Screening Tools
FASD Checklist (Informant Interview)
Maternal Drinking Pattern (Birth Mother/Informant
Interview)
FASD Checklist
Early Development
- Failure to thrive
- Tremors or jitteriness
- Seizures
- Feeding problems in infancy
- Sleeping problems
- Vision and/or hearing problems
- Difficulty with toilet training, wetting, or soiling
- Problems with personal hygiene
- Difficulty with the onset of puberty
- Problems with sexual functioning
Childhood Appearance
- Shorter or thinner than other children his age
- Anything unusual or different about eyes? (wide-spaced, smaller than normal, slanted, droopy eyelids)
- Anything unusual about mouth or upper lip? (long and/or smooth space between upper lip and nose, thin upper lip)
- Anything else about face or body during childhood that was unusual
Communication / Speech
- Loud, deep, or unusual sounding voice
- Talks too much, too fast
- Interrupts a lot
- Unusual conversational subjects
- Very opinionated
- Speaks indistinctly
- Makes off the wall comments
- Repeats phrases / words frequently
- Other
Memory / Learning / Information Processing
- Poor / inconsistent memory
- Slow to learn new skills
- Does not seem to learn from past mistakes
- Difficulty recognizing consequences before acting
- Slow information processing speed and accuracy
- Other
Behavior Regulation
- Poor anger management
- Fearless in the face of danger
- Mood swings
- Impulsive
- Compulsive
- Perseverative
- Inattentive
- Unusual activity level (high or low)
- Illogical lying
- Illogical stealing
- Unusual reactivity to sound__, touch __, light __
- Rocks or swings rhythmically
- Bangs head, bites or hits self
- Fidgety, can’t sit still
- Other
Abstract Thinking / Judgment
- Poor judgment
- Unable to plan and execute
- Functions poorly without assistance
- Concrete, black or white thinking
- Other
Planning / Temporal Skills
- Needs help organizing daily tasks
- Cannot organize time
- Misses appointments
- Has difficulty with multi-step instructions
- Other
Spatial Skills / Spatial Memory
- Gets lost easily, has difficulty navigating from point A to point B
- Poor memory for sequences and dates
- Other
Motor Skills
- Poor / delayed motor skills
- Overly active
- Poor balance
- Accident prone
- Other
Social Skills / Adaptive Behavior
- Poor social/adaptive skills
- Overly friendly
- Attention-seeking
- Behaves notably younger than chronological age
- Few close friends
- Easily led/manipulated by others
- Laughs inappropriately
- Poor social/sexual boundaries
- Inappropriate social behaviors
- Other
Academic / Work Performance
- Gives impression of being more capable than he actually is
- Tries hard and wants to please, but end result is often disappointing
- Has trouble completing tasks
- Has problems with school / job attendance
- School drop-out
- Poor work history
- Other
Maternal Drinking Pattern
(Birth Mother/Informant Interview)
BEFORE PREGNANCY
- Average number of drinks per drinking occasion:
- Maximum number of drinks per occasion:
- Average number of drinking days per week:
- Type of alcohol:
DURING PREGNANCY
- Average number of drinks per drinking occasion:
- Maximum number of drinks per occasion:
- Average number of drinking days per week:
- Type of alcohol:
- Trimester(s) in which alcohol was consumed:
- Was birth mother ever reported to have a problem with alcohol and/or drugs?
- Was birth mother ever diagnosed with alcoholism/drug addiction?
- Did birth mother ever receive treatment for substance abuse?
- Was alcohol use during this pregnancy positively confirmed?
If yes, source of confirmation: - Did you observe birth mother’s drinking or drug use during pregnancy?
- Could she have consumed alcohol/drugs during pregnancy prior to learning she was pregnant?
- How far along was she when she learned she was pregnant?
- Was she ever arrested or charged with an alcohol/drug-related violation (DUI, public intoxication) during her pregnancy?
- Other information about alcohol use during this pregnancy: