Excerpted from Fetal Alcohol Syndrome: A Guide for Families and Communities, by Ann Streissguth, Ph.D.

Copyright © 1997 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

It was January 1973. I was in shock. I had just finished administering a psychological examination to the seventh young child in the group that Jones and Smith, my dysmorphology colleagues (physicians with expertise in congenital malformations), had asked me to see. Although the seven children represented three racial groups and were not themselves related, they looked eerily alike: small, sparkly eyes; small heads; and an appearance about the mouth that appeared as though they were pursing their lips even when they weren't smiling. Except for the two who were still infants and the one who was so flaccid she was carried in the arms of her mother, the other children had a wispy, flighty quality. I thought to myself that these children who were so curiously and surprisingly unafraid of me were like butterflies.

These children clearly had brain damage. To an experienced clinician, their neurological insults were as obvious as the aftereffects of meningitis or encephalitis. Each of these children had experienced damage to his or her central nervous system (CNS) that was apparent in his or her erratic movements, poor coordination, flighty attentional states, and poor performance on psychological tests, despite a captivatingly alert and bright-eyed manner.

"You think that alcohol causes this?" I asked incredulously of Jones and Smith. "Well, we think so; their mothers were all alcoholic and drinking heavily throughout pregnancy," they explained. "But, wouldn't someone have written about this? Wouldn't someone have studied the effects of alcohol on the unborn child?" I asked in disbelief. "Not that we know of," they replied.

I dashed to the medical library, expecting to find information on alcohol and pregnancy but found nothing. After weeks of intensely searching the national and international citations, I realized that Jones and Smith were right--the available medical literature in 1973 contained no information whatsoever about the effects of alcohol on pregnancy and the unborn child.

I imagined the myriad of pregnant women consuming alcohol throughout the world. If this carries even the slightest risk of damaging their infants, shouldn't they have the right to know? I decided to spend 10 years of my professional life examining this unsettling question. Twenty years later, I decided to write this book.

* * *

People with fetal alcohol syndrome (FAS) are born with it. FAS is a birth defect that has its primary effect on the brain. Some people with FAS are slightly affected and manifest only mildly dysfunctional behavior; others are severely affected, devastatingly disabled in their ability to cope with even simple day-to-day interactions. Each child with FAS has his or her own special needs, problems, and capabilities. FAS is a birth defect whether or not it is not noticeable at birth. One does not outgrow FAS, although the manifestations may change with age. A bad environment (e.g., one in which there is abuse, neglect, or poverty) cannot cause FAS, just as a good environment (e.g., one with loving, caring parents) cannot fully undo it. A good environment and proper community supports, however, can protect the person with FAS from secondary disabilities, which can also be debilitating.

FAS is caused by prenatal alcohol exposure and characterized by growth deficiency, a specific pattern of facial features, and some signs of CNS dysfunction.

Prenatal Alcohol Exposure Can Cause a Spectrum of Effects

Prenatal alcohol exposure does not always result in FAS. Depending on the dose, timing, and conditions of exposure as well as on the individual characteristics of the mother and fetus, prenatal alcohol exposure can cause a range of disabling conditions. Some children are diagnosable with the full FAS; others have only partial manifestations, usually the CNS effects without the characteristic facial features or growth deficiency. Children who have only some of the characteristics of FAS (i.e., not enough for a full diagnosis) are often said to have fetal alcohol effects (FAE) or possible fetal alcohol effects (PFAE). These terms, although useful descriptively, have no specific differentiating criteria that would warrant their own diagnoses, even though these syndromes can be just as debilitating as FAS. In 1996, the term alcohol-related neurodevelopmental disorder (ARND) was introduced by the Institute of Medicine (IOM, Stratton, Howe, & Battaglia). Focusing on the CNS characteristics (rather than on the growth deficiency and characteristic face), ARND is used congruently with FAE in this book. As these CNS effects can be caused by alcohol but are not unique to alcohol, the terms FAE, PFAE, and ARND are not appropriately used in the absence of a prenatal alcohol exposure history.

Research has shown that people with both FAS and those with FAE/PFAE/ARND experience many of the same kinds of problems growing up. Their families and communities also face many of the same kinds of challenges raising them. Therefore, this book frequently refers to these terms in the collective (i.e., FAS/FAE) in tacit recognition of the fact that it is the behavior problems caused by the prenatal damage from alcohol that present the primary challenge to treatment and management.

People with FAS/FAE, 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 sites and degrees of prenatal brain damage due to different levels, patterns, and timing of prenatal alcohol exposure and individual differences in mothers and offspring. Despite their wide array of talents and abilities, many people with FAS exhibit some of the same general behavioral characteristics. They are usually trusting (even overly trusting), loving, and naive despite their years. They can also be grumpy, irritable, and rigid. As a result of their prenatal brain damage, they may have difficulty, especially as they mature, in evaluating a situation and using their past experiences to cope with the problems at hand. They seem to need more protection, supervision, and structure for a longer period of life than usual. Individuals with both FAS and FAE also vary widely in their ultimate outcomes and in the number of "secondary disabilities" that they acquire as they mature. In 1996, research from the University of Washington indicated that these secondary disabilities become more and more observable in people with FAS/FAE as they mature (Streissguth, Barr, Kogan, & Bookstein, 1996). Extremely high rates of mental illness as well as high rates of disrupted school experiences, trouble with the law, and alcohol and other drug problems are alarming. These secondary disabilities can be as debilitating as the primary disability--the brain damage--with which they were born. Many individuals with FAS/FAE need ongoing help across the life span--anything from a protective environment to a trusted friend, spouse, or advocate to help them stay grounded and focused.

Research, however, has also shown that there are "risk" and "protective" factors associated with these secondary disabilities. In other words, there are things that families and communities can do that can truly make a difference in what happens to children with FAS/FAE as they mature. But orchestrating these (i.e., mobilizing the "protective" factors and diminishing the "risk" factors) hinges on understanding the cause of the child's problems (i.e., getting a diagnosis).

Problems with Getting a Diagnosis

A diagnostic evaluation is the starting point for understanding, treating, and managing any medical condition. Yet, surprisingly, despite 2 decades of research and clinical observations, it remains difficult for families to find diagnosticians and clinicians specializing in FAS/FAE. An appropriate diagnosis and an understanding of that diagnosis can help families set realistic expectations, plan for some successes in their children's lives, and build a network of support and structure (see the discussion of an advocacy network in Part III). Diagnostic information about FAS not only helps people to better understand the syndrome's accompanying challenges, but also facilitates appropriate treatment, intervention, and planning.

Experienced parents and teachers know that the every-day behaviors of children with FAS/FAE can be "unexpected," "perplexing," and even "unusual." Yet, because these particular behaviors have not yet been clearly linked to structural anomalies in the human brain and because they have not yet been described in the authoritative listing of mental disorders (The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition [DSM-IV], American Psychiatric Association [APA], 1994), many professionals do not yet have the nomenclature to fully understand the syndrome and its implications or really "hear" what parents are saying. Although the field has grown dramatically since the mid-1980s, much confusion still exists, and there remains a gap between scientific knowledge and general clinical information. Often, parents have had to advocate for children whom they suspected had been prenatally affected by alcohol--searching out diagnosticians willing to diagnose this often-unheard of condition, searching out teachers willing to be instructed in appropriate educational methods, and searching out mental health and social services professionals willing to offer their children the extra support and understanding their condition requires.

* * *

As I was packing for an extended trip, the frantic mother of a 16-year-old boy with FAS called. She and her husband had just returned from a parent conference with Max's school psychologist. According to her report, the psychologist had indeed heard of FAS and, in fact, had read enough to know that children with FAS simply had mental retardation. Therefore, he concluded after examining this adolescent that Max couldn't possibly have FAS because with a performance IQ well into the normal range and a verbal IQ at the lower end of normal, he clearly wasn't mentally retarded. Furthermore, the psychologist was positive that Max had only attention-deficit/hyperactivity disorder and a conduct disorder and warned his parents against putting labels such as FAS on him because they would thwart his development.

The mother begged me to give Max some test that would prove that their son had the brain damage associated with FAS, so that he could get the help and support they knew he needed. Although we did work out a plan, her quest has no easy solution. The tests have not yet been developed, and the research has not yet been done. Understanding the personal consequences of FAS/FAE on children and families and on society at large should accelerate both prevention and intervention effects once the magnitude of the problem is recognized.

* * *

Incidence of FAS

It is important to outline what is known about prenatal alcohol exposure, which causes FAS/FAE. Alcohol is a teratogen (i.e., any agent or chemical that causes a birth defect). In fact, alcohol is the most frequently used teratogen in the world. Alcohol is an addictive, but entirely legal, drug. According to the Assistant Secretary of Health (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1990), more than 10 million adults in the United States are addicted to alcohol. An additional 7 million abuse alcohol but are not addicted. Many of these 17 million are women in their childbearing years.

Thousands of experiments with laboratory animals have shown conclusively that alcohol can cause birth defects in almost any species, even when it is not coupled with other drug use. Among humans, prenatal alcohol exposure can and does affect children of all races and socioeconomic backgrounds. Researchers at the IOM (1996) estimate that between 0.5 and 3.0 of every 1,000 infants are born with some degree of FAS. (For additional information, see Cordero, Floyd, Martin, Davis, & Hymbaugh, 1994; Dehaene, 1995; Dehaene et al., 1991; May, Hymbaugh, Aase, & Samet, 1983; NIAAA, 1990; and Sampson et al., 1996.) If this estimate is accurate, 2,000--12,000 of the projected 4 million children born in the United States each year will have FAS to some degree.

The most accurate estimates of incidence come from a small number of studies that used expert diagnosticians. Large variations can exist from one study population to another depending on the rate of maternal alcohol abuse and the study design. The NIAAA (1990) estimated that 1.9 in every 1,000 children are born with FAS or ARND, a rate that is nearly double the incidence of Down syndrome and almost five times that of spina bifida, two of the most commonly recognized birth defects. The NIAAA (1990) also estimated that FAE (as a clinical categorization) occurs three times more often than FAS. New studies, however, suggest higher rates--namely that 9.1 per 1,000 children are born with FAS or ARND (Sampson et al., 1996).

On some Indian reservations, where alcohol abuse is common among women, FAS has been reported in 1 in 100 children (May et al., 1983). In one small Native American community, the incidence of FAS was 1 in 8 (Robinson, Conry, & Conry, 1987). At that frequency, FAS is a community catastrophe that threatens to wipe out any culture in just a few generations. However, FAS is not a Native American problem nor a problem of poverty. It is an alcohol problem, and it is our problem.

Because it is caused by alcohol, FAS is completely preventable. Yet, it continues to swell the ranks of people with mental retardation. In fact, FAS is the most common cause of mental retardation (NIAAA, 1987). In one large study conducted throughout Sweden, more cases of mental retardation resulted from alcohol-related birth defects than from all other known genetic causes of mental retardation combined (Hagberg, Hagberg, Lewerth, & Lindberg, 1981).

Problems with Studying the FAS Population

Studying children affected by alcohol involves special problems. Alcohol is a legal drug, openly sold and advertised throughout the country. Alcohol is primarily a social drug, used in American society to celebrate or commemorate every occasion from marriage to death. Just as the alcoholic often uses denial to ward off awareness of impending alcoholism, society seems to use denial to avoid facing the fact that alcohol can be damaging to the next generation. It is more comfortable and easier to wage a war on illegal drugs than to face the not-so-hidden dangers that alcoholic beverages pose to the fetus.

To further complicate the issue, infants and children with FAS/FAE often appear physically quite "normal," which can prevent them from obtaining the help and services they need. Unlike many birth defects, which are identified at birth and often treated surgically, FAS and FAE are usually overlooked at birth and treated later by community professionals--often unknowingly. Because damage to the brain can occur at lower doses of alcohol than those that produce gross physical anomalies or low birth weights, the brain is the most vulnerable organ in the body to the effects of prenatal alcohol. Unfortunately, we don't yet have the technology to see the brain in living people in a manner that distinguishes the subtle disruptions that shape our misperceptions and guide our maladaptive responses.

In fact, the individual features of FAS are subtle enough that many people with this birth defect pass through life undiagnosed. Certainly, most occurrences of FAS are not recorded on birth certificates, making it useless to try to obtain this data from the usual birth defects surveillance registries that were set up to measure major congenital defects (e.g., club foot, cleft lip or palate). Consider for a moment the difficulty in detecting these subtle features in a newborn in the midst of a busy urban obstetric practice, especially when there is little time to talk with mothers about their drinking. Little and colleagues (1990) have shown a 100% failure rate in detecting FAS in one of the largest maternity hospitals in the country. Unless occurrences of FAS/FAE are associated with gross physical malformations, they often remain undetected in the newborn baby.

FAS and FAE are usually "hidden" birth defects that primarily affect the brain, a condition about which neither medical science nor society has much understanding beyond the general awareness that heavy prenatal alcohol use is bad for the outcome of pregnancy. For example, the 1990 National Health Survey of more than 50,000 women found that although 89%--92% of all women knew that heavy drinking during pregnancy could increase the chances of miscarriages, mental retardation, low birth weight, and birth defects, only 29% of women of childbearing age could correctly identify FAS as a type of birth defect. Most thought it meant being born drunk (Dufour, Williams, Campbell, & Aitken, 1994).

The effects of FAS are difficult to fathom--subtle disruptions in the proliferation and migration of the brain cells that provide the architecture for later problem solving and subtle deviations in the neurochemical balance that permits the transport of message from one part of the brain to another. When these processes are disrupted, it is difficult to store, retrieve, and transform past experiences into knowledge in order to modify future behaviors--a source of great frustration for those with FAS and a cause of dysfunctional and maladaptive behaviors.

Dysfunctional behavior is difficult to treat effectively, even when its causes are understood. When dysfunctional behavior occurs in children with undiagnosed FAS/FAE, the cause remains unknown and the children's behavior remains an enigma. As a result, the problem behaviors of people with alcohol-related birth defects are being regularly dealt with in schools, community mental health centers, and alcohol and other drug abuse treatment programs as well as through juvenile justice and adult corrections facilities. By failing to diagnose these people as having FAS/FAE and by failing to understand that their unpredictable and often bizarre behaviors stem from organic brain damage with which they were born, human services providers run the risk of actually causing more of the problem behaviors they are trying to ameliorate.

Much research is needed, particularly on recommended practices for treatment, education, job training, and management, but policy change is also needed to reduce barriers to existing services that people with FAS/FAE need but for which they often do not qualify. Every dollar spent on education, prevention, and intervention will reap benefits in future savings. Once the syndrome is fully understood, effective action is possible. Already, much is known that can benefit the lives of people with FAS/FAE and their families; there is no need for families or communities to wait another minute before putting this knowledge into action. This book seeks to provide this understanding necessary for effective action.

Overview of Sections

Preview of Part I: The Diseases of Fetal Alcohol

In most communities around the country, it is far too difficult to obtain a diagnostic evaluation. This is a huge obstacle to prevention, effective intervention planning, and community awareness and understanding. Part I of this book provides an overview of the spectrum of effects related to prenatal alcohol exposure. Chapter 2 describes the diagnostic process, including the importance of taking relevant prenatal alcohol histories. Chapter 3 gives a brief overview of the remarkable progress of a 25-year period of history in which the country moved from the initial awareness that prenatal alcohol exposure could damage the fetus to scientific validation and an effective and appropriate public policy for prevention.

Preview of Part II: Scientific Evidence of Fetal Alcohol Syndrome

Part II describes the research evidence produced during the 25-year period in which much of the mystery surrounding FAS/FAE was resolved. Chapter 4 explains why alcohol is a teratogenic drug and the magnificent body of animal studies that have documented the teratogenic properties of alcohol and how these are relevant to the human condition. Chapter 5 documents the impact of alcohol on children, reviewing studies on children born to alcoholic mothers in countries around the world and the impact of alcoholism on families (including fathers and the mothers themselves). It also reviews the population-based studies on the effects on children whose mothers drink socially during pregnancy, especially focusing on the neurobehavioral findings. Chapter 6 describes research on the organic brain damage (the primary disability of FAS) caused by fetal alcohol exposure and latest findings from a 1996 study of the largest group of people with FAS/FAE ever evaluated. Data on the frequency of "secondary disabilities" in people with FAS/FAE is useful to parent and community leaders in planning interventions and providing services for this population. For the first time, data is now available on environmental factors that increase the risk of these adverse "secondary disabilities" as well as those conditions (e.g., an early diagnosis, a stable and nurturing home, appropriate services) that "protect" individuals against secondary disabilities.

Preview of Part III: A Life-Span Approach to FAS

Part III presents a life-span look at FAS/FAE, based on data from clinical observations and from the reflections of individuals with FAS/FAE themselves and their parents and caregivers. Chapter 7 describes characteristics and needs of, as well as recommendations for, people with FAS/FAE from infancy to childhood. It also describes several ways to test some common misperceptions. Chapter 8 describes the advocacy model for helping people with FAS/FAE, answering such questions as What is an advocate? Who can be an advocate? What makes an advocate successful? and How can effective advocacy prevent or improve secondary disabilities? Chapter 9 is about families, including biological, adoptive, and foster families--virtually anyone involved in raising an individual with FAS/FAE. In telling their own stories, the families express their needs. Community leaders and service providers can learn much from these families in terms of interacting with and designing interventions for people with FAS/FAE.

Part IV: Preparing People with FAS for Life in the Community

Part IV is about preparing people with FAS/FAE for life in the community. Chapter 10 describes how families can begin early in planning for healthy lives for their young children with FAS/FAE and the support systems that communities must have in place in order to respond to the needs of those patients and their families. Chapter 11 gives specific recommendations for school districts and educators in meeting the challenges presented by students with FAS/FAE. A 10-step school plan for students suspected of having FAS/FAE is described, along with guidelines for incorporating the advocacy model into their educational plans. Chapter 12 presents strategies for effective management of people with FAS/FAE as they come under the jurisdiction of community institutions providing social services, namely corrections and juvenile justice, alcohol and day treatment, and mental health treatment programs. Guidelines for screening individuals for FAS/FAE at intake and developing an effective management or treatment plan as well as for after-care and continuing care management and advocacy.

Part V: Preventing Fetal Alcohol Syndrome

Part V deals with preventing FAS and FAE, a vital concern for all communities. Effective strategies for educating the public, training professionals, and changing public policy are described in Chapter 13. The Surgeon General issued a warning on alcohol and pregnancy in 1981, recommending that women refrain from alcohol consumption when pregnant or planning a pregnancy. Chapter 14 presents effective programs to intervene with mothers who abuse alcohol and other drugs during pregnancy. There is even a way to help those who do not obtain prenatal care.

* * *

Flying home from a trip, a beautiful older woman seated beside me inquired about my work. When I told her that I was writing a book on FAS, she said she'd never heard of it. As I explained more about FAS, she became intensely interested, asking very perceptive questions. Finally she said, "Well, that must be what's wrong with Daryl!"

"Who's Daryl?" I asked.

She told me this story: "When my husband and I were young, our three children grew up very closely with the three adopted children of our best friends. Daryl was the middle child of those three adopted children. From the start, Daryl seemed different--as though he were born irritable. He was never a 'bad kid'; he just never seemed to 'get it.' When he was older, he researched his biological family and learned that both parents were alcoholics. Now all of the children are in their 50s, and he's the only one that just never got his life together. He got married all right and had three children, but the marriage fell apart, and now my friends, the grandparents, are raising his three children. Daryl can never hold a job--he just goes from one thing to another, always talking these big pipe dreams about what he's going to do, but never does...."

As she spoke, my mind drifted to Johnny, one of my former patients who was fortunate to have been examined at age 3 by David Smith and diagnosed as having FAS. The diagnostic information about FAS, coupled with his own good sense and compassion, was enough to keep Johnny's father (who had custody of him) constantly vigilant to Johnny's needs at every age. The first thing he did was to find "Miss Pearl," an amazing special-needs preschool teacher who worked exclusively with Johnny at first, and later with a handful of other children, to help Johnny find alternate routes to learning in order to work around his cognitive disabilities. It was a long hard road, but the knowledge he gained after learning of the FAS diagnosis helped him to be able to understand how the world of first grade must have looked to feisty little Johnny when he bit and scratched at kids who teased him and when he couldn't remember his lessons.

Now Johnny is a grown man with a fairly responsible job in the armed services. Recently, I met with him and his father, who smiled modestly at Johnny's success. The two explained to me that one of the virtues of his placement is a system of checks and balances: Although Johnny checks on the work of others, there are also people above him checking on his work.

"A lot of the credit goes to Johnny" his father said. "He's really pulled himself up. He's developed a system for doing what he calls 'work arounds.' Because he thinks he's wired a certain way that is different from other people, he finds ways to 'work around' his problems."

Johnny explained, "Everybody's wired one way or another--it's like my brain's not in the same order as everybody else's. It's like I'm wired differently. Most people think in terms of a-b-c-d. I think a-g-y-b-x-c. I have to take a different route to get there. My route takes me longer but doesn't mean I can't get there. It's like I learn slower. I can't remember eight numbers, maybe I can do only four or five. But I just use a post-it note. I find a way to solve the problem; I write it all down. I had to learn how to do lots of abbreviations to write it all down."

When I asked Johnny what he'd like me to tell other families about raising people with FAS/FAE, he said, "People like me need lots of love and support and a good moral system. Teach us right and wrong and build us a web of support and good friends, trusted people we can easily call to back us up. Besides love and attention, we need someone sitting down and telling us when we've done something wrong. Focus on what makes us feel good about ourselves. Self-confidence is a real problem, as is hypersensitivity. Create your personality so you can be like a sponge and a mirror: A mirror is to reflect away the things you don't want to become part of yourself, the bad things, and a sponge to soak in the good things that will help you."

Daryl's home life was probably as stable as Johnny's (maybe even more so, as Daryl had two loving parents), but Johnny was raised knowing the cause of his dysfunctional behavior and his father realized that his actions were a sign for help, the manifestation of a subtle birth defect of the brain that required some special planning and support. Working with families like Johnny's over so many years has taught me how effective parents can be as advocates when they're properly informed of the child's diagnosis at an early age and encouraged to put that into the perspective of their own child's individuality.

...I returned from my reverie when she stopped talking. "Yes," I replied, "it's a sadly familiar story. That's why I 'm writing this book."

References

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Dehaene, Ph. (1995). La grossesse et l'alcool [What happened to me? The growing child and alcohol].Que Sais-Je? Paris: Presses Universitaires de France.

Dehaene, Ph., Samaille-Villette, C., Boulanger-Fasquelle, P., Subtil, D., Delahousse, G., & Crépin, G. (1991). Diagnostic et prévalence du syndrome d'alcoolisme fœtal en maternité [Diagnosis and prevalence of fetal alcohol syndrome]. Presse Médicale, 20, 1002.

Dufour, M.G., Williams, G.D., Campbell, K., & Aitken, S. (1994). Knowledge of FAS and the risks of heavy drinking during pregnancy, 1985 and 1990. Alcohol Health and Research World, 18(1), 86-92.

Hagberg, B., Hagberg, G., Lewerth, A., & Lindberg, U. (1981). Mild mental retardation in Swedish school children: I. Prevalence. Acta Paediatrica Scandinavica, 70, 441-444.

Institute of Medicine (IOM), Stratton, K.R., Howe, C.J., & Battaglia, F.C. (Eds.). (1996). Fetal alcohol syndrome: Diagnosis, epidemiology, prevention and treatment. Washington, DC: National Academy Press.

Little, B.B., Snell, L.M., Rosenfeld, C.R., Gilstrap, L.C., & Gant, N.F. (1990). Failure to recognize fetal alcohol syndrome in newborn infants. American Journal of Diseases of Children, 144(10), 1142-1146.

May, P.A., Hymbaugh, K.J., Aase, J.M., & Samet, J.M. (1983). Epidemiology of fetal alcohol syndrome among American Indians of the Southwest. Social Biology, 30(4), 374-387.

National Institute of Alcohol Abuse and Alcoholism (NIAAA). (1987). Sixth special report to the U.S. Congress on alcohol and health. Washington, DC: U.S. Department of Health and Human Services.

National Institute on Alcohol Abuse and Alcoholism (NIAAA). (1990, January). Seventh special report to the U.S. Congress on alcohol and health. (From the Secretary of Health and Human Services, U.S. Department of Health and Human Services, DHHS Publication No. [ADM] 90-1656. ) Washington, DC: U.S. Government Printing Office.

Robinson, G.C., Conry, J.L., & Conry, R.F. (1987). Clinical profile and prevalence of fetal alcohol syndrome in an isolated community in British Columbia. Canadian Medical Association Journal, 137, 203-207.

Streissguth, A.P., Barr, H.M., Kogan, J., & Bookstein, F.L. (1996). Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE): Final report to the Centers for Disease Control on Grant No. RO4/CCR008515 (Tech.Report No. 96-16). Seattle: University of Washington, Fetal Alcohol and Drug Unit.

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