Fetal Alcohol Spectrum Disorders (FASDs) are a range of disorders and conditions that can occur in a fetus when a woman consumes alcohol during any trimester of a pregnancy (Centers for Disease Control and Prevention, 2015). These disorders range from mild to severe and can include physical, behavioral, and/or intellectual complications (Centers for Disease Control and Prevention, 2015; Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015). These disorders are the “leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities” (Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015, p. 1395). All types of alcohol affect a fetus similarly during pregnancy with higher doses posing greater risk. Fetal Alcohol Syndrome (FAS) is one disorder on the spectrum and is the only condition on the spectrum with diagnostic criteria, however, efforts are underway to create and define criteria for the other conditions. To meet criteria for a diagnosis of FAS, an individual must have a prenatal and/or postnatal growth deficiency, possess three specific facial features (e.g., smooth philtrum, thin upper lip, and shorter length from the inner corner to the outer corner of the eye), and at least one of many other deficits in functioning (e.g., neurological or structural) (Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015). In addition to the diagnostic criteria for FAS, several other characteristic features have been identified including, but not limited to, other facial features, medical problems, behavioral issues, intellectual disabilities, difficulty paying attention, and cognitive deficits (Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015). These complications are life-long and can manifest in different ways as an individual ages (National Organization on Fetal Alcohol Syndrome, 2006).
Etiology and Prognosis
When a pregnant woman consumes alcohol, it passes to the fetus through the umbilical cord. This pre-natal exposure to alcohol can cause the range of symptoms that may be diagnosed as FAS or be characteristic of another FASD. There is no safe time and no safe amount of alcohol to consume during pregnancy. Most pregnancies are detected between four and six weeks after conception, thus, to prevent FASDs, a woman who is or could get pregnant should not consume alcohol (Centers for Disease Control and Prevention, 2015; Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015).
FASDs are not curable, however, several interventions and treatments are available to help manage the symptoms. According to the Centers for Disease Control and Prevention (2015), there are factors that can minimize the effect of some symptoms of FASD and lead to better outcomes. These include diagnosis/identification prior to age six, a stable and enriched home environment, minimized exposure to violence, and early intervention by all necessary professionals. Symptoms of FASDs can change as the individual ages. For example, infants can present with a variety of symptoms including “low birth weight, irritability, sensitivity to light, noises and touch, poor sucking, slow development, poor sleep-wake cycles, and increased ear infections” (National Organization on Fetal Alcohol Syndrome, 2006, p. 1), while toddlers may present with other symptoms including “poor memory capability, hyperactivity, lack of fear, no sense of boundaries, and a need for excessive physical contact” (National Organization on Fetal Alcohol Syndrome, 2006, p. 1). These dramatic changes and the wide variety of symptoms highlight the importance of individualized interventions and plans, frequent progress monitoring, and changes made to the intervention and plan as necessary (Centers for Disease Control and Prevention, 2015; Steinhausen, H., & Spohr, H., 1998).
Prevalence
Given the wide variety of symptoms and lack of diagnostic criteria for many FASDs, there is a discrepancy between studies about the prevalence of FASD. In the United States, prevalence rates have varied from less than nine cases per one thousand live births (less than 1%) to 5%. According to Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse (2015), “…the true FASD prevalence remains unknown and the actual impact underappreciated” (p. 1397).
Co-occurring Conditions
Individuals with FASDs tend to have a higher risk (than the general population) of being diagnosed with mental health issues, other psychiatric problems, emotional issues, and behavioral difficulties (Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015). Other long-term challenges that affect a significant number of individuals with FASD include “school disruptions, trouble with the law, and under- or unemployment” (Williams, J. F., & Smith, V. C., & The Committee on Substance Abuse, 2015, p. 1399).
Common Treatments
Treatments for individuals with FASD can be divided into four categories: nutritional, pharmacological, environmental, and behavioral. Several of the nutritional and pharmacological interventions are still undergoing research and are not typically implemented with individuals with FASD unless there is a known medical condition. Several studies have evaluated the effects of environmental enrichment interventions and discovered improvements in motor, social, and cognitive functioning (Idrus, N. M., & Thomas, J. D. (2011). Much research has evaluated behavioral interventions including parent-focused interventions, behavioral consultation, educational and cognitive interventions, cognitive control therapy, language and literacy training, self-regulation intervention, mathematics training, working-memory strategies, adaptive skills training, social skills interventions, and safety skills (Paley, B., & O’Connor, M. J., 2011). Given the wide variety of symptoms and the range of severity the authors of these studies stress the need for treatments to be tailored to the individual, continuously monitored, and altered as necessary (Centers for Disease Control and Prevention, 2015; Steinhausen, H., & Spohr, H., 1998).
Research Literature
Paley, B., & O’Connor, M. J. (2011) discuss the overall lack of research and evidence-based interventions for individuals with FASD and express the need to continue research for this population. Although several different types of interventions have achieved positive results in animal and some human studies, there have been limitations that need to be addressed before they can be implemented in the general FASD population. Much of the research has focused on school-aged children as well, necessitating research with other age groups. The authors stress the importance of spreading the knowledge of effective interventions in the language (e.g., translate research to be more understandable, explain technical terminology) of the people who will implement them (Paley, B., & O’Connor, M. J., 2011). A significant amount of initial research exists, however, the studies need to be replicated and the methods need to be disseminated in a technological manner to caregivers of individuals with FASD and other professionals working with them (Paley, B., & O’Connor, M. J., 2011).
Behavior Analytic Treatment Implications
As a behavior analyst, there are several important considerations when developing intervention plans. First, it is important to consider the variety of factors that could be influencing behavior of these individuals. Individuals with FASD “may experience postnatal environmental risk factors, including ongoing parental substance use/abuse, parental psychopathology, exposure to interparental conflict or domestic violence, and neglect or abuse” (Paley, B., & O’Connor, M. J., 2011, p. 65). This could limit the caregiver’s involvement in treatment and ability to implement interventions reliably in the home. Second, given the social stigmatization of an FASD diagnosis and other factors, individuals with FASD may not be referred for treatment until later in life. Paley, B., & O’Connor, M. J. (2011) suggest that this allows patterns of dysfunctional behavior to strengthen throughout the individual’s life, which may make behavioral interventions more difficult. Behavior analysts working with individuals with FASD should be aware and actively working to troubleshoot these and any other issues that evolve during treatment.