1. Behavioral Phenotype (Kodituwakku, 2007) A characteristic pattern of motor, cognitive, linguistic, and social observations consistently associated with a biological disorder (O’Brien & Yule, 1995) Causal connections between PAE and neurobehavioral effects are difficult to make because of the interaction of environmental and genetic factors.

2. Cognitive Functions (Kodituwakku, 2007) Intellectual ability: decreased IQ in children and adults with FASD. Some dose-dependent effects Deficits in both verbal and performance aspects Attention and speed of processing: Significant deficits in sustained and focused attention. Slower processing speed

3. Cognitive Functions (Kodituwakku, 2007) Executive Functioning (EF): higher-order cognitive processes involved in goal-oriented behavior such as planning, inhibition, working memory, set-shifting, flexible thinking, strategy use, fluency and behavior regulation. These EF deficits in FASD have been documented on tests of cognitive flexibility, inhibition, planning and strategy use, concept formation and verbal reasoning, set-shifting, working memory measures, and fluency – all cognitive-based or ‘cool’ EF tests. Also show deficits on ‘hot’ EF tests assessing emotion- related behaviors and decision making.

4. Cognitive Functions (Kodituwakku, 2007) Language: some mixed effects but generally poorer language abilities. Visual Perception: Most impaired on tasks that involve integration of information, planning, and visual-motor integration. Learning and Memory: slower at learning Deficits on both visual and verbal memory tasks.

5. Cognitive Functions (Kodituwakku, 2007) Number Processing: although children with FASD have difficulties in many academic areas, math appears to be the most severely affected. Streissguth et al. (1994) conducted a large longitudinal study on children with PAE. Out of many cognitive and academic tests, math was the most difficult and most highly correlated with PAE. These math deficits were stable over time Effects were generally dose-dependent Math deficits in FASD are even lower than expected based on IQ scores.

6. Behavioral Dysfunction (Kodituwakku, 2007) Classroom Behaviors: distractible, inattentive, hyperactive, and restless Adaptive Behavior: personal and social skills needed to live independently Most deficits in social skills, interpersonal relationships One study of adolescents and adults with FASD (mean age 17 years) found adaptive functioning skills to be at the level of a 7-year-old (Streissguth et al., 1991) Emotional Functioning: mental health disorders and emotional difficulties

7. Atypical Brain Development (Kodituwakku, 2007) Decrease in white matter and increase in gray matter Abnormalities in: Frontal lobe Corpus Callosum Basal Ganglia Cerebellum

8. FASD The incidence of FASD is estimated to range from 3-10 /1000 births. FASD is one of the most common known causes of mental retardation. Lifetime cost of FASD is estimated to be $1.5 - 2 million per person. A recent Canadian study estimates annual costs of FASD at $344,208,000 for care of those less than 21 years of age.

9. FASD and Risky Behaviors (Rasmussen & Wyper, 2007) Primary disabilities: those which directly result from the brain injuries of PAE and are evident in some form from birth. –Intelligence, memory, attention Secondary Disabilities: result from primary disabilities and environmental interactions and are not evident from birth –In theory they are preventable with better understanding of appropriate interventions

10. Secondary Disabilities Streissguth et al. (1996) conducted a longitudinal study on secondary disabilities in FASD. The Life History Interview (LHI), which measures common secondary disabilities, was administered to 415 individuals (6-51 years old) with FAS and FAE. The results were astounding: 1)More than 90% of the sample had mental health problems 2)49% of the adolescents/adults and 39% of the children demonstrated inappropriate sexual behaviors

11. 3)More than 60% of adolescents/adults and 14% of the children had disrupted school experience 4)60% of adolescents/adults and 14% of the children had been in trouble with the law 5)50% of the adolescents/adults had been confined (e.g. incarceration, inpatient mental health programs, or alcohol and drug treatment programs) 6)35% of the adolescents/adults had alcohol and drug problems. 67% had experienced physical or sexual abuse, or were victims of domestic violence 80% were not reared by their biological mother

12. Risk Factors Three risk factors were identified that were associated with higher rates of secondary disabilities: a) being diagnosed with FAE rather than FAS b) having an IQ above 70 c) higher scores on the Fetal Alcohol Behavior Scale which measures behaviors of fetal alcohol exposure Thus, having less severe physical effects (FAE instead of FAS) and a higher IQ were associated with a higher rate of secondary disabilities.

13. Protective Factors Streissguth et al identified 5 protective factors that resulted in lower rates of secondary disabilities: a)living in a good quality stable home environment b)infrequent changes in living arrangement c)not being exposed to violence d)receiving services for developmental disabilities e)being diagnosed before the age of 6.

14. Delinquency and FASD Maladaptive behaviors: impulsivity, teasing/bullying, dishonesty (lying, cheating, stealing), avoiding school or work, destruction of property, physical aggression, and self-injury behaviors (LaDue et al, 1992). FASD linked to behavior problems and delinquency in adolescents (Carmichael Olson et al., 1997). Children with PAE have higher rates of delinquent behaviors than children with ADHD, including cruelty, bullying (48% of children), lying or cheating (90% of children), and stealing. –97% children with fetal alcohol exposure lacked guilt after misbehaving. Nash et al (2006)

15. Delinquency and FASD PAE is also associated with conduct behaviors and lower overall moral maturity (Schonfeld et al., 2005) –Home environment related to delinquency in that youth living in biological or foster homes were more likely to engage in delinquent behaviors than youth living in adoptive homes. It is clear that individuals with FASD are particularly prone to delinquent behaviors; however some researchers suggest that this may be due to factors (e.g., family and individual characteristics) other than prenatal alcohol exposure (Lynch et al, 2003).

16. FASD and the Criminal Justice System Adolescents and adults with FASD are at particular risk for ending up in the criminal justice system. In Streissguth’s studies 60% of adolescents and adults with FASD had been in trouble with the law and 50% had been confined. A Canadian study found that 23% of youth remanded for a psychiatric inpatient assessment had an FASD (Fast et al., 1999). A recent Canadian report indicated that 10% of inmates had an FASD, which is 10 times higher than in the general population (Sandrers, 2007).

17. FASD and Psychopathology High rates of psychiatric disorders among children with PAE: 87% met criteria for a psychiatric disorder including mood disorders (61%), bipolar disorder (35%), major depressive disorder (26%) (O’Connor et al., 2002) –PAE is linked to depressive symptoms among 6-year-old girls (O’Connor et al., 2001). In one study 97% of the alcohol-exposed children were diagnosed with an axis 1 disorder (Fryer et al., 2007) –ADHD, depressive disorders, oppositional defiant disorder (ODD), conduct disorder (CD), phobias Adults with binge alcohol exposure have higher rates of many disorders including: somatoform, substance dependence/abuse, paranoid, passive-aggressive, antisocial, and personality disorders (Barr et al (2006)

18. FASD and Substance Abuse PAE associated with alcohol problems in adolescents and adults (Baer et al. 2003) In one sample of adults with PAE, 25% had an alcohol disorder. (Alati et al., 2006) PAE is associated with the development of nicotine, alcohol and illicit drug dependence, even when biological parental alcohol abuse is controlled for. (Yates et al, 1998).

19. FASD and Suicidality Adolescents and adults with FASD are at risk for suicide and attempted suicide. O’Malley and Huggins (2005) carried out a pilot study of 11 individuals affected by FASD. Over half (6) of the participants reported attempted suicide, a rate that is drastically higher than the general Canadian population rate of 4.6%.

20. Factors Relating to Risky Behaviors in FASD The significant EF deficits in individuals with FASD likely contribute to high risk behaviors. Impairments in EF skills such as planning, cause- effect reasoning, learning from past mistakes, and the lack of social adaptability may be related to why youth with FASD are overrepresented in the justice system. The connection between poor executive functioning and juvenile delinquency has been well-documented in other populations. –Adolescent/adult offenders are impaired on many tests of EF –Inhibition appears to be one aspect of EF that is strongly related to delinquency and high risk behaviors.

21. Factors Relating to Risky Behaviors in FASD Poor decisions making, linked to frontal lobe Individuals with frontal lobe damage show similar risky and maladaptive behaviors as those with FASD. PAE has a negative effect on the frontal cortex, thus putting individuals with FASD at increased risk for engaging in problematic behaviors. Risk taking increases during adolescence because they are more sensation-seeking and reward-driven but have a prefrontal cortex that is still developing. In FASD, adolescence is a time of heightened vulnerability, as these individuals have even more of a gap between their brain/cognitive development and their behaviors.