetal
Alcohol Spectrum Disorder: Building Strengths,
Creating Hope. Edmonton, Canada: Alberta
Learning.
Jonsson, E., Dennett, L., and Littlejohn, G. (eds)
(2009) Fetal Alcohol Spectrum Disorder (FASD):
Across the Lifespan (Proceedings from an IHE
Consensus Development Conference 2009).
Alberta, Canada: Institute of Health Economics.
Kleinfeld, J. and Wescott, S. (eds) (1993) Fantastic
Antone Succeeds! Experiences in Educating
Children with Fetal Alcohol Syndrome. Fairbanks:
University of Alaska Press.
Mattson, S.N. and Riley, E.P. (1997) Neurobehavioural
and neuroanatomical effects of heavy prenatal
exposure to alcohol, in Streissguth, A. and Kanter,
J. (eds) The Challenge of Fetal Alcohol Symdrome
Overcoming Secondary Disabilities. Seattle:
University of Washington Press, pp. 3-14.
Morleo, M., Woolfall, K., Dedman, D., Mukherjee,
R., Bellis, M.A., and Cook, P. (2011) Underreporting
of fetal alcohol spectrum disorders: an analysis of
hospital episode statistics, BMC Pediatrics, 11 (14).
Mattson, S.N. and Riley, E.P. (2011) The quest for
a neurodevelopmental profile of heavy prenatal
alcohol exposure, Alcohol Research and Health
34 (1): 51-55.
fetal alcohol spectrum disorders
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