Fetal Alcohol Syndrome: A Preventable Disorder. Laura McConahey. A Capstone Project submitted in partial fulfillment of the

Transcription

1 Running head: FETAL ALCOHOL SYNDROME i Fetal Alcohol Syndrome: A Preventable Disorder Laura McConahey A Capstone Project submitted in partial fulfillment of the requirements for the Master of Science Degree in Counselor Education at Winona State University Summer 2011

2 ii Winona State University College of Education Counselor Education Department CERTIFICATE OF APPROVAL CAPSTONE PROJECT Fetal Alcohol Syndrome: A Preventable Disorder This is to certify that the Capstone Project of Laura McConahey Has been approved by the faculty advisor and the CE 695 Capstone Project Course Instructor in partial fulfillment of the requirements for the Master of Science Degree in Counselor Education Capstone Project Supervisor: Name Approval Date:

3 iii Abstract Prenatal alcohol exposure is the most common cause of mental retardation and the leading preventable cause of birth defects in the United States. Fetal alcohol syndrome is characterized by a combination of retarded growth, face and body malformations, and disorders of the central nervous system. There is a significant need for effective prevention strategies for both pregnant and non-pregnant women who might be at risk for an alcohol-exposed pregnancy (AEP). Education about alcohol use during pregnancy and treatment programs for women who are unable to stop drinking due to addiction are key components for prevention.

4 iv Contents Introduction.1 Review of Literature...3 What is FAS.3 Diagnosis of FAS. 4 History of FAS. 6 Prevention/Education...8 FAS Related Problems Living with FAS Discussion..14 Conclusion References Figures/Table

5 1 Fetal Alcohol Syndrome: A Preventable Disorder Fetal Alcohol Syndrome (FAS) and other less severe alcohol related conditions are estimated to occur in nearly one in every hundred births (Sokol, Delaney-Black, & Nordstrom, 2003). Some women (and men) are under the unfortunate impression that drinking alcohol while being pregnant is acceptable and safe. This is a misconception that can have disastrous results. There is no amount of alcohol that is safe for consumption during pregnancy (Center for Disease Control and Prevention, 2009). Alcohol affects an individual s entire body and mind. How it will affect and damage fetuses differs from person-to-person. If an expecting mother is buzzed, so is the fetus, which can be detrimental to a developing baby. Fetal alcohol syndrome is one of the very few disorders that is completely preventable. If the mother does not drink alcohol during any part of her pregnancy her baby will not have fetal alcohol syndrome. Unfortunately, many women are uninformed of the dangers, while others are unaware that they are even pregnant and therefore unintentionally harm their babies. Pregnancy recognition does not occur in many women until 4- to 6-weeks gestation (Floyd, Decoufle & Hungerford, 1999), and thus many women may drink prior to realizing they are pregnant. Upon recognition of pregnancy, most women spontaneously reduce their alcohol use (Ebrahim, Diekman & Floyd, 1999). A recent report of alcohol use rates among women of childbearing age who are pregnant showed that use of any alcohol remains stable at approximately 12% and binge drinking is between 2 and 3% during pregnancy (see Table 1). Thus, alcohol use during pregnancy continues to be an important public health concern.

6 2 Education is the number one method of preventing FAS. The greatest opportunities for healthy pregnancy outcomes, however, lie in the prevention strategies implemented prior to conception (Floyd, Weber, Denny & O Connor, 2009) If women and men are educated about the facts of FAS the likelihoods of alcohol consumption would hopefully decrease. Education is especially needed for at-risk mothers. Fetal alcohol syndrome is preventable and education is the key factor in eliminating this disease.

7 3 Review of Literature Fetal Alcohol Syndrome (FAS) Defined Fetal alcohol syndrome (FAS) is caused by a pregnant mother drinking alcohol and exposing her fetus to the substance. FAS is a birth defect that primarily affects the brain. People with FAS are born with the disorder and will not outgrow its affects (Golden, 2005). Another more recent term for FAS is fetal alcohol spectrum disorders (FASD). 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, behavioral, and/or learning disabilities with lifelong implications (Golden, 2005). Often, a person with an FASD has a combination of these problems. FAS is the most identifiable and most serious disorder under the FASD umbrella, although it only accounts for approximately 25% of all alcohol related effects (National Organization on Fetal Alcohol Syndrome, 2010). Some people with FASD are slightly affected and manifest only mildly dysfunctional behavior; others are severely affected, devastatingly disabled in their ability to cope or function in simple everyday interactions (Streissguth, 2004). Also under the umbrella of FASD is alcohol-related neurobehavioral disorder (ARND) and alcohol-related birth defects (ARBD). Children with ARND and ARBD fail to meet the full FAS diagnostic criteria, but still exhibit the negative affects of gestational alcohol exposure (Boyce, 2010).

8 4 Diagnosing Fetal Alcohol Syndrome Alcohol can have a direct toxic effect on the rapidly developing cells of the embryo and fetus (Stressguth, 2004). Prenatal alcohol exposure can damage the developing fetus in many different ways, causing a whole spectrum of effects. Depending on which trimester of pregnancy the mother consumes alcohol affects the risk to the fetus and the kinds of problems that the developing infant might have (Zieman, 2010). Drinking alcohol during the first 3 months (first trimester) of the pregnancy is the most serious. Fetuses exposed to alcohol during that time frame often have small brains (see Figure 1), physical problems, and develop severe mental retardation (Zieman, 2010). The identification of individuals who have been exposed to alcohol prenatally can be challenging. Accurate maternal drinking histories may not be available and even if the child exhibits the defining characteristic of FAS, they may be missed if the child is not diagnosed by a trained dysmorphologist (Thomas, Warren & Hewitt, 2010). It can be even more difficult to identify individuals who have been exposed to alcohol prenatally but who do not meet the diagnostic criteria for FAS (i.e., do not exhibit all of the defining facial features). Thus, there is a need for better tools to enhance diagnosis, particularly because a proper diagnosis is often needed for the individual to receive appropriate services (Thomas, Warren & Hewitt, 2010). FAS, a birth defect caused by prenatal exposure to alcohol, is diagnosed when children meet the following three criteria (see Table 2):

9 5 1) A specific pattern of facial characteristics. Generally defined as short palpebral fissures (eye slits), a flat midface, a short unturned nose, a smooth or long philtrum (the ridge running between the nose and lips), and thin upper lip. 2) Growth deficiency, prenatally or postnatally, for height and weight 3) Neurological damage, including microcephaly (small size of brain), tremors, hyperactivity, fine or gross motor problems, attention deficits, learning disabilities and intellectual or cognitive impairments. A diagnosis of FAS also requires some presumed history of prenatal alcohol exposure. (Streissguth, 2004, p ). Diagnosing an infant or child with FASD can be difficult depending on the severity of the syndrome. Some children are not diagnosed until adolescence due to absence of the typical FAS physical characteristics. Currently there are no confirming laboratory tests that can detect FAS, but recent research findings have suggested that a test is imminent (Stressguth, 2004). The term FASD is not intended for use as a clinical diagnosis. However, to diagnose a child with FAS, the child must have all three findings: three facial abnormalities (see Figure 2), growth deficits and central nervous system abnormalities (Centers for Disease Control and Prevention, 2009). Consequently, children not meeting these diagnostic criteria are missed. Future research designed to find ethanol-induced gene expression alterations, as well as elucidating these mechanisms, will be important not only to help physicians diagnose and prevent FAS, but to reverse the physical and neurological consequences of alcohol by using in utero or postnatal treatments (Ismail, Buckley, Budacki, Jabbar, & Gallicano, 2010). Since an early stage diagnosis in the clinical setting is the key to reaching better outcomes in life, more research is required to obtain the necessary diagnostic tools.

10 6 One promising, although challenging, method of early FAS diagnosis is analyzing the levels of fatty acid ethyl esters (FAEE) in the meconium. The fetus metabolizes alcohol producing FAEE, which can be detected in the meconium, the first stool passed by the infant usually in the first 72 hours (Bearer, 2005). While FAEE levels appear to be increased in newborns exposed to alcohol in utero (Bearer, 2005), further investigation is needed to determine whether infants with high FAEE levels in the meconium are at high risk for developmental abnormalities. In addition, the meconium is produced only in the later part of pregnancy, which does not help in identifying infants exposed to alcohol in only the earlier part of pregnancy (Bearer, 2005). As a result, additional studies and markers are needed to better determine the specificity and sensitivity of this relatively new methodology. The use of fetal biological markers could aid in the early detection of children with FAS (Ismail, Buckley, Budacki, Jabbar, & Gallicano, 2010). This early diagnosis could allow for appropriate measures to be taken in order to support and assist the child and family in regard to education and social development. In addition to early diagnosis, fetal biological markers can be used to more thoroughly understand the pathogenesis of FAS (Ismail, Buckley, Budacki, Jabbar, & Gallicano, 2010). History of FAS Since ancient times, people have been aware of the dangers of drinking alcohol during pregnancy, perhaps without knowing the exact nature or reasoning for their concerns.

11 7 Behold, thou shalt conceive and bear a son: And now drink no wine or strong drinks. (Judges 13:7) Foolish, drunken, and harebrained women Most often bring forth children like unto themselves, morose and languid. (Aristotle). At the turn of the century, reports began to appear on children of alcoholic parents in many countries, but it was not until 1973 that the term fetal alcohol syndrome was introduced by Kenneth Jones and David Smith, two pediatric dysmorphologists, who rediscovered the tell-tale signs of alcohol exposure in infants at birth and notable in early childhood (Streissguth, 2004). The effect of maternal consumption of alcohol on birth weight and the development of children was noted in the 1700s, when there was a "gin epidemic" in England. By the middle of the 19th century, Dr. Lanceraux, a French physician, seemed to have described some of the significant characteristics of FAS when he stated: As an infant he dies of convulsions or other nervous disorders; if he lives, he becomes idiotic or imbecile, and in adult life bears the special characteristics: the head is small..., his physiognomy vacant [peculiar facial features], a nervous susceptibility more or less accentuated, a state of nervousness bordering on hysteria, convulsions, epilepsy...are the sorrowful inheritance,...a great number of individuals given to drink bequeath their children (Lanceraux, 1865; quoted by Gustafson, 1885, p. 21).

12 8 Animal research brought the issue to scientific status as it proved potential harm existed from prenatal alcohol exposure. By the 1920s, with the coming of the Prohibition era, the issues of prenatal alcohol exposure and birth defects were virtually ignored in the United States (Streissguth, 2004). By the 1960s, a large amount of medical literature condoned moderate alcohol use during pregnancy, doubting any relationship with birth defects other than a hereditary basis. With the exception of French researchers, who reported that children of alcoholic parents experienced high incidences of delayed growth and development and medical disorders, most of the world's researchers expressed no concern about alcohol ingestion and birth defects (Streissguth, 2004). However, that turned around in the 1970 s and it is now known today that alcohol consumption while pregnant can have devastating effects. Historically, FAS is more prevalent in lower socioeconomic classes, but certainly not limited to them. Particularly in settings where poverty, poor housing, high unemployment, alcohol and other drug abuse is rampant, the likelihood of FAS increases (Boyce, 2010). Prevention/Education Even small amounts of social drinking may be harmful a fetus (Sokol, 2003). The more that the mother drinks the greater the effects and damage will be. When a pregnant woman drinks alcohol, the blood-alcohol levels in the mother and fetus are approximately equal within minutes after consumption (Stressguth & Little, 1994). Education is a key element to the success of the future unborn babies. If mothers are aware of the potential damage that they could be causing their fetus they might take a moment to stop and think

13 9 about what that glass of wine or a few beers might be doing to their growing and developing fetus. Since this is one of the few preventable birth disorders women and men need to be properly educated about the facts of alcohol and how it can damage them and their babies (especially the babies). Everything an expectant mother consumes makes its way to the uterus. Alcohol will cross the placenta, just as oxygen, carbon dioxide and water do (Papalia, Olds, & Feldman, 2009). Vulnerability is greatest in the first few months of gestation, when development is most rapid. Unfortunately, as previously stated, some of the most damage can be caused during those first few months, a time when many women may not know that they are even pregnant. Once a woman does discover that she is pregnant the best possible outcome is stopping the consumption of all alcohol completely. FAS and other less severe, alcohol-related conditions are estimated to occur in nearly 1 in every 100 births (Sokol, Delaney-Black, & Nordstrom, 2003). This is higher than any other birth defect. Education about prenatal health needs to start at a very young age and continue throughout ones lifetime. Setting a good example for other women by not drinking is also important. Women that are at high risk of using alcohol or other substances while pregnant should seek professional help immediately. If a women is an alcoholic and has a difficult time stopping the use of alcohol she should receive help from a counseling group, individual therapy or AA meetings (Stratton, Howe, & Battaglia, 1996). Anything that will help her stay sober while she is pregnant is important. Treatment services for people with FASD should be different for each person depending on the symptoms. Some options include behavior and education therapy,

14 10 parent training, medications that may help with symptoms and also alternative approaches (Streissguth, 2004). It is believed that FAS and FASD is likely underestimated (Thomas, Warren & Hewitt, 2010). Determining the prevalence has proven to be difficult because often children with FASD are misdiagnosed with other disorders (such as attention deficit hyperactivity disorder, oppositional defiant disorder, or conduct disorder). This can be harmful to the child because they are not necessarily given the best treatment for their disorder. Having an identification of biomarkers that can reliably reflect fetal alcohol exposure and damage is important, especially because always getting reliable background information is not always possible (Thomas, Warren & Hewitt, 2010). Some possible reasons for this are that maternal memory is poor, biological parents are not available or drinking is denied. Having such markers may be useful for early case recognition and early intervention. Alcohol is a teratogen (i.e. any agent or chemical that causes a birth defect). Alcohol is the most frequently consumed teratogen in the world (National Institute on Alcohol Abuse and Alcoholism, 2005). Since so much is unknown about the exact mechanisms through which alcohol acts as a teratogen, the Centers of Disease Control and Prevention (CDC) recommend that there is no safe period of time during pregnancy to consume alcohol and that women who are considering becoming pregnant, who are at risk for becoming pregnant or who are pregnant abstain from alcohol consumption (CDC, 2005). Alcohol may have detrimental effects at any time during brain development;

15 11 therefore, at this time, it is better to err on the side of caution and assume that alcohol consumed at any time during pregnancy can be a potential threat to the developing fetus. One aspect of FAS prevention involves the recognition of high-risk drinking in women that are childbearing age by primary care physicians and prenatal clinics (Thomas, Warren & Hewitt, 2010). Importantly, research shows that screening and brief interventions in these settings are highly effective in reducing and eliminating risky drinking. However, such education programs and clinics are readily available and unfortunately, they are not routinely utilized (Thomas, Warren & Hewitt, 2010). FAS Related-Problems If a mother does consume alcohol while she is pregnant minor to severe problems can be expected. FAS related problems can include, in infants, reduced responsiveness to stimuli, slow reaction time, and reduced visual acuity (Carter, 2005) and, throughout childhood, short attention span, restlessness, distractibility, hyperactivity, learning disables, memory deficits, mood disorders, as well as aggression and behavioral problems (Sokol, 2003). Older children often have difficulty keeping up with school work, and may have low self-esteem because they recognize that they are different from peers. Teenagers can have poor impulse control and cannot distinguish between public and private behaviors. Adults with FAS will need to deal with many daily obstacles, such as transportation, employment and money management (National Organization on Fetal Alcohol Syndrome, 2010). Another possible barrier that people with FAS may face is the reality of developing a drinking problem themselves because prenatal alcohol exposure is a risk factor for development of a drinking problem and alcohol disorders in young adulthood. When situations go wrong in the life of a person with FAS, often they are unable to process, solve the problem, take responsibility and learn from their mistakes.

16 12 They are unable to make connections between actions and consequences (Sokol, 2003). FAS affects the baby, the family and the community as a whole. In a study of adverse adaptive behavioral problems of individuals diagnosed with FAS, five significant areas were noted through life history interviews with 415 patients. Of these individuals, 61% experienced disrupted school experiences, 60% noted some form of trouble with the law, 50% reported an incidence of confinement defined as in jail, prison or psychiatric inpatient setting, 49% described repeated inappropriate sexual behaviors, and 35% reported alcohol and/or drug problems (Streissguth, 2004). The report went on to note that children experienced a 2 to 4 fold increased chance of escaping these five identified adverse life outcomes if diagnosed with FAS at an early age and reared in a good, stable environment (Streissguth, 2004). As a result, it is of great importance to identify FAS at an early stage, so that the child may receive appropriate counseling and guidance throughout his/her life. Living with FAS Children with Fetal Alcohol Syndrome typically have multiple handicaps and require special medical, educational, family and community assistance. Their families need medical information, peer support, educational advocacy and financial assistance. People with FAS are at a higher than average risk for physical and sexual abuse and neglect when raised in their families of origin (Mack, 2010). These children need a supportive, loving home environment with clear guidelines and clear lines of communication in order to develop to their fullest potential.

17 13 People with FAS/FASD, like everyone else, have a variety of talents and capabilities. They exhibit a wide range of intellectual levels and functional disabilities that probably reflect differing degrees of prenatal brain damage due to different levels, patterns, and timing of prenatal alcohol exposure (Streissguth, 2004). Many people with FAS despite some differences exhibit the same general behavioral characteristics. They are usually trusting (even overly trusting), loving, and naive regardless of age. They can also be grumpy, irritable, and rigid. As a result of their brain damage they may have a difficult time appropriately evaluating a situation and using their past experiences to understand and cope with the current issue (Mack, 2010). Appropriate placement in special education classes beginning in elementary school is often necessary for children with FAS. A small classroom setting with clear guidelines and a great deal of individual attention can maximize the intellectual capabilities of these students (Mack, 2010). Many children with fetal alcohol syndrome reach an academic plateau in high school. Many will be unable to hold a regular job. Nonetheless, all of these students need to know basic life skills, including money management, safety skills, interpersonal relating, and so forth. The biological, foster or adoptive parent of a child with FAS assumes a responsibility far beyond that normally associated with parenting (Mack, 2010). The mixture of physical, intellectual, and behavioral problems that children with FAS have can create a very demanding situation for any family. It takes an extraordinary amount of energy, love, and most of all, consistency in parenting these children. Therefore, these parents need support in their efforts. Due to their poor social judgment, underdeveloped independent living skills and impaired intellectual functioning, most FAS children will require a structured, sheltered living

18 14 situation throughout their lives (Mack, 2010). The most severely affected may require a completely supervised and sheltered environment. For more functional people, a group home or halfway house for developmentally disabled adults may be appropriate if continued residence with a family is not possible or desirable (Mack, 2010). Discussion Indeed, prevention of FAS is an important goal primarily because so little is understood with regard to the adverse effects that alcohol has on the developing fetus. The CDC has a number of current prevention plans aimed at educating the potential mothers at risk for conceiving a child with FAS. One of these projects includes the Changing High-Risk Alcohol Use and Increasing Contraception Effectiveness Study (CHOICES). The CHOICES program is currently funded by CDC and developed brief interventions aimed at preventing alcohol exposed pregnancies among women of childbearing age. The targeted groups were women who drank at high risk levels and did not use contraceptives effectively (CDC, 2009). The objectives of the CHOICES study were to characterize the women in the high risk setting, reduce the rate of alcohol consumption among women who were not using contraception effectively, and increase contraceptive effectiveness among women who do not reduce their alcohol consumption. The project was done in three phases: (1) conducting an epidemiologic survey of women in special settings; (2) developing, implementing, and evaluating a behavioral intervention; and (3) measuring the effectiveness of this behavioral intervention further in a scientifically rigorous manner. Some of the participants received information plus a brief motivational intervention, while others received only information. The brief motivational intervention

19 15 consisted of four counseling sessions and one contraception consultation and services visit: In-depth assessment of alcohol use and contraceptive use patterns. Counseling about the consequences of alcohol use during pregnancy. Brief advice and counseling for moderate-to-heavy drinkers to reduce intake levels, or referral to community treatment services for alcohol-dependent drinkers. Reproductive health education about contraceptive methods, provision of contraceptive services, and client follow-up. The group that received both information and a brief motivational intervention were twice as likely to be at reduced risk for an alcohol-exposed pregnancy compared to the group that received only information. This shows that a brief motivational intervention can reduce the risk of an alcohol-exposed pregnancy. Project CHOICES has become a model program embraced by researchers and used in other federal initiatives (CDC, 2009). Another project being conducted is the Birth Control and Alcohol Awareness: Negotiating Choices Effectively (BALANCE) project (CDC, 2009). This project focuses on the many young women in the United States who drink alcohol and have unprotected sex are putting themselves at risk for an alcohol-exposed pregnancy. Not much is known about the relationship between moderate-to-heavy alcohol use, unprotected sex, and unplanned pregnancies in young women. Well-designed epidemiological and behavioral studies are needed to better understand and intervene with this population. Project BALANCE s objectives were to identify the prevalence of risky drinking and

20 16 contraceptive behaviors in this population, and to test the efficacy of an intervention in a randomized trial comparing a group receiving both assessment and one face-to-face session with a group receiving assessment only. A brief survey was administered to college women to identify those eligible for intervention and to further characterize the population. Focus groups with college women also explored qualitative issues related to drinking, contraception, and sexual behavior. The intervention focused both on drinking and unprotected sex, allowing a woman to modify either or both behaviors. Follow-up occurred at 1 month and 4 months. The campaign was built around four core messages: (1) drinking alcohol during pregnancy harms unborn babies, (2) pregnant women should abstain from alcohol, (3) sexually active women should not drink if they could be pregnant, and (4) women at risk for an alcohol-exposed pregnancy should see a physician (CDC, 2009). These prevention plans revolve around the goal of providing education about effective birth control methods and the risks of alcohol use (CDC, 2009). More education, research, and programs such as CHOICES and BALANCES need to be implemented nationally. The key component to success revolves around having accurate information and motivational intervention for at-risk mothers. Education should start early and be reinforced continually.

21 17 Conclusion Fetal alcohol syndrome and fetal alcohol spectrum disorders are 100% preventable, however the affects and devastation of FAS last a lifetime. No two people with FASD are exactly alike (CDC, 2009). FASD can include physical or intellectual disabilities, as well as problems with behavior and learning. These symptoms can range from mild to severe. Unfortunately, despite prevention efforts many women continue to drink alcohol during pregnancy. Furthermore, many people have yet to acknowledge that FASD occurs in their communities so polices and education to reduce alcohol consumption are not in place. The greatest opportunities for healthy pregnancy outcomes, however, lie in prevention strategies implemented prior to conception (Floyd, Weber, Denny & O Connor, 2009). Counseling is an effective intervention in reducing a woman s risk of FASD. Education started at an early age for both males and females will be instrumental in reducing this disorder. Progress is being made in diagnosing FAS, but much still needs to be done. Research has made great strides forward since the 1970s, when FAS was originally recognized as a syndrome. Today we have a better understanding of the consequences of prenatal alcohol exposure and the prevalence and alcohol related damage. Although we have developed diagnostic, prevention, and treatment strategies, challenges remain. Better identification and diagnosis of the full range of FASD are needed, which could be improved with the development of biomarkers that aid in detection and accurate

22 18 quantification of prenatal alcohol consumption (Thomas, Warren, & Hewitt, 2010). Continued development of effective prevention and treatment strategies also is critical. In conclusion, FAS and all other conditions under the umbrella of FASD are entirely preventable as long as the pregnancy is alcohol free. Awareness and education are needed and will help to dramatically decrease FAS and FASD.

23 19 References Bearer, C. (2005): Fatty acid ethyl esters: quantitative biomarkers for maternal alcohol consumption. Journal of Pediatrics 146, Boyce, M. (2010). A better future for baby: Stemming the tide of fetal alcohol syndrome. Journal of Family Practice, 59(6) Carter, R. (2005). Effects of prenatal alcohol exposure on infant visual acuity. Journal of Pediatrics, 147(4), Center for Disease and prevention. Alcohol and public health/ binge drinking. Quick stats Available at: Center for Disease and prevention. Fetal Alcohol Syndrome: Guidelines for Referrals and Diagnosis Available at: Ebrahim, S.H., Diekman, S.T., & Floyd, R.L. (1999). Comparison of binge drinking among pregnant and nonpregnant women. American Journal of Obstetrics and Gynecology, 180, 1-7. Floyd, R., Decoufle, P., & Hungerford, D. (1999). Alcohol use prior to pregnancy recognition. American Journal of Preventative Medicine, 12, Floyd, R., Weber, M., Denny, C., & O Connor, M. (2009).Prevention of fetal alcohol spectrum disorders. Developmental Disablities Research Reviews 15, Golden, J. (2005). Message in a Bottle. Cambridge: Harvard University Press.

24 20 Ismail, S., Buckley, S., Budacki, R., Jabbar, a., & Gallicano, I. (2010). Screening, diagnosing and prevention of fetal alcohol syndrome. Journal of Developmental Neuroscience, 32, Kulp, L., & Kulp, J. (2007). The Best I Can Be- living with fetal alcohol syndrome or effects. (2 nd ed.). Brooklyn Park: Better Endings New Beginnings. Mack, M. (2005). Living with Fetal Alcohol Syndrome. Colorado: Lighthouse National Institute on Alcohol Abuse and Alcoholism. Drinking and your pregnancy Available at: Papalia, D., Olds, S., & Feldman, R. (2009). Human Development (11 th ed.). New York: McGraw-Hill. Sokol, R. J., Delaney-Black, v., & Nordstrom, B. (2003). Fetal alcohol spectrum disorder. Journal of the American Medical Association, 209, Stratton, K., Howe, C., & Battaglia, F. (1996). Fetal Alcohol Syndrome. Washington, D.C.: National Academy Press. Streissguth, A. (2004). Fetal Alcohol Syndrome- A guide for families and communities. Baltimore: Paul H. Brookes Publishinig Co. Streissguth, A. & Little, R. (1994). Alcohol, Pregnancy, and the Fetal Alcohol Syndrome. Hanover: Dartmouth Medical School. Thomas, J., Warren, K., & Hewitt, B. (2010). Fetal alcohol spectrum disorder. Journal of Alcohol Research & Health, 33,

25 21 Zieman, G. (2010). Fetal Alcohol Problems. New York: RelayHealth

26 22 Table 1 Percentage of women aged years who reported any alcohol use or binge drinking, by pregnancy status; defined as five or more drinks on at least one occasion. In 2006, the definition of binge drinking by women changed to four drinks on at least one occasion. Because of this change, data collected after 2005 are not included.

27 23 Table 2 The following is a chart that show the criteria of FAS and other alcohol related disorders Summary of diagnostic categories and methods. (Hoyme 2005). 1. Fetal Alcohol Syndrome : Confirmed alcohol exposure a. Alcohol Exposure. b. Facial pattern of Short palpebral fissures < / = 10 percentile, Thin upper lip vermillion, Smooth philtrum. c. Evidence of pre / postnatal growth retardation. d. Evidence of Neurocognitive deficits. 2. Fetal Alcohol Syndrome: No confirmed alcohol exposure. a. As above but no alcohol exposure found. 3. Partial Fetal Alcohol syndrome: Confirmed Alcohol Exposure a. Not all of the above features are present but neurocognitive and some facial features needed. 4. Alcohol Related Birth Defect (ARBD) a. Confirmed maternal alcohol consumption as well as some but not all of the facial features are present however the behavioral features or structural abnormalities are more pronounced. 5. Alcohol Related Neurodevelopmental Disorder (ARND) a. Confirmed maternal alcohol consumption with the absence of growth retardation or facial features and with the neurocognitive features being prominent.

28 24 Figure 1 Normal Infant Brain FAS Infant Brain Figure 2 Facial features of FAS.