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.

Diagnostic Process: Step 1

FUNCTIONAL ASSESSMENT and MATERNAL DRINKING HISTORY

FASD evaluation of forensic clients begins with functional assessment by psychologist Dr. Natalie Novick Brown, who looks for evidence of primary functional disabilities associated with FASD in the client’s behavioral history. These abnormalities include cognitive deficits, executive skill deficits, motor skill deficits, attention deficits, adaptive functioning deficits, and social skill deficits. Records include original source documents (i.e., birth and prenatal/postnatal records, medical records from childhood up to the present time, school records, mental health records, criminal records, institutional records, records from social service agencies, childhood photographs, and other documents regarding the subject’s behavioral history) as well as any psychological, neurological, and/or neuropsychological testing ever done.

This review process also includes any records that can be obtained regarding the birth mother’s medical history and, in particular, her drinking history prior to, during, and following the pregnancy in question. (This latter analysis may include telephonic interview with the birth mother, assuming she is available and willing, and/or collateral informants using a protocol developed in FASD research at the University of Washington.) During a face-to-face interview with the subject, Dr. Brown will administer the Fetal Alcohol Behaviors checklist as well as the following standardized tests:


Mental Health/Psychiatric Conditions:

The Symptom Checklist-90-Revised (SCL-90-R) is a brief, multidimensional self-report inventory designed to screen for a broad range of psychological problems. Over 90% of individuals with FASD conditions have co-occurring mental disorders.

Adaptive Behavior / Development:

The Achenbach Behavior Checklists assess diverse aspects of adaptive functioning and problems, both in childhood and as an adult. The Behavior Rating Inventory of Executive Function (BRIEF) is administered by phone to an informant who is aware of the subject’s functioning. The measure assesses executive function skills such as judgment and impulse control. Dr. Brown’s associate Joan Siekiewicz, RN, administers the Vineland Adaptive Behavior Scales-II to assess the subject’s adaptive functioning. The Vineland involves a one-hour phone interview with a family member or other individual who has considerable knowledge of the subject’s daily functioning. FASD research has demonstrated that adaptive functioning is often more impaired than would be predicted based on IQ and is indicative of real-world deficits in appropriate functioning.

Dr. Brown also reviews the record to determine if environmental factors (e.g., abuse, unstable residential/caregiver history, neglect, other specific traumas) may have impacted the subject during childhood. Likewise, she examines adolescent and early adult records to determine if substance abuse plays a role in the subject’s functioning.

If the initial record review finds a life history of functional deficits consistent with FASD, Dr. Brown consults with the defense team regarding the results and prepares a written report.

Diagnostic Process: Step 2

NEUROPSYCHOLOGICAL TESTING

The second 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 in conjunction with the history of cognitive difficulties.

Next, the assessment is categorized into the following domains of cognitive functioning that are particularly sensitive to prenatal alcohol damage:

Cognition:

The Wechsler Adult Intelligence Scale – 3rd Edition (WAIS-III) is used to assess intellectual functioning. Research has demonstrated that only a minority of subjects with FASD have intellectual functioning within the mentally retarded range.

Academic Achievement:

Academic achievement is assessed using the Woodcock Johnson – 3rd Edition (WJ-III). This test measures a wide range of academic functions. In individuals with FASD, one or more areas of achievement may be depressed beyond expectation based on the individual’s IQ.

Executive Functioning / Neuropsychological:

This domain includes a variety of skills that enable the individual to function in a competent and pro-social manner (e.g., problem solving, learning from mistakes, generation of ideas, flexibility, and multi-tasking). Scanning and switching of attention are assessed with the Trail Making Test (TMT). Fluency of idea generation is assessed with the Controlled Oral Word Association Test (COWAT) in the verbal modality and Ruff’s Figural Fluency Test (RFF) in the nonverbal modality. Response inhibition is measured with the Stroop Test. Working memory and multi-tasking are assessed with the Consonant Trigrams Test (CTT). Planning, problem solving, rule switching, and learning from past mistakes are measured with three tests: the Wisconsin Card Sorting Test (WCST), the Tower of London (TOL), and the Iowa Gambling Test (IGT).

Motor / Sensory Integration:

The Grooved Pegboard is used to assess fine motor eye-hand coordination, Finger Tapping is used to assess coordinated finger movement, and Grip Strength is used to assess general strength. Research has demonstrated that coordinated motor functioning is often impacted in FASD.

Attention / Activity Level:

Attention is assessed in a visual modality with the Conner’s Continuous Performance Test (CPT), which measures sustained attention and impulsivity.

Learning / Memory:

Auditory learning and memory are assessed with the California Verbal Learning Test (CVLT), a list-learning task. Nonverbal memory and visuospatial construction are assessed with the Rey Osterrieth Complex Figure Test (RCFT).

Language / Social Communication:

Malingering:

Because of concern about effort and possible malingering in forensic contexts, Green’s Word Memory Test (WMT) and the forced choice task on the CVLT are used. It should be noted that in addition to malingering, deficits on these tests could also be the result of genuine memory impairment, so careful analysis of test results is important.

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 3

MEDICAL DIAGNOSIS

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

Dr. Richard Adler reviews the reports of Drs. Brown and Connor for evidence of functional and neurological deficits associated with FASD as well as information about the birth mother’s drinking history and conducts a face-to-face medical examination (typically with Dr. Brown, who conducts a face-to-face psychological examination to assess the subject’s current functioning and confirm the result in her records assessment).In addition to determining the subject’s height and weight and examining the three features of his face that are associated with FAS (i.e., philtrum, upper lip, and palpebral fissures), Dr. Adler also examines childhood photographs, birth and prenatal/postnatal records, and the medical records of the subject and birth mother.

At the conclusion of his analysis, Dr. Adler diagnoses the subject. The most common FASD diagnosis for adults is Alcohol Related Neurodevelopmental Disorder (ARND). However, if records and/or physical examination indicate the presence of facial anomalies and growth deficits, the subject may meet criteria for FAS with or without confirmed maternal alcohol exposure or Partial FAS with confirmed maternal alcohol exposure. During his medical examination and analysis, Dr. Adler looks for other medical syndromes and organic conditions in order to determine if factors other than FASD might be operative. He then prepares a written report of his findings and medical opinion.