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0145-6008/98/2202-0279$03.00/~

Ai.coi~oi \M: CI NICAL A N D EXrl KIM1

N I A I

R l - s Z~ R c l 1

Vol.

22

No. 2

April 1998

A Review of the Neurobehavioral Deficits

with Fetal Alcohol Syndrome or Prenatal

Alcohol

Sarah N. Mattson and Edward P.

Fetal alcohol syndrome is a devastating developmental disorder

caused by prenatal exposure to high amounts of alcohol.

In

addition

to structural abnormalities and growth deficits fetal alcohol syn-

drome is assoc iated with a broad spectrum of neurobehavioral

anomalies. This paper reviews the behavioral and cognitive effects of

prenatal alcohol exposure. More than

20

years of research are dis-

cussed with a focus on 10 activity attention learning memory

language motor and visuospatial abilities in children prenatally ex-

posed o varying amounts of alcohol including those with fetal alco-

hol syndrome.

Key Words: FAS PrenatalAlcohol Exposure Brain Function Neu-

ropsychological Effects.

HROUGHOUT HISTORY, the negative effects of

Tmaternal drinking on offspring have been suspected.

Aristotle has been quoted as saying that foolish, drunken,

or hare-brain women, for the most part bring forth children

like unto themselves,

morosos

et

Zanguidos

and in

Carthage and Sparta, laws prohibited the use of alcohol by

newlyweds presumably to prevent conception during intox-

ication. During the gin epidemic in England, in the first

half of the 18th century, physicians warned against alcohol

consumption during pregnancy, claiming this was the cause

of weak, feeble, and distempered children. Such beliefs

continued until the early 20th century. In the postprohibi-

tion medical community, however, the idea that alcohol

taken during pregnancy could be harmful to the developing

fetus was dismissed as moralism. It was thought that harm-

ful effects noted in the offspring of alcoholic women were

the result of constitutional factors that also were the cause

of the alcohol problem. It was not until the late 1960s and

early 1970s that interest in the adverse effects of alcohol

was renewed. In 1968, a group of French researchers pub-

lished the results of a study of 127 children of alcoholic

parents.2 They reported the highly distinctive appearance

From the Center for Behavioral Teratology, Department of Psychology,

San Diego State University, San Diego, C alifornia.

Presented at the 1996 Borchard Foundation Symposium on the Behavioral

Effects in Children ollowing Prenatal Alcohol Exposure, Missillac, France,

This work was supported by the National Institute

on

Alcohol Abuse and

Alcoholism Grant AA10417 and AA10820.

Reprint requests: Sarah N . M attson, Ph.D., Center for Behavioral Tera-

tolog? 6363 Alvarado Court, Suite 209, San Diego State University, San

Diego, C 92120.

July 28-30, 1996.

Copyright 998 by The Research Society

on

Alcoholism.

Alcoho l

Clm

Exp

Res Vol22, No 2, 1998: pp

279-294

of children

Riley

in Children

Exposure to

of alcoholic parents, particularly alcoholic

mothers. . . . This report went virtually unnoticed in the

United States until 1973, when Seattle dysmorphologists

documented similar findings3 and defined a specific pattern

of malformations in children born to chronic alcoholic

women as fetal alcohol syndrome (FAS).4

More than 20 years later,

it

is estimated that FAS affects

approximately 0.29 to 0.4SilOOO live born children. Preva-

lence estimates vary depending on socioeconomic and eth-

nic factors, and those that include Native American popu-

lations report incidences of up to 2.99/1000 births. In the

United States, at least 1200 children are born each year

with FAS, and the annual cost associated with caring for

such infants is estimated at 74.6 million dollar^.^ These

estimates are strictly limited to those children who meet the

clinical criteria for FAS and do not include the spectrum of

effects caused by prenatal alcohol exposure. It is obvious,

however, that the effects of alcohol use during pregnancy

are widespread and devastating, and that these problems

are entirely preventable.

The effects of prenatal alcohol exposure fall on a con-

tinuum with FAS and perinatal death at one end and

relative normalcy on the other. Between these two end-

points are a variety of behavioral and physical features that

are termed fetal alcohol effects (FAEs) or alcohol-related

birth defects. The wide range of behavioral and cognitive

effects associated with prenatal alcohol exposure is repre-

sentative of the continuous nature

of

alcohols behavioral

teratogenicity. Importantly, FAS represents only one point

on

the continuum, and the effects of in utero alcohol

exposure on children without FAS should also be assessed.

In the offspring, the diagnosis of FAS is based on a triad

of features: (1) pre- and/or postnatal growth deficiency; (2)

a pattern of craniofacial malformations; and 3) central

nervous system (CNS) dysfunction. Babies born with FAS

are often small for gestational age4 and continue to show

evidence of growth deficiency.6For example, in a sample of

adolescents and adults with FAS, the mean height and

weight were 2.1 and 1.4 standard deviations below the

population mean, re~pectively.~he pattern of craniofacial

malformations includes microcephaly, short palpebral fis-

sures, a long smooth philtrum, a thin vermilion border,

epicanthal folds, and flat mi d f a ~ e . ~he CNS dysfunction is

279

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280

MATTSON AND

RILEY

Table 1. IQ

Scores of Individual Cases of FAS or Alcohol-Exposed Individuals Reported in the Literature, Presented in Chronological Order Through 1996

~

~ ~

Authors Age n Tests

IQ

estimatet Comments

Jones, Smith, Ulleland,

8

Streissguth3

Palmer, Ouellette, Warner,

8

Leichtman

Root,

Reiter, Andrioia, 8 Ducken

Tenbrinck

8

B ~ c h i n ~

Ko ~ s s e f f ~

Char

Mulvihill Klimas, Stokes,

8

Ri~emberg~

Bierich, Majewski, Michaelis,

8

Tillner40

Majewski, Bierich, Loeser, Michaelis, Leiber,

8

Ijaiya, Schwenk, 8 Gladtke14

Be t te~ken ~

Van BiervlietS5

Fryns, Deroover, Parloir, Goffaux, Lebas, Van Den

Berghe

42

Dehaene, Walbaum, Titran, Samaille-Villette,

Samaille, Crepin, Delahousse, Decocq, Delacroix,

Caquant,8 Q ~ e r l e u ~ ~

Koranyi 8 CsikyiiZ

Neidengard, Carter, 8 Smith

Ballesta 8 Cruz17

Slavney

8

Grau

Qazi, Masakawa, Milman, McGann, Chua,

8

HalleP

Qazi, Madahar, Masakawa, 8 McGann

Maller, Brandt, & T y g s t r ~ p ~ ~

Shaywitz, Caparulo,

8

Hodgson l

losub, Fuchs, Bingol, Stone,

8

G r ~ m i s c h ~ ~

Naselli. De Toni. Vianolo. Di Battista. 8 AicardP4

14m

3m

57m

46m

40m

48m

34m

3y l Om

14.5m

22m

14.5m

22m

11.7~

14.5y

11

oy

9.9y

2y4m

3y5rn

1 Y

6m

NfA

5Y

3y7m

6y2m

7y9m

6y6m

l Y

2y6m

15Y

1 6 ~

21Y

31-17

6m

7m

1

Om

I am

26m

13Y

4y6m

7y3m

l l m

21m

16Y

1lY

1OY

15Y

7Y

8Y

4y6m

7Y

6Y

16m

3yl

m

4y4m

4yl Om

9Y

13Y

17Y

1

Y

17Y

1am

4Y

6~

8y6m

6v6m

1 (case

1)

1

(case 2)

1

(case 3)

1 (case 4)

1 (case 6)

1

(case 7)

1 (case 8)

1 (case 1)

1 (case 2)

1 (case 3)

1 (KC)

1 (AC)

1 (PC)

1 (RC)

1

1

1

1 (case 5)

1 (case 2)

1 (case 5)

1

(case 23)

1 (case 1)

1

(case 3)

1 (case 4)

1

1

(case 2)

1 (case 3)

I

(case 4)

1

(case 7)

1

(case 10)

1 (case 11)

1 (case 12)

1

(case 13)

I (case 14)

1

(case 1)

1

(case 2)

1

(case 3)

1

(case 4)

1 (case

5)

1 (case 2)

1 (case 1)

1 (case 2)

1

1

(case

1)

1

(case 2)

1 (case 3)

1 (case 4)

1

1

1

(case

1)

1

(case

1)

1

(case 2)

1 (case 3)

1

Bayley MDI

Bayley MDI

Stanford-Binet

Stanford-Binet

Stanford-Binet

Stanford-Binet

Bayley MDI

Stanford-Binet

Bayley MDI

Bayley MDI

NfA

Cattell

NIA

NfA

Cattell

Kramer

Kramer

HAWIK

(German WISC)

Stanford-Binet

Stanford-Binet

Griffith

NfA

Brunet-Lezine

NfA

N/A

N/A

WISC-R

NIA

Merrill-Palmer

Cattell

NfA

Leiter

NIA

NIA

WAlS

N/A

WAlS

Bayley MDI

Stanford-Binet

WlSC

WlSC

WlSC

59

83

75

57

79

70

150

65

56

76

59

70

80

75

112

68

36

75

85

41

93

84

105

76

a7

54

52

65

52

35

25

37

75

58

50

60

72

59

82

54

72

73

33

70

55

66

52

70

65

74

68

50

45

68 Pa)

69 (DQ)

120

70

67

60

72

50

50

50

50

46

a0

Twins placed in foster home between

testings

Siblings; case PC had fewer

dysrnorphic features

Not identified as FAS by author$

Noonan syndrome

AEIf

Klippel-Feil malformation

Chromosomal abnormalities$

Schizophrenia

Renal anomalies

Chromosomal abnormalities$

Language disordered+

Siblings

8/11/2019 j.1530-0277.1998.tb03651.x

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NEUROBEHAVIORAL FINDINGS IN FAS

281

Table

1.

Continued

Authors Age*

n

Tests

IQ

estimate7 Comments

Ticha, Santavy, Matlochaz3

Aronson OlegPrdZ4

Streissguth, Clarren,

&

Jones

Usowicz, Golabi, Curry6

Marcus

Mattson, Riley, Jernigan, Ehlers, Delis, Jones, Stern,

Mattson, Riley, Jernigan, Garcia, Kaneko, Ehlers,

Harris, MacKay. & O ~ b o r n ~ ~

Johnson, Hesselink,

&

B e l l ~ g i ~ ~

Jones45

Ernhart, Greene, Sokol, Martier, Boyd, & Ager23

3Y

3Y

4Y

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282

MATTSON AND RILEY

Table 2. IQ Scores for Groups of Alcohol-Exposed Subjects Reported in the Literature, Presented in Chronological Order Through 1996

Authors Age n Tests Mean IQ IQ range

Streisguth & R o h s e n o ~ ~ ~ * ~ 8m 15

4Y 13

7Y 15

Dehaene, Samaille-Villette, Samaille, Crepin, NIA 22

Walbaum, Deroubaix, & B l a n ~ -G a r i n ' ~ ~ ' ~

Streissguth, Herman, & Smith26^Rb

Streissguth, Herman, & Smith54'R

M a j e ~ s k i ~ ~ . ~ ~ . ' ~ ~ f ~ ;ajewski

M a j e ~ s k i ~ ~

Oleglrd, Sabel, Aronsson, Sandin,

Johansson, Carlsson, Kyllerman, Iversen.

&

HrbekZgfR

Shaywitz. Cohen,

8

S h a y ~ i t z ~ ~ ' ~

Streissguth, Barr, Martin, & Herman39*P

losub, Fuchs, Bingol. & G r o m i ~ c h ~ ~

Golden, Sokol, Kuhnert,

&

Steinhausen, Nestler, & Spohr'

Spohr

&

Steinhau~en'~'~~;teinhausen,

Aronson, Kyllerman. Sabel, Sandin, 8

O'Connor, Brill, & Sig ~n an ~O *~

Gobel,

8

N e ~ t l e ? ~ ' ~ ~

Oleglrd3Z*R

Coles, Smith,

8

Falek66*P

Aronson & Oleglrd'32*R

Fried & Watkir ~son ~'* ~

Streissguth, Barr, Sampson, Darby,

&

IOffe 8 C h e m i ~ k ~ ~ ' ~

M a ~ t i n ~ ~ * ~

conry71'~

Streissguth, Barr, & S a m p ~ o n ~ ~ * ~

Fried

8

W a t k i n s ~ n ~ ~ * ~ ~

Streissguth. Aase, Clarren. Randels, LaDue,

Carney

&

Chermak'Z''R

Forrest, Florey, Taylor, McPherson, 8

Streissguth, Randels. & Smith34Rc

&

Smith7R

Y o ~ n g ~ ~ * ~

Coles, Brown, Smith, Platzman, Erickson, &

Falek4'*'

9m-2.5y

2.51-5y

6-1

5y

7m-21y

21 m-22y

20-21 y

5-9Y

4-25y

5

10

3

2

17

4

9

48 total

NIA 15

Em

10

(AAP 4)d

12 (AAP 3)

25 (AAP 2)

97 (AAP 1)

365 (AAP

0.85)

71

AA 3.5)9

11 (PPAA

0.10)

20 (Wday

1 SD from their original evalu-

ation (two improved). The mean IQ from the first testing

was 66 (range

=

15-99), and the second testing was 67

(range

=

10-96). In th e 10-year follow-up mentioned pre-

viously,6 he me an im provement was 9.1 IQ points (range

=

1-30), with only on e patien t (12.5 ) improv ing >1 SD. In

an extension

of

these earlier studies, Streissguth reported

additional test-retest d ata of adolescents and adult^. Over

an average test-retest interval of 8.3 years, the correlation

of I Q between testings was 0.78 for FAS patients

(n

= 27)

and 0.88 for FAE patients

(n

=

13). Th e mean IQ scores

were 66.0 (range = 29-105) at initial test and 66.7 (range =

20-91) at retest for the FAS group and 79.5 (range

56-101) and 82.2 (rang e

=

65-114) for the FA E group. In

all, only 7 of 40 patients (17.5 ) were >1 SD from their

previous test performance (five improved). Other reports

of

repea ted indicate relatively good stability

of IQ ove r time, with the mo st variability in younger pa-

tients (see Table

1

for summary). One study indicated

improvement in intellectual functioning over a 3-year peri-

~ d , ~ ~lthough this may have been due

to

a few children

who moved from the below average range (70-85) to av-

erage range (86-115) of in te l l ig e n ~ e . ~ ~n th e children with

IQ scores in the mentally retard ed 115), there was no significant change in

performance. Later reports by the same authors suggest

grea ter stability over longer periods

of

time.59

WQ vs. PZQ

in

Individuals

with

FAS

It has been suggested that FAS is associated with gre ater

decrements in Verbal IQ (V IQ) than in Performance IQ

(PIQ).60,61 However, a review of the studies where this

information is actually available suggests that the results

are equivocal. In eight case reports of individuals with FAS,

four

cases16,19,62,63 displayed PIQ > VIQ, with a mean

difference of 8.5 IQ points (range = 3-22). However, six

cases11,56,64,65 em onstra ted VIQ > PIQ, and the mean

difference was 17 IQ points (range = 11-26). In two cas-

e ~ , ~ ~ , ~ ~her e was no difference between the two subscales.

Th e average VIQ and P IQ scores from these case reports

are 61.00 (SD = 12.82) and 55.33 (SD = 13.45), respec-

tively. In t he 17 group studies of individuals with FAS

where the relevant data were available, 10 stud-

ies25,32,33,44,49,50,66-69ndicated no differential effect of pre-

natal alcohol exposure on verbal versus nonverbal abilities.

In on e of these

although the scores for VIQ and

PIQ were equal, PIQ was more affected than VIQ. How-

ever, in another

the opposite was true. PIQ (or

PDI) was greater than VIQ (or MDI) in five group stud-

ies,7341,61270,71hereas VIQ was greater than PIQ in two

s t ~ d i e s . ~ ~ , ~ ~n o ne of these studies,71 which has be en cited

as evidence for the PIQ-VIQ differential, the FAS and

FAE

subjects did in fact display greater PIQ than VIQ

scores. However, the greatest difference between these two

subscales was in the con trol group; in fact, PI Q a ppe ared to

be more affected than VIQ when the alcohol-exposed sub-

jects were compared with these controls. It is therefore

unclear whether VIQ is consistently affected to a greater

degree than PIQ in individuals with FAS. It is clear, how-

ever, that FAS is related to d ecreased intellectual function-

ing with an average IQ between 65 and 75, and that this

level of performanc e is stable across time. Furth erm ore this

decrease in performance is also seen in children with pre-

natal alcohol exposure in the absence of FAS.

OTHER NEUROBEHAVIORAL DOMAINS

Th e following sections de tail the ability levels of children

with FAS in five neurobehavioral domains: activity and

attention, learning and memory, language, motor, and

visuospatial functioning. Studies involving children with

FAS or prenatal alcohol exposure are included, and brief

discussions of animal studies are included when appropri-

ate. T he results of neuropsychological studies of children

with FAS are summarized in Table 3.

ACTIVITY AND ATTENTION

Hyperactivity and attentional deficits are hallmark features

of prenatal alcohol exposure. In fact, offspring activity level

may be a more sensitive indicator of alcohols teratogenicity

than physical Children with FAS have been de-

scribed as tremulous, hyperactive, and irritable.74Caretakers

note that the children are always on th e go, and never sit

In a long-term follow-up of children with FAS, hy-

perlanetic disorders were among the most frequently diag-

nosed disorders and persisted throughout ~ h il d h o o d ? ~n ad-

dition, hyperactivity may occur in the absence of intellectual

impairment. On e study of 15 alcohol-exposed children of

average intelligence (IQ range

=

82-113, mean

=

98.2) re-

ported all but o ne as being hyperactive? Even in the absence

of the diagnosis of FAS, modera te levels of alcohol exposure

(mean

=

0.45 AA/day) have caused offspring to be more

fidgety and less ~o m pl ia nt ?~

Anim al models of prenatal alcohol exposure have reiter-

ated and emphasized the effect of maternal alcohol expo-

s ur e o n activity levels in o f f ~ p r i n g . ~ ~ , ~ ~n a review of the

literature concerning prenatal alcohol and hyperactivity,

Bond77 concluded th at, if rats are exposed to alcohol

greater than 6-7 g/kg/day, and a re tested prior t o 70days of

age, they exhibit an increase in activity in comp arison with

con trol offspring. Hyperactivity in rats is easily tested in a

variety of ways, and all metho ds of prenatal treatment an d

assessment a ppe ar to pro duc e similar results.10778

In addition to hyperactivity, attentional deficits have long

been associated with FAS and prenatal alcohol exposure.

Early naturalistic observations of infants suggested that pre-

natal alcohol exposure was associated with

an

increased

nonalert state. That is, the infants spent m ore time w ith eyes

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288

MATSON

AND

RILEY

open, but not attending.79Such deficits in attention appear to

LEARNING AND

MEMORY

continue through

and may be

to those Of

Although learning processes, per se, have not been system-

children with Attention Deficit Disorder (ADD).8oBoth FAS/

atically

addressed until recently,

learning

abilities, broadly

defined, have been described in alcohol-exposed infants and

AE and ADD children showed deficits in investing, organiz-

ing, and maintaining attention and had an increase in impul-

children. The earliest studies of Streissguth and colleagues

sive responses. Similarly, adolescents and adults with FAS

measured early learning and behaviors thought to be related

demonstrated deficits in

tasks

involved in the focusing (Tal- to learning. In an operant learning study, extinction after

reinforcement of two simple behaviors was measured in new-

and Letter Cancellation Test), encoding (WISC-R Digit

Span), and shifting [Wisconsin Card Sorting Test (WCST)] of

borns exposed to alcohol and nicotine prenatally? Alcohol

attention.8l Alternatively, in an examination of children with

and nicotine interacted to produce significantly poorer learn-

per-

ing in the infants. In the same sample, decreased habituation

formed similarly to controls and better than ADD children on

on the Brazelton Scale was related to alcohol use in mid

tests of reaction time and vigilance.

pregnancy.93Deficits in learning continue to be reported from

Attentional deficits have also been related to prenatal

the Seattle cohort. Decreased academic achievement and in-

alcohol exposure in non-FAS children. Four-year-old chil-

creased parent and teacher ratings of learning problems at 7%

dren of social drinkers (mean consumption

=

0.45 AA

years of age were related to maternal binge drinkinga and

day during pregnancy, 0.88 AA/day prior to pregnancy)

measures associated with learning ~kills.8~n addition, learn-

were observed to have poorer attention spans than control

ing difficulties were also observed in children with IQ scores

children when parity, maternal smoking, home environ-

ment, and sex of the child

were

used as covariates.73 Stre-

within the average range who were born to alcoholic moth-

issguth et al.83 also examined 4-year-old children for sus- ers although this sample was selected from a learning dis-

tained attention using a continuous performance task. abilities clinic.

and

with ADD the

After covarying maternal smoking, caffeine use, nutrition,

education, and childs birth order, prenatal alcohol expo-

of omission, commission, and a decrease in the ratio of

Studies targeting more specific aspects Of learning and

learning

When compared with children matched for age, sex, and

are now being reported*

sure was significantly associated with an increase in errors

correct to total responses. Importantly, in this study the

level of activity did not differ from normal controls,

indicating that hyperactivity did not play

a

significant

role

in the attentional problems noted in this sample. At age

7,

this cohort again demonstrated an increase in reaction

time, and errors

of

commission and vigilance84; and, at

age

11, maternal binge drinking was associated with behavioral

difficulties at school, including hyperactivity and atten-

tional problems.85At age 14, prenatal alcohol exposure was

again related to attentional measures,86 as well as perfor-

mance on the WISC-R Arithmetic ~ u b t e s t , ~ ~hich is com-

monly thought of as a measure of attention and freedom

from

Streissguths findings of deficits on

attentional measures were supported by Brown et al.,89who

reported deficits in the ability to sustain attention following

alcohol exposure throughout pregnancy.

Not

all

studies find effects on attention, however. Fried and

colleaguesg0 ound no relationship between alcohol exposure

and attentional measures at 6 years of age. In fact, there was

a decrease in impulsive responses and maternal perception of

behavior in relation to alcohol exposure. These authors sug-

gest differences between study cohorts and measures

as

pos-

sible reasons for the discrepancies between their findings and

those of Streissguth et al.83 mportantly, the alcohol exposure

levels in this cohort were very low. However, Boyd and col-

leagues also reported no effect of prenatal alcohol exposure

on

sustained attention in preschool children of alcoholic

mothers who drank during pregnancy. The alcohol exposure

levels in this study, while still relatively low, were higher than

in the previous study.go

and

memory

were assessed in 2o with FAs.94

race, the children with FAS demonstrated deficits in both

learning and recalling a word list. Their recall was impaired

on both free and recognition recall trials, and they made an

increased number Of intIllSiOn, perseveration, and false-

positive errors. These errOr.5 are COnSiStent with deficits in

response inhibition. However, given their decreased level

Of learning, their retention Of the material Was relatively

intact. This Same pattern

O f

impaired learning and rela-

tively unimpaired retention was also dtmonstrated in

adults with FAS95and are suggestive of pervasive deficits in

encoding verbal information.

Reports from the Seattle cohort also SukXest a relationship

between memory functioning and Prenatal alcohol exposure.

For example, deficits have been noted in auditory memo-

Iy 8196memory for stories and designs97 and spatial memo-

ryF6 Other reports of spatial memory deficits have been re-

ported

n

chMren with

FAS98

as

have deficits on some

measures of working Alternatively,in the Ottawa

cohort, prenatal alcohol exposure was not related to perfor-

mance on the memory component of the McCarthy Scales of

Childrens Abilities in

3-

or 4-year-old childred or 5- or

6-year-old children.51 n addition, prenatal alcohol exposure

was not related to Visual recognition memory in alcohol-

exposed infants in a study of the Detroit cohort.00

The animal literature is replete with studies of learning

deficits following prenatal alcohol exposure. o Offspring of

rats given alcohol during gestation show learning deficits

that include active avoidance,75passive avoidance, dis-

crimination and reversal, and taste aversion learning.lo3

Memory deficits have also been reported in rats exposed to

8/11/2019 j.1530-0277.1998.tb03651.x

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NEUROBEHAVIORAL FINDINGS IN FAS 289

alcohol prenatally. Specifically, deficits in spatial memo-

ry104,105and retention of learned tasks'06 have been re-

ported following prenatal alcohol exposure. Other studies,

however, suggest that long-term retention of information

after learning is relatively i n t a ~ t . ~ ' ' ~ ~ ' ~ ~ ~hereas a com-

plete discussion of the findings of animal studies, as well as

their strengths and limitations, is beyond the scope of this

paper, several reviews of the literature

LANGUAGE

The effects of prenatal alcohol exposure on language

have been mixed. Case reports suggest the presence of

speech and language disturbances resulting from prenatal

alcohol exposure. Abe122 ists 53 reports of speech delay or

impediment in 550 FAS cases published between 1973 to

1988. These reports range from complete lack of intelligible

speech ' to mild dysarthria ' or lisping. 2 Both receptive

(e.g., Ref. 113) and expressive (e.g., Ref.

114)

language

deficits have been noted as have articulation disor-

d e r ~ ~ ~ , ~ ~ , ~ ~nd developmental

Group studies of language functioning in children with

FAS also find deficits in speech and language functioning

(e.g., Refs. 38 and 118). Reported deficits include word

c o m p r e h e n s i ~ n ~ ~ ~ ~ ~ ~ ~ ~ ~naming ability,' articulation, '

and expressive and receptive language skills.68,'21On tests

of verbal fluency, children with FAS display impairments in

letter fluency although category fluency appears to be less

affected.993122n contrast, a recent report of eight children

with FAS documented relatively intact language develop-

ment, when compared with controls.'23

In prospective studies of children exposed to varying

amounts of alcohol, however, the results are not as clear. In

a sample of alcohol-exposed children from Ottawa, Can-

ada, decreases in language comprehension were found in

13-m0nth-old,~'2-year-0ld,~'and 3-year-old5' children ex-

posed to relatively low levels of alcohol (mean exposure =

0.31 M d a y for the entire 2-year-old sample,

0.45

M d a y

for the heavier exposed group in the 3-year-old sample).

No deficits were found, however, in the same cohort at 4

5, or 651years of age. Furthermore, no effect on expressive

or receptive language skills was found in a separate group

of alcohol-exposed children at

1, 2,

or

3

years of age.124

Like the Ottawa cohort, this group of children were ex-

posed to relatively low levels of alcohol exposure (mean

exposure =

0.07

M d a y ) .

Other studies have documented effects of alcohol on

language, however. Russell and colleagues67 reported

deficits in offspring receptive language functioning re-

lated to indications of maternal problem drinking (e.g.,

an individual's perceptions of what others think about

their drinking or reported alcohol-related family prob-

lems). This same report also documented deficits in

WPPSI Verbal IQ, which has a significant language com-

ponent. Finally, a recent report from the Seattle prospec-

tive study demonstrated a dose-response relationship

between maternal alcohol use and offspring Word At-

tack performance at

14

years of age.87 Word Attack is a

subtest of the Woodcock Reading Mastery Tests and

involves reading of nonwords. This task requires a

knowledge of pronunciation rules and is related to read-

ing ability. To summarize, children with FAS appear to

have deficits in speech and language, and similar deficits

are noted

in

some groups of prospectively identified

alcohol-exposed children.

MOTOR ABILITIES

In addition to alcohol's effects on higher level cognitive

functions, there is also an effect on the developing motor

system. Although a few studies find no effect of prenatal

alcohol on motor de v e l ~ p me n t , ~ ~ - ~ ~ . ' ~ ~ost studies of mo-

tor development and motor skills suggest an effect of pre-

natal alcohol exposure. Early descriptions of children of

chronic alcoholic mothers3 reported delayed motor devel-

opment and fine-motor dysfunction. One report noted a

nonspecific dyscoordinated motor pattern, hemiplegia,

ataxia, and an increase in cerebral palsy in children of

alcohol abusing women.29Later studies also noted delayed

motor development in infants and children exposed to

alcohol prenatall~9,'00,'26nd fine- and gross-motor dys-

functions were noted in children of alcoholic mothers127

and social drinkers.12' In addition, Marcus' noted axial

ataxia and kinetic tremor in children with FAS. Finally,

several reports exist of deficits in motor speed/precision,

finger tapping speed, and grip strength in children with

Animal models have also provided evidence for motor

dysfunction following prenatal alcohol exposure. Gait dis-

tu rbance~ , '~~elays in reflex de~elopment,'~' nd poor

balan~e'~ 'ave all been reported in rats exposed to alcohol

during the perinatal period.

~ ~ s . 6 8 ~ 7 1 ~ 1 1 9

VlSUOSPATlAL ABILITIES

Visuospatial abilities in children with FAS have not been

well documented. Many studies report deficits in simple

drawing tasks like the Beery Developmental Test of Visual

Motor I n t e g r a t i ~ n ~ ~ , ~ ~ , ~ ~ , ~nd the Frostig Developmental

Test of Visual Pe r ~e p t i o n ~~ ~ ~ , '~ ~;owever, very few stud-

ies have addressed more complex visuospatial abilities in

FAS. As mentioned previously, spatial memory appears to

be impaired in children with FAS.81,96,98nterestingly, the

study of Uecker and Nadel suggested deficits in memory

for the location of objects but not for the objects them-

selves. In addition, this study documented alcohol-associ-

ated deficits in clock drawing, a traditional measure of

visuospatial ability.133 n a recent of more specific

visuospatial ability, children with FAS displayed deficits in

local processing of hierarchical stimuli. These children

were impaired in recalling and copying local (details) but

not global (configural) features of the stimuli. These defi-

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NEUROBEHAVIORAL FINDINGS IN FAS 291

cits were not du e to the size of the stimuli o r to deficits in

memory, and suggested a specific impairment in processing

local features of hierarchical visual information. Similar

def ic i t s have been noted in o ther de~elopmenta l ~~nd

d e m e n t i ~ ~ g ~ ~isorders.

OTHER NEUROPS YCHOLO GICAL ABILITIES

In addition to the abilities already discussed, a few stud-

ies have docum ented oth er specific neuropsychological def-

icits in individuals with FAS. The WCST is a test of non-

verbal p roblem solving, which requires both problem

solving and cognitive flexibility, and has b een proposed to

be sensitive to frontal system dysfunction. Adolescents and

adults w ith F AS display decr eased accuracy,81 achieve

fewer categories, and m ake more perseverative responses99

on the WCST. Alternatively, the computerized version of

the WCST was found to be only moderately sensitive to

prenatal alcohol exposure in the 14-year assessment of the

Seattle cohort.s6 Our data suggest that, whereas children

with FAS perform mo re poorly than con trols, these deficits

are considerably less severe than we would expect, given

their overall level of ability (i.e., IQ).i37

Finally, tests of planning ability are also thought to be

sensitive to frontal systems dysfunction, although few such

studies have been done in individuals with FAS. On the

Progressive Planning T esty 9 which is similar to the T ower

of London Test, children with F A S F A E had difficulty

with planning ahea d and tended to perseverate on incorrect

strategies.

SUMMARY

In summary, FAS is a devastating developmental disor-

de r tha t is associated with a wide variety of neurobeh avioral

deficits. Studies of FAS have documented consistent defi-

cits in language, motor, learning, and visuospatial function-

ing. Memory seems to also be affected; however, studies

that include a comparison of learning and recall suggest

that, at least in the verbal dom ain, retention is fairly nor-

mal. Tha t is, learning deficits (i.e., encoding) may be at th e

root of observed memory deficits and that once informa-

tion is learned it can be retained. In addition, m ost studies

of attention suggest deficits in this domain, although the

study of Coles e t a1.82 suggests tha t fu rth er, mo re specific

evaluation

of

the components of attention is necessary. In

addition, visuospatial functioning an d problem solving are

two,

as yet, understudied areas in FAS. Existing studies

suggest deficits in simple visuospatial functioning, but m or e

complex abilities are yet to be described. Similarly, several

studies show deficits on the WCST, although it is unclear

how these deficits relate to overall cognitive ability. Many

of these deficits have been supported by cohort studies that

provide invaluable information about the role of prenatal

alcohol exposure in the development

of

neurobehavioral

abilities. Futu re research is required t o m ore clearly delin-

ea te whether areas of relative strength or weakness exist in

children with FAS and how their cognitive abilities relate t o

other types of mental retardation. In addition, correlation

of neuropsychological an d ne uroanatom ical dat a may help

us understand the role of abnormal brain development in

cognitive ability. Taken together, results from these

two

types of studies can help provide the background for edu-

cational and training programs specific to individuals with

FAS or prenatal alcohol exposure.

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