Since September 27, 2022, Fetal Alcohol Spectrum Disorders (FASD) has been included in the eligibility definition of Other Health Impairment. Dr. Bylund addressed FASD in this informative training, setting out definitions, symptoms and traits, assessment, and interventions. Key concepts from his training are presented below.

What is FASD?

FASD is an umbrella term used to refer to individuals affected by prenatal exposure to alcohol, which includes those with Fetal Alcohol Syndrome (FAS), alcohol related neurodevelopmental disorder (ARND), and alcohol related birth defects (ARBD). FAS characteristics includes prenatal and/or postnatal growth deficiencies, facial dysmorphic features, such as widely spaced eyes and a smooth upper lip, and a range of neurodevelopmental and/or neurobehavioral features that do not follow the typical trajectory of other disorders. ARND does not have impaired growth or dysmorphic facial features but does have the neurodevelopment and neurobehavioral deficits. ARBD involves congenital abnormalities such as impaired organ functioning, hearing loss, and impaired vision). Dr. Bylund noted that FASD impacts 1 in 20 in the US, more than twice the number of people with autism. In California, as many as 300,000 students may have FASD. Diagnostic criteria are included in the DSM-5 and eligibility is derived from these.

Impacted Brain Structures

The frontal lobes, hippocampus, amygdala, and the autonomic nervous system (ANS) are specifically impacted by alcohol exposure in utero. Given the impacted areas, it is unsurprising that people with an FASD experience issues with executive functioning, impaired emotional regulation, and struggle to regulate their response to fear and threats, often incorrectly perceiving threats and remaining on alert beyond the immediate danger.

Areas to Assess

Parent/Guardian Interview

Dr. Bylund recommended asking about prenatal exposures to drugs and alcohol in a parent interview, understanding it is a sensitive question. Additionally, a comprehensive health and education background is required.

Adaptive Skills

School psychologists should look for impaired adaptive skills that get worse, rather than better, with age. The phrase ‘developmental arrest’ is used to describe this dynamic. Specifically, deficits in planning and problem solving stand out.

Executive Functioning

School psychologists should consider investigating executive functioning using self, teacher and parent report, and continuous performance tests. Dr. Bylund reported that ‘more than 60% of children with prenatal alcohol exposure exhibit inattention and/or hyperactivity’ (Mattson, Crocker, & Nguyen, 2011). Further, ‘children affected by FASD often show deficits on tasks requiring vigilance, reaction time, and information processing’ (Mattson, Crocker, & Nguyen, 2011). As in adaptive skills, Dr. Bylund noted that executive functioning may deteriorate in adolescence in FASD.

Cognitive Functioning

Cognitive assessment should be given, however not all FASDs result in a below average FSIQ. Specific cognitive areas to examine include memory (studies have shown impaired verbal memory on list learning tasks v. story memory tasks, and poorer learning and recall rates on visual memory, making the WRAML-3 a strong choice). Additionally, expressive, and receptive language should be assessed (Dr. Bylund noted that expressive language may be relatively stronger than receptive) and visual spatial processing. Academically, math is a common weakness with FASD and many struggle with abstract concepts such as time and money. The inability to understand abstract concepts means information needs to be presented in concrete language with visual cues whenever possible.

Motor Functioning

Studies show that as many as half of students with FASD have fine motor impairments, while nearly a third have gross motor impairments.

Social Emotional Functioning

Due to damage to the ANS, people with FASD may struggle to respond appropriately to stress or strong emotions. This dynamic is well explained by the Polyvagal Theory. Studies show externalizing, internalizing, and anxiety has been linked to FASD.

Sensory Processing

Over- or under-reactions to sensory stimuli are reported by many with FASD, though not tied to DMS-5 diagnostic criteria. It is expected that FASD assessment is multidisciplinary, including Occupational Therapists, Speech and Language Therapists, Physical Therapists, and possibly adaptive physical education teachers.

Interventions

Dr. Bylund indicated that standard interventions can be considered for students with FASD. However, standard interventions should be accompanied by a mindset of unconditional positive regard, an understanding that difficulties are related to the brain, not behavior, a mindfulness of sensory stimulation, and a bias toward routines and continuity. Interventions are complicated by a dysregulated ANS, meaning that instructors need to emphasize stability, de-escalation strategies, and environmental modifications to maintain a tolerable stress level. Teaching students to recognize their own stress responses, and to be able to describe the three states increases self-awareness and can help improve regulation. Emphasis on concrete language is important. Activities involving art, movement and drama may provide an opportunity for processing stress responses and emotions in a safe way.