View source for Fetal alcohol spectrum disorder

{{Short description|Group of conditions resulting from maternal alcohol consumption during pregnancy}}
{{cs1 config|name-list-style=vanc}}
{{Use dmy dates |date=November 2016 }}
{{Use American English |date=September 2025 }}
{{Infobox medical condition
| name = Fetal alcohol spectrum disorders
| image = Photo of baby with FAS.svg
| caption = Only 10% of individuals with FASD have associated facial features.
| field = [[Embryology]], [[toxicology]], [[psychiatry]], [[neurology]], [[gynaecology]], [[obstetrics]], [[neonatology]], [[pediatrics]]
| synonyms = Foetal alcohol spectrum disorders, Foetal alcohol syndrome, Fetal alcohol syndrome, FASD, FAS, PAE, Prenatal alcohol exposure, Prenatal substance exposure, PSE
| symptoms = Varied; [[Craniofacial abnormality]], [[Short stature|short height]], [[Underweight|low body weight]], [[microcephaly|small head size]], [[Developmental coordination disorder|poor coordination]], behavior problems similar to [[Attention deficit hyperactivity disorder|ADHD]], [[learning disability|learning]] and [[Speech disorder|speech problems]], [[intellectual disability]]<ref name=CDC2015Fact/><ref name=Canadian/>
| complications = {{ubl|'''Babies''': [[Miscarriage]], [[stillbirth]], [[preterm birth]] |
'''Adults''': [[Alcoholism]], [[substance abuse]]
}}
| onset = Prenatal
| duration = Lifelong<ref name=CDC2015Fact/><ref name=Ras2016/>
| types = Fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder, static encephalopathy, alcohol-related birth defects<ref name=CDC2015Fact/>
| causes = Drinking [[alcohol (drug)|alcohol]] during [[pregnancy]]<ref name=CDC2015Fact/>
| risks = 
| diagnosis = Based on symptoms and [[prenatal alcohol exposure]]<ref name=CDC2015Fact/>
| differential = [[ADHD]], [[autism]], [[bipolar disorder]], [[conduct disorder]], [[learning disability]], [[oppositional defiant disorder]]
| prevention = Avoiding drinking alcohol during pregnancy<ref name="CDC2014Prev" />
| treatment = [[Parent-child interaction therapy]], efforts to modify child behavior, possibly medications<ref name=Roz2015/>
| medication = 
| prognosis = Varies based on severity with FAS having a life expectancy of 34 years old without interventions.<ref name="Life Expectancy of People with Feta">{{cite journal | vauthors = Thanh NX, Jonsson E | title = Life Expectancy of People with Fetal Alcohol Syndrome | journal = Journal of Population Therapeutics and Clinical Pharmacology | volume = 23 | issue = 1 | pages = e53–e59 | date = 2016 | pmid = 26962962 }}</ref><br />Unconfirmed (other types)
| frequency = Unconfirmed; between 1 in 20 (~390 million)<ref name=FASDfrequency>{{cite journal | vauthors = May PA, Chambers CD, Kalberg WO, Zellner J, Feldman H, Buckley D, Kopald D, Hasken JM, Xu R, Honerkamp-Smith G, Taras H, Manning MA, Robinson LK, Adam MP, Abdul-Rahman O, Vaux K, Jewett T, Elliott AJ, Kable JA, Akshoomoff N, Falk D, Arroyo JA, Hereld D, Riley EP, Charness ME, Coles CD, Warren KR, Jones KL, Hoyme HE | display-authors = 6 | title = Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities | journal = JAMA | volume = 319 | issue = 5 | pages = 474–482 | date = February 2018 | pmid = 29411031 | pmc = 5839298 | doi = 10.1001/jama.2017.21896 }}</ref> and 1 in 13 (~600 million) (all types)<ref name="FASD Mortality">{{cite journal | vauthors = Oh SS, Kim YJ, Jang SI, Park S, Nam CM, Park EC | title = Hospitalizations and mortality among patients with fetal alcohol spectrum disorders: a prospective study | journal = Scientific Reports | volume = 10 | issue = 1 | article-number = 19512 | date = November 2020 | pmid = 33177533 | pmc = 7658994 | doi = 10.1038/s41598-020-76406-6 | bibcode = 2020NatSR..1019512O }}</ref><br />0.2 and 9 per 1,000 (FAS)
| deaths = 
| alt = 
}}

<!-- Definition and symptoms -->
'''Fetal alcohol spectrum disorders''' ('''FASDs''') are a group of conditions that can occur in a person who is exposed to [[alcohol (drug)|alcohol]] during [[gestation]].<ref name="CDC2015Fact" /> In the United States FASD affects 1 in 20 Americans,{{Globalize inline |1=USA |date=September 2025 }} but is highly misdiagnosed and underdiagnosed.<ref>{{Cite journal |last=May |first=Phil |date=2018 |title=Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. |journal=JAMA |volume=319 |issue=5 |pages=474–482 |doi=10.1001/jama.2017.21896 |pmid=29411031 |pmc=5839298 }}</ref>

The several forms of the condition (in order of most severe to least severe) are: '''fetal alcohol syndrome''' ('''FAS'''), '''partial fetal alcohol syndrome''' ('''pFAS'''), '''alcohol-related neurodevelopmental disorder''' ('''ARND'''),<ref name="CDC2015Fact" /> and '''neurobehavioral disorder associated with prenatal alcohol exposure''' ('''ND-PAE''').<ref>{{cite journal | vauthors = Hagan JF, Balachova T, Bertrand J, Chasnoff I, Dang E, Fernandez-Baca D, Kable J, Kosofsky B, Senturias YN, Singh N, Sloane M, Weitzman C, Zubler J | display-authors = 6 | title = Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure | journal = Pediatrics | volume = 138 | issue = 4 | article-number = e20151553 | date = October 2016 | pmid = 27677572 | pmc = 5477054 | doi = 10.1542/peds.2015-1553 | publisher = AAP Publications }}</ref> Other terms used are fetal alcohol effects (FAE), partial fetal alcohol effects (PFAE), alcohol-related birth defects (ARBD),<ref name="CDC2015Fact" /><ref name="Ril2011" /> and static [[encephalopathy]],<ref>{{cite web |title=FASD Fact #1: FASD = Fetal Alcohol Spectrum Disorder |url=https://fafasd.org/fasdfact1/ |website=Families Affected by Fetal Alcohol Spectrum Disorder FAFASD |access-date=4 December 2020}}</ref> but these terms have fallen out of favor and are no longer considered part of the spectrum.<ref name="FASGuide" />

<!-- Cause and diagnosis -->
Not all infants exposed to alcohol in utero will have detectable FASD or pregnancy complications. The risk of FASD increases with the amount consumed, the frequency of consumption, and the longer duration of alcohol consumption during pregnancy, particularly [[binge drinking]]. The variance seen in outcomes of alcohol consumption during pregnancy is poorly understood. Diagnosis is based on an assessment of growth, facial features, central nervous system, and alcohol exposure by a multidisciplinary team of professionals. The main criteria for diagnosis of FASD are nervous system damage and alcohol exposure, with FAS including congenital malformations of the lips and growth deficiency. FASD is often misdiagnosed as or comorbid with ADHD.

<!-- Prevention and treatment -->
Almost all experts recommend that the mother abstain from alcohol use during pregnancy to prevent FASDs. As the woman may not become aware that she has conceived until several weeks into the pregnancy, it is also recommended to abstain while attempting to become pregnant. Although the condition has no known cure, treatment can improve outcomes. Treatment needs vary but include psychoactive medications, behavioral interventions, tailored accommodations, case management, and public resources.
<!-- Epidemiology and culture -->
Globally, 1 in 10 women drinks alcohol during pregnancy, and the prevalence of having any FASD disorder is estimated to be at least 1 in 20. The rates of alcohol use, FAS, and FASD are likely to be underestimated because of the difficulty in making the diagnosis and the reluctance of clinicians to label children and mothers. Some <small>(who?)</small> have argued that the FAS label stigmatizes alcohol use, while authorities point out that the risk is real.
{{TOC limit|3}}

==Signs and symptoms==
[[Image:Fetal alcohol spectrum disorder svg hariadhi.svg|thumb|upright=1.6|Facial characteristics of a child with FAS]]
The key signs of fetal alcohol syndrome (FAS) required for diagnosis include:
* Growth deficiency or [[failure to thrive]]: slow fetal growth [[low birth weight]] or height, small head circumference ([[microcephaly]])<ref name="growthchart"/>{{efn|ICD-codes in Popova study: R62.8††, R62.8¶¶, P05.9, P07.1, R62.8§§, R62.8‡‡, Q02}}
* Congenital malformations of [[lip]]s: short [[palpebral fissure]] lengths, smooth [[philtrum]], and thin upper lip.<ref name =facial/>{{efn|Q10.3†, Q38.0*, Q38.0†}}
* Nervous system damage: Clinically significant structural neurological, or functional impairment{{efn|R94.1}}

Popova et al. identified 428 [[ICD-10]] conditions as co-occurring in individuals with FAS. Excluding conditions used in FAS diagnosis, co-occurring conditions with 50% prevalence or greater include:<ref name="Popova2016">{{Cite journal |last1=Popova |first1=Svetlana |last2=Lange |first2=Shannon |last3=Shield |first3=Kevin |last4=Mihic |first4=Alanna |last5=Chudley |first5=Albert E. |last6=Mukherjee |first6=Raja A. S. |last7=Bekmuradov |first7=Dennis |last8=Rehm |first8=Jürgen |date=2016-03-05 |title=Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis |url=https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01345-8/fulltext |journal=The Lancet |language=English |volume=387 |issue=10022 |pages=978–987 |doi=10.1016/S0140-6736(15)01345-8 |issn=0140-6736 |pmid=26777270|s2cid=24660949 |url-access=subscription }}</ref>
* [[Conduct disorder]], behavioral problems, disruptive behavior, or impulsivity{{efn|F91}}
* [[Developmental language disorder]]{{efn|F80, F80.1, F80.2, F80.9}}
* [[Hearing loss]]{{efn|H65.2,H90.2,H90.5,H65.0}}
* [[Visual impairment]], including blindness or [[astigmatism]]{{efn|H54,H52.2,H52.6,H54.2/54.4/54.5}}
* Developmental delay, cognitive disorder, or mental deficiency{{efn|F89}}
* [[Premature birth]]{{efn|P07.3}}
* [[Substance dependence]]{{efn|F10.2/F19.2}}
* Congenital malformation of retina{{efn|Coccygeal fovea (Q14.1‡). Retinal tortuosity (Q14.1§)}}
* Congenital fusion of cervical vertebrae or cervical spine fusion{{efn|Q76.4}}
* [[Attention deficit hyperactivity disorder]] (ADHD) or otherwise impaired attention{{efn|F90.0}}
* Small eye openings ([[blepharophimosis]]),{{efn|Q10.0¶}} or an abnormally increased distance between the eyes, or both ([[hypertelorism]]){{efn|Q75.2}}

Other FASD conditions are partial expressions of FAS, where the central nervous system shows clinical deficits. In these other FASD conditions, an individual may be at greater risk for adverse outcomes because brain damage is present without associated visual cues of poor growth or the "FAS face" that might ordinarily trigger an FASD evaluation. Such individuals may be misdiagnosed with primary [[DSM-IV Codes|mental health disorders]] such as [[Attention-deficit hyperactivity disorder|ADHD]] or [[oppositional defiance disorder]] without appreciation that brain damage is the underlying cause of these disorders, which requires a different treatment paradigm than typical mental health disorders. While other FASD conditions may not yet be included as an [[ICD]] or [[Diagnostic and Statistical Manual of Mental Disorders|DSM-IV-TR]] diagnosis, they nonetheless pose significant impairment in [[Adaptive behavior|functional behavior]] because of underlying brain damage.<ref>{{Cite journal |last1=Brown |first1=Jasmine M. |last2=Bland |first2=Roger |last3=Jonsson |first3=Egon |last4=Greenshaw |first4=Andrew J. |date=2019-03-03 |title=The Standardization of Diagnostic Criteria for Fetal Alcohol Spectrum Disorder (FASD): Implications for Research, Clinical Practice and Population Health |journal=Canadian Journal of Psychiatry. Revue Canadienne de Psychiatrie |volume=64 |issue=3 |pages=169–176 |doi=10.1177/0706743718777398 |issn=0706-7437 |pmc=6405816 |pmid=29788774 }}</ref> Many indications of fetal alcohol spectrum disorders are developmental. Therefore, although a child may appear 'normal' at birth, intellectual disabilities caused by alcohol before birth may not appear until the child begins school.<ref name = cdc1/>

More broadly, alcohol use during pregnancy is also associated with:<ref name="CDC2015Fact">{{cite web|date=April 16, 2015|title=Facts about FASDs|url=https://www.cdc.gov/ncbddd/fasd/facts.html|url-status=live|archive-url=https://web.archive.org/web/20150523194618/http://www.cdc.gov/ncbddd/fasd/facts.html|archive-date=23 May 2015|access-date=10 June 2015}}</ref><ref name=IOM>{{cite book|author1=Institute of Medicine Committee to Study Fetal Alcohol Syndrome | veditors = Stratton K, Howe C, Battaglia FC |title=Fetal alcohol syndrome: diagnosis, epidemiology, prevention, and treatment|date=1995|publisher=National Academy Press|location=Washington, D.C.|isbn=978-0-309-05292-4|url=http://www.nap.edu/catalog/4991/fetal-alcohol-syndrome-diagnosis-epidemiology-prevention-and-treatment|url-status=live|archive-url=https://web.archive.org/web/20160311182331/http://www.nap.edu/catalog/4991/fetal-alcohol-syndrome-diagnosis-epidemiology-prevention-and-treatment|archive-date=11 March 2016}}</ref>
* Intellectual disability, both in overall IQ measurements and in many functional tests<ref name="Cor2013">{{cite journal|last1=Coriale|first1=G|last2=Fiorentino|first2=D|last3=Di Lauro|first3=F|last4=Marchitelli|first4=R|last5=Scalese|first5=B|last6=Fiore|first6=M|last7=Maviglia|first7=M|last8=Ceccanti|first8=M|date=2013|title=Fetal Alcohol Spectrum Disorder (FASD): neurobehavioral profile, indications for diagnosis and treatment.|journal=Rivista di Psichiatria|volume=48|issue=5|pages=359–369|doi=10.1708/1356.15062|pmid=24326748| s2cid = 14826585}}</ref>
* Fetal mortality, such as spontaneous abortion ([[Miscarriage]]), [[stillbirth]],<ref name="who2">{{cite web|date=2014|title=Guidelines for the identification and management of substance use and substance use disorders in pregnancy|url=http://apps.who.int/iris/bitstream/10665/107130/1/9789241548731_eng.pdf?ua=1|access-date=11 August 2017|publisher=World Health Organization}}</ref> and [[sudden infant death syndrome]]<ref name="kingdon" />{{failed verification|date=March 2023}}
* Domestic violence and potential harm to the infant<ref name="who2"/>
* Sleep and sucking problems as a baby<ref name="CDC2021">{{Cite web|last=CDC|date=2021-05-24|title=Alcohol Use in Pregnancy|url=https://www.cdc.gov/ncbddd/fasd/alcohol-use.html|access-date=2021-09-13|website=Centers for Disease Control and Prevention|language=en-us}}</ref>
* Heart: A [[heart murmur]] that frequently disappears by one year of age. [[Ventricular septal defect]], [[atrial septal defect]], [[tetralogy of Fallot]], [[coarctation of the aorta]], or [[Arrhythmia|cardiac rhythm dysfunction]].
* Bones: [[Joint]] anomalies including abnormal position and function, altered [[Single transverse palmar crease|palmar crease]] patterns, small distal [[phalanges]], and small fifth fingernails.
* Kidneys: [[Horseshoe kidney|Horseshoe]], aplastic, dysplastic, or [[Renal hypoplasia|hypoplastic kidneys]].
* Eyes: [[Strabismus]], [[optic nerve hypoplasia]]<ref>{{cite journal | vauthors = Strömland K, Pinazo-Durán MD | title = Ophthalmic involvement in the fetal alcohol syndrome: clinical and animal model studies | journal = Alcohol and Alcoholism | volume = 37 | issue = 1 | pages = 2–8 | year = 2002 | pmid = 11825849 | doi = 10.1093/alcalc/37.1.2 | doi-access = free }}</ref> (which may cause [[light sensitivity]], decreased [[visual acuity]], or involuntary eye movements).
* [[Cleft lip]] with or without a [[cleft palate]]: Alcohol is known to be a folic acid antagonist, and a baby's palate and lip develop during the first trimester of the pregnancy (first 12 weeks). Heavy alcohol consumption and binge drinking during this time have been linked to orofacial cleft.<ref>{{Cite journal |last1=Yin |first1=X. |last2=Li |first2=J. |last3=Li |first3=Y. |last4=Zou |first4=S. |date=November 2019 |title=Maternal alcohol consumption and oral clefts: a meta-analysis |url=https://linkinghub.elsevier.com/retrieve/pii/S0266435619303298 |journal=British Journal of Oral and Maxillofacial Surgery |language=en |volume=57 |issue=9 |pages=839–846 |doi=10.1016/j.bjoms.2019.08.013|pmid=31473040 |s2cid=201716448 |url-access=subscription }}</ref>
* Occasional problems: [[ptosis (eyelid)|ptosis]] of the eyelid, microphthalmia, webbed neck, short neck, [[radioulnar synostosis]], [[spina bifida]], and [[hydrocephalus]].

Alcohol can also harm the fertility of women who are planning for pregnancy. Adverse effects of alcohol can lead to malnutrition, seizures, vomiting, and dehydration. The mother can suffer from anxiety and depression, which can result in child abuse/neglect. It has also been observed that when the pregnant mother withdraws from alcohol, its effects are visible on the infant as well. The baby remains in an irritated mood, cries frequently, does not sleep properly, weakening of sucking ability and increased hunger.<ref>{{Cite web|url=https://drugabuse.com/library/drinking-while-pregnant/|title=Dangers of Drinking While Pregnant - DrugAbuse.com|website=drugabuse.com|language=en|access-date=2018-11-17|date=2016-07-27}}</ref>

In 2019, a study found that individuals with FASD have a higher risk of [[hypertension]] independent of race/ethnicity and obesity.<ref>{{cite journal |last1=Cook |first1=Jonathan C. |last2=Lynch |first2=Mary Ellen |last3=Coles |first3=Claire D. |title=Association Analysis: Fetal Alcohol Spectrum Disorder and Hypertension Status in Children and Adolescents |journal=Alcoholism: Clinical and Experimental Research |date=5 June 2019 |volume=43 |issue=8 |pages=1727–1733 |doi=10.1111/acer.14121 |pmid=31166027 |s2cid=174811433 |url=https://onlinelibrary.wiley.com/doi/10.1111/acer.14121 |access-date=30 March 2023|url-access=subscription }}</ref>

==Causes==
Fetal alcohol spectrum disorders are caused by alcohol exposure during gestational development.<ref name=CDC2015Fact/> If an individual was not exposed to alcohol before birth, they will not have FASD.<ref>{{cite web |title=Understanding Fetal Alcohol Spectrum Disorders |url=https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-fetal-alcohol-spectrum-disorders |website=National Institute on Alcohol Abuse and Alcoholism (NIAAA)|access-date=18 March 2024}}</ref> However, not all infants exposed to alcohol in utero will have detectable FAS, FASD, or pregnancy complications.<ref name="Popova2017"/>

=== Exposure limit ===

No safe level of fetal alcohol exposure has been established.<ref>{{Cite web |title=Alcohol during pregnancy |url=https://www.marchofdimes.org/find-support/topics/pregnancy/alcohol-during-pregnancy#:~:text=It%20is%20not%20safe%20to,wine%20coolers,%20beer%20and%20liquor. |access-date=2024-07-17 |website=www.marchofdimes.org |language=en}}</ref> Because alcohol is a known [[teratogen]], it is considered unethical to do randomized controlled trials on pregnant women to determine the precise toxicity effects of alcohol.<ref>{{cite news |last1=Welch |first1=Ashley |title=CDC to younger women: Better take your birth control before you drink that glass of wine |url=https://www.latimes.com/science/sciencenow/la-sci-sn-cdc-alcohol-pregnancy-20160203-story.html |work=Los Angeles Times |date=4 February 2016}}</ref> Among women who consume any quantity of alcohol during pregnancy, the risk of giving birth to a child with FASD is about 15%, and to a child with FAS about 1.5%. Drinking 2 [[standard drink]]s a day, or 6 standard drinks in a short time, carries a 4.3% risk of a FAS birth (i.e. one of every 23 heavy-drinking pregnant women will deliver a child with FAS). Furthermore, alcohol-related congenital abnormalities occur at an incidence of roughly one out of 67 women who drink alcohol during pregnancy.<ref name="Popova2017">{{cite journal | vauthors = Popova S, Lange S, Probst C, Gmel G, Rehm J | title = Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis | journal = The Lancet. Global Health | volume = 5 | issue = 3 | pages = e290–e299 | date = March 2017 | pmid = 28089487 | doi = 10.1016/S2214-109X(17)30021-9 | s2cid = 5002534 | doi-access = free }}</ref> Among those mothers who have an alcohol use disorder, an estimated one-third of their children have FAS.<ref name="Yaf2011">{{cite book| vauthors = Yaffe SJ |title=Drugs in pregnancy and lactation: a reference guide to fetal and neonatal risk|date=2011|publisher=Wolters Kluwer Health/Lippincott Williams & Wilkins|location=Philadelphia|isbn=978-1-60831-708-0|page=527|edition=9|url=https://books.google.com/books?id=OIgTE4aynrMC&pg=PA527|url-status=live|archive-url=https://web.archive.org/web/20170910233951/https://books.google.com/books?id=OIgTE4aynrMC&pg=PA527|archive-date=10 September 2017}}</ref> The variance seen in outcomes of alcohol consumption during pregnancy is poorly understood. Aggravating factors may include [[advanced maternal age]], [[smoking]], poor diet,<ref name="An Update on Fetal Alcohol Syndrome">{{cite journal | vauthors = Gupta KK, Gupta VK, Shirasaka T | title = An Update on Fetal Alcohol Syndrome-Pathogenesis, Risks, and Treatment | journal = Alcoholism: Clinical and Experimental Research | volume = 40 | issue = 8 | pages = 1594–1602 | date = August 2016 | pmid = 27375266 | doi = 10.1111/acer.13135 }}</ref><ref name=NIH2015>{{cite web|title=Fetal Alcohol Exposure|url=https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/understanding-fetal-alcohol-spectrum-disorders|access-date=10 June 2015|date=April 2015|url-status=live|archive-url=https://web.archive.org/web/20150610050738/http://pubs.niaaa.nih.gov/publications/FASDFactsheet/FASDfact.htm|archive-date=10 June 2015}}</ref> genetics, and social risk factors.<ref name="UpToDate"/>

The risk of FASD increases with the amount consumed, the frequency of consumption, and a longer duration of alcohol consumption during pregnancy.<ref name="UpToDate" /><ref name="NIH2015" /><ref name="Committee2011">{{Cite journal|date=August 2011|title=Committee opinion no. 496: At-risk drinking and alcohol dependence: obstetric and gynecologic implications|journal=Obstetrics and Gynecology|volume=118|issue=2 Pt 1|pages=383–388|doi=10.1097/AOG.0b013e31822c9906|issn=1873-233X|pmid=21775870|s2cid=205474115}}</ref> [[Blood alcohol concentration]] has been identified as a relevant factor.<ref name="Burd2012" /> All forms of alcohol, such as beer, wine, and liquor, pose similar risk.<ref name="Williams2015">{{cite journal |year=2015 |title=Fetal Alcohol Spectrum Disorders |journal=Pediatrics |volume=136 |issue=5 |pages=e1395–e1406 |doi=10.1542/peds.2015-3113 |pmid=26482673 |s2cid=23752340 |doi-access=free |author3=COMMITTEE ON SUBSTANCE ABUSE | vauthors = Williams JF, Smith VC |article-number=e20153113 }}</ref> [[Binge drinking]] increases the chances and severity of FASD to such an extent that Svetlana Popova has stated that "binge drinking is the direct cause of FAS or FASD".<ref name="who1" />  Small amounts of alcohol may not cause an abnormal appearance, however, small amounts of alcohol consumption while pregnant may cause behavioral problems and also increases the risk of miscarriage.<ref name="Mc2014" /><ref name="Yaf2011" /><ref>{{cite journal | vauthors = Sundermann AC, Zhao S, Young CL, Lam L, Jones SH, Velez Edwards DR, Hartmann KE | title = Alcohol Use in Pregnancy and Miscarriage: A Systematic Review and Meta-Analysis | journal = Alcoholism: Clinical and Experimental Research | volume = 43 | issue = 8 | pages = 1606–1616 | date = August 2019 | pmid = 31194258 | pmc = 6677630 | doi = 10.1111/acer.14124 }}</ref><ref name="Mamluk2017">{{cite journal | vauthors = Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore TH, Ijaz S, Lewis SJ, Donovan JL, Lawlor D, Smith GD, Fraser A, Zuccolo L | display-authors = 6 | title = Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently 'safe' levels of alcohol during pregnancy? A systematic review and meta-analyses | journal = BMJ Open | volume = 7 | issue = 7 | article-number = e015410 | date = August 2017 | pmid = 28775124 | pmc = 5642770 | doi = 10.1136/bmjopen-2016-015410 }}</ref> Quasi-experimental studies provide moderately strong evidence that prenatal alcohol exposure causes detrimental cognitive outcomes, and some evidence of reduced birthweight, although no study was fully rated at low risk of bias and quantity of studies was limited.<ref>{{cite journal |last1=Mamluk |first1=Loubaba |last2=Jones |first2=Timothy |last3=Ijaz |first3=Sharea |last4=Edwards |first4=Hannah B |last5=Savović |first5=Jelena |last6=Leach |first6=Verity |last7=Moore |first7=Theresa H M |last8=von Hinke |first8=Stephanie |last9=Lewis |first9=Sarah J |last10=Donovan |first10=Jenny L |last11=Lawlor |first11=Deborah A |last12=Davey Smith |first12=George |last13=Fraser |first13=Abigail |last14=Zuccolo |first14=Luisa |title=Evidence of detrimental effects of prenatal alcohol exposure on offspring birthweight and neurodevelopment from a systematic review of quasi-experimental studies |journal=International Journal of Epidemiology |date=23 January 2021 |volume=49 |issue=6 |pages=1972–1995 |doi=10.1093/ije/dyz272|pmid=31993631 |pmc=7825937 }}</ref>

The evidence is inconsistent and contradictory regarding the effects of low-to-moderate drinking, for example, less than 12 grams of ethanol per day.<ref name="Flak2014">{{Cite journal|last1=Flak|first1=Audrey L.|last2=Su|first2=Su|last3=Bertrand|first3=Jacquelyn|last4=Denny|first4=Clark H.|last5=Kesmodel|first5=Ulrik S.|last6=Cogswell|first6=Mary E.|date=2014|title=The association of mild, moderate, and binge prenatal alcohol exposure and child neuropsychological outcomes: a meta-analysis|journal=Alcoholism: Clinical and Experimental Research|volume=38|issue=1|pages=214–226|doi=10.1111/acer.12214|issn=1530-0277|pmid=23905882|doi-access=free}}</ref> Many studies find no significant effect, but some find beneficial associations, and others find detrimental associations, even on the same outcomes. Summarizing studies by country shows some similarity in results, due to using the same data sources. The definition of low alcohol consumption varies significantly among studies and often fails to incorporate all aspects of timing, dose, and duration. Recall bias and socioeconomic and psychosocial factors have been controlled for in most studies, but it is likely that residual confounding due to missing factors and variation in methods still exists and is larger than any observed effects.<ref>{{cite journal |last1=Bandoli |first1=G |last2=Hayes |first2=S |last3=Delker |first3=E |title=Low to Moderate Prenatal Alcohol Exposure and Neurodevelopmental Outcomes: A Narrative Review and Methodological Considerations. |journal=Alcohol Research: Current Reviews |date=2023 |volume=43 |issue=1 |page=01 |doi=10.35946/arcr.v43.1.01 |pmid=36950180|pmc=10027299 }}</ref><ref>{{cite journal | vauthors = Mamluk L, Edwards HB, Savović J, Leach V, Jones T, Moore TH, Ijaz S, Lewis SJ, Donovan JL, Lawlor D, Smith GD, Fraser A, Zuccolo L | display-authors = 6 | title = Low alcohol consumption and pregnancy and childhood outcomes: time to change guidelines indicating apparently 'safe' levels of alcohol during pregnancy? A systematic review and meta-analyses | journal = BMJ Open | volume = 7 | issue = 7 | article-number = e015410 | date = August 2017 | pmid = 28775124 | pmc = 5642770 | doi = 10.1136/bmjopen-2016-015410 | s2cid = 2941340 }}</ref><ref name="Yaf2011" /><ref>{{cite journal | vauthors = | title = Pregnancy and alcohol: occasional, light drinking may be safe | journal = Prescrire International | volume = 21 | issue = 124 | pages = 44–50 | date = February 2012 | pmid = 22413723 }}</ref><ref name="CDC2021" /><ref name="IOM" />

===Paternal alcohol use===
Fathers who consume alcohol before conception may contribute to FASD through long-term [[epigenetic]] modification of the father's sperm,<ref>{{citation |title=Genetic and Epigenetic Perspectives on the Role of Fathers in Fetal Alcohol Spectrum Disorder |vauthors=Liyanage-Zachariah V, Harding K |year=2019 |url=https://canfasd.ca/wp-content/uploads/publications/Fathers-Role-1-Issue-Paper-Final.pdf |publisher=Canada FASD Research Network}}</ref> but this has been challenged; evidence it can cause complete FAS is inconclusive.<ref name=Yaf2011/>

== Prevention and stigma ==
[[File:Zero alcool pendant la grossesse.svg|thumb|A [[Alcohol packaging warning messages|label on alcoholic drinks]] promoting zero alcohol during [[pregnancy]]]]

Almost all experts recommend that the mother abstain from alcohol use during pregnancy to prevent FASDs.<ref name=CDC2014Prev>{{cite web|title=Alcohol Use in Pregnancy|url=https://www.cdc.gov/ncbddd/fasd/alcohol-use.html|access-date=10 June 2015|date=17 April 2014|url-status=live|archive-url=https://web.archive.org/web/20150628214658/http://www.cdc.gov/ncbddd/fasd/alcohol-use.html|archive-date=28 June 2015}}</ref><ref name=FASGuide/><ref>{{cite web|title=Alcohol and Pregnancy Questions and Answers {{!}} FASD {{!}} NCBDDD {{!}} CDC|url=https://www.cdc.gov/ncbddd/fasd/faqs.html|website=www.cdc.gov|access-date=25 September 2017|date=4 August 2017}}</ref> A pregnant woman may not become aware that she has conceived until several weeks into the pregnancy, so it is also recommended to abstain from alcohol while attempting to become pregnant.<ref name=SG/> The recommendations of abstaining from alcohol during pregnancy and while attempting to become have been made by the [[Surgeon General of the United States]],<ref name="MD2011">{{cite book|last=Rankin|first=Lissa |title=Fertility, Pregnancy, and Childbirth|date=23 August 2011|publisher=St. Martin's Press|isbn=978-1-4299-5932-2|page=14|quote=In 1981, the surgeon general put out the now-ubiquitous warning about alcohol and pregnancy. }}</ref><ref name=SG>{{cite web| vauthors = Carmona RH |title=A 2005 Message to Women from the U.S. Surgeon General |url=https://www.cdc.gov/ncbddd/fasd/documents/sg-advisory.pdf |access-date=12 June 2015|date=2005|url-status=live|archive-url=https://web.archive.org/web/20150924081635/http://www.cdc.gov/ncbddd/fasd/documents/sg-advisory.pdf|archive-date=24 September 2015}}</ref> the Centers for Disease Control,<ref name="CDC2021"/> the American College of Obstetricians and Gynecologists, the [[American Academy of Pediatrics]],<ref name="Williams2015"/> the [[World Health Organization]],<ref name="WHO">{{cite web|title=Framework for alcohol policy in the WHO European Region|url=http://www.euro.who.int/document/e88335.pdf|publisher=World Health Organisation|access-date=15 March 2024|archive-date=3 May 2010|archive-url=https://web.archive.org/web/20100503022214/http://www.euro.who.int/document/e88335.pdf}}</ref> the United Kingdom's [[National Institute for Health and Clinical Excellence]],<ref>{{cite web |title=Drinking alcohol while pregnant |url=https://www.nhs.uk/pregnancy/keeping-well/drinking-alcohol-while-pregnant/ |website=NHS |date=2 December 2020 |access-date=31 December 2020 |archive-url=https://archive.today/20201231124518/https://www.nhs.uk/pregnancy/keeping-well/drinking-alcohol-while-pregnant/ |archive-date=31 December 2020}}</ref> and many others.<ref name="Williams2015" /> In the United States, federal legislation has required that warning labels be placed on all alcoholic beverage containers since 1988 under the [[Alcoholic Beverage Labeling Act]].<ref>{{Cite journal| vauthors = Deaver EL |date=1997-01-01|title=History and implications of the Alcoholic Beverage Labeling Act of 1988|journal=Journal of Substance Misuse|volume=2|issue=4|pages=234–237|doi=10.3109/14659899709081975|issn=1357-5007}}</ref>

=== Stigma ===
The most current advocacy perspectives encourage people and systems to approach FASD with interventions and support for individuals already living with FASD. Focusing on prevention often only further stigmatizes individuals with FASD and their birth parents. Advocates say, if a person is supporting people currently living with FASD, then that person is spreading the awareness needed for successful prevention efforts; "Intervention is Prevention". Many [[social determinants of health]] impact the effects of PAE:<ref>{{cite journal |last1=Jonsson |first1=Egon |last2=Salmon |first2=Amy |last3=Warren |first3=Kenneth R |title=The international charter on prevention of fetal alcohol spectrum disorder |journal=The Lancet Global Health |date=March 2014 |volume=2 |issue=3 |pages=e135–e137 |doi=10.1016/S2214-109X(13)70173-6|doi-access=free|pmid=25102841 }}</ref>
* Genetics
* Poverty/Access to nutritious food
* Malnutrition
* Poor social support networks
* Lack of personal autonomy
* Access to healthcare
* Generational and sociocultural traumas
* Access to mental health care and treatment

=== Medication ===

Women can experience serious symptoms that accompany alcohol withdrawal during pregnancy. According to the World Health Organization, these symptoms can be treated during pregnancy with brief use of [[benzodiazepine]] [[Anxiolytic|tranquilizers]].<ref name = who2/> Currently, the FDA has approved three medications—naltrexone, acamprosate, and disulfiram—for the treatment of [[Alcoholism|alcohol use disorder]] (AUD).  However, there is insufficient data regarding the safety of these medications for pregnant women.<ref name="DeVido2015">{{Cite journal|last1=DeVido|first1=Jeffrey|last2=Bogunovic|first2=Olivera|last3=Weiss|first3=Roger D.|date=2015|title=Alcohol Use Disorders in Pregnancy|journal=Harvard Review of Psychiatry|volume=23|issue=2|pages=112–121|doi=10.1097/HRP.0000000000000070|issn=1067-3229|pmc=4530607|pmid=25747924}}</ref>

* [[Naltrexone]] is a nonselective opioid antagonist that is used to treat AUD and [[opioid use disorder]].<ref name="Fairbanks2020">{{Cite journal|last1=Fairbanks|first1=Jeremiah|last2=Umbreit|first2=Audrey|last3=Kolla|first3=Bhanu Prakash|last4=Karpyak|first4=Victor M.|last5=Schneekloth|first5=Terry D.|last6=Loukianova|first6=Larissa L.|last7=Sinha|first7=Shirshendu|date=2020-09-01|title=Evidence-Based Pharmacotherapies for Alcohol Use Disorder: Clinical Pearls|url=https://www.mayoclinicproceedings.org/article/S0025-6196(20)30088-4/abstract|journal=Mayo Clinic Proceedings|language=English|volume=95|issue=9|pages=1964–1977|doi=10.1016/j.mayocp.2020.01.030|issn=0025-6196|pmid=32446635|s2cid=218872499|doi-access=free}}</ref>  The long-term effects of naltrexone on the fetus are currently unknown.<ref name="Thibaut2019">{{Cite journal|last1=Thibaut|first1=Florence|last2=Chagraoui|first2=Abdeslam|last3=Buckley|first3=Leslie|last4=Gressier|first4=Florence|last5=Labad|first5=Javier|last6=Lamy|first6=Sandrine|last7=Potenza|first7=Marc N.|last8=Kornstein|first8=Susan G.|last9=Rondon|first9=Marta|last10=Riecher-Rössler|first10=Anita|last11=Soyka|first11=Michael|date=2019-01-02|title=WFSBP and IAWMH Guidelines for the treatment of alcohol use disorders in pregnant women|journal=The World Journal of Biological Psychiatry|volume=20|issue=1|pages=17–50|doi=10.1080/15622975.2018.1510185|issn=1562-2975|pmid=30632868|s2cid=58586890}}</ref>  Animal studies show that naltrexone administered during pregnancy increases the incidence of early fetal loss; however, there are insufficient data available to identify the extent to which this is a risk in pregnant women.<ref>Alkermes. VIVITROL (naltrexone for extended-release injectable suspension) U.S. Food and Drug Administration website. [https://web.archive.org/web/20210319080134/https://www.accessdata.fda.gov/drugsatfda_docs/label/2021/021897s052lbl.pdf]. Revised March 2021. Accessed September 12, 2021.</ref>
* [[Acamprosate]] functions as both an antagonist of [[N-Methyl-D-aspartic acid|NMDA]] and [[Glutamic acid|glutamate]] and an agonist at GABA<sub>A</sub> receptors, although its molecular mechanism is not completely understood. Acamprosate is effective at preventing alcohol relapse during abstinence.<ref name="Fairbanks2020" /> Animal data, however, suggest that acamprosate can have possible teratogenic effects on fetuses.<ref name="DeVido2015" />
* [[Disulfiram]] prevents relapse by blocking the metabolism of [[acetaldehyde]] after consumption of alcohol, which leads to headache, nausea, and vomiting.<ref name="Fairbanks2020" /> Some evidence suggests that disulfiram use during the first trimester is associated with an increased risk of congenital malformations such as reduction defects and [[Cleft lip and cleft palate|cleft palate]].<ref name="Thibaut2019" /> Additionally, the effects of disulfiram can involve hypertension, which can be harmful to both the pregnant woman and the fetus.<ref name="DeVido2015" />

[[American Psychiatric Association]] guidelines recommend that medications not be used to treat alcohol use disorder in pregnant women except in cases of acute alcohol withdrawals or other co-existing conditions.<ref>{{Cite journal|last1=Reus|first1=Victor I.|last2=Fochtmann|first2=Laura J.|last3=Bukstein|first3=Oscar|last4=Eyler|first4=A. Evan|last5=Hilty|first5=Donald M.|last6=Horvitz-Lennon|first6=Marcela|last7=Mahoney|first7=Jane|last8=Pasic|first8=Jagoda|last9=Weaver|first9=Michael|last10=Wills|first10=Cheryl D.|last11=McIntyre|first11=Jack|date=2018-01-01|title=The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder|url=https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2017.1750101|journal=American Journal of Psychiatry|volume=175|issue=1|pages=86–90|doi=10.1176/appi.ajp.2017.1750101|pmid=29301420|issn=0002-953X|url-access=subscription}}</ref> Instead, behavioral interventions are usually preferred as treatments for pregnant women with AUD. Medications should only be used for pregnant women after carefully considering the potential risks and harms of the medications versus the benefits of alcohol cessation.<ref name="DeVido2015" />

==Mechanism==
After a pregnant woman consumes alcohol, the alcohol crosses through the placenta and umbilical cord to the developing fetus. Alcohol metabolizes slowly in the fetus and remains for a long time when compared to an adult.<ref name="Bhuvaneswar 2007 455–460">{{Cite journal|last1=Bhuvaneswar|first1=Chaya G.|last2=Chang|first2=Grace|last3=Epstein|first3=Lucy A.|last4=Stern|first4=Theodore A.|date=2007|title=Alcohol Use During Pregnancy: Prevalence and Impact|journal=Primary Care Companion to the Journal of Clinical Psychiatry|volume=9|issue=6|pages=455–460|issn=1523-5998|pmc=2139915|pmid=18185825|doi=10.4088/PCC.v09n0608}}</ref><ref name="Burd2012">{{Cite journal|last1=Burd|first1=L|last2=Blair|first2=J|last3=Dropps|first3=K|date=2012-05-17|title=Prenatal alcohol exposure, blood alcohol concentrations and alcohol elimination rates for the mother, fetus and newborn|journal=Journal of Perinatology|language=En|volume=32|issue=9|pages=652–659|doi=10.1038/jp.2012.57|pmid=22595965|s2cid=1513758|issn=0743-8346}}</ref> A human fetus appears to be at triple risk from maternal alcohol consumption:<ref>{{cite journal | vauthors = Brien JF, Loomis CW, Tranmer J, McGrath M | title = Disposition of ethanol in human maternal venous blood and amniotic fluid | journal = American Journal of Obstetrics and Gynecology | volume = 146 | issue = 2 | pages = 181–186 | date = May 1983 | pmid = 6846436 | doi = 10.1016/0002-9378(83)91050-5 }}</ref><ref>{{cite journal | vauthors = Nava-Ocampo AA, Velázquez-Armenta Y, Brien JF, Koren G | title = Elimination kinetics of ethanol in pregnant women | journal = Reproductive Toxicology | volume = 18 | issue = 4 | pages = 613–617 | date = June 2004 | pmid = 15135856 | doi = 10.1016/j.reprotox.2004.02.012 | bibcode = 2004RepTx..18..613N }}</ref>
# The placenta allows free entry of ethanol and toxic metabolites like [[acetaldehyde]] into the fetal compartment. The so-called placental barrier is practically absent concerning ethanol.
# The developing fetal nervous system appears particularly sensitive to ethanol toxicity. The latter interferes with proliferation, differentiation, neuronal migration, axonal outgrowth, integration, and fine-tuning of the synaptic network. In short, all major processes in the developing central nervous system appear compromised.
# Fetal tissues are quite different from adult tissues in function and purpose. For example, the main detoxifying organ in adults is the [[Human liver|liver]], whereas the fetal liver is incapable of detoxifying ethanol, as the ADH and ALDH enzymes have not yet been brought to expression at this early stage. Up to term, fetal tissues do not have significant capacity for the detoxification of ethanol, and the [[fetus]] remains exposed to ethanol in the amniotic fluid for periods far longer than the decay time of ethanol in the maternal circulation. The lack of significant quantities of ADH and ALDH means that fetal tissues have much lower quantities of antioxidant enzymes, like [[Superoxide dismutase|SOD]], glutathione transferases, and [[glutathione peroxidase]]s, resulting in antioxidant protection being much less effective.

Although alcohol is known to be a [[teratogen]] (causing birth defects), the exact biological mechanisms for the development of FAS or FASD are unknown. However, clinical and animal studies have identified a broad spectrum of pathways through which maternal alcohol can negatively affect the outcome of a pregnancy. Clear conclusions with universal validity are difficult to draw, since different ethnic groups show considerable [[genetic polymorphism]] for the hepatic enzymes responsible for ethanol detoxification.<ref>{{cite journal | vauthors = Warren KR, Li TK | title = Genetic polymorphisms: impact on the risk of fetal alcohol spectrum disorders | journal = Birth Defects Research. Part A, Clinical and Molecular Teratology | volume = 73 | issue = 4 | pages = 195–203 | date = April 2005 | pmid = 15786496 | doi = 10.1002/bdra.20125 | url = https://zenodo.org/record/1000669 | doi-access = free }}</ref> Genetic examinations have revealed a continuum of long-lasting molecular effects that are not only timing specific but are also dosage specific; with even moderate amounts being able to cause alterations.<ref name=Lauferetal2013>{{cite journal | vauthors = Laufer BI, Mantha K, Kleiber ML, Diehl EJ, Addison SM, Singh SM | title = Long-lasting alterations to DNA methylation and ncRNAs could underlie the effects of fetal alcohol exposure in mice | journal = Disease Models & Mechanisms | volume = 6 | issue = 4 | pages = 977–992 | date = July 2013 | article-number = dmm.010975 | pmid = 23580197 | pmc = 3701217 | doi = 10.1242/dmm.010975 }}</ref> Additionally, ethanol may alter fetal development by interfering with [[retinoic acid]] signaling as acetaldehyde can compete with retinaldehyde and prevents its oxidation to retinoic acid.<ref>{{cite journal | vauthors = Shabtai Y, Fainsod A | title = Competition between ethanol clearance and retinoic acid biosynthesis in the induction of fetal alcohol syndrome | journal = Biochemistry and Cell Biology | volume = 96 | issue = 2 | pages = 148–160 | date = April 2018 | pmid = 28982012 | doi = 10.1139/bcb-2017-0132 | bibcode = 2018BCB....96.0132S }}</ref>

===Developmental stages===
Different body systems in the infant grow, mature, and develop at specific times during gestation. The effect of consumption of alcohol differs during each of these developmental stages:<ref name="cdc1">{{cite web |title=An Alcohol-free pregnancy is the best choice for your baby |url=https://www.cdc.gov/ncbddd/fasd/documents/fasdbrochure_final.pdf |archive-url=https://web.archive.org/web/20231220052233/https://www.cdc.gov/ncbddd/fasd/documents/fasdbrochure_final.pdf |archive-date=2023-12-20 |access-date=10 August 2017 |publisher=Centers for Disease Control and Prevention}}{{PD-notice}}</ref>
* From conception to the third week, the most susceptible systems and organs are the brain, spinal cord, and heart. The effects of alcohol consumption early in the pregnancy can result in defects in these systems and organs.<ref name = cdc1/>
* During the third week, alcohol can also damage the central nervous system of the fetus.<ref name="NIAAA_Pregnancy"/>
* During the fourth week of gestation, the limbs are being formed, and it is at this point that alcohol can affect the development of arms, legs, fingers, and toes. The eyes and ears also form during the fourth week and are more susceptible to the effects of alcohol.<ref name = cdc1/>
* By the sixth week of gestation, the teeth and palate are forming, and alcohol consumption at this time will affect these structures. Alcohol use in this window is responsible for many of the facial characteristics of fetal alcohol syndrome.<ref name = cdc1/>
* During the twelfth week, frequent alcohol exposure can negatively impact brain development, which affects cognitive, learning, and behavioral skills before birth.<ref name="NIAAA_Pregnancy">{{Cite web|url=https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-and-your-pregnancy|title=Drinking and Your Pregnancy|website=pubs.niaaa.nih.gov|language=en|access-date=2018-11-16}}</ref>
* By the 20th week of gestation, the formation of organs and organ systems is well-developed. The infant is still susceptible to the damaging effects of alcohol.<ref name = cdc1/>
* Ethanol exposure in the second trimester reduces nutrition levels and can affect the functioning of the endocrine system in both fetus and mother. This is because blood flow via the umbilical artery to the fetal brain is reduced.<ref>{{Cite journal|last1=Bake|first1=Shameena|last2=Tingling|first2=Joseph D.|last3=Miranda|first3=Rajesh C.|date=5 December 2011|title=Ethanol exposure during pregnancy persistently attenuates cranially-directed blood flow in the developing fetus: Evidence from ultrasound imaging in a murine second trimester equivalent model|journal=Alcoholism: Clinical and Experimental Research|volume=36|issue=5|pages=748–758|doi=10.1111/j.1530-0277.2011.01676.x|issn=0145-6008|pmc=3297711|pmid=22141380}}</ref>{{better source needed|date=March 2024}}

==Diagnosis==
Fetal alcohol spectrum disorders encompass a range of [[birth defect|physical]] and [[neurodevelopmental disorder|neurodevelopmental]] problems which can result from prenatal alcohol exposure. Diagnosis is based on the signs and symptoms in the person and evidence of alcohol use.<ref name=CDC2015Fact/> These diagnoses of fetal alcohol spectrum disorders are currently recognized:
* Fetal alcohol syndrome (FAS)<ref name=CDC2015Fact/>
* Partial fetal alcohol syndrome (pFAS) refers to individuals with a known, or highly suspected, history of prenatal alcohol exposure who have alcohol-related physical and neurodevelopmental deficits that do not meet the full criteria for FAS.<ref name="kingdon" />
* Alcohol-related neurodevelopmental disorder (ARND)<ref name="kingdon" /><ref name=CDC2015Fact/>
* Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE)<ref name=CDC2015Fact/>

As of 2016, the [[Swedish Agency for Health Technology Assessment and Assessment of Social Services]] accepts only FAS as a diagnosis, seeing the evidence as inconclusive for other types. The agency feels it is unclear if identifying a FASD-related condition benefits the diagnosed individual.<ref name=SBU2017>{{Cite web|url=http://www.sbu.se/en/publications/sbu-assesses/fetal-alcohol-syndrome-fas-and-fetal-alcohol-spectrum-disorders-fasd--conditions-and-interventions/|title=Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Spectrum Disorders (FASD) – conditions and interventions|publisher=[[Swedish Agency for Health Technology Assessment and Assessment of Social Services]] (SBU)|date=14 December 2016|website=www.sbu.se|archive-url=https://web.archive.org/web/20170606050431/http://www.sbu.se/en/publications/sbu-assesses/fetal-alcohol-syndrome-fas-and-fetal-alcohol-spectrum-disorders-fasd--conditions-and-interventions/|archive-date=6 June 2017|url-status=live|access-date=2017-06-08}}</ref>

===Classification===
Presently, four FASD diagnostic systems that diagnose FAS and other FASD conditions have been developed in North America:
* The [[Institute of Medicine]]'s guidelines for FAS, the first system to standardize diagnoses of individuals with prenatal alcohol exposure;<ref name =IOM/>
* The [[University of Washington]]'s "The 4-Digit Diagnostic Code", which ranks the four key features of FASD on a [[Likert scale]] of one to four and yields 256 descriptive codes that can be categorized into 22 distinct clinical categories, ranging from FAS to no findings;<ref name=4digitcode/>
* The [[Centers for Disease Control]]'s "Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis", which established consensus on the diagnosis FAS in the U.S. but deferred addressing other FASD conditions;<ref name=CDC>[https://www.cdc.gov/ncbddd/fasd/documents/FAS_guidelines_accessible.pdf Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis (PDF).] CDC (July 2004). Retrieved on 2019-10-19</ref> and
* Canadian guidelines for FASD diagnoses, which established criteria for diagnosing FASD in Canada and harmonized most differences between the IOM and the University of Washington's systems.<ref name=Canadian>{{cite journal | vauthors = Chudley AE, Conry J, Cook JL, Loock C, Rosales T, LeBlanc N | title = Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis | journal = Canadian Medical Association Journal | volume = 172 | issue = 5 Suppl | pages = S1–S21 | date = March 2005 | pmid = 15738468 | pmc = 557121 | doi = 10.1503/cmaj.1040302 }}</ref>

Each diagnostic system requires an assessment of four key features: growth, facial features, central nervous system, and alcohol exposure. To determine any FASD condition, a [[Interdisciplinarity|multi-disciplinary]] evaluation is necessary to assess each of the four key features for assessment. Generally, a trained [[physician]] will determine growth deficiency and FAS facial features. While a qualified physician may also assess central nervous system structural abnormalities or neurological problems, usually central nervous system damage is determined through [[Psychological testing|psychological]], [[Speech pathology|speech-language]], and [[occupational therapy]] assessments to ascertain clinically significant impairments in three or more of the Ten Brain Domains.<ref name =Lang/> Prenatal alcohol exposure risk may be assessed by a qualified physician, [[psychologist]], [[social work]]er, or chemical health counselor. These professionals work together as a team to assess and interpret data of each key feature for assessment and develop an integrative, multi-disciplinary report to diagnose FAS (or other FASD conditions) in an individual.<ref>{{Cite journal |last1=Chudley |first1=Albert E. |last2=Conry |first2=Julianne |last3=Cook |first3=Jocelynn L. |last4=Loock |first4=Christine |last5=Rosales |first5=Ted |last6=LeBlanc |first6=Nicole |date=2005-03-01 |title=Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis |journal=Canadian Medical Association Journal |volume=172 |issue=5 Suppl |pages=S1–S21 |doi=10.1503/cmaj.1040302 |issn=0820-3946 |pmid=15738468|pmc=557121 }}</ref>

A positive finding on all four features is required for a diagnosis of FAS, and the four diagnostic systems essentially agree on criteria for fetal alcohol syndrome (FAS). However, there are differences among systems when full criteria for FAS are not met. Prenatal alcohol exposure and central nervous system damage are the critical elements of the spectrum of FASD, and a positive finding in these two features is sufficient for an FASD diagnosis in all FASD systems.<ref>{{Cite journal |date=2021-07-15 |title=Diagnosis of Fetal Alcohol Spectrum Disorders (FASDs): Guidelines of Interdisciplinary Group of Polish Professionals |journal=International Journal of Environmental Research and Public Health |volume=18 |issue=14 |page=7526 |doi=10.3390/ijerph18147526 |doi-access= free|issn=1661-7827 |pmc=8304012 |pmid=34299977| vauthors = Okulicz-Kozaryn K, Maryniak A, Borkowska M, Śmigiel R, Dylag KA }}</ref> But different researchers and systems may use a wide variety of terminology to describe an individual's FASD condition, as the nomenclature is still evolving. Most individuals with deficits resulting from prenatal alcohol exposure do not express all features of FAS and fall into other FASD conditions.<ref name =IOM/> The Canadian guidelines recommend the assessment and descriptive approach of the "4-Digit Diagnostic Code" for each key feature of FASD and the terminology of the IOM in diagnostic categories, excepting ARBD.<ref name=Canadian/>

====Fetal alcohol syndrome====
The most severe condition is called Fetal Alcohol Syndrome (FAS),<ref name=CDC2015Fact/> which refers to individuals who have a specific set of birth defects and neurodevelopmental disorders characteristic of the diagnosis.<ref name=kingdon>{{cite journal | vauthors = Kingdon D, Cardoso C, McGrath JJ | title = Research Review: Executive function deficits in fetal alcohol spectrum disorders and attention-deficit/hyperactivity disorder - a meta-analysis | journal = Journal of Child Psychology and Psychiatry, and Allied Disciplines | volume = 57 | issue = 2 | pages = 116–131 | date = February 2016 | pmid = 26251262 | pmc = 5760222 | doi = 10.1111/jcpp.12451 }}</ref> The following criteria must be fully met for an FAS diagnosis:<ref name =Canadian/><ref name =IOM/><ref name =4digitcode/><ref name =CDC/>

# Prenatal or postnatal height or weight (or both) at or below the 10th percentile<ref name="growthchart"/>
# All three FAS facial features present<ref name =facial/>
# Clinically significant structural, neurological, ''or'' functional impairment of the central nervous system
# Confirmed or Unknown prenatal alcohol exposure

FAS is the only expression of FASD that has garnered consensus among experts to become an official [[ICD-9]] and [[ICD-10]] diagnosis.

====Partial FAS====
Partial FAS (pFAS) was previously known as atypical FAS in the 1997 edition of the "4-Digit Diagnostic Code". People with pFAS have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the complete facial stigmata. Central nervous system damage is present at the same level as FAS. These individuals have the same functional disabilities but "look" less like FAS.<ref>{{Cite journal |last1=Moore |first1=Eileen M. |last2=Riley |first2=Edward P. |date=2015-09-03 |title=What Happens When Children with Fetal Alcohol Spectrum Disorders Become Adults? |journal=Current Developmental Disorders Reports |volume=2 |issue=3 |pages=219–227 |doi=10.1007/s40474-015-0053-7 |issn=2196-2987 |pmc=4629517 |pmid=26543794}}</ref>

The following criteria must be fully met for a diagnosis of Partial FAS:<ref name =Canadian/><ref name =IOM/><ref name =4digitcode/>

# Two or three FAS facial features present<ref name =facial/>
# Clinically significant structural, neurological, ''or'' functional impairment in three or more of the Ten Brain Domains<ref name =Lang/>
# Confirmed prenatal alcohol exposure

Growth or height may range from normal to deficient.<ref name =growthchart/>

====Alcohol-related neurodevelopmental disorder====
Alcohol-related neurodevelopmental disorder (ARND) is the specific diagnosis of the non-dysmorphic type of FASD, where a majority of the symptoms are witnessed.<ref name="nd-pae"/> The diagnosis was initially suggested by the Institute of Medicine to replace the terms FAE (fetal alcohol effects). It focuses on central nervous system damage, rather than growth deficiency or FAS facial features. The Canadian guidelines also use this diagnosis and the same criteria. While the "4-Digit Diagnostic Code" includes these criteria for three of its diagnostic categories, it refers to this condition as [[static encephalopathy]]. The behavioral effects of ARND are not necessarily unique to alcohol however, so use of the term must be within the context of confirmed prenatal alcohol exposure.<ref name =FASGuide/> ARND may be gaining acceptance over the terms FAE and ARBD to describe FASD conditions with central nervous system abnormalities or behavioral or cognitive abnormalities or both due to prenatal alcohol exposure without regard to growth deficiency or FAS facial features.<ref name =FASGuide/><ref name =MalbinTry>Malbin, D. (2002). ''Fetal Alcohol Spectrum Disorders: Trying Differently Rather Than Harder''. Portland, Oregon: FASCETS, Inc. {{ISBN|0-9729532-0-5}}.</ref>

The following criteria must be fully met for a diagnosis of ARND or static encephalopathy:<ref name =Canadian/><ref name =IOM/><ref name =4digitcode/>

# Minimal or no FAS facial features present<ref name =facial/>
# Clinically significant structural, neurological, ''or'' functional impairment in three or more of the Ten Brain Domains<ref name =Lang/>
# Confirmed prenatal alcohol exposure

Growth or height may range from normal to minimally deficient.<ref name =growthchart/>

====Neurobehavioral disorder associated with prenatal alcohol exposure====
Neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) is the spectrum-wide term for the psychiatric, behavioral, and neurological symptoms of all FASDs. It was introduced into the [[DSM-5]] as a "[[DSM-5#Conditions for further study|condition for further study]]" and as a specified condition under, "other specified neurodevelopmental disorders" as a way to better study the behavioral aspects of all FASD disorders.<ref name="nd-pae">{{cite journal | vauthors = Hagan JF, Balachova T, Bertrand J, Chasnoff I, Dang E, Fernandez-Baca D, Kable J, Kosofsky B, Senturias YN, Singh N, Sloane M, Weitzman C, Zubler J | display-authors = 6 | title = Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure | journal = Pediatrics | volume = 138 | issue = 4 | pages = e20151553 | date = October 2016 | pmid = 27677572 | pmc = 5477054 | doi = 10.1542/peds.2015-1553 | author14 = Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Workgroup | author15 = American Academy of Pediatrics }}</ref>

===Specific criteria===
====Growth====
In terms of FASD, [[Human development (biology)|growth]] deficiency is defined as significantly below average [[Human height|height]], [[Human weight|weight]] or both due to prenatal alcohol exposure and can be assessed at any point in the [[Maximum life span|lifespan]]. Growth measurements must be adjusted for parental height, [[Gestational age (obstetrics)|gestational age]] (for a [[premature birth|premature infant]]), and other [[postnatal]] insults (e.g., [[poor nutrition]]), although birth height and weight are the preferred measurements.<ref name =4digitcode/> Deficiencies are documented when height or weight falls at or below the 10th percentile of standardized growth charts appropriate to the population.<ref name=growthchart>[https://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm#Clin%202 Clinical growth charts.] {{webarchive|url=https://web.archive.org/web/20101203192127/http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm |date=3 December 2010 }} National Center for Growth Statistics. Retrieved on 2007-04-10</ref> Prenatal or postnatal presentation of growth deficits can occur, but are most often postnatal.<ref>{{cite journal | vauthors = Del Campo M, Jones KL | title = A review of the physical features of the fetal alcohol spectrum disorders | journal = European Journal of Medical Genetics | volume = 60 | issue = 1 | pages = 55–64 | date = January 2017 | pmid = 27729236 | doi = 10.1016/j.ejmg.2016.10.004 | s2cid = 33641835 }}</ref>

Criteria for FASD are least specific in the [[Institute of Medicine]] (IOM) diagnostic system ("low birth weight..., decelerating weight not due to nutrition..., [or] disproportional low weight to height" p.&nbsp;4 of executive summary),<ref name=IOM/> while the CDC use the 10th percentile as a cut-off to determine growth deficiency.<ref name=CDC/> The "4-Digit Diagnostic Code" allows for mid-range gradations in growth deficiency (between the 3rd and 10th percentiles) and severe growth deficiency at or below the 3rd percentile.<ref name=4digitcode/> Growth deficiency (at severe, moderate, or mild levels) contributes to diagnoses of FAS and pFAS, but not ARND or static encephalopathy.{{citation needed|date=July 2021}}

The "4-Digit Diagnostic Code" from 2004 ranks growth deficiency as follows:<ref name=4digitcode>Astley, S.J. (2004). ''Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code''. Seattle: University of Washington. PDF available at [http://depts.washington.edu/fasdpn/htmls/4-digit-code.htm FAS Diagnostic and Prevention Network] {{webarchive|url=https://web.archive.org/web/20061216110134/http://depts.washington.edu/fasdpn/htmls/4-digit-code.htm |date=16 December 2006 }}. Retrieved on 2007-04-11.</ref>
* Severe: Height and weight at or below the 3rd percentile.
* Moderate: Either height or weight at or below the 3rd percentile, but not both.
* Mild: Either height or weight or both between the 3rd and 10th percentiles.
* None: Height and weight both above the 10th percentile.

In the initial studies that described FAS, growth deficiency was a requirement for inclusion in the studies; thus, all the original people with FAS had growth deficiency as an [[Artifact (observational)|artifact]] of [[Chorionic villus sampling|sampling]] characteristics used to establish criteria for the syndrome.{{Citation needed|date=April 2007}} That is, growth deficiency is a key feature of FASD because growth deficiency was a criterion for inclusion in the study that defined FAS. Growth deficiency may be less critical for understanding the disabilities of FASD than the neurobehavioral sequelae to the brain damage.<ref name =IOM/> Canadian guidelines updated in 2016 deleted growth as a diagnostic criterion.<ref>{{cite journal | vauthors = Cook JL, Green CR, Lilley CM, Anderson SM, Baldwin ME, Chudley AE, Conry JL, LeBlanc N, Loock CA, Lutke J, Mallon BF, McFarlane AA, Temple VK, Rosales T | display-authors = 6 | title = Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan | journal = Canadian Medical Association Journal | volume = 188 | issue = 3 | pages = 191–197 | date = February 2016 | pmid = 26668194 | pmc = 4754181 | doi = 10.1503/cmaj.141593 }}</ref>

====Facial features====
[[file:Philtrum FAS 6 months.jpg|thumb|Smooth philtrum seen on a six-month-old baby with FAS]]
Several characteristic [[craniofacial]] abnormalities are often visible in individuals with FAS.<ref>{{cite journal | vauthors = Jones KL, Smith DW | title = The fetal alcohol syndrome | journal = Teratology | volume = 12 | issue = 1 | pages = 1–10 | date = August 1975 | pmid = 1162620 | doi = 10.1002/tera.1420120102 }}</ref> The presence of FAS facial features indicates [[brain damage]], although brain damage may also exist in their absence. FAS facial features (and most other visible, but non-diagnostic, deformities) are believed to be caused mainly during the 10th to 20th week of gestation.<ref>{{cite journal | vauthors = Renwick JH, Asker RL | title = Ethanol-sensitive times for the human conceptus | journal = Early Human Development | volume = 8 | issue = 2 | pages = 99–111 | date = July 1983 | pmid = 6884260 | doi = 10.1016/0378-3782(83)90065-8 }}</ref>

Refinements in diagnostic criteria since 1975 have yielded three distinctive and diagnostically significant facial features which distinguish FAS from other disorders with partially overlapping characteristics.<ref name =photo>{{cite journal | vauthors = Astley SJ, Clarren SK | title = A case definition and photographic screening tool for the facial phenotype of fetal alcohol syndrome | journal = The Journal of Pediatrics | volume = 129 | issue = 1 | pages = 33–41 | date = July 1996 | pmid = 8757560 | doi = 10.1016/s0022-3476(96)70187-7 }}</ref><ref name =photoapp>{{cite journal | vauthors = Astley SJ, Stachowiak J, Clarren SK, Clausen C | title = Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population | journal = The Journal of Pediatrics | volume = 141 | issue = 5 | pages = 712–717 | date = November 2002 | pmid = 12410204 | doi = 10.1067/mpd.2002.129030 }}</ref> The three FAS facial features are:
* A smooth [[philtrum]]: The divot or groove between the nose and upper lip flattens with increased prenatal alcohol exposure.
* Thin vermilion: The [[upper lip]] thins with increased prenatal alcohol exposure.
* Small [[palpebral fissure]]s: [[human eyeball|Eye]] width decreases with increased prenatal alcohol exposure.

Measurement of FAS facial features uses criteria developed by the [[University of Washington]]. The lip and philtrum are measured by a trained physician with the Lip-Philtrum Guide,<ref name=lipphiltrum>[http://depts.washington.edu/fasdpn/htmls/lip-philtrum-guides.htm Lip-philtrum guides] {{webarchive|url=https://web.archive.org/web/20070208212724/http://depts.washington.edu/fasdpn/htmls/lip-philtrum-guides.htm |date=8 February 2007 }}. FAS Diagnostic and Prevention Network, University of Washington. Retrieved on 2007-04-10.</ref> a five-point [[Likert scale]] with representative photographs of lip and philtrum combinations ranging from normal (ranked 1) to severe (ranked 5). Palpebral fissure length (PFL) is measured in millimeters with either [[calipers]] or a clear ruler and then compared to a PFL growth chart, also developed by the University of Washington.<ref name=facial>[http://depts.washington.edu/fasdpn/htmls/fas-face.htm FAS facial features] {{webarchive|url=https://web.archive.org/web/20071027175622/http://depts.washington.edu/fasdpn/htmls/fas-face.htm |date=27 October 2007 }}. FAS Diagnostic and Prevention Network, University of Washington. Retrieved on 2007-04-10</ref>

Ranking FAS facial features is complicated because the three separate facial features can be affected independently by prenatal alcohol. A summary of the criteria follows:<ref name=4digitcode/><ref>Astley, Susan. [http://depts.washington.edu/fasdpn/pdfs/lipguides2004-backside.pdf Backside of Lip-Philtrum Guides (2004) (PDF)] {{webarchive|url=https://web.archive.org/web/20070619195808/http://depts.washington.edu/fasdpn/pdfs/lipguides2004-backside.pdf |date=19 June 2007 }}. University of Washington, Fetal Alcohol Syndrome Diagnostic and Prevention Network. Retrieved on 2007-04-11</ref>
* Severe: All three facial features ranked independently as severe (lip ranked at 4 or 5, philtrum ranked at 4 or 5, and PFL two or more standard deviations below average).
* Moderate: Two facial features ranked as severe and one feature ranked as moderate (lip ''or'' philtrum ranked at 3, ''or'' PFL between one and two standard deviations below average).
* Mild: A mild ranking of FAS facial features covers a broad range of facial feature combinations:
** Two facial features ranked severe, and one ranked within normal limits,
** One facial feature ranked severe, and two ranked moderate, or
** One facial feature ranked severe, one ranked moderate, and one ranked within normal limits.
* None: All three facial features ranked within normal limits.

====Central nervous system====
[[Central nervous system]] (CNS) damage is the primary feature of any FASD diagnosis. Prenatal alcohol exposure, which is classified as a [[teratogen]], can damage the brain across a continuum of gross to subtle impairments, depending on the amount, timing, and frequency of the exposure as well as genetic predispositions of the fetus and mother.<ref name=IOM/><ref>West, J.R. (Ed.) (1986). ''Alcohol and Brain Development''. New York: Oxford University Press.{{page needed|date=October 2014}}</ref> While functional abnormalities are the behavioral and cognitive expressions of the FASD disability, CNS damage can be assessed in three areas: structural, neurological, and functional impairments.{{citation needed|date=July 2021}}

All four diagnostic systems allow for assessment of CNS damage in these areas, but the criteria vary. The IOM system requires structural or neurological impairment for a diagnosis of FAS, but also allows a "complex pattern" of functional anomalies for diagnosing PFAS and ARND.<ref name=IOM/> The "4-Digit Diagnostic Code" and CDC guidelines allow for a positive CNS finding in any of the three areas for any FASD diagnosis, but functional anomalies must measure at two standard deviations or worse in three or more functional domains for a diagnosis of FAS, PFAS, and ARND.<ref name=4digitcode/><ref name=CDC/> The "4-Digit Diagnostic Code" also allows for an FASD diagnosis when only two functional domains are measured at two standard deviations or worse.<ref name=4digitcode/> The "4-Digit Diagnostic Code" further elaborates the degree of CNS damage according to four ranks:
* Definite: Structural impairments or neurological impairments for FAS or static encephalopathy.
* Probable: Significant dysfunction of two standard deviations or worse in three or more functional domains.
* Possible: Mild to moderate dysfunction of two standard deviations or worse in one or two functional domains ''or'' by judgment of the clinical evaluation team that CNS damage cannot be dismissed.
* Unlikely: No evidence of CNS damage.

=====Structural=====
Structural abnormalities of the brain are observable, and physical damage to the brain or brain structures caused by prenatal alcohol exposure. Structural impairments may include [[microcephaly]] (small head size) of two or more standard deviations below the average, or other abnormalities in brain structure (e.g., [[agenesis of the corpus callosum]], [[cerebellar hypoplasia]]).<ref name=IOM/>

Microcephaly is determined by comparing head circumference (often called occipitofrontal circumference, or OFC) to appropriate OFC growth charts.<ref name=growthchart/> Other structural impairments must be observed through [[medical imaging]] techniques by a trained physician. Because imaging procedures are expensive and relatively inaccessible to most people, diagnosis of FAS is not frequently made via structural impairments, except for microcephaly.{{citation needed|date=July 2021}}

Evidence of a CNS structural impairment due to prenatal alcohol exposure will result in a diagnosis of FAS, and neurological and functional impairments are highly likely.<ref name=Canadian/><ref name=IOM/><ref name=4digitcode/><ref name=CDC/>

During the first trimester of pregnancy, alcohol interferes with the migration and organization of [[brain cell]]s, which can create structural deformities or deficits within the brain.<ref>{{cite journal | vauthors = Clarren SK, Alvord EC, Sumi SM, Streissguth AP, Smith DW | title = Brain malformations related to prenatal exposure to ethanol | journal = The Journal of Pediatrics | volume = 92 | issue = 1 | pages = 64–67 | date = January 1978 | pmid = 619080 | doi = 10.1016/S0022-3476(78)80072-9 }}</ref> During the third trimester, damage can be caused to the [[hippocampus]], which plays a role in memory, learning, emotion, and encoding visual and auditory information, all of which can create neurological and functional CNS impairments as well.<ref>{{cite journal | vauthors = Coles CD, Brown RT, Smith IE, Platzman KA, Erickson S, Falek A | title = Effects of prenatal alcohol exposure at school age. I. Physical and cognitive development | journal = Neurotoxicology and Teratology | volume = 13 | issue = 4 | pages = 357–367 | year = 1991 | pmid = 1921915 | doi = 10.1016/0892-0362(91)90084-A | bibcode = 1991NTxT...13..357C }}</ref>

As of 2002, there were 25 reports of [[Autopsy|autopsies]] on infants known to have FAS. The first was in 1973, on an infant who died shortly after birth.<ref name=Jones1973/> The examination revealed extensive brain damage, including microcephaly, migration anomalies, [[corpus callosum]] dysgenesis, and a massive [[neuroglial]], [[leptomeningeal]] [[Heterotopia (medicine)|heterotopia]] covering the left hemisphere.<ref name=Mattson10>Mattson, S.N., & Riley, E.P. (2002). "Neurobehavioral and Neuroanatomical Effects of Heavy Prenatal Exposure to Alcohol," in Streissguth and Kantor. (2002). p. 10.</ref>

In 1977, Clarren described a second infant whose mother was a binge drinker. The infant died ten days after birth. The autopsy showed severe [[hydrocephalus]], abnormal neuronal migration, and a small corpus callosum.<ref name=Mattson10/> FAS has also been linked to [[brainstem]] and cerebellar changes, agenesis of the corpus callosum and [[anterior commissure]], neuronal migration errors, absent [[olfactory bulb]]s, [[meningomyelocele]], and [[porencephaly]].<ref name=Mattson10/>

Additional sturctural defects were identified in various autopsies since then, including: [[Ulegyria]], [[microgyria]], Hypoxic-Ischemic and/or Hemorrhagic lesions due to [[Perinatal stroke]], [[ventriculomegaly]], and [[Cerebellar degeneration|cerebellar atrophy]].<ref name=Jarmasz2017> {{cite journal | vauthors = Jarmasz JS, Basalah DA, Chudley AE, Del Bigio MR | year = 2017 | title = Human Brain Abnormalities Associated With Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder | journal = J Neuropathol Exp Neurol | volume = 76 | issue = 9| pages = 813–833 | doi = 10.1093/jnen/nlx064 | pmid = 28859338 | pmc = 5901082 }}</ref>

=====Neurological=====
When structural impairments are not observable or do not exist, neurological impairments are assessed. In the context of FASD, [[Neurology|neurological impairments]] are caused by prenatal alcohol exposure, which causes general neurological damage to the [[central nervous system]] (CNS), the [[peripheral nervous system]], or the [[autonomic nervous system]]. A determination of a neurological problem must be made by a trained physician, and must not be due to a postnatal insult, such as [[meningitis]], [[concussion]], [[traumatic brain injury]], etc.{{citation needed|date=July 2021}}

All four diagnostic systems show virtual agreement on their criteria for CNS damage at the neurological level, and evidence of a CNS neurological impairment due to prenatal alcohol exposure will result in a diagnosis of FAS or pFAS, and functional impairments are highly likely.<ref name=Canadian/><ref name=IOM/><ref name=4digitcode/><ref name=CDC/>

Neurological problems are expressed as either hard signs, or diagnosable disorders, such as [[epilepsy]] or other [[seizure disorder]]s, or soft signs. Soft signs are broader, nonspecific neurological impairments, or symptoms, such as impaired [[fine motor skills]], [[sensory processing disorder|neurosensory]] [[hearing loss]], poor [[Gait (human)|gait]], [[developmental coordination disorder|clumsiness]], and poor [[eye–hand coordination]]. Many soft signs have [[Norm-referenced test|norm-referenced criteria]], while others are determined through clinical judgment. "Clinical judgment" is only as good as the clinician, and soft signs should be assessed by either a pediatric neurologist, a pediatric neuropsychologist, or both.{{citation needed|date=July 2021}}

=====Functional=====
When structural or neurological impairments are not observed, all four diagnostic systems allow CNS damage due to prenatal alcohol exposure to be assessed in terms of functional impairments.<ref name=Canadian/><ref name=IOM/><ref name=4digitcode/><ref name=CDC/> Functional impairments are deficits, problems, delays, or abnormalities due to prenatal alcohol exposure (rather than hereditary causes or postnatal insults) in observable and measurable domains related to daily functioning, often referred to as [[developmental disabilities]]. There is no consensus on a specific pattern of functional impairments due to prenatal alcohol exposure<ref name=IOM/> and only CDC guidelines label developmental delays as such,<ref name=CDC/> so criteria (and FASD diagnoses) vary somewhat across diagnostic systems.

The four diagnostic systems list various CNS domains that can qualify for functional impairment, which can determine an FASD diagnosis:
* Evidence of a complex pattern of behavior or cognitive abnormalities inconsistent with developmental level in the following CNS domains – Sufficient for a pFAS or ARND diagnosis using IOM guidelines<ref name=IOM/>
** [[Learning disability|Learning disabilities]], academic achievement, [[Deferred gratification|impulse control]], [[Social learning (social pedagogy)|social perception]], [[communication]], [[abstraction]], math skills, [[memory]], [[attention]], judgment
* Performance at two or more [[standard deviation]]s on [[standardized testing]] in three or more of the following CNS domains – Sufficient for an FAS, pFAS or [[static encephalopathy]] diagnosis using 4-Digit Diagnostic Code<ref name=4digitcode/>
** [[Executive functioning]], [[memory]], cognition, [[Adaptive behavior|social/adaptive skills]], academic achievement, [[communication|language]], [[motor skill]]s, [[attention]], activity level
* General cognitive deficits (e.g., [[IQ]]) at or below the 3rd percentile on standardized testing – Sufficient for an FAS diagnosis using CDC guidelines<ref name=CDC/>
* Performance at or below the 16th percentile on [[standardized testing]] in three or more of the following CNS domains – Sufficient for an FAS diagnosis using CDC guidelines<ref name=CDC/>
** [[Cognition]], [[executive functioning]], [[motor skill|motor functioning]], [[ADHD|attention and hyperactive problems]], [[social skills]], [[sensory processing disorder]], social communication, memory, difficulties responding to common [[parenting]] practices
* Performance at two or more standard deviations on standardized testing in three or more of the following CNS domains – Sufficient for an FAS diagnosis using Canadian guidelines
** Cognition, communication, academic achievement, memory, executive functioning, adaptive behavior, motor skills, social skills, social communication

=====Ten brain domains=====
A recent{{When|date=April 2023}} effort to standardize assessment of functional CNS damage has been suggested by an experienced FASD diagnostic team in Minnesota. The proposed framework attempts to harmonize IOM, 4-Digit Diagnostic Code, CDC, and Canadian guidelines for measuring CNS damage vis-à-vis FASD evaluations and diagnosis. The standardized approach is referred to as the Ten Brain Domains and encompasses aspects of all four diagnostic systems' recommendations for assessing CNS damage due to prenatal alcohol exposure. The framework provides clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines intervention considerations that address the complex nature of FASD with the intention to avoid common secondary disabilities.<ref name=Lang/>

The proposed Ten Brain Domains include:<ref name=Lang/>
* [[Outcome-based education|Achievement]]
* [[Adaptive behavior]]
* [[Attention]]
* [[Cognition]]
* [[Executive functioning]]
* [[Language]]
* [[Memory]]
* [[Motor skills]]
* [[Multisensory integration]] or soft [[Neurology|neurological]] problems
* Social [[communication]]<ref name=Lang>{{cite journal | vauthors = Lang J |year=2006 |title=Ten Brain Domains: A Proposal for Functional Central Nervous System Parameters for Fetal Alcohol Spectrum Disorder Diagnosis and Follow-up |journal=Journal of the FAS Institute |volume=4 |pages=1–11 |url=http://www.motherisk.org/JFAS_documents/JFAS_5012_Final_e12_6.28.6.pdf |archive-url=https://web.archive.org/web/20060926012830/http://www.motherisk.org/JFAS_documents/JFAS_5012_Final_e12_6.28.6.pdf |archive-date=26 September 2006 |access-date=4 February 2007 }}</ref>

The Fetal Alcohol Diagnostic Program (FADP) uses unpublished Minnesota state criteria of performance at 1.5 or more [[standard deviation]]s on [[standardized testing]] in three or more of the Ten Brain Domains to determine CNS damage. However, the Ten Brain Domains are easily incorporated into any of the four diagnostic systems' CNS damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for FASD.<ref name=fadp>{{Cite web|url=https://fadpmn.org/|archive-url=https://web.archive.org/web/20070223032007/http://www.fadpmn.org/ |title=fadpmn.org, Nisan 2022|archive-date=23 February 2007|website=fadpmn.org}}</ref>

====Alcohol exposure====
Prenatal alcohol exposure is determined by interview of the biological mother or other family members knowledgeable of the mother's alcohol use during the pregnancy (if available), prenatal health records (if available), and review of available birth records, court records (if applicable), [[drug rehabilitation|chemical dependency treatment]] records (if applicable), chemical biomarkers,<ref name="Biomarkers for the Detection of Pre">{{cite journal | vauthors = Bager H, Christensen LP, Husby S, Bjerregaard L | title = Biomarkers for the Detection of Prenatal Alcohol Exposure: A Review | journal = Alcoholism: Clinical and Experimental Research | volume = 41 | issue = 2 | pages = 251–261 | date = February 2017 | pmid = 28098942 | doi = 10.1111/acer.13309 | s2cid = 2595225 }}</ref> or other reliable sources.

Exposure level is assessed as ''confirmed exposure'', ''unknown exposure'', and ''confirmed absence of exposure'' by the IOM, CDC, and Canadian diagnostic systems. The "4-Digit Diagnostic Code" further distinguishes confirmed exposure as ''High Risk'' and ''Some Risk'':{{citation needed|date=December 2021}}
* Confirmed exposure: The CDC guidelines are silent on using information on the amount, frequency, and timing of prenatal alcohol use for diagnostic purposes. The IOM and Canadian guidelines explore this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol consumption in determining, but offer no standard for diagnosis. Canadian guidelines discuss this lack of clarity and parenthetically point out that "heavy alcohol use" is defined by the [[National Institute on Alcohol Abuse and Alcoholism]] as five or more drinks per episode on five or more days during 30 days.<ref>U.S. Department of Health and Human Services. (2000). National Institute on Alcohol Abuse and Alcoholism. ''Tenth special report to the U.S Congress on alcohol and health: Highlights from current research''. Washington, DC: The Institute.</ref> "The 4-Digit Diagnostic Code" ranking system distinguishes between levels of prenatal alcohol exposure as ''high risk'' and ''some risk''. It operationalizes high risk exposure as a [[blood alcohol content|blood alcohol concentration]] (BAC) greater than 100&nbsp;mg/dL delivered at least weekly in early pregnancy. This BAC level is typically reached by a 55&nbsp;kg female drinking six to eight beers in one sitting.<ref name =4digitcode/>
** High Risk: Confirmed use of alcohol during pregnancy known to be at high [[blood alcohol content|blood alcohol levels]] (100&nbsp;mg/dL or greater) delivered at least weekly in early pregnancy.
** Some Risk: Confirmed use of alcohol during pregnancy with use less than High Risk or unknown usage patterns.
* Unknown Risk: Unknown use of alcohol during pregnancy. For many adopted adults and children in foster care, records or other reliable sources may not be available for review. Reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol use is ongoing. Many are reluctant to admit to drinking or to provide an accurate report of the quantity they drank.<ref name=CDC/> In these cases, all diagnostic systems use an unknown prenatal alcohol exposure designation. A diagnosis of FAS is still possible with an unknown exposure level if other key features of FASD are present at clinical levels.{{citation needed|date=July 2021}}
* No Risk: Confirmed absence of prenatal alcohol exposure. Confirmed absence of exposure would apply to planned pregnancies in which no alcohol was used or pregnancies of women who do not use alcohol or report no use during the pregnancy. This designation is relatively rare, as most people presenting for an FASD evaluation are at least ''suspected'' to have had a prenatal alcohol exposure due to the presence of other key features of FASD.<ref name =4digitcode/><ref name =CDC/>

====Biomarkers====
Evidence is insufficient for the use of chemical biomarkers to detect prenatal alcohol exposure.<ref>{{cite journal | vauthors = McQuire C, Paranjothy S, Hurt L, Mann M, Farewell D, Kemp A | title = Objective Measures of Prenatal Alcohol Exposure: A Systematic Review | journal = Pediatrics | volume = 138 | issue = 3 | article-number = e20160517 | date = September 2016 | pmid = 27577579 | doi = 10.1542/peds.2016-0517 | s2cid = 420106 | url = https://orca.cardiff.ac.uk/97906/1/Mcquire.%20Objective%20Measures%20of%20prenatal%20alcohol%20exposure.%20%20Pediatrics..pdf }}</ref> Biomarkers being studied include fatty acid ethyl esters (FAEE) detected in the meconium (first feces of an infant) and hair. FAEE may be present if chronic alcohol exposure occurs during the second and third trimesters since this is when the meconium begins to form. Concentrations of FAEE can be influenced by medication use, diet, and individual genetic variations in FAEE metabolism, however.<ref name="Biomarkers for the Detection of Pre"/><ref name="Dejong2019">{{cite journal | vauthors = Dejong K, Olyaei A, Lo JO | title = Alcohol Use in Pregnancy | journal = Clinical Obstetrics and Gynecology | volume = 62 | issue = 1 | pages = 142–155 | date = March 2019 | pmid = 30575614 | pmc = 7061927 | doi = 10.1097/GRF.0000000000000414 }}</ref>

===Differential diagnosis===
The CDC reviewed nine [[syndromes]] that have overlapping features with FAS; however, none of these syndromes include all three FAS facial features, and none are the result of prenatal alcohol exposure:<ref name="CDC" />
* [[Aarskog syndrome]]
* [[Williams syndrome]]
* [[Noonan syndrome]]
* [[Dubowitz syndrome]]
* [[Cornelia de Lange syndrome|Brachman-DeLange syndrome]]
* [[Toluene (toxicology)|Toluene syndrome]]
* [[Fetal hydantoin syndrome]]
* [[Fetal valproate syndrome]]
* Maternal [[Phenylketonuria|PKU]] fetal effects

Other disorders that have overlapping behavioral symptoms that might be comorbid to fetal alcohol spectrum disorder might include:<ref name="Overlapping Behavioral Characteristics of FASD's & Related Mental Health Diagnosis">{{cite web |title=Overlapping Behavioral Characteristics of FASD's & Related Mental Health Diagnosis |url=http://i1.wp.com/www.fasdfamilies.com/wp-content/uploads/2016/02/overlapping-characteristics-sources1.jpg?resize=791%2C1024 |website=www.fasdfamilies.com |publisher=Cathy Bruer-Thompson |access-date=28 July 2019}}</ref>
* [[Attention deficit hyperactive disorder]]
* [[Autism spectrum disorder]]
* [[Reactive attachment disorder]]
* [[Oppositional defiant disorder]]
* [[Sensory integration dysfunction]]
* [[Bipolar disorder]]
* [[Major depressive disorder|Depression]]

Most people with FASD have most often been misdiagnosed with ADHD due to the large overlap between their behavioral deficits.

==Treatment==
Although the condition has no available cure, treatment can improve outcomes.<ref name=CDC2015Fact/><ref name=Ras2016>{{cite journal | vauthors = Rasmussen C, Andrew G, Zwaigenbaum L, Tough S | title = Neurobehavioural outcomes of children with fetal alcohol spectrum disorders: A Canadian perspective | journal = Paediatrics & Child Health | volume = 13 | issue = 3 | pages = 185–191 | date = March 2008 | pmid = 19252695 | pmc = 2529423 }}</ref> Because central nervous system damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type that works for everyone.<ref name="An Update on Fetal Alcohol Syndrome"/>

Between 2017 and 2019 researchers made a breakthrough when they discovered a possible cure using neural [[stem cells]]; they propose that if applied to a newborn, the damage can be reversed and prevent any lasting effects in the future.<ref>{{cite journal | vauthors = Lippert T, Gelineau L, Napoli E, Borlongan CV | title = Harnessing neural stem cells for treating psychiatric symptoms associated with fetal alcohol spectrum disorder and epilepsy | journal = Progress in Neuro-Psychopharmacology & Biological Psychiatry | volume = 80 | issue = Pt A | pages = 10–22 | date = January 2018 | pmid = 28365374 | doi = 10.1016/j.pnpbp.2017.03.021 | s2cid = 30200836 }}</ref>

===Medications===
[[Psychoactive drug]]s are frequently tried as many FASD symptoms are mistaken for or overlap with other disorders, most notably [[ADHD]]. Medications are used to specifically treat symptoms of FASDs and not FAS entirely. Some of the medications used are antidepressants, stimulants, neuroleptics, and anti-anxiety drugs.<ref name=Buxton/>

===Behavioral interventions===
[[Early intervention]] from birth to age 3 has been shown to improve the development of a child born with FASD.<ref name="Dejong2019" /> Interventions may include [[parent–child interaction therapy]], efforts to modify child behavior, and drugs.<ref name=Roz2015>{{cite journal | vauthors = Roszel EL | title = Central nervous system deficits in fetal alcohol spectrum disorder | journal = The Nurse Practitioner | volume = 40 | issue = 4 | pages = 24–33 | date = April 2015 | pmid = 25774812 | doi = 10.1097/01.NPR.0000444650.10142.4f }}</ref> [[Behaviorism|Behavioral]] interventions are based on the [[Learning theory (education)|learning theory]], which is the basis for many parenting and [[Psychology|professional]] strategies and interventions.<ref name=MalbinTry/> Along with ordinary [[parenting styles]], such strategies are frequently used by default for treating those with FAS, as the diagnoses [[oppositional defiance disorder]], [[conduct disorder]], and [[reactive attachment disorder]] often overlap with FAS (along with [[ADHD]]), and these are sometimes thought to benefit from behavioral interventions. Frequently, a person's poor academic achievement results in [[special education]] services, which also utilize principles of [[Learning theory (education)|learning theory]], [[behavior modification]], and [[outcome-based education]].{{citation needed|date=July 2021}}

Children with FAS benefit from behavioral and functional training, social skill training, and tutoring. Support groups and talk therapy not only help the children suffering from FAS, but also help the parents and siblings of these children.{{citation needed|date=July 2023}}

===Developmental framework===
Many books and handouts on FAS recommend a developmental approach, based on [[developmental psychology]], even though most do not specify it as such and provide little theoretical background. Optimal human development generally occurs in identifiable stages (e.g., [[Jean Piaget]]'s [[theory of cognitive development]], [[Erik Erikson]]'s [[Erikson's stages of psychosocial development|stages of psychosocial development]], [[John Bowlby]]'s [[Attachment theory|attachment framework]], and other [[developmental stage theories]]). FAS interferes with normal development,<ref name="McCreight">{{cite book |last=McCreight |first=B. |year=1997 |title=Recognizing and Managing Children with Fetal Alcohol Syndrome/Fetal Alcohol Effects: A Guidebook |location=Washington, DC |publisher=[[Child Welfare League of America]] |isbn=0-87868-607-X}}</ref> which may cause stages to be delayed, skipped, or immaturely developed. Over time, an unaffected child can negotiate the increasing demands of life by progressing through stages of development normally, but not so for a child with FAS.<ref name=McCreight/>

By knowing what developmental stages and tasks children follow, treatment and interventions for FAS can be tailored to helping a person meet developmental tasks and demands successfully.<ref name=McCreight/> If a person is delayed in the [[adaptive behavior]] domain, for instance, then interventions would be recommended to target specific delays through additional education and practice (e.g., practiced instruction on tying shoelaces), giving reminders, or making accommodations (e.g., using slip-on shoes) to support the desired functioning level. This approach is an advance over behavioral interventions, because it takes the person's developmental context into account while developing interventions.{{Citation needed|date=August 2010}}

===Advocacy model===
The [[advocacy]] model takes the point of view that someone is needed to actively mediate between the environment and the person with FAS.<ref name=FASGuide/> Advocacy activities are conducted by an advocate (for example, a family member, friend, or [[Case management (mental health)|case manager]]) and fall into three basic categories. An advocate for FAS: (1) interprets FAS and the disabilities that arise from it and explains it to the environment in which the person operates, (2) engenders change or accommodation on behalf of the person, and (3) assists the person in developing and reaching attainable goals.<ref name=FASGuide/>

The advocacy model is often recommended, for example, when developing an [[individualized education program]] for the person's progress at school.<ref name=Buxton>{{cite book |last=Buxton |first=B. |year=2005 |title=Damaged Angels: An Adoptive Mother Discovers the Tragic Toll of Alcohol in Pregnancy |location=New York |publisher=Carroll & Graf |isbn=0-7867-1550-2}}</ref>

An understanding of the developmental framework would presumably inform and enhance the advocacy model, but advocacy also implies interventions at a systems level as well, such as educating schools, social workers, and so forth on best practices for FAS. However, several organizations devoted to FAS also use the advocacy model at a [[community practice]] level as well.<ref name=agencies>Organizations in the United States include: 
*[http://www.nofas.org National Organization on Fetal Alcohol Syndrome]. {{webarchive|url=https://web.archive.org/web/20070405231125/http://www.nofas.org/ |date=5 April 2007 }}
* [http://www.mofas.org Minnesota Organization on Fetal Alcohol Syndrome]. {{webarchive|url=https://web.archive.org/web/20070405231157/http://www.mofas.org/ |date=5 April 2007 }} Retrieved April 11, 2007.</ref>

Treating FAS at the [[public health]] and [[public policy]] level promotes FAS prevention and diversion of [[Public services|public resources]] to assist those with FAS.<ref name=FASGuide/> It is related to the advocacy model but promoted at a systems level (rather than with the individual or family), such as developing community education and supports, state or province level prevention efforts (e.g., screening for maternal alcohol use during [[obstetrics and gynaecology]] or prenatal medical care visits), or national awareness programs. Several organizations and state agencies in the U.S. are dedicated to this type of intervention.<ref name=agencies/>

==Prognosis==
The prognosis of FASD is variable depending on the type, severity, and whether treatment is issued.{{citation needed|date=July 2021}} Prognostic disabilities are divided into primary and secondary disabilities.

===Primary disabilities===
The primary disabilities of FAS are the functional difficulties with which the child is born as a result of central nervous system damage due to prenatal alcohol exposure.<ref name=2disabilities>{{cite techreport |last1=Streissguth |first1=A. P. |last2=Barr |first2=H. M. |last3=Kogan |first3=J. |last4=Bookstein |first4=F. L. |year=1996 |title=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 and Prevention on Grant No. RO4/CCR008515 |id=Tech. Report No. 96-06 |location=Seattle |publisher=University of Washington, Fetal Alcohol and Drug Unit}}</ref>

Often, primary disabilities are mistaken as ''behavior problems'', but the underlying central nervous system damage is the originating source of a functional difficulty,<ref name="MalbinFAE">{{cite book |last=Malbin |first=D. |year=1993 |title=Fetal Alcohol Syndrome, Fetal Alcohol Effects: Strategies for Professionals |location=Center City, Minnesota |publisher=Hazelden |ISBN=0-89486-951-5}}</ref> rather than a mental health condition, which is considered a secondary disability. The exact mechanisms for functional problems of primary disabilities are not always fully understood, but [[Animal testing|animal studies]] have begun to shed light on some correlates between functional problems and brain structures damaged by prenatal alcohol exposure.<ref name=FASGuide/> Representative examples include:

* [[Learning disability|Learning impairments]] are associated with impaired [[dendrite]]s of the [[hippocampus]]<ref>{{cite journal | vauthors = Abel EL, Jacobson S, Sherwin BT | title = In utero alcohol exposure: functional and structural brain damage | journal = Neurobehavioral Toxicology and Teratology | volume = 5 | issue = 3 | pages = 363–366 | year = 1983 | pmid = 6877477 }}</ref>
* Impaired [[Motor skill|motor development]] and functioning are associated with reduced size of the [[cerebellum]]<ref>{{cite journal | vauthors = Meyer LS, Kotch LE, Riley EP | title = Neonatal ethanol exposure: functional alterations associated with cerebellar growth retardation | journal = Neurotoxicology and Teratology | volume = 12 | issue = 1 | pages = 15–22 | year = 1990 | pmid = 2314357 | doi = 10.1016/0892-0362(90)90107-N | bibcode = 1990NTxT...12...15M }}</ref>
* [[Hyperactivity]] is associated with decreased size of the [[corpus callosum]]<ref>{{cite journal | vauthors = Zimmerberg B, Mickus LA | title = Sex differences in corpus callosum: influence of prenatal alcohol exposure and maternal undernutrition | journal = Brain Research | volume = 537 | issue = 1–2 | pages = 115–122 | date = December 1990 | pmid = 2085766 | doi = 10.1016/0006-8993(90)90347-e | s2cid = 21989095 }}</ref>

Functional difficulties may result from CNS damage in more than one domain, but common functional difficulties by domain include:<ref name=FASGuide/><ref name=MalbinTry/><ref name=McCreight/><ref name=MalbinFAE/> Note that this is not an exhaustive list of difficulties.
* Achievement: [[Learning disability|Learning disabilities]]
* Adaptive behavior: Poor [[Deferred gratification|impulse control]], poor [[personal boundaries]], poor [[anger management]], stubbornness, intrusive behavior, too friendly with strangers, poor [[daily living skills]], developmental delays
* Attention: [[ADHD|Attention-deficit/hyperactivity disorder]] (ADHD), poor attention or concentration, distractible
* Cognition: [[Intellectual disability]], confusion under pressure, poor [[Abstraction|abstract skills]], difficulty distinguishing between fantasy and reality, slower [[cognitive processing]]
* Executive functioning: Poor [[Decision making|judgment]], [[Sensory processing disorder|information-processing disorder]], poor at perceiving patterns, poor cause and effect reasoning, inconsistent at linking words to actions, poor [[generalization]] ability
* Language: [[Expressive language disorder|Expressive]] or [[Mixed receptive-expressive language disorder|receptive]] language disorders, grasp parts but not whole concepts, lack understanding of metaphor, idioms, or sarcasm
* Memory: Poor [[short-term memory]], inconsistent memory and knowledge base
* Motor skills: Poor handwriting, poor [[fine motor skill]]s, poor [[gross motor skill]]s, [[Developmental coordination disorder|delayed motor skill development]] (e.g., riding a bicycle at an appropriate age)
* [[Sensory processing]] and soft neurological problems: [[sensory processing disorder]], sensory defensiveness, undersensitivity to stimulation
* Social communication: Intrude into conversations, inability to read [[Nonverbal communication|nonverbal]] or [[Social learning (social pedagogy)|social]] cues, "chatty" but without substance

===Secondary disabilities===
The secondary disabilities of FAS are those that arise later in life, secondary to central nervous system damage. These disabilities often emerge over time due to a mismatch between the primary disabilities and environmental expectations; secondary disabilities can be ameliorated with early interventions and appropriate supportive services.<ref name=2disabilities/>

Six main secondary disabilities were identified in a University of Washington research study of 473 subjects diagnosed with FAS, PFAS (partial fetal alcohol syndrome), and ARND (alcohol-related neurodevelopmental disorder):<ref name=FASGuide/><ref name=2disabilities/>

* Mental health problems: Diagnosed with [[ADHD]], [[clinical depression]], or other [[mental illness]], experienced by over 90% of the subjects
* Disrupted school experience: Suspended or expelled from school or dropped out of school, experienced by 60% of the subjects (age 12 and older)
* Trouble with the law: Charged with or convicted of a crime, experienced by 60% of the subjects (age 12 and older)
* Confinement: For inpatient psychiatric care, inpatient chemical dependency care, or incarceration for a crime, experienced by about 50% of the subjects (age 12 and older)
* Inappropriate sexual behavior: Sexual advances, sexual touching, or promiscuity, experienced by about 50% of the subjects (age 12 and older)
* Alcohol and drug problems: Abuse or dependency, experienced by 35% of the subjects (age 12 and older)

Two additional secondary disabilities exist for adults:<ref name=FASGuide/><ref name=2disabilities/>

* Dependent living: Group home, living with family or friends, or some sort of assisted living, experienced by 80% of the subjects (age 21 and older)
* Problems with employment: Required ongoing job training or coaching, could not keep a job, unemployed, experienced by 80% of the subjects (age 21 and older)

===Protective factors and strengths===

Eight factors were identified in the same study as universal protective factors that reduced the incidence rate of the secondary disabilities:<ref name=FASGuide/><ref name=2disabilities/>

* Living in a stable and nurturing home for over 73% of life
* Being diagnosed with FAS before age six
* Never having experienced violence
* Remaining in each living situation for at least 2.8 years
* Experiencing a "good quality home" (meeting 10 or more defined qualities) from age 8 to 12 years old
* Having been found eligible for developmental disability (DD) services
* Having basic needs met for at least 13% of life
* Having a diagnosis of FAS (rather than another FASD condition)

Malbin (2002) has identified the following areas of interest and talents as strengths that often stand out for those with FASD and should be utilized, like any strength, in treatment planning:<ref name="MalbinTry"/>

* Music, playing instruments, composing, singing, art, spelling, reading, computers, mechanics, woodworking, skilled vocations (welding, electrician, etc.), writing, poetry
* Participation in non-impact sports or physical fitness activities

===Lifespan===

One study found that the people with FAS had a significantly shorter [[life expectancy]].<ref name="Life Expectancy of People with Feta"/> With the average life span of 34 years old, a study found that 44% of the deaths were of "external cause", with 15% of deaths being suicides.

==Epidemiology==
Globally, one in 10 women drinks alcohol during pregnancy. Out of this population, 20% [[binge drink]] and have four or more alcoholic drinks per single occasion.<ref name="who1" /> The use of alcohol during pregnancy occurs at different rates across the world, potentially due to various cultural differences and legislation. The five countries with the highest prevalence of alcohol use during pregnancy are Ireland (60%), Belarus (47%), Denmark (46%), the UK (41%), and the Russian Federation (37%).<ref name="Popova2017"/>

In a recent count, the prevalence of having any FASD disorder was 1 person out of 20, but some people estimate it could be as high as 1 in 7.<ref name=FASDfrequency/> The rates of FAS and FASD are likely to be underestimated, because of the difficulty in making the diagnosis and the reluctance of clinicians to label children and mothers.<ref>{{Cite journal|last1=Larkby|first1=C.|last2=Day|first2=N.|date=1997|title=The effects of prenatal alcohol exposure|journal=Alcohol Health and Research World|volume=21|issue=3|pages=192–198|issn=0090-838X|pmc=6826810|pmid=15706768}}</ref>

===Australia===
{{See also|Drinking culture in Australia}}
FASD among [[Australians|Australian]] youth is more common in [[indigenous Australians]].<ref name="Elliott2006">{{cite journal | vauthors = Elliott EJ, Payne J, Haan E, Bower C | title = Diagnosis of foetal alcohol syndrome and alcohol use in pregnancy: a survey of paediatricians' knowledge, attitudes and practice | journal = Journal of Paediatrics and Child Health | volume = 42 | issue = 11 | pages = 698–703 | date = November 2006 | pmid = 17044897 | doi = 10.1111/j.1440-1754.2006.00954.x | s2cid = 22479922 }}</ref> The only states that have registered birth defects in Australian youth are [[Western Australia]], [[New South Wales]], [[Victoria (Australia)|Victoria]] and [[South Australia]].<ref name="Burns2013" /> In Australia, only 12% of Australian health professionals are aware of the diagnostics and symptoms of FASD.<ref name="Elliott2006" /> In Western Australia, the rate of births resulting in FASD is 0.02 per 1,000 births for non-Indigenous Australians, however among indigenous births the rate is 2.76 per 1,000 births.<ref name="Burns2013" /> In Victoria, there have been no registered FASD related births for indigenous Australians, but the rate for the general population in Victoria is 0.01–0.03 per 1000 births.<ref name="Burns2013" /> There have been no dedicated FASD clinics within Western Australia, but there are also no nationally supported diagnostic criteria anywhere in Australia.<ref name="Mutch2015">{{cite journal | vauthors = Mutch RC, Watkins R, Bower C | title = Fetal alcohol spectrum disorders: notifications to the Western Australian Register of Developmental Anomalies | journal = Journal of Paediatrics and Child Health | volume = 51 | issue = 4 | pages = 433–436 | date = April 2015 | pmid = 25412883 | doi = 10.1111/jpc.12746 | s2cid = 25740666 | doi-access = free }}</ref> Passive surveillance is a prevention technique used within Australia to assist in monitoring and establishing detectable defects during pregnancy and childhood.<ref name="Burns2013">{{cite journal | vauthors = Burns L, Breen C, Bower C, O' Leary C, Elliott EJ | title = Counting fetal alcohol spectrum disorder in Australia: the evidence and the challenges | journal = Drug and Alcohol Review | volume = 32 | issue = 5 | pages = 461–467 | date = September 2013 | pmid = 23617437 | doi = 10.1111/dar.12047 }}</ref>

===Canada===
A 2015 review article estimated the overall costs to Canada from FASD at $9.7 billion (including from crime, healthcare, education, etc.).<ref>{{cite journal |last1=Thanh |first1=Nguyen Xuan |last2=Jonsson |first2=Egon |date=2015 |title=Costs of Fetal Alcohol Spectrum Disorder in the Canadian Criminal Justice System |url=https://jptcp.com/index.php/jptcp/article/view/281 |journal=Journal of Population Therapeutics and Clinical Pharmacology |volume=22 |issue=1 |pages=e125-31 |pmid=26072470 |access-date=November 14, 2022}}</ref>

===South Africa===
In South Africa, some populations have rates as high as 9%.<ref name=Ril2011/>

===United States===
In the United States, alcohol use at some point during [[pregnancy]] is common and appears to be rising in prevalence.<ref>{{Cite journal|last1=Denny|first1=Clark H.|last2=Acero|first2=Cristian S.|last3=Naimi|first3=Timothy S.|last4=Kim|first4=Shin Y.|date=2019-04-26|title=Consumption of Alcohol Beverages and Binge Drinking Among Pregnant Women Aged 18-44 Years - United States, 2015-2017|journal=MMWR. Morbidity and Mortality Weekly Report|volume=68|issue=16|pages=365–368|doi=10.15585/mmwr.mm6816a1|issn=1545-861X|pmc=6483284|pmid=31022164}}</ref><ref name="auto">{{Cite journal|last=Centers for Disease Control and Prevention (CDC)|date=2012-07-20|title=Alcohol use and binge drinking among women of childbearing age--United States, 2006-2010|journal=MMWR. Morbidity and Mortality Weekly Report|volume=61|issue=28|pages=534–538|issn=1545-861X|pmid=22810267}}</ref><ref>{{Cite journal|last1=Tan|first1=Cheryl H.|last2=Denny|first2=Clark H.|last3=Cheal|first3=Nancy E.|last4=Sniezek|first4=Joseph E.|last5=Kanny|first5=Dafna|date=2015-09-25|title=Alcohol use and binge drinking among women of childbearing age - United States, 2011-2013|journal=MMWR. Morbidity and Mortality Weekly Report|volume=64|issue=37|pages=1042–1046|doi=10.15585/mmwr.mm6437a3|issn=1545-861X|pmid=26401713|doi-access=free}}</ref><ref name="UpToDate">{{Cite web|last=Chang|title=UpToDate: Alcohol intake and pregnancy|url=https://www.uptodate.com/contents/alcohol-intake-and-pregnancy?search=alcohol%20and%20pregnancy&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1|access-date=2021-09-11|website=www.uptodate.com}}</ref> In 2006–2010, an estimated 7.6% of pregnant women used alcohol, while 1.4% of pregnant women reported binge drinking during their pregnancy. The highest prevalence estimates of reported alcohol use during pregnancy were among women who are aged 35–44 years (14.3%), white (8.3%), college graduates (10.0%), or employed (9.6%).<ref name="auto"/> In 2015, about 10% of pregnant women drank alcohol in the past month, and 20% to 30% drank at some point during the pregnancy.<ref name=NIH2015/> Of pregnant American women, 3.6% met criteria for an alcohol use disorder in a 2001 epidemiological study.<ref name=Mc2014>{{cite journal | vauthors = McHugh RK, Wigderson S, Greenfield SF | title = Epidemiology of substance use in reproductive-age women | journal = Obstetrics and Gynecology Clinics of North America | volume = 41 | issue = 2 | pages = 177–189 | date = June 2014 | pmid = 24845483 | pmc = 4068964 | doi = 10.1016/j.ogc.2014.02.001 }}</ref> As of 2016, the US Centers for Disease Control estimated 3 million women in the United States are at risk of having a baby with FASD.<ref>{{Cite web|url=https://www.cdc.gov/media/releases/2016/p0202-alcohol-exposed-pregnancy.html|title=More than 3 million US women at risk for alcohol-exposed pregnancy &#124; CDC Online Newsroom &#124; CDC|website=www.cdc.gov|access-date=2016-11-20|url-status=live|archive-url=https://web.archive.org/web/20161121002034/https://www.cdc.gov/media/releases/2016/p0202-alcohol-exposed-pregnancy.html|archive-date=21 November 2016|date=2 February 2016}}</ref>

FASD is estimated to affect between 1–2% and 5% of people in the United States and Western Europe.<ref name=CDC2015Prev/> FAS is believed to occur in between 0.2 and 9 per 1,000 live births in the United States.<ref name=CDC2015Prev/> Using medical and other records, CDC studies have identified 0.2 to 1.5 infants with FAS for every 1,000 live births in certain areas of the United States.<ref>{{Cite web|title=Fetal Alcohol Syndrome --- Alaska, Arizona, Colorado, and New York, 1995--1997|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5120a2.htm|access-date=2021-09-13|website=www.cdc.gov}}</ref> A more recent CDC study of 2010 data analyzed medical and other records and found FAS in 0.3 out of 1,000 children from 7 to 9 years of age.<ref>{{Cite web|title=Fetal Alcohol Syndrome Among Children Aged 7–9 Years — Arizona, Colorado, and New York, 2010|url=https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6403a2.htm?s_cid=mm6403a2_w|access-date=2021-09-13|website=www.cdc.gov}}</ref>

The lifetime cost per child with FAS in the United States was estimated at $2 million (for an overall cost across the country of over $4 billion) by the [[Centers for Disease Control and Prevention|CDC]] in 2002.<ref name=CDC2015Prev>{{cite web|title=Data & Statistics Prevalence of FASDs|url=https://www.cdc.gov/ncbddd/fasd/data.html|website=Center for Disease Control and Prevention|access-date=10 June 2015|date=April 16, 2015|url-status=live|archive-url=https://web.archive.org/web/20150629003029/http://www.cdc.gov/ncbddd/fasd/data.html|archive-date=29 June 2015}}</ref>

==History==
===Before designation===
Some hold that ancient sources describe the negative effects of alcohol during pregnancy,<ref name=Ril2011>{{cite journal | vauthors = Riley EP, Infante MA, Warren KR | title = Fetal alcohol spectrum disorders: an overview | journal = Neuropsychology Review | volume = 21 | issue = 2 | pages = 73–80 | date = June 2011 | pmid = 21499711 | pmc = 3779274 | doi = 10.1007/s11065-011-9166-x }}</ref> identifying admonitions from [[ancient Greece]], [[Ancient Rome|Rome]], the [[Talmud]], and the [[Bible]].<ref>{{cite web |title= History of FASD | vauthors = Oba PS |date= 2007 |website= FAS Aware UK |access-date= 2016-11-20 |url= http://fasaware.co.uk/wp-content/uploads/2014/10/15_history.doc |archive-url= https://web.archive.org/web/20170104230554/http://fasaware.co.uk/wp-content/uploads/2014/10/15_history.doc |archive-date= 2017-01-04}}</ref> For example, [[Plato]] writes in his fourth-century B.C. ''[[Laws (dialogue)|Laws]]'' (6.775): "Drinking to excess is a practice that is nowhere seemly ... nor yet safe. ... It behooves both bride and bridegroom to be sober ... in order to ensure, as far as possible, in every case that the child that is begotten may be sprung from the loins of sober parents." The sixth-century AD [[Talmud]] ([[Ketubot (tractate)|Kethuboth]] 60b) cautions, "One who drinks intoxicating liquor will have ungainly children." However, ancient sources rarely, if ever, distinguish maternal alcohol consumption from paternal, and are more concerned with conception than pregnancy. The sources can often be viewed as expressing [[heredity]], that children are likely to turn out like their (alcoholic) parents, rather than presenting the modern viewpoint that alcohol itself has an impact.<ref name="Sanders2009">{{cite journal |last1=Sanders |first1=JL |title=Were our forebears aware of prenatal alcohol exposure and its effects? A review of the history of fetal alcohol spectrum disorder. |journal=The Canadian Journal of Clinical Pharmacology |date=2009 |volume=16 |issue=2 |pages=e288-95 |pmid=19439773 |url=https://www.researchgate.net/publication/24424997}}</ref><ref name="Jones1973">{{cite journal | vauthors = Jones KL, Smith DW | title = Recognition of the fetal alcohol syndrome in early infancy | journal = Lancet | volume = 302 | issue = 7836 | pages = 999–1001 | date = November 1973 | pmid = 4127281 | doi = 10.1016/s0140-6736(73)91092-1 }}</ref>

[[File:Beer-street-and-Gin-lane.jpg|thumb|upright=2.2|[[Beer Street and Gin Lane|''Beer Street'' and ''Gin Lane'']], William Hogarth (1751)]]
In 1725, in the midst of the [[Gin Craze]], British physicians petitioned the [[House of Commons]] on the effects of strong drink when consumed by pregnant women saying that such drinking is "too often the cause of weak, feeble, and distempered children, who must be, instead of an advantage and strength, a charge to their country".<ref>{{cite journal | vauthors = Jackson R |title= Considerations on the Increase of Crime, and the Degree of its Extent |date= 1828-04-24 | veditors = Valpy AJ |editor-link= Abraham John Valpy |journal= The Pamphleteer |volume= 29 |number= 57 |oclc= 1761801 |publisher= John Hatchard and Son ... and T. and G. Underwood ... |location= [[London]] |page= 325 |url= https://books.google.com/books?id=7rYRAAAAYAAJ&pg=PA325 |quote= [Alcohol consumption is] too often the cause of weak, feeble, and distempered children, who must be, instead of an advantage and strength, a charge to their country}}. [[s:Jackson, Randle (DNB00)|Biography of author Randle Jackson]]</ref> There are many other such historical references during that period.<ref name="Price2021">{{cite book |last1=Price |first1=Alan D. |chapter=Overview of FASD: How Our Understanding of FASD Has Progressed |title=Prevention, Recognition and Management of Fetal Alcohol Spectrum Disorders |date=2021 |pages=9–22 |doi=10.1007/978-3-030-73966-9_2|isbn=978-3-030-73965-2 }}</ref> Gin specifically was implicated as affecting children's health and causing stillbirth and infant mortality, as depicted in William Hogarth's ''Gin Lane''. In contrast, Hogarth's ''Beer Street'' shows commerce and happiness, suggesting that the alcohol in beer was not known to have deleterious effects at this time.<ref name="Sanders2009"/>

In the 19th century, [[Benjamin Rush]] and [[Thomas Trotter (physician)|Thomas Trotter]] lobbied against alcohol consumption during pregnancy to avoid dependence and mental deficiency in children.<ref name="Sanders2009"/> The [[teetotalism]] and [[temperance movement]]s popularized these and other claims,<ref>Jonathan Townley Crane, ''Arts of Intoxication: The Aim and the Results'' (New York: Carlton & Lanahan, 1870), 173–175</ref><ref>Jennifer L. Tait, ''The Poisoned Chalice'' (Tuscaloosa, Alabama: University of Alabama Press, 2010), 27,28.</ref> including the teratogenic effects of alcohol on animal embryos,<ref name="Sanders2009"/> but they were often sensationalized, so much so that any finding that alcohol was harmful was largely denounced as propaganda.<ref name="Price2021"/> A prominent observation of possible links between maternal alcohol use and fetal damage was made in 1899 by Dr. William Sullivan, a [[Liverpool]] prison physician who noted higher rates of [[stillbirth]] for 120 alcoholic female prisoners than their sober female relatives. He suggested the causal agent to be alcohol use.<ref>{{cite journal | vauthors = Sullivan WC | year = 1899 | title = A note on the influence of maternal inebriety on the offspring | url = https://zenodo.org/record/1448716| journal = Journal of Mental Science | volume = 45 | issue = 190| pages = 489–503 | doi=10.1192/bjp.45.190.489}}</ref> This contradicted the predominant belief at the time that heredity caused intellectual disability, poverty, and criminal behavior, which contemporary studies on the subjects usually concluded.<ref name=FASGuide/> A case study by [[Henry H. Goddard]] of [[The Kallikak Family|the Kallikak family]]—popular in the early 1900s—represents this earlier perspective,<ref>Goddard, H. H. (1912). ''The Kallikak Family: A Study in the Heredity of Feeble-Mindedness''. New York: Macmillan.</ref> though later researchers have suggested that the Kallikaks almost certainly had FAS.<ref>{{cite journal | vauthors = Karp RJ, Qazi QH, Moller KA, Angelo WA, Davis JM | title = Fetal alcohol syndrome at the turn of the 20th century: An unexpected explanation of the Kallikak family | journal = Archives of Pediatrics & Adolescent Medicine | volume = 149 | issue = 1 | pages = 45–48 | date = January 1995 | pmid = 7827659 | doi = 10.1001/archpedi.1995.02170130047010 }}</ref> General studies and discussions on alcoholism throughout the mid-1900s were typically based on a heredity argument.<ref>Haggard, H. W., & Jellinek, E. M. (1942). ''Alcohol Explored''. New York: Doubleday.</ref> Researchers were often temperance advocates and funded by like-minded organizations such as the [[Anti-Saloon League]], so clinicians viewed all such research with heavy skepticism. The temperance movement effectively shut down serious research into the subject for nearly 50 years after Prohibition.<ref name="Sanders2009"/> In the 1940s it was generally dismissed as superstition.<ref name="Yaf2011" />

From the 1960s to the 1980s, alcohol was commonly used as a [[tocolytic]], a method to stop preterm labor (born at less than 37 weeks gestation). The method originated with Dr. [[Fritz Fuchs (medicine)|Fritz Fuchs]], the chairman of the department of obstetrics and gynecology at Cornell University Medical College.<ref name="Armstrong, E. M. 2003">Armstrong, E. M. (2003). Conceiving risk, bearing responsibility: Fetal alcohol syndrome & the diagnosis of moral disorder. Baltimore: The Johns Hopkins University Press.</ref><ref>{{cite news |url=https://www.nytimes.com/1995/03/04/obituaries/dr-fritz-fuchs-76-who-advanced-obstetrics.html |title=Dr. Fritz Fuchs, 76, Who Advanced Obstetrics |access-date=2017-02-16 |url-status=live |archive-url=https://web.archive.org/web/20170627093149/http://www.nytimes.com/1995/03/04/obituaries/dr-fritz-fuchs-76-who-advanced-obstetrics.html |archive-date=27 June 2017 |newspaper=The New York Times |date=4 March 1995 | vauthors = Saxon W }}</ref> Doctors recommended a small amount of alcohol to calm the uterus during contractions in early pregnancy or Braxton Hicks contractions. In later stages of pregnancy, the alcohol was administered intravenously and often in large amounts. "Women experienced similar effects as occur with oral ingestion, including intoxication, nausea and vomiting, and potential alcohol poisoning, followed by hangovers when the alcohol was discontinued."<ref>King, T. L., & Brucker, M. C. (2011). Pharmacology for women's health. Sudbury, MA: Jones and Bartlett.</ref> Vomiting put the mother at a high risk for aspiration and was "a brutal procedure for all involved".<ref name="Armstrong, E. M. 2003"/> Because the alcohol was being given intravenously, the doctor could continue giving the treatment to the mother long after she had passed out, resulting in her being more intoxicated than would otherwise be possible. Such heavy intoxication was highly likely to contribute to FASD.<ref name="Armstrong, E. M. 2003"/> In a 2015 review, ethanol was found to be no better than a placebo (sugar water) in suppressing preterm birth and neonatal mortality. Not only was ethanol worse than other beta-mimetic drugs (tocolytic agents) at postponing birth, it also led to a higher rate of low birthweight babies, babies with breathing problems at birth, and neonatal death.<ref>{{cite journal |last1=Haas |first1=David M |last2=Morgan |first2=Amanda M |last3=Deans |first3=Samantha J |last4=Schubert |first4=Frank P |title=Ethanol for preventing preterm birth in threatened preterm labor |journal=Cochrane Database of Systematic Reviews |issue=11 |article-number=CD011445 |date=5 November 2015 |volume=2015 |doi=10.1002/14651858.CD011445.pub2|pmid=26544539 |pmc=8944412 }}</ref>

=== Recognition as a syndrome ===
In France in 1957, Jacqueline Rouquette had described 100 children whose parents were alcoholics in a thesis, which was not published. "She gave a good description in certain cases of the facies" according to her mentor, Paul Lemoine.<ref>{{Cite journal |last=Lemoine |first=Paul |date=August 1994 |title=The letter from Professor Lemoine |url=https://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.1994.tb03364.x |journal=Addiction |language=en |volume=89 |issue=8 |pages=1021–1023 |doi=10.1111/j.1360-0443.1994.tb03364.x |issn=0965-2140|url-access=subscription }}</ref>
In 1968, Paul Lemoine of [[Nantes]] published a study in a French medical journal about children with distinctive features whose mothers were alcoholics.<ref name=Lemoine>{{cite journal |last1=Lemoine |first1=P. |last2=Harousseau |first2=H. |last3=Borteyru |first3=J. B. |last4=Menuet |first4=J. C. | year = 1968 | title = Les enfants de parents alcooliques. Anomalies observées, à propos de 127 cas | journal = Quest Medical | volume = 21 | pages = 476–482 }} Reprinted in {{cite journal | vauthors = Lemoine P, Harousseau H, Borteyru JP, Menuet JC | title = Children of alcoholic parents—observed anomalies: discussion of 127 cases | journal = Therapeutic Drug Monitoring | volume = 25 | issue = 2 | pages = 132–136 | date = April 2003 | pmid = 12657907 | doi = 10.1097/00007691-200304000-00002 | s2cid = 8894309 }}</ref>

Independently, in the U.S., Christy Ulleland at [[University of Washington]] Medical School conducted an 18-month study in 1968–1969 documenting the risk of maternal alcohol consumption among the offspring of 11 alcoholic mothers.<ref name=Ulleland1972>{{cite journal | vauthors = Ulleland CN | title = The offspring of alcoholic mothers | journal = Annals of the New York Academy of Sciences | volume = 197 | issue = 1 | pages = 167–169 | date = May 1972 | pmid = 4504588 | doi = 10.1111/j.1749-6632.1972.tb28142.x | s2cid = 84514766 | bibcode = 1972NYASA.197..167U }}</ref> This study is arguably the true source of the modern understanding.<ref name="Price2021"/> The infants were studied by [[Dysmorphology|dysmorphologists]] Kenneth Lyons Jones and [[David Weyhe Smith]], colleagues of Ulleland at University of Washington,<ref name="Price2021"/> who identified a pattern of "craniofacial, limb, and cardiovascular defects associated with prenatal onset growth deficiency and developmental delay" in eight children. The pattern of malformations indicated that the damage was prenatal. They named these defects "fetal alcohol syndrome".<ref name=Jonesetal1973/> News of the discovery shocked some, while others were skeptical of the findings.<ref name=Streissguth1>{{cite book |first=Streissguth |last=A. P. |year=2002 |editor1-first=A. |editor1-last=Streissguth |editor2-first=J. |editor2-last=Kanter |title=The Challenge in Fetal Alcohol Syndrome: Overcoming Secondary Disabilities |location=Seattle |publisher=University of Washington Press |isbn=0-295-97650-0}}</ref>{{title missing|title=Authorship credited to one of the editors, presumably a specific contribution. TOC suggests it's the preface|date=October 2025}} While many [[syndrome]]s are [[eponym]]ous, i.e. named after the physician first reporting the association of symptoms, Smith named FAS after the causal agent of the symptoms.<ref name=foreword>{{cite book |contributor-last=Clarren |contributor-first=S. K. |year=2005 |contribution=Foreword: A thirty-year journey from tragedy to hope |last=Buxton |first=B. |title=Damaged Angels: An Adoptive Mother Discovers the Tragic Toll of Alcohol in Pregnancy |location=New York |publisher=Carroll & Graf |isbn=0-7867-1550-2}}</ref> He reasoned that doing so would encourage prevention, believing that if people knew maternal alcohol consumption caused the syndrome, then abstinence during pregnancy would follow from [[health education|patient education]] and public awareness.<ref name=foreword/> At the time, nobody was aware of the full range of possible birth defects from FAS or its rate of prevalence.<ref name=foreword/>

In 1978, within nine years of the Washington discovery, animal studies, including non-human monkey studies carried out at the University of Washington Primate Center by [[Sterling Clarren]], had confirmed that alcohol was a [[Teratogenesis|teratogen]]. By 1978, 245 cases of FAS had been reported by medical researchers, and the syndrome began to be described as the most frequent known cause of [[intellectual disability]].{{citation needed|date=July 2021}} In 1979, the Washington and Nantes findings were confirmed by a research group in [[Gothenburg]], Sweden.<ref name=Olegard>{{cite journal | vauthors = Olegård R, Sabel KG, Aronsson M, Sandin B, Johansson PR, Carlsson C, Kyllerman M, Iversen K, Hrbek A | display-authors = 6 | title = Effects on the child of alcohol abuse during pregnancy. Retrospective and prospective studies | journal = Acta Paediatrica Scandinavica. Supplement | volume = 275 | pages = 112–121 | year = 1979 | pmid = 291283 | doi = 10.1111/j.1651-2227.1979.tb06170.x | s2cid = 2799171 }}</ref> Researchers in France, Sweden, and the United States were struck by how similar these children looked, though they were not related, and how they behaved in the same unfocused and [[hyperactive]] manner.<ref name=Olegard/>

==="Spectrum" rather than "syndrome"===
Over time, subsequent research and clinical experience suggested that a range of effects could arise from prenatal alcohol exposure. The term ''fetal alcohol effects'' (FAE) was used for alcohol-related neurodevelopmental disorder and alcohol-related birth defects.<ref name=CDC2015Fact/> It was initially used in research studies to describe humans and animals in whom teratogenic effects were seen after confirmed prenatal alcohol exposure (or unknown exposure for humans), but without obvious physical anomalies.<ref name =FAE/> Smith (1981) described FAE as an "extremely important concept" to highlight the debilitating effects of brain damage, regardless of the growth or facial features.<ref name =FAESmith>{{cite journal | vauthors = Smith DW | title = Fetal alcohol syndrome and fetal alcohol effects | journal = Neurobehavioral Toxicology and Teratology | volume = 3 | issue = 2 | page = 127 | year = 1981 | pmid = 7254460 }}</ref> This term fell out of favor with clinicians in the 1990s because it was often regarded by the public as a less severe disability than FAS, when in fact its effects could be just as detrimental.<ref>{{cite journal | vauthors = Aase JM, Jones KL, Clarren SK | title = Do we need the term 'FAE'? | journal = Pediatrics | volume = 95 | issue = 3 | pages = 428–430 | date = March 1995 | pmid = 7862486 }}</ref> In 1996, the replacement terms ''alcohol-related brain damage'' (ARBD) and ''alcohol-related neurodevelopmental disorder'' (ARND) were introduced. in 2002, the US Congress mandated that the CDC develop diagnostic guidelines for FAS and in 2004 a definition of a term that already had been used by some in the 1990s, ''fetal alcohol spectrum disorder'' (FASD), was adopted,<ref name="Williams2015" /> to include FAS as well as other conditions resulting from prenatal alcohol exposure.<ref name=foreword/> Currently, FAS<ref name=IOM/><ref name=FAE>{{cite journal | vauthors = Clarren SK, Smith DW | title = The fetal alcohol syndrome | journal = The New England Journal of Medicine | volume = 298 | issue = 19 | pages = 1063–1067 | date = May 1978 | pmid = 347295 | doi = 10.1056/NEJM197805112981906 }}</ref><ref name=Jonesetal1973>{{cite journal | vauthors = Jones KL, Smith DW, Ulleland CN, Streissguth P | title = Pattern of malformation in offspring of chronic alcoholic mothers | journal = Lancet | volume = 1 | issue = 7815 | pages = 1267–1271 | date = June 1973 | pmid = 4126070 | doi = 10.1016/S0140-6736(73)91291-9 }}</ref> is the only expression of prenatal alcohol exposure defined by the [[ICD|International Statistical Classification of Diseases and Related Health Problems]] and assigned [[ICD-9]] and diagnoses.{{citation needed|date=July 2021}}

Alcohol-related birth defects (ARBD), formerly known as possible fetal alcohol effect (PFAE),<ref name=FAE/> was a term proposed as an alternative to FAE and PFAE.<ref>{{cite journal | vauthors = Sokol RJ, Clarren SK | title = Guidelines for use of terminology describing the impact of prenatal alcohol on the offspring | journal = Alcoholism: Clinical and Experimental Research | volume = 13 | issue = 4 | pages = 597–598 | date = August 1989 | pmid = 2679217 | doi = 10.1111/j.1530-0277.1989.tb00384.x }}</ref> The IOM presents ARBD as a list of congenital anomalies that are linked to maternal alcohol use but have no key features of FASD.<ref name=IOM/> PFAE and ARBD have fallen out of favor because these anomalies are not necessarily specific to maternal alcohol consumption and are not criteria for diagnosis of FASD.<ref name=FASGuide>{{cite book |last=Streissguth |first=A. |year=1997 |title=Fetal Alcohol Syndrome: A Guide for Families and Communities |location=Baltimore |publisher=Brookes |isbn=1-55766-283-5}}</ref>

In 2013, the [[American Psychiatric Association]] introduced ''neurobehavioral disorder associated with prenatal alcohol exposure'' (ND-PAE).<ref name="nd-pae"/>

==Society and culture==
===Criminalization===
Criminalization of substance use during pregnancy because of harm to the fetus or child is fiercely debated.<ref>{{cite journal |last1=Angelotta |first1=C. |last2=Appelbaum |first2=P. S. |title=Criminal Charges for Child Harm from Substance Use in Pregnancy |journal=The Journal of the American Academy of Psychiatry and the Law |date=June 2017 |volume=45 |issue=2 |pages=193–203 |pmid=28619859}}</ref><ref>{{cite journal |last1=Hackler |first1=C. |title=Ethical, legal and policy issues in management of fetal alcohol spectrum disorder. |journal=The Journal of the Arkansas Medical Society |date=November 2011 |volume=108 |issue=6 |pages=123–24 |pmid=23252025|pmc=4049518 }}</ref> Elizabeth Armstrong has questioned the zero-tolerance approach taken towards alcohol consumption during pregnancy, describing it as a [[moral panic]].<ref name="Armstrong2000">{{Cite journal|last1=Armstrong|first1=Elizabeth M.|last2=Abel|first2=Ernest L.|date=2000|title=Fetal alcohol syndrome: the origins of a moral panic |journal=Alcohol and Alcoholism|language=en|volume=35|issue=3|pages=276–282|doi=10.1093/alcalc/35.3.276|pmid=10869248|issn=0735-0414|doi-access=free}}</ref><ref name="Armstrong2017">{{cite journal |last1=Armstrong |first1=E. M. |title=Making Sense of Advice About Drinking During Pregnancy: Does Evidence Even Matter? |journal=The Journal of Perinatal Education |date=2017 |volume=26 |issue=2 |pages=65–69 |doi=10.1891/1058-1243.26.2.65 |pmid=30723369|pmc=6353268}}</ref> While heavy alcohol consumption during pregnancy is known to be damaging to the unborn child, the effects of low intakes remain debatable, particularly in the absence of randomized controlled trials (cf. {{section link|#Causes}}).<ref name="Flak2014"/><ref name="Mamluk2017"/> The UK's abstinence recommendation was not chosen based on scientific evidence, but rather because it was simple advice that would ensure no one underestimated the risk.<ref>{{cite news |title='No alcohol in pregnancy' advised |work=BBC News |date=25 May 2007 |url=https://news.bbc.co.uk/2/hi/health/6687761.stm}}</ref> Tennessee's 2014 fetal assault law (which expired in 2016) was criticized for not addressing alcohol use.<ref>{{cite news |last1=Humphrey |first1=Tom |title=Legislators clash with doctors, judges over renewing fetal assault law |url=https://archive.knoxnews.com/news/politics/legislators-clash-with-doctors-judges-over-renewing-fetal-assault-law-2e6d62dc-0331-7bbf-e053-010000-372736971.html/ |work=Knoxville News Sentinel |date=20 March 2016 |language=en}}</ref><ref>{{cite news |last1=Bassett |first1=Laura |title=State Enacts Law To Incarcerate Pregnant Women Who Use Drugs |url=https://www.huffpost.com/entry/tennessee-to-incarcerate_n_5241770 |work=HuffPost |date=30 April 2014 |language=en}}</ref> The law criminalized opioid use during pregnancy and resulted in women avoiding professional medical care for fear of prosecution.<ref>{{cite journal |last1=Darlington |first1=Caroline K. |last2=Compton |first2=Peggy A. |last3=Hutson |first3=Sadie P. |title=Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward |journal=Policy, Politics, & Nursing Practice |date=May 2021 |volume=22 |issue=2 |pages=93–104 |doi=10.1177/1527154421989994|pmid=33567969 }}</ref> A wide variety of professional organizations oppose criminalization.<ref>{{cite news |last1=Picciuto |first1=Elizabeth |title=Court Says Fetal Alcohol Syndrome Isn't a Crime |url=https://www.thedailybeast.com/court-says-fetal-alcohol-syndrome-isnt-a-crime |work=The Daily Beast |date=9 December 2014 |language=en}}</ref><ref>{{cite web |title=Medical and Public Health Groups Oppose Punishment of Pregnant People |url=https://www.pregnancyjusticeus.org/resources/medical-public-health-groups-statementss/ |website=Pregnancy Justice |access-date=15 March 2024 |date=2023}}</ref> Minnesota, North Dakota, Oklahoma, South Dakota, and Wisconsin have statutory authorization for the involuntary civil commitment of women who abuse alcohol during pregnancy.<ref>{{cite web |title=Civil Commitment: About This Policy |url=https://alcoholpolicy.niaaa.nih.gov/apis-policy-topics/civil-commitment/20/about-this-policy |website=Alcohol Policy Information System |publisher=NIAAA |access-date=15 March 2024 |language=en}}</ref>

===2016 CDC controversy===
In 2016, a [[Centers for Disease Control and Prevention|CDC]] press release and infographic entitled "More than 3 million US women at risk for alcohol-exposed pregnancy" caused controversy.<ref>{{Cite news|url=https://www.cbsnews.com/news/cdc-backlash-telling-women-avoid-alcohol-if-not-using-birth-control/|title=CDC faces backlash over alcohol warning to women|work=CBS News|access-date=2018-04-06|language=en}}</ref> The CDC release contained the message "The risk is real. Why take the chance?".<ref>{{cite news |title=More than 3 million US women at risk for alcohol-exposed pregnancy |url=https://archive.cdc.gov/www_cdc_gov/media/releases/2016/p0202-alcohol-exposed-pregnancy.html |publisher=Centers for Disease Control and Prevention |date=2 February 2016 |language=en-us}}</ref><ref>{{Cite web|url=https://www.cdc.gov/VitalSigns/Fasd/infographic.html#graphic2|archive-url=https://web.archive.org/web/20160926022613/http://www.cdc.gov/VitalSigns/Fasd/infographic.html#graphic2|archive-date=26 September 2016|title=Alcohol and Pregnancy |website=VitalSigns |publisher=Centers for Disease Control and Prevention |date=2017-03-20|language=en-us|access-date=2018-04-06}}</ref> Darlena Cunha of ''Time'' magazine interpreted the infographic as telling all women of child-bearing age not to drink at all, in case they might accidentally fall pregnant, and called them "scare tactics" and "shaming recommendations".<ref>{{Cite magazine|url=https://time.com/4209491/cdc-alcohol-pregnancy/|title=The CDC's Alcohol and Pregnancy Warning Shames Women|magazine=Time|date=5 February 2016 |access-date=2018-04-06}}</ref> Julie Beck said that the infographic insinuated that "your womb is a Schrödinger's box and you shouldn't pour alcohol into it unless you've peeked in there to be 100 percent sure the coast is clear".<ref>{{cite news |last1=Khazan |first1=Olga |last2=Beck |first2=Julie |title=CDC to Women: Don't Drink Unless You're On Birth Control |url=https://www.theatlantic.com/health/archive/2016/02/protect-your-womb-from-the-devil-drink/459813/ |access-date=15 March 2024 |work=The Atlantic |date=3 February 2016 |language=en}}</ref> The CDC later clarified that the infographic was not intended to make any new guidelines or recommendations for women who are not pregnant, but rather to encourage conversations about alcohol with health professionals.<ref>{{cite news |last1=Schumaker |first1=Erin |title=No, The Government Did Not Just Tell Women To Stop Drinking |url=https://www.huffpost.com/entry/cdc-alcohol-young-women-pregnancy-warning_n_56b22f03e4b04f9b57d805bc |access-date=15 March 2024 |work=HuffPost |date=4 February 2016 |language=en}}</ref> Nonetheless, half of all pregnancies in developed countries and over 80% in developing countries are unplanned. Many women do not realize they are pregnant during the early stages and continue drinking when pregnant.<ref name="who1">{{cite journal|url=https://www.who.int/bulletin/volumes/95/5/17-030517/en/|title=Counting the costs of drinking alcohol during pregnancy|journal=Bulletin of the World Health Organization|volume=95|issue=5|pages=320–321|access-date=11 August 2017|doi=10.2471/BLT.17.030517|pmid=28479632|pmc=5418824|year=2017}}</ref>

===In fiction===
In [[Aldous Huxley]]'s 1932 novel ''[[Brave New World]]'' (where all fetuses are gestated [[in vitro]] in a factory), lower [[caste]] fetuses are created by receiving alcohol transfusions (Bokanovsky Process) to reduce intelligence and height, thus conditioning them for simple, menial tasks. Connections between alcohol and incubating embryos are made multiple times in the novel.<ref>{{cite journal | vauthors = Brown JM, Bland R, Jonsson E, Greenshaw AJ | title = A Brief History of Awareness of the Link Between Alcohol and Fetal Alcohol Spectrum Disorder | journal = Canadian Journal of Psychiatry | volume = 64 | issue = 3 | pages = 164–168 | date = March 2019 | pmid = 29807454 | pmc = 6405809 | doi = 10.1177/0706743718777403 }}</ref>

==See also==
* [[Smoking and pregnancy]]
* [[Environmental toxicants and fetal development]]
* [[Long-term effects of alcohol consumption]]

==Notes==
{{notelist}}

==References==
{{Reflist}}

==External links==
{{Commons category|Fetal alcohol syndrome}}
{{Medical resources
 | ICD10 = {{ICD10|Q|86|0|q|80}}
 | ICD9 = {{ICD9|760.71}}
 | DiseasesDB = 32957
 | MedlinePlus = 000911
 | eMedicineSubj = ped
 | eMedicineTopic = 767
 | MeshID = D005310
}}
* [https://web.archive.org/web/20181015090219/https://www.helpguide.org/harvard/women-and-alcohol.htm Harvard health]
* [https://www.cdc.gov/ncbddd/fasd/index.html Center for Disease Control's page on Fetal Alcohol Spectrum Disorders (FASDs)]

{{Pregnancy}}
{{Alcohol and health}}
{{Pathology of pregnancy, childbirth and the puerperium}}
{{Reproductive physiology}}
{{Humandevelopment}}
{{Infants and their care}}
{{Psychoactive substance use}}
{{Congenital malformation due to exogenous toxicity}}
{{Pediatric conditions originating in the perinatal period}}
{{Central nervous system disease}}
{{Authority control}}

[[Category:Biology of attention deficit hyperactivity disorder]]
[[Category:Congenital disorders]]
[[Category:Congenital disorders of nervous system]]
[[Category:Congenital malformation due to exogenous toxicity]]
[[Category:Drugs and pregnancy]]
[[Category:Health effects of alcohol]]
[[Category:Health issues in pregnancy]]
[[Category:Human pregnancy]]
[[Category:Mental disorders due to brain damage]]
[[Category:Neurodevelopmental disorders]]
[[Category:Neurological disorders]]
[[Category:Neurological disorders in children]]
[[Category:Obstetrics]]
[[Category:Spectrum disorders]]
[[Category:Syndromes]]
[[Category:Syndromes with craniofacial abnormalities]]
[[Category:Syndromes with intellectual disability]]
[[Category:Teratogens]]
[[Category:Women's health]]