Symptoms/ Characteristics
The stereotype of a person with FAS is that of a retarded child, profoundly incapacitated and unable to learn much, unable to care for him or herself or to ever live successfully outside of an institution or the family home. And it is true that prenatal alcohol exposure is the most common known cause of mental retardation-accounting for more cases, for example, than Down syndrome.

While that bleak image represents part of the story, it is far from the whole picture of the disability. On the positive side, only half of people with full FAS are mentally retarded, and some even have above average IQ's. On the other hand, because the whole FASD spectrum is marked by often profound difficulties with planning and recognizing the consequences of one's behavior, even those with few intellectual deficits may have severe difficulty with independent living. When the condition is recognized and proper support is provided, however, many people with FAS and other FASD spectrum disorders can work and live in the community. The main symptoms of FASD fall into several key categories:

Physical birth defects: While the facial characteristics of full FAS are quite well known, prenatal alcohol exposure consistently leads to a number of other birth defects that are not as commonly associated with it in public perceptions. The kidneys and the heart are particularly susceptible as are the eyes and ears and their associated neural connections. Partial deafness and significant visual impairments are common. Balance and motor coordination are also often impaired.

Growth and Development: Babies with FASD tend to be born smaller and to grow much more slowly than other babies. Especially stunted is the growth of the head, which may remain significantly undersized even in adulthood. Some FASD adults have heads the normal size for five year old children.

Attention: Problems with attention are one of the defining characteristics of FASD. Such difficulties are so common amongst people with FASD that they are often misdiagnosed with attention deficit disorders. Unfortunately, the types of attention problems associated with FASD are not the same as those found in people with other attention deficits. People with classic attention deficit disorder tend to have difficulty focusing and maintaining attention-while those with FASD have fewer problems with those skills, but more trouble shifting attention from one task to another (what researchers call "set shifting").

Cognitive/Learning: Even when it doesn't cause mental retardation, prenatal alcohol exposure can lower IQ and can also affect other aspects of learning. One of its key effects is to slow reaction time and reduce brain processing speed. Both of these affect overall intelligence by limiting the brain's capacity to take in information rapidly, particularly in a setting like an ordinary classroom. People with FASD also have problems with verbal learning, although these are different from the types of problems seen with verbal learning in Down syndrome. FASD seems to affect people's ability to initially encode verbal information in memory-but once the information is encoded, recall is as good as for anyone else. With Down syndrome, both storage and recall are impaired. People with FASD also have particular difficulty with learning spacial relationships between objects and with mathematics, deficits which may be connected.

Executive Function: One of FASD's cruelest effects is the way it affects executive function - the ability to plan for the future and to change behavior in response to the effects of previous actions. People with FASD are often incapable of learning from experience and may repeat behaviors over and over despite negative results. They often cannot put together a sequence of actions in order to achieve a goal-for example, taking the steps necessary to do homework adequately or to pay a bill on time. This may in part result from their inability to shift attention well: they get "stuck" on certain things and cannot keep the whole process in mind while carrying out the steps needed to complete it.

Behavior: Behavioral problems are common with FASD-unsurprisingly, given the problems listed above with planning and with learning from bad experience. And since people with FASD are also often impulsive and may react without thinking, this can produce a horrendous vicious cycle in connection with their difficulty changing behavior once it has started. Consequently, people with FASD are often diagnosed with conduct disorder and/or oppositional defiant disorder and may have frequent run-ins with law enforcement as they appear to be willfully disobeying authorities and actively seeking repeat punishment. FASD also appears to make people more likely to lie; though whether this is simply because they are more likely to be caught doing so due to their other deficits is hard to tell.

Socialization: FASD also seems to produce difficulties recognizing social cues. People with FASD often "can't take a hint," or recognize when others are suggesting something non-verbally. They may be overly demanding of attention and may lack empathy towards others. They also tend to be eager-to-please and easily lead, which means that if they fall in with anti-social peer groups, they may be preyed upon and pushed to commit crimes that they couldn't have engineered themselves. Adolescents and adults with FASD also have a tendency towards sexual promiscuity, which may be linked both to their desire to please others and their impulsiveness.

Secondary Disabilities: As one might imagine from the litany above, being faced with FASD can be enormously difficult. Behavior that the person has difficulty controlling can repeatedly get him in trouble with authorities-but he may not know what, exactly, he's doing wrong or how to behave differently. If the condition is not diagnosed early, damage to self-esteem from negative reactions by teachers and peers is extremely common as is sexual abuse due to high vulnerability to suggestion. Criminal convictions and other social consequences can often cause just as much damage as the early alcohol exposure itself. Some researchers estimate that 90% of people with FASD have at least one additional mental illness-frequently including severe depression-and it is hard to know how much of this is due to vulnerability of the brain due to early damage and how much is due to secondary effects of trying to cope with the condition.

Treatment
While numerous educational, behavioral and even pharmacological interventions have been tried for FASD, there is little research on the outcome of these interventions and even less research that is empirically sound or which has been replicated. Medications like stimulants for the attention problems associated with FASD do seem to help - but some research suggests that the most commonly prescribed medication, Ritalin, is less likely to work than other stimulants in FASD. Antidepressants are also helpful for co-occurring depression.

Longitudinal research suggests that early diagnosis may reduce the odds of secondary disabilities like depression and criminal justice system involvement by making parents and others involved in the care of people with FASD aware of what to expect. While the best strategies for treating the disorder have not yet been elucidated, people who recognize that someone has brain damage tend to treat that person with more sympathy and to be more forgiving of inappropriate behavior than those who believe the person is deliberately misbehaving.

A study which followed 500 people with FASD over 15 years found that some 60% had serious trouble in school, including repeated disciplinary actions related to incomplete school work, inappropriate behavior in class and difficulty with peer relationships . Sixty percent of the adolescents had been involved with the juvenile justice system, usually for shoplifting and theft. Of those aged 21 and older, 80% were not living independently and the same percent had difficulty holding a job.

Factors which seemed to protect people with FASD from secondary disabilities included having a stable home life, not being a victim of violence, having received services for the disabled, having been diagnosed before age six, having full FAS and having an IQ below 70.

The last two protective factors may seem counter-intuitive, but the lead author of the study, Ann Streissguth, believes that low IQ and more visible disability are protective because they make obvious the fact that the person has brain damage. Those without the facial features and those who have higher intelligence are far more likely to be seen as capable of changing behavior that, in fact, they have impaired ability to control.

An empirically-supported treatment called Multisystemic Family Therapy has been effectively used for juveniles with a wide variety of behavior problems that bring them in contact with the criminal justice system. Since research by the federal government has found that nearly 40% of those sent to Drug Courts have some form of FASD, many such people have probably already been included in these studies and this approach certainly should be further researched explicitly for FASD.

Furthermore, because many people in special education programs are likely to have FASD, approaches that work with this population need to be studied in this setting. Some experts believe that people with severe FASD may be uneducable, and more research is needed to determine whether this pessimistic prediction is correct and what to do if it is. Since children with antisocial behavior are often placed in special education programs, it may be important to keep children with FASD away from these peers in order to avoid introduction to behaviors like shoplifting and drug use that may be hard to stop once started by FASD children.

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