Evaluation Protocol - The Diagnostic Process

The four general features that constitute an FAS diagnosis have remained essentially the same since they were first described in 1973:

  1. specific facial malformations
  2. growth retardation
  3. Central Nervous System abnormalities
  4. maternal alcohol consumption during pregnancy

These four general criteria were reaffirmed in an Institute of Medicine report in 1996. Criteria for FAS were further refined and delineated by the Centers for Disease Control (CDC) in 2004. These diagnostic criteria are supported by multiple, convergent scientific findings, making the CDC criteria more reliable in general than diagnoses found in other diagnostic compendia (e.g., DSM-IV-TR, ICD-10).

FAS is a severe outcome from prenatal alcohol exposure. Other outcomes also occur, often resulting in major deficits as severe as those seen in FAS.

Because prenatal exposure to alcohol can result in an array of structural, functional, and neurological problems that are caused by brain damage in the central nervous system (CNS) of the fetus, it is generally accepted that assessment and diagnosis involve a multi-step process incorporating specialists in several areas to investigate specific affected domains. FASDExperts uses a three-step process of assessment, done sequentially for cost-benefit purposes. All three members should receive the entirety of records available. Each member of the team will review the documents that are relevant to the consultative questions being asked.

Diagnostic Process: Step 1

NEUROPSYCHOLOGICAL TESTING

The first step in the diagnostic process involves neuropsychological testing by Dr. Paul Connor to detect functional evidence of neurological damage. Dr. Connor’s standard protocol for FASD assessment is based upon 30 years of research involving neuropsychological tests that have been found to be most sensitive to executive dysfunction and other cognitive deficits associated with prenatal alcohol exposure.

Dr. Connor’s test battery also includes standard tests typically administered in general neuropsychological testing. Although there is no known single “behavioral phenotype” of FASD because of alcohol’s diverse effects on the developing fetus, the tests included in Dr. Connor’s standardized battery also detect cognitive-behavioral dysfunction due to other neurological causes such as traumatic brain injury, stroke, dementia, or even childhood environmental experiences (e.g., repetitive trauma or neglect). Therefore, all test results are interpreted with consideration for competing etiologies, including prenatal alcohol exposure.

The neuropsychological assessment begins with an interview to determine cognitive complaints, the duration of these complaints, other neurological insults that could have occurred in the subject’s life, mental health concerns including substance use, educational history, and employment history. The purpose of the interview is to assemble a timeline of insults to the Central Nervous System iin conjunction with the history of cognitive difficulties.

The results of neuropsychological assessment are summarized in a one-page chart. Typically, the following tests are used in the assessment:

Cognition: Wechsler Adult Intelligence Scale – 4th Edition (WAIS-IV) 

Academic Achievement: Wide Range Achievement Test -4th Edition (WRAT-4)

Adaptive Skills Assessment: Vineland Adaptive Behavior Scales-2 (VABS)

Executive Functioning: Trail Making Test (TMT), Controlled Oral Word Association Test (COWAT), Ruff’s Figural Fluency Test (RFF), Stroop Test, Consonant Trigrams Test (CTT), Wisconsin Card Sorting Test (WCST),  Delis Kaplan Executive Function System (DKEFS) Tower Test and DKEFS Proverbs Test 

Motor / Sensory Integration: Grooved Pegboard, Finger Tapping, and Grip Strength.

Attention / Activity Level: Conner’s Continuous Performance Test (CPT).

Learning / Memory: California Verbal Learning Test (CVLT) and Rey Osterrieth Complex Figure Test (RCFT)

Malingering: Green’s Word Memory Test (WMT), the forced choice task on the CVLT, Structured Inventory of Malingered Symptomatology (SIMS), and Validity Indicator Profile (VIP)

Following testing, Dr. Connor compares the pattern of observed deficits in the subject with neuropsychological deficits found in the FASD literature, taking into account other competing etiologies. He then summarizes his findings and opinion in a report that correlates the subject’s functional deficits with the areas in his brain that are likely impacted.

Diagnostic Process: Step 2

FUNCTIONAL ASSESSMENT and MATERNAL DRINKING HISTORY

FASD evaluation of forensic clients involves lifelong functional assessment by psychologist Dr. Natalie Novick Brown. The objective of functional assessment is to determine whether there is evidence of the kinds of cognitive-behavioral deficits and developmental delays in the subject’s history that would be expected in FASD and, if so, how those deficits affected his/her behavior during the instant offense.

Record Review:

Dr. Brown also conducts a face-to-face interview in order to determine if the subject’s presentation is consistent with FASD. At that time, additional testing may be conducted (e.g., competency and/or suggestibility assessment). This process also involves screening for differential diagnosis.

Face-to Face Interview: 

The purpose of the interview is to gain direct clinical impressions of the subject’s current psychosocial functioning and conduct testing/assessment. A semi-structured interview guides this process, which involves screening for Axis I and Axis II disorders and social/environmental factors that may be relevant in differential diagnosis. Because competency deficits are often associated with FASDs, full competency assessment also may be conducted in pretrial situations (i.e., Competency to Waive Miranda Rights, Competency to Proceed to Trial, and a malingering assessment).  

Testing / Assessment: 

Diagnostic Process: Step 3

MEDICAL DIAGNOSIS

If Steps 1 and 2 yield results consistent with FASD, the final step in assessment is formal diagnosis. FASD conditions involve physical brain damage and other physical birth defects. Thus, an FASD diagnosis – if relevant – is made on Axis III by a medical doctor who relies on testing and functional/developmental assessment by our other specialists as well as direct, face-to-face examination.

Dr. Adler conducts a face-to-face medical examination, during which he takes facial photographs and measures facial features among other things. He also examinez childhood photographs, birth and prenatal/postnatal records, and the medical records of the subject and birth mother in order to confirm prenatal alcohol exposure.

At the conclusion of his analysis, Dr. Adler may diagnose an FASD condition if data support such a diagnosis. He also conducts differential diagnosis in order to rule out (or rule in) other potential diagnoses.