Dina E Hill PhD dhillsaludunmedu Cynthia King MD cykingsaludunmedu Department of Psychiatry University of New Mexico School of Medicine DISCLOSURES Dr Hill has a contract with IHS for neuropsychological assessment of children through her private practice ID: 911025
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Slide1
FETAL ALCOHOL SPECTRUM DISORDER (FASD): UPDATE AND FUTURE DIRECTIONS
Dina E. Hill, Ph.D. (dhill@salud.unm.edu)
Cynthia King, MD (cyking@salud.unm.edu)
Department of Psychiatry, University of New Mexico, School of Medicine
Slide2DISCLOSURES
Dr. Hill has a contract with IHS for neuropsychological assessment of children through her private practice.
Dr. King has no financial relationships or conflicts of interest related to this presentation. She is not involved in any clinical drug trials.
Slide3GOALS/OBJECTIVES
Define FASD, including its relevance to American Indian and Alaska Native (AI/AN) populations.
Describe best practices in FASD for screening and diagnosis.
Describe best practices in FASD for assessment and therapeutic interventions over the lifespan.
Describe factors that contribute to resiliency. Describe what some AI/AN groups are doing to support and help develop resiliency in children, caregivers, community members, medical providers, educators, and others interacting with individuals with FASD.
Slide4Fetal Alcohol Spectrum Disorders (FASD)
FASDs are a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. These conditions can affect each person in different ways, and can range from mild to severe. They can include physical problems and problems with behavior and learning. (CDC)
Slide5Fetal Alcohol Spectrum Disorders
Institute of Medicine* – 4 categories
FAS – Fetal Alcohol Syndrome
PFAS –Partial Fetal Alcohol Syndrome
ARBD – Alcohol-Related Birth Defects
ARND – Alcohol-Related Neuro-developmental Disorder
*
Hoyme
, et al., (2016). Updated clinical guidelines for diagnosing fetal alcohol spectrum disorder.
Pediatrics:
138, 1-18.
Slide6History of FASD
It has been known for centuries that alcohol causes problems for the fetus
Late 1800s mothers, who were inmates in the UK, were observed drinking and had poor pregnancy outcomes
Lemoine
(France -1968): described 127 babies born to drinking mothers
Jones & Smith (1973): coined the term FAS
Slide7Epidemiology: Rates of Alcohol Use among
Women of Childbearing Age
CDC 2015 Morbidity and Mortality Report
Non-pregnant women
Any Alcohol Use = 54%
Binge Drinking (4 or more) = 18%
Pregnant women
Any Alcohol Use = 10% (1 in 10 consuming alcohol)
Binge drinking = 3% (1 in 33 binge drinking)
Among Binge drinkers: Pregnant women have
higher frequency
of binge drinking than non-pregnant women
Prevalence of alcohol use in pregnant women is higher for women with college degrees compared to less education
Slide8FASD Epidemiology
It is not known what percentage of babies will be born with FASD if the mother drinks alcohol during pregnancy.
FASD is likely underdiagnosed
Dysmorphic features can be less noticeable in newborns
CNS deficits may not be recognized until preschool age
Less consideration for prenatal alcohol use to be underlying factor in behavioral and learning disorders
The CDC: up to 1.5 infants per 1000 births with FAS
The CDC: 0.3 out of 1000 children from 7 to 9 years of age with FAS
May et al. (2009): 10.9 to 25.2 cases of FAS/
pFAS
per 1000.
May et al. (2014): 24 to 48 of FASD per 1000.
Slide9FAS Surveillance in US
2009: CDC – Surveillance for FAS in 3 states (AZ, CO, NY) among 7-9 year olds
FAS rates ranged from 0.3 to 0.8 FAS cases per 1000 children ages 7-9 years
Highest among Native Americans: 2 FAS cases per 1000 children ages 7-9 years
Lowest among Hispanic: 0.2 cases per 1000 children ages 7-9 years
No differences in prevalence by age or sex
Slide10FASD Surveillance in US
May et al (2014) – Surveillance for FASD in Midwestern town among first graders
Active Case Ascertainment –Tier I, II, III
Interview Mothers, then examiners review all cases for final diagnosis
Estimated Prevalence
FAS: 6-9 per 1000 children
PFAS: 11-17 per 1000 children
Total FASD: 24-48 per 1000 children
Slide11FASD Can Happen to Any Child
Slide12Primary Care Setting:
Screening for FASD
Maternal Factors
Report of maternal drinking during pregnancy
Other risk factors
Child Factors
Sibling with FAS
Unusual physical appearance/anomalies
Behavioral/developmental problems
Awareness of Populations with higher prevalence
Child Welfare Services
Slide13Diagnostic Evaluation Process for FASD
With a positive screening: refer for diagnostic evaluation
Multidisciplinary approach (includes morphological, behavioral, and neuropsychological assessment)
Diagnosis of Exclusion
Slide14Reminder:
Fetal Alcohol Spectrum Disorders
Institute of Medicine* – 4 categories
FAS – Fetal Alcohol Syndrome
PFAS –Partial Fetal Alcohol Syndrome
ARBD – Alcohol-Related Birth Defects
ARND – Alcohol-Related Neuro-developmental Disorder
*
Hoyme
, et al., (2016). Updated clinical guidelines for diagnosing fetal alcohol spectrum disorder.
Pediatrics:
138, 1-18.
Slide15Diagnostic Criteria for
Fetal Alcohol Syndrome (FAS)
With or without documented prenatal alcohol exposure
The diagnosis of FAS requires A – D:
Characteristic pattern of minor facial anomalies
Prenatal and/or postnatal growth deficiency
Evidence of CNS involvement
Neurobehavioral Impairment
**For children
>
3: cognitive and/or behavioral impairment
**For children < 3 years of age: Evidence of developmental delay
Slide16Confirmation of Maternal Alcohol Consumption
One or more of the following conditions:
>
6 drinks/week for
>
2 occasions during pregnancy
>
3 drinks per occasion on
>
2 occasions during pregnancy
Documentation of alcohol-related social or legal problems in proximity to the pregnancy
Documentation of intoxication during pregnancy by blood, breath, or urine content testing
Positive testing with established alcohol-exposure biomarker(s) during pregnancy or at birth
Increased prenatal risk associated with drinking during pregnancy as assessed by validated screening tool
Slide17Characteristic Pattern of
Minor Facial Anomalies
Including
>
2 of the following:
Short palpebral fissures (less than or equal to the 10
th
percentile)
Thin vermilion border of the upper lip (score 4 or 5 on the lip/philtrum guide)
Smooth philtrum (score 4 or 5 on the lip/philtrum guide)
Slide18Palpebral Fissure Measurement
Slide19Normative Data for Palpebral Fissure Measurements
Slide20Lip-Philtrum Guide
Slide21Microcephaly
Slide22Prenatal and/or Postnatal
Growth Deficiency
Restricted prenatal and/or postnatal growth including:
Height – less than 10
th
percentile on normal growth curves*
Weight – less than 10
th
percentile on normal growth curves
*Plot on racially or ethnically appropriate growth curve if available
Slide23Slide24Evidence of CNS Involvement
Including
>
1 of following:
Decreased head circumference at birth
(
<
10
th
percentile)
Structural brain abnormalities
Recurrent, non-febrile seizures
Slide25Evidence of Neurobehavioral Impairment
>
3 years of age
With Cognitive Impairment:
Evidence of global impairment (> 1.5 SD below mean) OR cognitive deficit (> 1.5 SD) in at least one domain
With Behavioral Impairment:
Evidence of behavioral deficit in at least 1 domain > 1.5 SD below mean in self-regulation
< 3 years of age
Evidence of
developmental delay
>
1.5 SD below the mean
Slide26FAS – Only the Tip of the Iceberg
PFAS –Partial Fetal Alcohol Syndrome (PFAS)
Alcohol-Related Birth Defects (ARBD)
Alcohol-Related Neurodevelopmental Disorders (ARND)
Slide27Diagnostic Criteria for PFAS: With Confirmed Maternal Alcohol Consumption
Characteristic pattern of
>
2 minor facial anomalies
Neurobehavioral impairment (either cognitive or behavioral):
>
3 years of age: global impairment or cognitive deficit in 1 domain or behavioral deficit in at least 1 domain
< 3 years of age: developmental delay
Slide28Diagnostic Criteria for PFAS: Without Confirmed Maternal Alcohol Consumption
Characteristic pattern of
>
2 minor facial anomalies
Growth deficiency or deficient brain growth, abnormal morphogenesis, or abnormal neurophysiology
Neurobehavioral Impairment:
>
3 years of age: global impairment or cognitive deficit in 1 domain or behavioral deficit in at least 1 domain
< 3 years of age: developmental delay
Slide29Diagnostic Criteria for ARBD
Documented prenatal alcohol exposure
One or more specific major malformations demonstrated in animal models and human studies to be the results of prenatal alcohol exposure
Slide30Associated congenital anomalies, malformations, &
dysplasias
:
Cardiac
ASD
Aberrant great vessels
VSD
Conotruncal heart defects
Skeletal
Hypoplastic nails
Clinodactyly of 5
th
fingers
Short 5
th
digits
Pectus carinatum/excavatum
Radioulnar synostosis
Vertebral segmentation defects
Lg joint contractures
Scoliosis
Camptodactyly
“
Hockey stick
”
palmar creases
Renal
Aplastic/hypoplastic/
Dysplastic kidneys
“
Horseshoe
”
kidneys/
Ureteral duplications
Eyes
Strabismus
Refractive errors
Retinal vascular anomalies
Optic nerve hypoplasia
Ears
“
Railroad track
”
ears
Conductive/ neurosensory hearing loss
Slide31Hockey Stick Palmar Crease
Slide32Railroad Track Ears
Slide33Diagnostic Criteria for ARND
Diagnosis cannot be made in children <3 years old
Confirmed maternal alcohol consumption
Neurobehavioral impairment:
With cognitive impairment: evidence of global impairment, cognitive deficits in at least 2 domains
With behavioral impairment: behavioral deficits in at least 2 domains
Slide34BREAK TIME
Slide35Evidence of Neurobehavioral Impairment
>
3 years of age
With Cognitive Impairment:
Evidence of global impairment (> 1.5 SD below mean) OR cognitive deficit (> 1.5 SD) in at least one domain
With Behavioral Impairment:
Evidence of behavioral deficit in at least 1 domain > 1.5 SD below mean in self-regulation
< 3 years of age
Evidence of
developmental delay
>
1.5 SD below the mean
Slide36Neuropsychological Assessment
Clinical Interview - Parent or caregiver
Background History
Cognitive & Behavioral Concerns
Adaptive Behavior Concerns
Record Review – Medical & Academic
Standardized Testing
Cognitive
Behavioral
Adaptive Skills
Slide37Neurobehavioral Impairments in FASD
Language Deficits
Learning and Memory
Attention
Executive Functions
Self-Regulation
Adaptive Functioning
Sensory Processing
Slide38Neuropsychological Assessment
Standardized Testing
Intellectual Ability
Attention/Information Processing
Executive Functions
Language
Visual Perception/Visual Construction
Learning and Memory
Motor Function
Academic Functioning
Slide39Intellectual Ability
Diminished intellectual functioning, with group means falling in the borderline to extremely low range (IQs 65-75)
Low intellectual functioning remains relatively unchanged over lifespan
Slide40Attention & Information
Processing Speed
Attention deficits common including: vigilance, focused attention, sustained attention (visual>auditory), and shifting attention
Impaired processing speed including: slower processing speed on effortful tasks
Slide41Executive Functions
Impairment in executive control including: planning, shifting, fluency, and concept formation
Difficulties with processes underlying executive functioning: working memory, response inhibition
Slide42Language
Expressive Language:
includes verbal and nonverbal skills and how an individual uses language
Receptive Language: comprehension of language
Pragmatic Language: social language skills
Slide43Visual Perception &
Visual Construction
Less known about these skills
Generally intact facial recognition
Impaired skills include: visual-motor integration, spatial learning/working memory, spatial recall, visual-perceptual matching
Slide44Learning and Memory
Children with FASD are known to have difficulty with learning new information
“What is learned one day is gone the next day”
Animals exposed to alcohol show damage to the hippocampus- an area in the brain that is critical for learning new information
Slide45Motor Function
Fine Motor Deficits include: delayed development, weak grasp, and poor eye-hand coordination
Gross Motor Deficits include: balance, coordination, and ball skills
Slide46Academic Functioning
Reading: weaker reading comprehension than decoding skills
Mathematics: Primary learning difficulty
Written Expression: writing mechanics, organization, production
Slide47Cognitive Functioning in FASD: Summary
Slide48Behavioral Assessment
Standardized Questionnaires
Sensory Processing/Integration
Behavior: Behavioral Phenotype
Adaptive Functioning
Examiner Observation/Provided History
Goal: differential diagnosis, identify comorbid diagnoses
Slide49Sensory Integration/Processing
Sensory Processing Differences include
Auditory
Visual
Tactile
Pain Perception
Vestibular
Need for Occupational Therapy
Slide50Behavioral Phenotype
Externalizing Behaviors: hyperactivity, conduct problems
Internalizing Symptoms: inattention, mood disorders
Need for psychotherapy/behavioral support; possible medication management
Slide51Adaptive Functioning
Adaptive Functioning includes assessment of
Social Skills
Adaptive Communication Skills
Personal Living Skills
Community Living Skills
Adaptive Motor Skills
Slide52Neuropsychological Assessment
Putting It All Together
Comprehensive Report
Feedback sessions with parents/caregivers
Slide53Diagnostic Coding
Other Specified Neurodevelopmental Disorder due to prenatal alcohol exposure
DSM-5: 315.8
ICD-10: F88
Fetal Alcohol Syndrome (dysmorphic)
ICD-10: Q86.0
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (DSM 5)
Slide54Slide55Common Comorbid Diagnoses
~40% ADHD
~15-20% Intellectual Disability
~25% Learning Disability
~30% Sensory Impairment
~4% Cerebral Palsy
~30% Speech & Language Disorders
Slide56FASD: Differential Diagnosis
Facial Features
Smooth Philtrum:
Opitz
syndrome, Cornelia de Lange syndrome, Toluene
embryopathy
, Floating-Harbor syndrome
Thin Vermillion Border: Miller-
Dieker
syndrome, Cornelia de Lange syndrome, fetal
valproic
syndrome
Short Palpebral Fissures: Williams syndrome, Trisomy 18 syndrome, PKU fetal effects,
Opitz
syndrome
Growth Retardation
CNS involvement
Slide57FASD: Differential Diagnosis
Slide58.
BREAK TIME
Slide59FASD Interventions
What helps maximize an individual’s potential?
Slide60Video: Mother of Adoptive Child with FASD
https://www.youtube.com/watch?v=m7VfRg8u-5w
Slide61General Guidelines:
Strengthening Families
Strengthening Families, a project of the Center for the Study of Social Policy:
www.strengtheningfamilies.net
Protective Factors Framework:
1. Parent Resilience
2. Knowledge of Parenting and Child Development
3. Social and Emotional Competence of Children
4. Social Connections
5. Concrete Support in Times of Need
Slide62General
Caregiver Guidelines
Provide a safe, stable, and structured home
Avoid too much sensory stimulation
Use calming approaches/techniques
Use simple, specific directions (1 step)
Keep rules simple and consistent
Have immediate consequences/feedback on behavior
Slide63General Guidelines for
Interventions with FASD Children
Minimize change
Offer services over a longer period of time
Expect slower progress
Use examples, modalities and treatment goals that are appropriate for children with FASD
Consider child’s cognitive abilities, behavior regulation problems; other comorbid conditions
Slide64General Guidelines: Behavioral Problems
Recognizing your child's strengths and limitations
Implementing daily routines
Creating and enforcing simple rules and limits
Keeping things simple by using concrete, specific language
Using repetition to reinforce learning
Pointing out and using rewards to reinforce acceptable behavior
Teaching skills for daily living and social interactions
Slide65FASD Presenting Concerns
Infant & Toddlers
Sleep disturbances
Feeding difficulties
Reduced attention
Decreased visual focus
Hyper-arousal
Problems with coordination and balance
Frequently irritable
Slide66Interventions to Support Infant & Toddlers
Early identification and referral for EI
Support for caregivers is essential
Early intervention and a stable, nurturing home are important factors in protecting children with fetal alcohol syndrome from some of the secondary disabilities they're at risk of later in life
Slide67FASD Presenting Concerns
4 – 5 Year Olds
Delayed speech development
Altered motor skills
Attention deficits
Learning deficits
Behavioral concerns
Slide68Example
:
Strategies for Enhancing Early Developmental Success (SEEDS)
Enhances child’s capacity to regulate emotions and behaviors and impacts multiple levels of the family system
Parent education and advocacy module
Attachment-based parenting skills group
Music-based parent-child play group
Slide69Example: Manitoba Canada
Community-Based Home-Visiting Program with
Preschool Children Prenatally Exposed to Alcohol
Community home-based attachment intervention, Circle of Security® (COS), with preschool children affected by PAE/FASD
Slide70Video: 9 year-old boy with FASD
https://www.youtube.com/watch?v=bd3tsHOzTr0
Slide71FASD Presenting Concerns for
School-Aged Children
Neurocognitive
Self-Regulation
Adaptive/Social
Slide72Interventions to Support
School-Age Children
Home-Based: treatment for mother; individual therapy; parent/caregiver support; medication; adaptive skills training
Education-Based: special education; speech/language, occupational, & physical therapies; FASD-specific strategies; social skills intervention; assistive technology
Slide73The Families Moving Forward Program
takes a
positive parenting approach
that uses weekly therapeutic intervention to help you care for a child with known or suspected FASD.
Slide74Example: Alert Program
Self-Regulation Program
Program Aims
Teach children concept of self-regulation
Teach sensory self-awareness
Teach child to select behaviors that match the environment
Slide75Example: Visual Cues to Support Behavior Regulation
Slide76Example: Project Bruin Buddies
Parent-Assisted Child Friendship Training
Project Aims
Develop understanding of social cues
Develop social problem solving
Develop conflict avoidance/negotiation
Slide77Video: Adult with FASD
https://www.youtube.com/watch?v=LafUmARkPpg
Slide78FASD Presenting Concerns
for Adolescents
Behavioral Problems
Problems with planning, organization, & time-management
Problems with focusing
Problems with temper, mood, & impulsive behaviors
Poor judgment
Acts like younger child
Slide79FASD Presenting Concerns
for Adolescents
Learning Problems
Reading comprehension
Math achievement
Language problems
Faulty logic
Problems with abstract thinking
Slide80General Guidelines for Working with
Adolescents & Young Adults
Safety & Health Considerations
Higher accidents and injuries
More experiences of abuse and mistreatment by adults and peers
Problems following medication routines
Problems making decisions about legal and illegal substances
Difficulties driving safely
Risk for suicide
Slide81General Guidelines for Working with Adolescents & Young Adults
14-60 % have Legal Problems
Poor impulse & temper control
Problems understanding future consequences
Trouble understanding what is illegal
Difficulty connecting cause and effect
Difficulty taking responsibility
Vulnerability to peer pressure & high suggestibility/ victimization
Weaknesses in learning from experience
Slide82General Guidelines for Working with
Adolescents & Young Adults
The 4 S
’
s + C
Structure
Supervision
Simplicity
Steps
Context
Slide83Interventions for
Adolescents & Young Adults
Recognize potential for co-occurring disorders, secondary disabilities, risk for health, safety, and legal problems
Holistic approach - consider all aspects of life
Safe, structured environments – home/community
Include family and caregivers
Include client in building a treatment plan
Consider needs for transition to adulthood: Family planning, vocational training, guardianship to support financial & medical decisions
Slide84Interventions for
Adolescents & Young Adults
Individual treatment may be more effective than group treatment
Establish routines & written guidelines: Need to teach social rules, boundaries
Awareness of sensory issues interfering with success – too bright, too loud
Use multiple methods for processing and learning new skills
Watching videos, role-play specific scenarios
Expressing self in creative ways, music & art
Use active listening and build success
Slide85Presenting Concerns for Adults
Behavior & Learning Problems
Perseverates, Rigid Thinking/Behavior
Difficulty holding a job/living independently
Poor social skills/lack of reciprocal relationships
Drug/alcohol abuse
Slide86FASD Secondary Disabilities
Disrupted school experience/school failure
Mental health problems
Inappropriate sexual behavior
Trouble with the law/incarceration
Alcohol & drug problems
Unemployment
Dependent living
Slide87General Guidelines:
Low Intellectual Ability
Speak slowly and use simple and clear language at all times.
Stop between ideas and allow for processing.
Use concrete terms like “walk slowly” rather than “straighten up”
Avoid using the negative terms like “stop running” instead say “thank you for walking slowly”
Use visual cues to help with the explanations
Slide88General Guidelines Continued:
Low Intellectual Ability
Break each task into small steps and teach through repetition
Reinforce behaviors you want and use the same language each time
Understand the child will have difficulty benefitting from feedback
“Think younger”: Understanding (especially social/emotional) will be below chronological age
Slide89Examples: FASD-Specific
Strategies
Multi-modal presentation
Experiential teaching methods
Routines/Schedules
Memory aids
Repeat, repeat, repeat
Slide90General Guidelines:
Comorbid Behavioral & Psychiatric Disorders
Psychiatry referral for medication
Stimulants
Antidepressants/Anti-Anxiety
Neuroleptics
Slide91FASD Positive Characteristics/Strengths
Creativity (artistic, musical)
Perseverance (determined, committed)
Friendly/trusting, affectionate
Spontaneous, lots of energy
Great sense of humor
Slide92FASD Long-Term Support
Section 1115 of the Social Security Act
State-specific waiver plans:
www.medicaid.gov
Vocational Rehabilitation Programs
College/University Programs
Slide93Neuroimaging Methods: Structural & Functional
Neuroimaging methods allow visualizing brain structures in detail (MRI, DTI)
Some other imaging methods allow looking at what is happening in the brain (function) while someone doing a task (fMRI, EEG, MEG)
Slide94Structural MRI: Cortical
Overall Brain Size
Cerebral Cortex
Frontal Lobes
Parietal Lobes
Temporal Lobes
Slide95Brain Differences: FASD versus Control
Slide96Structural MRI: Subcortical
Basal Ganglia
Caudate Nucleus
Corpus Callosum
Hippocampus
Cerebellum
Slide97Basal Ganglia: Caudate Nucleus
Basal Ganglia: motor control and learning
Caudate Nucleus: associated with learning, mental flexibility, and behavioral inhibition
Basal ganglia structures are significantly smaller even when controlling for overall brain size
Slide98Caudate Nucleus in Two 18-Year Olds
Normal
FAS
Slide99Corpus Callosum
The corpus callosum is the fiber tract that connects the two hemispheres
Anomalies in the corpus callosum can range from thinning in some regions to the total absence called agenesis
The integrity of corpus callosum is critical to the integration of information from two hemispheres
Slide100Slide101Hippocampus
The hippocampus is a structure located inside the medial temporal lobe
The hippocampus plays a critical role in learning and memory
Slide102Hippocampus: FASD versus Control
Slide103Cerebellum
Important for attention, executive functions, and movement
Differences seen in cerebellar structures for individuals with FASD
Slide104Cerebellum: Control versus FASD
Slide105Functional Brain Imaging
Magnetoencephalography (MEG)
Functional Magnetic Resonance Imaging (fMRI)
Slide106Magnetoencephalography
Slide107Delayed neural responses to stimuli as revealed by magnetoencephalography; Stephen et al. (in press)
Slide108Functional Magnetic Resonance Imaging (fMRI)
Spatial Working Memory
Inhibitory Control
Verbal Learning & Working Memory
Visual Working Memory
Summary fMRI Findings
Slide109Summary
At a behavioral level children with FASD show slow information processing and increased inattentiveness.
At a neurocognitive level children with FASD display impaired performance on tasks that involve the integration and manipulation of information.
At a neuronal level children with FASD show both structural and functional differences.
Slide110Research Challenges & Opportunities
Mechanisms of Alcohol’s Prenatal Effects
Preventing Potentially Harmful Alcohol Consumption
Combination Drug Use and FASD
Biomarkers of FASD
Animal Models
Slide111FASD Resources
State-specific waiver plans
www.medicaid.gov
Substance Abuse and Mental Health Services Administration (SAMHSA)
https://store.samhsa.gov/shin/content/SMA13-4803/SMA13-4803.pdf
National Institute on Alcohol Abuse and Alcoholism
http://pubs.niaaa.nih.gov/publications/arh341/toc34_1.htm
Slide112FASD Resources
NoFAS
: National Organization on Fetal Alcohol Syndrome - (800) 66-NOFAS;
www.nofas.org
American Academy of Pediatrics – FASD Toolkit:
www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/fetal-alcohol-spectrum-disorders-toolkit/Pages/default.aspx
CDC:
www.cdc.gov/ncbddd/fasd/index.html
IHS
: www.ihs.gov/telebehavioral/icp/icpfaqs
/
The Arc: www.thearc.org/what-we-do/resources/fact-sheets/fetal-alcohol-spectrum-disorder
Slide113QUESTIONS
Slide114