Back to homepage



Fetal Alcohol Syndrome
Maia Szalavitz,, 2005 - 2010
Heavy drinking by mothers-to-be during pregnancy has been associated with birth defects and problematic behavior in children since antiquity. But what does science tell us about the risks of Fetal Alcohol Syndrome now?

Heavy drinking by mothers-to-be during pregnancy has been associated with birth defects and problematic behavior in children since antiquity. A passage in Judges (13:7) in the Bible says: "Behold, thou shalt conceive and bear a son; and now drink no wine or strong drinks." Aristotle wrote that "foolish, drunken and hare-brained women most often bring forth children like unto themselves, morose and languid."

However, "Fetal Alcohol Syndrome" (FAS) was not characterized in the medical literature until 1968, by Paul LeMoine of Nantes, France-and the diagnosis did not get widespread attention until 1973 when a paper by David Smith and Ken Jones of the University of Washington suggested specific criteria for its diagnosis.

Because research in this area has only begun so recently, many key questions remain unanswered. How exactly does alcohol cause damage to unborn children? How many affected infants are born each year? Will all children of women who drink heavily while pregnant be affected by alcohol-related damage in some way? Which women are at highest risk of having an affected child? And what about women who drink moderately-is there any safe level of consumption of alcohol during pregnancy? This guide will explore what we know-and what we don't-about problems associated with drinking during pregnancy.

A Guide Through the Alphabet Soup of Fetal Alcohol Spectrum Disorders
When fetal alcohol syndrome was first described, the diagnosis consisted of three primary groups of symptoms. These include a distinct set of facial features, which may include skin folds at the corner of the eye, smaller than normal head circumference, small opening area around the eye, short nose, thin upper lip and an absent or hard to detect philtrum (the indentation between the nose and upper lip). The second group of symptoms involves slower rates of physical development and growth, particularly of the head. The third group consists of neurological problems which can include lowered IQ, behavior problems, attention disorders, learning problems and difficulties with socialization.

But while FAS facial features have come to be associated with the most severe cases of the condition, researchers now believe that these simply mark significant alcohol exposure only early in pregnancy. Consequently, some affected people may have neurological defects just as severe as full FAS, but without the characteristic facial structure. Their development was most strongly affected by alcohol consumed at other points during pregnancy - which were just as damaging to brain growth, but did not affect the development of the face. Recent research suggests that people with the facial anomalies of FAS have more severely impaired cognitive function than those without them, but the correlations are not strong enough to use physical characteristics in children to predict later cognitive function (1).

At first, such people were defined as having Fetal Alcohol Effects (FAE), but this diagnosis was seen as too vague and too suggestive of the idea that these defects weren't as severe as FAS itself. As a result, the Institute of Medicine of the National Academy of Sciences, which advises Congress on medical controversies, decided in 1996 to label the full range of the disorder FASD-Fetal Alcohol Spectrum Disorder. They defined five categories of affected children.

These include those with the full facial features and known maternal alcohol exposure (FAS), those with these features but whose alcohol exposure in utero could not be determined (FAS without confirmed maternal exposure), those with some but not all of the facial features and known alcohol exposure in the womb (Partial FAS) and two new diagnoses. These are alcohol-related birth defects (ARBD), which include kidney, heart, eye and ear defects in the absence of FAS facial features; and alcohol-related neuro-developmental disorder (ARND), which involves brain defects, behavior problems and learning problems known to be associated with alcohol exposure in utero but without FAS-qualifying facial features. The latter two diagnoses can occur together and both require known maternal alcohol use.

True Number of FASD Cases Unknown
It is hard to get good estimates of how common FASD cases are. In some particularly vulnerable populations, such as certain Native American groups and some South African communities, full FAS is estimated to affect 10-40 infants per 1000 live births (2).

A 2009 review of the research estimated the overall U.S. prevalence of FAS to be 2-7 cases per 1000 live births (3) - but CDC estimates are lower, .5 to 1.5 per 1000 live births (4). Even the lower rate, however, makes FAS as common as Down syndrome.

Moreover, researchers estimate that for every one child with full FAS, there are at least 3 who have one of the other IOM diagnoses, which means that 1% of all children born in the U.S. may be affected (5).

These are probably under-estimates. Because drinking during pregnancy is strongly discouraged to prevent alcohol-related problems in the fetus, women may not admit to doing so or may not admit to the actual quantities of alcohol consumed. Further, especially amongst middle class or upper class populations, children may not be screened for these disorders as they stereotypically only affect the poor. As a result, many children without obvious distinguishing facial features, particularly in the higher socioeconomic groups, may be misdiagnosed with less stigmatized conditions like attention-deficit disorder or other learning or psychiatric disorders which have similar symptoms to FASD.

How Alcohol Harms Children Before Birth

Researchers have discovered numerous mechanisms by which alcohol can interfere with the growth and development of embryos and fetuses. It can interfere with the proliferation of nerve cells, causing fewer to be produced and making some cells wind up in the wrong places. It can alter the way nerve cells develop and divide to produce new cells. It can directly kill nerve cells or derange the formation of axons, the projections that send brain messages from one cell to another. It can change the signaling pathways within cells. One reason it may be able to affect all these different processes is because it also seems to interfere with the genes that tell cells when to make proteins and when to stay silent.

Alcohol also seems to directly affect the development of two important neurotransmitter systems, the serotonin system, which appears to help regulate mood and aggression; and the glutamate system, which is involved in learning and memory. Serotonin release by cells during development seems to influence the development of receptors for this chemical messenger.

There is also a genetic component to alcohol-related birth defects. Certain genes have found to have a “protective” effect on children of drinking mothers, while others seem to predispose children to FASD if their mothers drink while pregnant (6).

Interestingly, researchers found that alcohol-related brain damage to the serotonin system could be mitigated in mice by giving the anti-anxiety drug buspirone, which affects the specific receptors that are influenced by prenatal alcohol exposure (7).

Some research has tied certain detrimental effects of alcohol to the action of genes that produce a protein called L1 adhesion factor. Children born with defects in these genes are remarkably similar to those with FASD-so researchers decided to look more closely at what L1 adhesion factor does. It appears to guide neurons to their places in the brain, making them stick together and form connections at appropriate places.

A 2003 study in the Proceedings of the National Academy of Sciences by Michael Charness and colleagues found that a protein called NAP could prevent alcohol from affecting L1 adhesion factor (8). Mice given high doses of alcohol during fetal development along with NAP did not show the expected brain damage.

Alcohol-linked damage can occur at any time during pregnancy.  The specific effects seem to vary with the timing of exposure. Damage in the first trimester appears to produce facial malformations and interfere with very basic brain development. Exposure during the second trimester seems to reduce the number of brain cells, while drinking during the third trimester seems to kill off brain cells and impair the final stages of brain development that immediately precede birth.

With other toxic exposures during pregnancy, exposure later in pregnancy often causes less serious damage than exposure early on-but this does not seem to be the case with alcohol, because critical periods for brain development occur throughout pregnancy, not just at the start.

Alcohol also seems to have an overall stunting effect on growth, particularly of the head and brain. But some brain regions are especially hard-hit. For example, the corpus callosum, which connects the left and right sides of the brain, in FASD (9) - and approximately seven percent of people with FAS have no corpus callosum at all. This is 20 times more common than the rate of this brain defect in the general population (10).

Other structures especially prone to damage are the basal ganglia, which are involved in control of movement and motivation and the cerebellum which is believed to be responsible for balance and the coordination of complex learned activities (i.e., how to ride a bike, how to play the piano, etc.). The cerebellum may also play a role in attention. The frontal lobes, which play key roles in judgment and planning also seem to be damaged by prenatal alcohol exposure.

No other recreational drug is as damaging to the developing brain; in fact, recent research suggests that much of the damage once attributed to crack cocaine in children born to mothers who smoked the drug during pregnancy was actually caused by concomitant alcohol use and other factors like stress, malnutrition and a lack of prenatal care. (This is not to suggest that cigarette smoking and cocaine use during pregnancy are safe.) (11)

The Moderate Drinker
In a world of drug scare stories warning that "crack babies" were doomed to become a lost, degenerate generation, people often discount reports of harm related to psycho-active substances. Many feel that the "nanny state" is probably crying wolf again, and that just as marijuana didn't turn them into heroin addicts or crazed killers, a few drinks during pregnancy probably won't do much harm either. They figure, too, that before the discovery of FAS most women drank throughout their pregnancies and didn't produce generations of severely alcohol-damaged children.

Women who drink amounts that would define them as moderate drinkers when not pregnant-between 7-14 drinks per week- are extremely unlikely to have babies with full FAS. Nonetheless, when you compare mothers who report this level of drinking to mothers who say they didn't drink at all while expecting, studies find subtle difficulties with attention and often slightly lowered IQ's. Greater difficulty with mathematics and with memory is also reported.

A 2001 study of alcohol consumption by pregnant women found a dose/response relationship, with higher doses linked to anxious/depressed and aggressive child behavior at age 6-7 and even light alcohol consumption linked to worse behavior compared to children of nondrinkers. (12)

More serious alcohol-linked deficits that can result from slightly higher levels of consumption can move children from having average intelligence to the lowest levels of the normal range, where, for example, passing math classes can become seriously problematic. Any deficit that has this result is said to cause "functional impairment." Such deficits have greater impact than those which can be discovered only by testing for subtle differences, which have hard to measure 'real world' effects.

However, some studies find no significant effects at all—for example, a 2009 study found no association between delayed acquisition of speech and low levels of drinking and only non-significant effects of binge-drinking in the second trimester (13).

There are also many factors-most of which are unknown- that can significantly modify alcohol's ability to cause functional impairments. As a result, Wayne State University Professor Sandra Jacobson estimates that only 4 in 100 children of heavy drinkers will have full FAS; another, larger group may have other FASD diagnoses but most children will not be measurably affected.

One critical determinant appears to be maternal age: in one study, a mother over thirty who drank seven or more drinks a week was 3-5 times more likely to have a child who was functionally impaired at age one in terms of motor skills and complex play than a woman that age who drank seven or fewer drinks a week (14). Researchers have long known that if a woman has given birth to one FAS child, and if she drinks during her further pregnancies, each successive child will be more severely affected. Why this occurs and how age has such an effect is not known.

In the same study, children of mothers under 30 did not appear to be significantly harmed by drinking at these levels: there was no difference between the group who drank 7 to 14 drinks per week and those who drank 7 or fewer and both groups were indistinguishable from non-drinkers on measures of motor skills and complex play. On a measure of brain processing speed, however, consuming more than seven alcoholic drinks per week doubled the risk of functional impairment in all age groups.

Another key variable is drinking pattern. High concentrations of alcohol in the blood appear to do the most damage to the developing child-so "binge" drinking patterns that produce large spikes in BAC, especially if alcohol is consumed on an empty stomach, are most dangerous. In the Jacobson study, four of five women who drank at least four days a week and averaged at least five drinks per occasion had functionally impaired babies, while none of the children of the six women who drank 1.3 to 4.6 drinks per day on four or more days per week had affected children.

Genetics and stress also seem to play important roles in whether or not a woman who drinks during pregnancy will harm her child. Some studies suggest that race has genetic correlates which may predispose them to FASD susceptibility. In particular, black babies are more likely to exhibit symptoms of FASD than whites with the same amount of maternal drinking.

Chronic, unrelenting stress can also produce hormonal effects which in themselves can damage fetuses. Stress, of course, is also likely to increase the desire to drink and the amount consumed. This is one reason why there may be higher rates of FASD amongst the poor, even accounting for under-diagnosis in other groups.

Some scientists have criticized the studies on moderate drinking, saying that the research often lumps people on the heavy end of the moderate spectrum in with those who were truly light drinkers and that pregnant women who drink often say they drink less than they really do. If you separate out the truly light drinkers (two or fewer drinks per occasion, two or fewer times a week), they say, there is no effect of light drinking. But even these researchers believe that the advice to pregnant women should be to abstain entirely.

Symptoms/ Characteristics
The stereotype of a person with FAS is that of a retarded child, profoundly incapacitated and unable to learn much, unable to care for him or herself or to ever live successfully outside of an institution or the family home. And it is true that prenatal alcohol exposure is the most common known cause of mental retardation-accounting for more cases, for example, than Down syndrome.

While that bleak image represents part of the story, it is far from the whole picture of the disability. On the positive side, only half of people with full FAS are mentally retarded, and some even have above average IQ's. On the other hand, because the whole FASD spectrum is marked by often profound difficulties with planning and recognizing the consequences of one's behavior, even those with few intellectual deficits may have severe difficulty with independent living. When the condition is recognized and proper support is provided, however, many people with FAS and other FASD spectrum disorders can work and live in the community. The main symptoms of FASD fall into several key categories (15):

Physical birth defects: While the facial characteristics of full FAS are quite well known, prenatal alcohol exposure consistently leads to a number of other birth defects that are not as commonly associated with it in public perceptions. The kidneys and the heart are particularly susceptible as are the eyes and ears and their associated neural connections. Partial deafness and significant visual impairments are common. Balance and motor coordination are also often impaired.

Growth and Development: Babies with FASD tend to be born smaller and to grow much more slowly than other babies. Especially stunted is the growth of the head, which may remain significantly undersized even in adulthood. Some FASD adults have heads the normal size for five year old children.

Attention: Problems with attention are one of the defining characteristics of FASD. Such difficulties are so common amongst people with FASD that they are often misdiagnosed with attention deficit disorders. Unfortunately, the types of attention problems associated with FASD are not the same as those found in people with other attention deficits. People with classic attention deficit disorder tend to have difficulty focusing and maintaining attention-while those with FASD have fewer problems with those skills, but more trouble shifting attention from one task to another (what researchers call "set shifting").

Cognitive/Learning: Even when it doesn't cause mental retardation, prenatal alcohol exposure can lower IQ and can also affect other aspects of learning. One of its key effects is to slow reaction time and reduce brain processing speed. Both of these affect overall intelligence by limiting the brain's capacity to take in information rapidly, particularly in a setting like an ordinary classroom. People with FASD also have problems with verbal learning, although these are different from the types of problems seen with verbal learning in Down syndrome. FASD seems to affect people's ability to initially encode verbal information in memory-but once the information is encoded, recall is as good as for anyone else. With Down syndrome, both storage and recall are impaired. People with FASD also have particular difficulty with learning spacial relationships between objects and with mathematics, deficits which may be connected.

Executive Function: One of FASD's cruelest effects is the way it affects executive function - the ability to plan for the future and to change behavior in response to the effects of previous actions. People with FASD are often incapable of learning from experience and may repeat behaviors over and over despite negative results. They often cannot put together a sequence of actions in order to achieve a goal-for example, taking the steps necessary to do homework adequately or to pay a bill on time. This may in part result from their inability to shift attention well: they get "stuck" on certain things and cannot keep the whole process in mind while carrying out the steps needed to complete it.

Behavior: Behavioral problems are common with FASD-unsurprisingly, given the problems listed above with planning and with learning from bad experience. And since people with FASD are also often impulsive and may react without thinking, this can produce a horrendous vicious cycle in connection with their difficulty changing behavior once it has started. Consequently, people with FASD are often diagnosed with conduct disorder and/or oppositional defiant disorder and may have frequent run-ins with law enforcement as they appear to be willfully disobeying authorities and actively seeking repeat punishment. FASD also appears to make people more likely to lie; though whether this is simply because they are more likely to be caught doing so due to their other deficits is hard to tell.

Socialization: FASD also seems to produce difficulties recognizing social cues. People with FASD often "can't take a hint," or recognize when others are suggesting something non-verbally. They may be overly demanding of attention and may lack empathy towards others. They also tend to be eager-to-please and easily lead, which means that if they fall in with anti-social peer groups, they may be preyed upon and pushed to commit crimes that they couldn't have engineered themselves. Adolescents and adults with FASD also have a tendency towards sexual promiscuity, which may be linked both to their desire to please others and their impulsiveness.

Secondary Disabilities: As one might imagine from the litany above, being faced with FASD can be enormously difficult. Behavior that the person has difficulty controlling can repeatedly get him in trouble with authorities-but he may not know what, exactly, he's doing wrong or how to behave differently. If the condition is not diagnosed early, damage to self-esteem from negative reactions by teachers and peers is extremely common as is sexual abuse due to high vulnerability to suggestion. Criminal convictions and other social consequences can often cause just as much damage as the early alcohol exposure itself. Some researchers estimate that 90% (16) of people with FASD have at least one additional mental illness-frequently including severe depression-and it is hard to know how much of this is due to vulnerability of the brain due to early damage and how much is due to secondary effects of trying to cope with the condition.

While numerous educational, behavioral and even pharmacological interventions have been tried for FASD, there is little research on the outcome of these interventions and even less research that is empirically sound or which has been replicated. Medications like stimulants for the attention problems associated with FASD do seem to help - but some research suggests that the most commonly prescribed medication, Ritalin, is less likely to work than other stimulants in FASD. Antidepressants are also helpful for co-occurring depression.

New research here is just beginning to support particular interventions. A 2009 paper included five separate studies: one looked at Parent/Child Interactive Therapy, another examined a social skills program called “Bruin Buddies,” a further study explored the “Georgia Sociocognitive Habilitation using the Math Interaction Learning Experience (MILE),” and the other two included “Neurocognitive Habilitation,” and a program called “Families Moving Forward.”

Four of the five studies found significant results favoring that particular intervention, the fifth study found Parent Child Interactive Therapy and a less intensive alternative were equally effective.  Because of ongoing pessimism related to helping these children, the range of studies showing measurable improvements is promising (17).

Longitudinal research suggests that early diagnosis may reduce the odds of secondary disabilities like depression and criminal justice system involvement by making parents and others involved in the care of people with FASD aware of what to expect. While the best strategies for treating the disorder have not yet been elucidated, people who recognize that someone has brain damage tend to treat that person with more sympathy and to be more forgiving of inappropriate behavior than those who believe the person is deliberately misbehaving.

A study which followed 500 people with FASD over 15 years found that some 60% had serious trouble in school, including repeated disciplinary actions related to incomplete school work, inappropriate behavior in class and difficulty with peer relationships (18). Sixty percent of the adolescents had been involved with the juvenile justice system, usually for shoplifting and theft. Of those aged 21 and older, 80% were not living independently and the same percent had difficulty holding a job.

Since children with antisocial behavior are often placed in special education programs, it may be important to keep children with FASD away from these peers in order to avoid introduction to behaviors like shoplifting and drug use that may be hard to stop once started by FASD children.

Factors which seemed to protect people with FASD from secondary disabilities included having a stable home life, not being a victim of violence, having received services for the disabled, having been diagnosed before age six, having full FAS and having an IQ below 70.

The last two protective factors may seem counter-intuitive, but the lead author of the study, Ann Streissguth, believes that low IQ and more visible disability are protective because they make obvious the fact that the person has brain damage. Those without the facial features and those who have higher intelligence are far more likely to be seen as capable of changing behavior that, in fact, they have impaired ability to control.

The University of South Dakota has published a comprehensive FASD handbook, which contains tips for helping affected children learn (19).

Given the severe impact FASD has on its victim's entire life, prevention is obviously the optimal approach to the condition. In March 2009, the CDC and the Department of Health and Human Services released a report of the National Task Force on Fetal Alcohol Syndrome and Fetal Alcohol Effect, which discusses future directions for addressing the problem (20).

Women are increasingly aware that drinking during pregnancy is not safe-with, for example, 62% of women reported knowledge about the cause of FAS in 1985 and 73% reported awareness by 1990. However, studies of the impact of warning labels on bottles show little effect: one found a short-lived, modest decrease in drinking amongst African American women attending a prenatal clinic eight months after the labels were introduced, another found no association between awareness of the labels and drinking by pregnant women in the general population (21).

Prevention efforts aimed at heavy-drinking pregnant women do have some impact: screening for drinking problems alone and providing brief advice on drinking habits has been show to be effective in significantly reduced alcohol consumption amongst this group in one study (22).

One large trial of a similar “brief intervention” found that pregnant women who received this kind of advice were nearly twice as likely at those who did not to cut their drinking by 20% or more (23).

Teaching women how much they are actually drinking by using drinking glasses and computerized calculations of alcohol content in various drinks and discussing the actual birth defects linked with prenatal alcohol exposure also appears to help.

As with other interventions with heavy drinkers or drug-takers, it is important for those attempting to reach these stigmatized groups to be non-judgmental as other approaches seem to drive patients underground. This exacerbates harm to infants by pushing women away from prenatal care. Prenatal care is critical, both because it gives health professionals further chances of reaching women and helping them stop drinking and because it minimizes the chances of other damages to the fetus.

Since women who drink during one pregnancy are likely to drink during their next, and since those who do have FASD children as a result are more likely to have a more severe case in their next pregnancy, researchers have targeted women known to have consumed alcohol during at least one pregnancy.

A study followed 300 such women for up to five years, 96 of whom had one or more babies during the follow up period. Their average alcohol consumption was 16 drinks a week when they conceived the first child which brought them to the researchers' attention. Half were given a cognitive/behavioral intervention which advised them on the dangers of FAS, helped them set goals on reducing or preferably eliminating drinking while pregnant and gave them advice on how to meet their goals. The other half, the controls, were simply told that their baby would be healthier if they abstained while pregnant.

While 25% of controls drank at least 4 drinks a week, only 11% of the experimental group drank that much or more: less than half the control group's rate. And, amongst the women who did drink during these pregnancies, the amount consumed was half as much in the experimental group compared to the controls. The treatment group also had healthier babies as measured by neurological tests at 13 months. They had fewer babies with low birth weights and fewer premature babies (24).

Prevention efforts that would mitigate the damage done to fetuses if a woman cannot stop drinking while pregnant are controversial-however, animal research already suggests two potential medications—both already available for other uses-- that could possibly make FASD less likely. Buspirone, the anti-anxiety medication, for example, reduces some of the damage to the serotonin system caused by alcohol in rodents, as noted above.  Also, a 2009 study found that supplementing the diets of rats with the nutrient choline reduced many of the effects of alcohol on fetal development and eliminated behavioral effects of exposure (25).

Whether these drugs themselves are safe in pregnancy is not yet known. They may cause other side effects that this research did not pick up and of course, they may have different effects on humans. Political opposition against making drinking "safer" for pregnant women might prevent development of such medications - as might the liability fears pharmaceutical companies already have about developing any drugs for use in pregnancy.

However, given the extreme nature of the damage caused by FASD, if such a drug worked without side effects, such problems might be overcome.

Key Questions
Though research is beginning to help us understand FASD, very little is known about the true rates of these disorders in the population and whether they are increasing or decreasing.

The Centers for Disease Control and Prevention tracks drinking during pregnancy sporadically via its Behavioral Risk Factor Surveillance System Survey. The latest available figures show that 12.2% of women who were pregnant reported any drinking and 1.9% reported binge drinking, or having five or more drinks on a particular occasion in 2005, which is the most dangerous pattern in terms of FAS (26). This has not changed significantly since 1991.

Better ways to keep all women planning a child aware of the disorder and how to prevent it are also necessary, as is greater outreach to known heavy drinking women who become pregnant. FASD does not receive much media coverage these days, which could reduce public awareness of the severity of the problem and the need to prevent it.

Alcoholism in general is a difficult condition to treat-though many people recover, there is a hardcore group of people for whom it is a lifelong relapsing condition. Research is needed on the best treatment for women in this group - either to help them avoid pregnancy until they are in stable recovery or to help them begin alcohol abstinence rapidly if they do get pregnant. Because this treatment-resistant group is exactly the group most likely to have repeat FASD babies, research should be conducted on medications that might reduce the harm to these children if their mothers cannot or will not stop drinking.

Another big unanswered question is what works to help people with FASD and their families minimize the effects of this condition on their lives. There's anecdotal evidence about what works from the community of parents who support each other in dealing with these difficult to raise children-but systematic research to find the best ways to help them in school, with work and with socializing is sorely needed. Better data on medications like stimulants and behavior treatments like Multisystemic Family Therapy would also help answer these questions. A 2007 study systematically reviewed all the literature on “challenging behavior” of children exposed to substances of abuse, and found just three of them addressed intervention (and all showed some success). (27)

The need for research on how to help adults with FASD is acute. Many require a great deal of support in order to be able to manage their lives, but what kinds of help are the most effective and the least restrictive are not known. How to deal with conflicts between the civil liberties and rights of people with FASD given the problems they have in controlling their own behavior is an area of special concern, presenting difficult ethical problems.

Diagnosis is also an area that needs more research. Research suggests that diagnosis before age six by itself helps prevent against secondary disabilities- but many people with FASD are not diagnosed until much later. Parents, physicians, educators and law enforcement personnel are often unaware of FASD's symptoms and those who should screen for it often don't. As a result, many people with FASD are incarcerated or given inappropriate psychological or psychiatric treatment. Research is also needed to ensure against late diagnosis, misdiagnosis and over-diagnosis because of the subjective and morally charged elements of many FASD symptoms.

Finally, because people with FASD are likely to have contact with the criminal justice system at some point in their lives-and because they may be responsible for a disproportionate amount of petty crime and drug-related crimes- criminal justice authorities need to find effective ways to held people with FASD change their behavior. Drug courts, especially those with high levels of supervision, may prove useful; but they could also result in more people with FASD being incarcerated as such people are more likely to relapse than others with substance abuse problems.

Learning how people who have problems with executive function can be taught to manage their lives could be the critical element to solving most FASD-related criminal justice problems, since people with various impulse control disorders are disproportionately represented in prison populations. Like people with FASD, they are also over-represented in those who are sent to prison after noncompliance with treatment in drug courts. Understanding how to treat FASD effectively might help this larger problem as well, but right now, there is insufficient empirical evidence about what works and what doesn't.

FASD is an enormously complex problem-- but finding effective prevention and treatment could have huge benefits, not just for families struggling with the disorder, but also for other women with alcoholism and other children with similar learning and executive function disorders. Effective solutions could have a large impact on criminal justice and addiction treatment results more generally as well.


1. Relationship between dysmorphic features and general cognitive function in children with fetal alcohol spectrum disorders, by Ervalahti N, Korkman M, Fagerlund A, Autti-Rämö I, Loimu L, Hoyme HE. Am J Med Genet A. 2007 Nov 13;143A(24):2916-2923.

2. NIAAA Alcohol Alert #50, May PA and Gossage JP Estimating the prevalence of fetal alcohol syndrome: A summary. Alcohol Research and Health 25: 159-167, 2001.

3. Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus">Pubmed_ResultsPanel. Pubmed_RVDocSum&ordinalpos=1

4. Bertrand, J., Floyd, R.L., Weber, M.K., O’Connor. M., Riley, E.P., Johnson, K.A., & Cohen, D.E. (2004).

5. NIAAA Alcohol Alert #50, May PA and Gossage JP Estimating the prevalence of fetal alcohol syndrome: A summary. Alcohol Research and Health 25: 159-167, 2001.

6. Genetic polymorphisms: impact on the risk of fetal alcohol spectrum disorders, by Warren KR, Li TK. Birth Defects Res A Clin Mol Teratol. 2005 Apr;73(4):195-203.

7. Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=3


9. Carroll, L. Alcohol's toll on fetuses: Even worse than thought. NewYork Times, 11/4/03, p. F1.

10. NIAAA Alcohol Alert # 50.

11.Pre-natal exposures to cocaine and alcohol and physical growth patterns to age 8 years. Lumeng JC, Cabral HJ, Gannon K, Heeren T, Frank DA. Neurotoxicol Teratol. 2007 Jul-Aug;29(4):446-57. Epub 2007 Mar 12.

Growth, Development, and Behavior in Early Childhood Following Prenatal Cocaine Exposure A Systematic Review. Deborah A. Frank, MD; Marilyn Augustyn, MD; Wanda Grant Knight, PhD; Tripler Pell, MSc; Barry Zuckerman, MD JAMA. 2001;285:1613-1625.

12. 3f3eb9d444763920108f6ca66c63d3d6184cde2f&keytype2=tf_ipsecsha


14. Jacobson JL, Jacobson SW, Drinking moderately and pregnancy. Effects on child development.
Alcohol Res Health. 1999;23(1):25-30.

16. Pre-natal exposures to cocaine and alcohol and physical growth patterns to age 8 years. Lumeng JC, Cabral HJ, Gannon K, Heeren T, Frank DA. Neurotoxicol Teratol. 2007 Jul-Aug;29(4):446-57. Epub 2007 Mar 12.

Growth, Development, and Behavior in Early Childhood Following Prenatal Cocaine Exposure A Systematic Review. Deborah A. Frank, MD; Marilyn Augustyn, MD; Wanda Grant Knight, PhD; Tripler Pell, MSc; Barry Zuckerman, MD JAMA. 2001;285:1613-1625.

17. Link

18. Streissguth AP Barr HM Kogan J Bookstein FL, Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome and fetal alcohol effects. Final report to the Centers for Disease Control and Prevention, August 1996 (Tech. Rep. No. 96-06).




22. Bertrand, J., Floyd, R.L., Weber, M.K., O’Connor. M., Riley, E.P., Johnson, K.A., & Cohen, D.E. (2004)

23. Manwell LB, Fleming MF, Mundt MP, Stauffacher EA, Barry KL. Treatment of problem alcohol use in women of childbearing age: results of a brief intervention trial. Alcohol Clin Exp Res. 2000 Oct;24(10):1517-24.

24. Prevention research above reviewed in Hankin, JR, Fetal Alcohol Syndrome prevention research, Alcohol Res Health. 2002;26(1):58-65.

25. Link

26 .Link

27. A systematic review of challenging behaviors in children exposed prenatally to substances of abuse, by Dixon DR, Kurtz PF, Chin MD.  Research in developmental disabilities, 2007 Nov 22.