J. COMMUN. DISORD. 25 (1992), 221-240

COMMUNICATION EFFECTS OF PRENATAL ALCOHOL EXPOSURE G. G. ABKARIAN

ofCommunication

Department Colorudo

Disorders,

Colorado

State

Uni\lersity.

Fort Collins,

This paper surveys the literature on prenatal alcohol exposure. The focus is on studies of speech, language, and communication skills evidenced by children diagnosed with fetal alcohol syndrome and fetal alcohol effects. Concommitant physical, behavioral, intellectual, and learning patterns are reviewed. Symptoms presented by alcohol-exposed children are compared to those seen in other developmentally delayed children. Future needs in areas of identification,

assessment,

and treatment

are discussed.

INTRODUCTION The negative effects of alcohol on the unborn fetus have been suspected since biblical times. Renewed interest in the role of alcohol as a teratogenie agent was sparked by the 1973 study (Jones and Smith, 1973), in which fetal alcohol syndrome (FAS) was identified and named. FAS is now recognized as the leading cause of mental retardation in the U.S. (Abel and Sokol, 1986) with about one in every 750 live births (5,000 each year) diagnosed with full FAS. In some Native American populations, the incidence of FAS may be up to ten times higher. Even these incidence data may be conservative. Little et al. (1990) reported that one major obstetrics service had a 100% failure rate in diagnosing FAS at delivery. As with most dysmorphic syndromes, variability within the phenotype is the rule. Many more infants are born who show only partial realization of the full syndrome (Streissguth, 1991). It has been estimated that $670 million is needed each year to treat the current population of 68,000 children with FAS under the age of 18 years. Estimates range between $600,000 to $1.4 million across the lifetime of each FAS patient (Abel & Sokol, 1987). The popular but incorrect perception is that alcohol-affected children are the offspring

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of patently alcoholic women. Although this maternal population clearly puts the fetus at serious risk, a recent comprehensive study (Streissguth et al., 1990) found that one in every six women of primary childbearing age (18-34) drink enough, characteristically or episodically, to present a hazard to the unborn child. Speech-language clinicians and teachers, especially those who work with younger children, arc often the first professionals to encounter children who show the effects of undiagnosed prenatal alcohol exposure. In her 1984 review. Sparks (1984) was able to cite few investigations centering on communication disorders in this population. The purpose of this paper is to provide a review and update on the effects of in utero alcohol exposure on the educational, social. and communicative characteristics in this under-identified population.

FETAL

ALCOHOL

SYNDROME

FAS was first identified in 1973 (Jones and Smith, 1973). There is currently no laboratory test (e.g.. chromosomal) used in making the diagnosis. Instead, a trained physician or geneticist makes the diagnosis based on physical examination, birth record, and history of maternal drinking in combination with a cluster of characteristics in three areas: growth deficiencies, dysmorphic features, and central nervous system dysfunction. The child with FAS is usually small in stature (height and especially weight) with head circumference below the tenth percentile. Distinctive facial features include short palpebral fissures (eye slits). indistinct or long philtrum, narrow upper lip, micrognathia, epicanthal folds (folds in the inner corner of the eye), and flat midface. Dental. finger, arm. and skeletal anomalies are common. Children with FAS show a wide variation in IQ scores. from severe retardation to normal intelligence. AVerdge IQ for FAS children is in the 65-70 range. The severity of morphologic and growth deficiencies is usually related to the severity of intellectual disability (Streissguth et al., 1985). Prenatal alcohol exposure is related to abnormalities in a number of behaviors observed in infancy: for example. orientation to auditory and visual stimuli, autonomic regulation, retlexive behavior. habituation, arousal. gross-motor performance, oral-motor function. electroencephalographic (EEG) patterns (Coles et al.. 1987; loffe and Chernick. 1989: Streissguth, 1986; Streissguth et al.. 19X3; Van Dyke et al., 1982). Preschool and older children often have hyperactivity, impulsivity. attention disorders, proprioceptive disturbances. learning and memory problems (Aaronson et al.. 1985; Conroy, 1990: Shaywitz et al., 1980; Streissguth, 1986: Streissguth et al., 1986). Church and Gerkin (198X) found that 93% of children diagnosed with FAS had recurrent otitis

PRENATALALCOHOLEXPOSURE

223

media with effusion (OME) during the first six years of life. This is the highest reported OME rate of any group of disabled children in the literat me. Social-behavioral characteristics are equally important in the identification of FAS. Streissguth and LaDue (1987), reviewing 12 years of empirical studies, concluded that FAS presents a behavioral phenotype as robust as the physical characteristics in marking FAS. These authors (as well as Shaywitz et al., 1980) describe affected children as impulsive, uninhibited, fearless, overly friendly, extremely inquisitive, and excessive in demands for affection and physical contact. Although young children are affectionate, outgoing, and socially engaging, they also tend to be intrusive, insensitive to social cues, and lacking in social judgment. They have difficulty establishing friendships with children their own age (Guinta and Streissguth, 1988). Maladaptive behaviors persist and, in adolescence and adulthood, naivete is coupled with sexual curiosity and a lack of socially appropriate sexual behavior (Streissguth et al., 1986). Problems with self-direction, follow through on goals, and decision making have been identified. Anecdotal reports also include lying, acting out, misappropriation of others’ property (Streissguth and LaDue, 1987; Streissguth et al., 1986). Children with FAS are likely to come from disrupted or dysfunctional families whose instability can exacerbate the child’s intellectual and social delays. One study (Streissguth et al., 1986) found that among 5year-old children, fewer than half had a mother who was still living. Multiple foster-home placements are not unusual. In short, the child with FAS is not constrained only by mental delays and physical anomolies; the child is multihandicapped (Hill et al., 1989), with maladaptive behaviors that persist into adulthood (Streissguth et al., 1991). (See Appendix). FETAL

ALCOHOL

EFFECTS

Diagnosis of fetal alcohol effects (FAE) is much more difficult to make with certainty. These children may show some of the physical symptoms to warrant diagnosis as FAS. It is often difficult to determine that alcohol is the etiologic agent. In fact, ambiguities in defining FAE prompted Sokol and Clarren (1989) to suggest that the term be abandoned. Most estimates put FAE as two to four times as common as FAS. Although fewer children with FAE are severely retarded, IQ ranges of FAS and FAE overlap. Average FAE IQ (full scale) is generally reported to be in the borderline range (80 IQ). Streissguth et al. (1986) reported, however, that among their adolescent/adult subjects with FAS or FAE (n = 61), the groups had the same proportion of individuals with IQ at 70 or below. Cognitive deficits often go unnoticed

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in FAE or are mistaken for poor motivation. A general air of alertness, grossly appropriate affect, sense of humor, and good but superficial verbal abilities all complicate diagnosis. Children with FAE generally show unevenness in academic ability with arithmetic skills least well developed. Importantly, children with FAE have behavioral and social impairments every bit as debilitating as children evidencing full-blown FAS.

NONFAWONFAE,

ALCOHOL

EXPOSED

CHILDREN

It is becoming increasingly clear from animal studies, large epidemiologic studies, and from controlled empirical studies that even moderate maternal alcohol consumption is linked to a variety of developmental and school-related difficulties (Church, 1989: Clarren et al., 1990; Coles et al.. 1987; Ioffe and Chernick. 1989; Landesmann-Dwyer and Ragozin, 1981: Streissguth, 1986). The Streissguth et al. (1990) is worth describing in this context. The authors conducted a prospective study of the single offspring of 500 women during the period 1974- 198 I. The group was primarily white, middle-class, and married. Mothers were asked about drinking habits during two time periods prior to childbirth; prior to the time of pregnancy recognition. and in midpregnancy (5 months). Binge drinking (defined as five or more drinks on a single occasion) was also tracked. Offspring were evaluated at ages I day, 8 months, 18 months, 4 years, and 7 years. A variety of achievement and neuropsychologic tests were administered to the children at age 7:6 years. Scores were adjusted statistically for important covariants (e.g., maternal age and race; parity; use of cigarettes, caffeine, marijuana; family history of learning disabilities; life stress at home: parental education). At levels of maternal alcohol consumption above I oz per day, the authors reported a downward shift of half a standard deviation (7 points) in offspring IQ score. Deficits in reading and especially arithmetic scores were evident Twith a l-3 month academic delay noted by the end of first grade. Alcohol effects were compounded by two environmental factors: lower paternal education and larger numbers of small children in the household. Decrements in attention and speed of central processing noted in children at each of the testing periods between ages 1 day and 7 years were predicted by moderate prenatal alcohol exposure. Fully 24% of the binge drinker’s offspring were enrolled in special remedial school programs (compared to 15% for nonbinge offspring). Among the classroom behaviors rated by teachers, word comprehension and word recall were most highly correlated with prenatal alcohol consumption. Streis-

PRENATAL

ALCOHOL

EXPOSURE

22s

sguth et al. (1990), as well as Nanson and Hiscock (1990) and Van Dyke (1990), noted the persistent appearance of attentional deficits among alcohol-exposed children. They suggest alcohol exposure defines one important cause of learning disabilities in school and may be related to real-life problems of children as they mature. In sharp contrast to the findings of Streissguth et al. (1990), are those of Greene et al. (1991) who followed 260 children, largely from disadvantaged homes. Cognitive measures were administered during inhome assessments at ages 6 months, 1 year, 2 years, 3 years, and 4 years, 10 months. The Wechsler Preschool and Primary Scale of Intelligence (WPPSI) (Wechsler, 1967) was employed at age 4: 10. Multiple analyses of data failed to find direct evidence of an inverse relationship between maternal drinking during pregnancy and comprehensive tests of cognitive development administered during the first 5 years of life. None of the WPPSI subscales were negatively related to alcohol indices. Results did not support a “substantial widespread effect of fetal alcohol exposure on cognitive functioning . . . whatever measurable effect is either small or is limited to a relatively small number of severely affected cases” (Greene et al., 1991). Greene et al. (1990) explored the relationship between prenatal alcohol consumption and language development (in the absence of diagnosed FAS or FAE). These researchers conducted a longitudinal study of about 270 children, none of whom had been diagnosed with FAS. The major variables of interest were parental alcohol consumption during pregnancy (self-report), amount of stimulation in the home, and child language ability. Language measures were derived from the Sequenced Inventory of Communicative Development (Hedrick et al., 1975), administered in the child’s home at ages 1, 2, and 3 years. An audiotaped sample of each child’s speech, collected at age 2, was evaluated for mean length of utterance (MLU), intelligibility, and spontaneity (i.e., the ability to initiate a conversation). In covariate analysis, language score and alcohol measures showed no overall trend, even among the heaviest alcohol users. The authors found no detectable trend between language performance and alcohol use among that subset of children having higher numbers of physical anomolies or reduced birth weight. (Anomolies were strongly related to the alcohol indices, however). In sum, Greene et al. found “little support for the hypothesis of an adverse alcohol effect on language development in the absence of FAS” (Greene et al., 1990, p. 942). In contrast, the quality of the caretaking environment was the major predictor of language functioning. The authors came to another conclusion of far-reaching importance. Based on the results of this study and others involving the same cohort of children, Greene et al. suggest

226

G.G. ABKARIAN

their evidence fails to support the view that functional characteristics provide more sensitive indicators of teratogenic exposure than either growth retardation or physical malformation.

SPEECH, LANGUAGE CHARACTERISTICS

AND COMMUNICATIVE OF FAS/FAE PERSONS

Much of the information on speech and language abilities in children with FAS has been mentioned in passing by authors whose focus was on the intellectual or developmental status of subjects. Nearly every study on people with FAS or FAE, regardless of client age, reports a general discrepancy between subject ability to use verbal language and ability to communicate effectively. Even among youngsters evidencing no (or few) cognitive impairments and seeming to present with normal verbal language development, difficulties are reported in the comprehension and use of effective social communication, Streissguth et al. (1978) described “unintelligible verbalizations” and “loose associations.” Streissguth et al. (1986) reported that preschool children are excessively talkative, intrusive, and use speech lacking in richness and grammatic complexity. Church and Gerkin (1988) reported that 13 of their 14 subjects had receptive and expressive language delays but did not report the instruments (if any) used to reach these conclusions. They did, however, comment that communication disorders often go unnoticed because of the small stature of children with FAS. That is, observers assume children to be younger than their chronologic age and adjust expectations about communication accordingly. Shaywitz and coworkers (198 1) focused their case study on the communication characteristics of two youngsters who had been exposed to significant amounts of alcohol in utero. Neither child showed the full FAS syndrome but both showed significant deficits in speech discrimination, comprehension (of prepositions and two-stage commands), syntax development, prosodic features, and in knowledge of the rules of dialogue. Iosub et al. (1981) tested a group of 45 black and Hispanic subjects with FAS using a battery of standardized tests (Test of Auditory Comprehension oflanguage, (Carrow, 1973); Peabody Picture Vocabulary Test, (Dunn and Dunn, 1981); Illinois Test ofPsycholinguistic Abilities, (Kirk et al., 1968). Patient ages ranged from I to 20 years. Data were reported as a percentage of the sample showing four generic communication disturbances (speech, language, voice, and fluency disorders). The authors reported that 80% of this diverse group evidenced impairments in one or more of the four communicative domains. The authors also reported that the presence of dysmorphic features of FAS were

PRENATALALCOHOLEXPOSURE

227

unrelated to the number and type of communication disorders in evidence. Hamilton (1981) conducted one of the earliest empirical studies of language and communication performance of FAS. Ten children with FAS, ages 4:5 to 6: 10 years, had IQs ranging between 65 and 85. Children were tested with a series of tasks to evaluate comprehension and production of syntax and semantics. A loo-utterance language sample was also evaluated for syntactic, semantic, and pragmatic features. Subject performance was compared to that of three other child groups: a chronological-age (CA) matched group of unimpaired children, a group of MLU-matched unimpaired children (mean age 3 years), and a group of Prader-Willi syndrome children matched for age and intellectual ability to the FAS group using the Wechsler Preschool and Primary Scale of Intelligence (Wechsler, 1967) or the Stanford-Binet (Terman and Merrill, 1973). Findings revealed delays in both production and comprehension abilities compared to age-matched controls. Comparisons to the MLUmatched younger subjects were asymmetric. No significant betweengroup differences were found in syntactic and single-word comprehension; in type-token ratios; in the percentage of initiations, requests, or comments. Affected children were poorer, however, at producing syntactically and semantically complex sentences and in what Hamilton appropriate to the pragcalled “adequate responses” (i.e., responses matic intent of an interlocuter). Hamilton concluded that children with FAS demonstrated quantitative (delayed) language and, based on differences with MLU controls, showed qualitatively different linguistic systems as well. Subjects’ productive language delays were largely responsible for these qualitative differences. Compared to the PraderWilli group, children with FAS performed better on all production tasks. These results made it difficult to interpret the role of intellectual delay on the language development of children with FAS; that is, both FAS and Prader-Willi syndrome may be associated with a unique set of communicative characteristics even when intellectual ability is accounted for. Hamilton reported that children with FAS engaged in conversational interactions and took their turns appropriately. But the content provided on their turn had little relationship to the content of the investigator’s previous utterance. This finding is an important one and may help to explain the reports common in the literature that children with FAS have good social speech but, at the same time, seem to ignore the messages they receive. Because of a superficial conversational talent, adults may wrongly surmise that children with FAS have better linguistic skills than they actually possess. Then when the child responds

228

G. 0.

ABKARIAN

inappropriately to the content of messages, the behavior is ascribed erroneously to inattentiveness. Two recent studies evaluated Native American (Canadian) children. Becker and colleagues (1990) studied the language and speech abilities of six children with FAS (4 : 6-9 : 6 years) and MA controls (3 : 6-6 : 6) matched for ethnic background, living situation (adoptive or foster homes), and nonverbal cognitive ability using the Ravens Coloured Progressil~c~ Matrices (Raven et al.. 1977). The authors employed a battery of ten measures selected from a variety of standard instruments to test grammar, semantics, and memory ability. The structure and function of the oral-motor mechanism was evaluated and two tests of articulation were administered in their entirety: Photzologicczl Process Analysis (Weiner. 1979) and Arizoncz Articzrlatory Proficiency Sculc (Fudala, 1974). Becker et al. found that FAS performance was significantly below CA norms on all 10 language measures. Performance was also poorer than that of the MA controls in the comprehension of morphologic and syntactic forms, single-word vocabulary, and verbal commands. Subjects with FAS produced fewer grammatically accurate and complete sentences. Additionally, they demonstrated more severe articulatory defects and evidenced structural and functional deviations of the oral-speech mechanism. Three subjects displayed mild verbal apraxia. Interpretation of these results is complicated by the small number of subjects studied and by the characteristics and performance of MA controls who were heterogeneous in terms of native language and degree of bilingual ability. Further, on some test measures, MA controls failed to complete the tasks or themselves fell below the tenth percentile for their CA. Carney and Chermak (1991) studied 10 children with FAS and a CA control group of 17 Native American children using the Test of‘ Lutzg14agc~ De\v~lopment (TOLD). The younger group (FAS n = 7. controls rz = 9) ranged in age from 4:0 to 8: 11 years and were tested with TOLD-Primary (Newcomer and Hammill, 1982). The older group (FAS II = 3, controls II = 8) were administered the TOLD-Intermediate (Hammill and Newcomer, 1982) and ranged in age from 9: 0 to 12 : 11 years. The FAS children were tested for cognitive ability using the Wechsler Intelligrrzce Scale .fiw Cl?ildrcJtz-Re~,ised (Wechsler, 1974) (full scale IQ range 50-91, mean = 79). Control children were reported by their teachers to be functioning at grade level but were not subject to cognitive evaluation. TOLD performance of subjects with FAS was compared to that of the control group and to the standards developed in the TOLD normative sample. In the FAS control-group comparisons: younger children with FAS

PRENATAL

ALCOHOL

EXPOSURE

scored significantly more poorly than controls on all TOLD-P measures except the word-articulation subtest. Older subjects scored more poorly on three of the five TOLD-I subtests: sentence combining, word ordering, grammatic completion. Surprisingly, the test group did not differ significantly from the unimpaired controls on the two remaining subtests: characteristics and generals. When TOLD norms served as the measure of performance, younger children with FAS scored below - 1 SD on all TOLD-P subtests except grammatic understanding and word articulation. The three older subjects with FAS scored below - 1 SD on all TOLD-I subtest norms except for generals. Carney and Chermak concluded that younger children with FAS presented with more global deficits than did their older peers, who were especially poor on tests requiring syntactic manipulation. Results were interpreted to show that children make advances in vocabulary knowledge as they mature but continue to find grammatic-morphologic rules troublesome. This pattern is consistent with that of cognitively intact, specific language-impaired children (Leonard, 1989) in that “Certain aspects of language are more difficult than others and hence more vulnerable to delay if the learner has limited resources” (Dale and Cole, 1991, p. 80). As Carney and Chermak noted, their study must be interpreted cautiously because of the small numbers of subjects (particularly in the older FAS group), the wide age range within the younger FAS group, and the lack of cognitive testing in the control groups. This latter point is of concern as some of the control subjects themselves scored below - 1 SD on some TOLD-I subtests. It is difficult to compare the results of the Hamilton (1981), Becker et al. (1990), and Carney and Chermak (1991) studies. Hamilton used an MLU-matched (younger) control group to interpret her results; Becker et al. employed a (younger) control group selected on the basis of a nonverbal cognitive measure: Carney and Chermak used a group of CA-based (same age) controls. Notwithstanding these methodologic differences, Becker et al. found their young children with FAS to be at risk for articulation disorders compared to younger controls. Carney and Chermak found no articulation deficiencies compared to a sameage unimpaired control group; word articulation was the one area of performance in which the FAS and control groups did not differ significantly. Hamilton did not test articulation ability in her subjects. Hamilton’s young subjects with FAS were significantly poorer than MLU controls in the production (but not comprehension) of syntactically and semantically complex utterances. Becker et al. reported poor production and comprehension of grammatical markers. Similarly, Carney and Chermak found their younger subjects to have pervasive pro-

230

G. G. ABKARIAN

duction and comprehension deficits in syntactic and semantic areas when compared to TOLD-P age norms. Only Hamilton attempted to assess pragmatic communication abilities. Although comparable to their MLU-matched controls in initiations, requests, and comments, children with FAS were poorer in responding appropriately to the pragmatic intent contained in the utterances of others. Becker et al. and Hamilton reported uneven language performance among subjects with FAS. In some areas, subjects were not significantly different from controls matched by MLU or nonverbal cognitive ability. Differences were found in other language areas. The reader is reminded that the three studies reviewed and compared here tested a total of only 26 children. A clearer picture of communicative skill among children with FAS must await results collected from a larger pool of subjects. Communicative deficits continue to plague persons with FAS into adolescence and adulthood. Streissguth et al. (1986) tested a group of 52 subjects (12-40 years of age) on the Wechsler Adult tntelligencc~ Scule-Revised (Wechsler, 1981) and, for persons under age 17, on the WISC-R. Ninety-five percent of the subjects scored higher on the performance than on the verbal scales. This was a robust finding that held across subject race, sex, overall IQ, academic level, and socioeconomic status. Despite their chatty manner, scores for a subgroup of 34 subjects (mean = 19 years) showed Peabody Picture Vocabulary Test scores at the 8-year-old level, fairly consistent with their overall level of intellectual functioning. The authors described abnormally loud, deep voice quality among some males. Other common characteristics found among the sample subjects were excessive amounts and rapid rate of speech, shallow content, and incessant interruption of other’s speaking turns. Among the more severely handicapped, verbal perseveration and echolalia were also evident.

DIFFERENTIATING DEVELOPMENTALLY

FAS/FAE FROM OTHER DELAYED CHILDREN

Children diagnosed with FASiFAE share many of the deficits associated with other intellectually impaired persons. Although most states in the U.S. do not recognize FASFAE as a distinct handicapping condition, emergent research has identified a cluster of characteristics that are unique, in varying degrees, to the individual exposed to prenatal alcohol. First, children with FAS/FAE are small in stature and demonstrate. in total or in part, the facial and skeletal dysmorphologies described

PRENATALALCOHOLEXPOSURE

231

earlier. They also suffer sensory deficits: ophthalmologic (Stromland, 1987), visual perceptual (Aaronson et al., 1985), and auditory (Church and Gerkin, 1988). Second, they evidence a range of maladaptive social behaviors inconsistent with their chronologic and mental age that interfere with the establishment of friendships and lead to social isolation (Burgess and Streissguth, 1990; Guinta and Streissguth, 1988; Streissguth et al., 1991). Third, children with FAS/FAE show uneven patterns of academic performance. Middle- or high-functioning children are likely to perform at or near grade level in the first few years. Difficulties tend to emerge when curricula require independent functioning, skill in reading comprehension (as opposed to word recognition), and especially, mathematics. As academic demands increase, teachers often report problems in staying on task, a constant need for monitoring, a tendency to distract classmates, negative social attitudes, and stubbornness. Transition from elementary to middle school is difficult because of decreasing amounts of adult supervision and increasing peer pressure (Streissguth et al., 1986). FAS/FAE is also related to birth order (parity) with second, third, or later children being more likely to evidence symptoms (Abel, 1988). This may be related to maternal age. More importantly, parity effects likely results from continued or increased use of and tolerance to alcohol (Streissguth et al., 1990). Speech, language, and communicative abilities may also be differentiated among alcohol-exposed and other mentally retarded individuals. Although some qualitative differences exist in the communicative skills of mentally retarded children (compared to younger, MA-matched unimpaired controls), differences are largely quantitative rather than qualitative (Owens, 1989). Although the evidence is still sketchy, FAS/FAE communication skills appear to be qualitatively different from their MA-matched peers. In one important area, there are clear differences. Children with FAYFAE are almost universally described as intrusive, loquacious, and over-inquisitive, whereas they demonstrate a marked discrepancy between high verbal and ineffective communication skills. In contrast, the conversational role of other retarded persons is generally one of submission.

FUTURE

NEEDS

To better meet the challenges of prenatal alcohol effects, a number of needs can be identified. First among these needs is prevention. Statistics suggest that although there has been a recent decline in the use of hard drugs among teenagers and young adults, alcohol consumption is increasing in these groups. It is unclear whether alcohol use during

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G. G. ABKARIAN

pregnancy is increasing or decreasing (Little et al., 1989; Streissguth, Grant et al., 1991). Alcohol use in combination with other drugs and current levels of sexual activity among teens portends an increase in births showing alcohol-related deficits. Persons of childbearing age (especially in high-risk groups) should be educated concerning the deleterious effects of alcohol on the developing fetus. Among women already pregnant, prenatal counseling should be available. Early identification of children with FAS/FAE is essential. Physicians and other health workers encountering neonates should be trained to recognize the physical characteristics associated with prenatal alcohol exposure. Even children with the most obvious physical manifestations of alcohol exposure in utero have been underidentified (Little et al., 1990). The pediatrician is critical because identification is easier in infancy and early childhood when the physical signs are most pronounced. Health personnel must also be willing to report such births to state agencies in the interest of developing accurate incidence data. Suspected alcohol effects should be reported to parents and social services professionals so that early counseling and habilitative services may be initiated and future needs (e.g., vision and hearing deficits) are anticipated and met. Research is needed on the educational interventions most successful with FAWFAE students (Burgess and Streissguth, 1992). Typically identified in school settings as mentally retarded or behaviorally-emotionally disabled, these labels provide teachers with little direction concerning special individual needs. Academic and vocational programs that target functional skills and instruction in social cognition must be developed (Burgess and Streissguth, 1990). There is a need for the development of sensitive profiles of early communicative characteristics of alcohol-affected children. Such profiles would enhance differential diagnosis among mentally handicapped children and result in more appropriately tailored referral, counseling, and treatment plans. There is a need for comprehensive research concerning developmental changes in the communicative skills and needs shown by such children. The experimental literature and anecdotal reports concerning highfunctioning children with FAS/FAE contain one overriding theme: social but dysfunctional communicative interaction. This pattern is suggestive of persons aware of turn-taking responsibilities but unaware of or unable to make their conversational responses relevant to the topics or purposes of interlocyter’s speech. Difficulties of this type may be rooted in a number of causes, each of which suggests a different treatment focus. For example, the social-but-irrelevant pattern may result from (a) purely linguistic comprehension deficits, (b) from an

PRENATAL

ALCOHOL

233

EXPOSURE

inability to interpret semantic/propositional content underlying the language directed to the child, (c) from a failure to understand the need to be relevant, (d) from factors related to attentional deficits (e.g., confusion stemming from transitions between role as listener and role as speaker, (e) from a presuppositional deficit in reading the communicative purposes of others, (f) from failure to recognize communication breakdowns coupled with poorly developed conversational repair strategies. There is a need for treatment research designed to determine the sorts of techniques that are most successful in addressing speech, language, and social-communicative deficits. Such clinical treatment studies have yet to be conducted. It is likely that highly individual treatments will be necessary given the wide range of cognitive and linguistic-communicative capabilities reported in the FAS/FAE literature. Therapy plans will need to account for the nonverbal capabilities and use patterns of children as well as the plausibility of developing compensatory or alternate forms of communication. Finally, there is a need for speech-language clinicians to become aware of the existence, identification, and the scope of needs of the alcohol-affected child. One hopes the current review makes a contribution to this purpose. The author acknowledges the significant Breighton to the development of this review.

contribution

of Paula

APPENDIX Stage Infancy

Characteristics Small, scrawny appearance; below 10th percentile in weight/length at birth Tremulous and irritable at birth Weak sucking reflex; feeding difftculties Hypotonia; microcephaly Erratic sleep patterns Readmissions to hospital for pneumonia; evaluation of heart defects: hip dysplasia; scoliosis Slow to achieve motor milestones Slow to talk and to combine words Poor appetite Little or no stranger anxiety

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Preschool

Early

Middle

school

school

years

years

Short and elf-like in manner and appearance Short upturned nose Seem alert, outgoing, extremely friendly More interested in people than in objects Insatiable need for bodily contact: touching, patting, fondling Pronounced hyperactivity; flit from one activity to another Seem fearless; tend to wander Problems with coordination; fine motor and gross motor control Delays in expressive speech may be seen When talking; many questions asked Expressive speech lacks richness of thought and grammatic complexity Excessive, intrusive talk sometimes masks speech/language impairments Kindergarten often repeated with hope that motor skills will develop and hyperactivity will subside Referrals for special education common for children with most severe mental handicaps More intellectually able children often continue in regular classroom during early school years Attentional deficits become more manifest as classroom demands increase Emotional lability more pronounced: poor impulse control; social intrusiveness Poor peer relations; social isolation may be seen Demands for bodily contact continue Facial features tend to “normalize” making FAS diagnosis more difficult School achievement reaches maximum point. Special difficulties with math and math concepts Continued or increased difficulty

PRENATAL

ALCOHOL

235

EXPOSURE

maintaining attention, completing assignments, mastering new skills Evaluation and remedial placement usually necessary for even the most able children Increased risk for truancy and dropout Increased stress, decreased classroom performance can lend to lack of motivation and attendance problems Superficially good verbal skills; friendly, social manner, good intentions, may all mask seriousness of delays Adapted from Streissguth, Manual on Adolescents with Special Reference

A., LaDue, R., and Randels, (1986) A

and Adults to American

with Fetal Alcohol Syndrome Indians. Albuquerque, NM:

Indian Health Service.

REFERENCES Aaronson, M., Kyllerman, M., Sabel, K., Sandin, B., and Olegaard, R. (1985) Children of alcoholic mothers: Developmental, perceptual and behavioral characteristics compared to matched controls. Acta Pediatrica

Scandinavia,

74127-35.

Abel, E. (1988) Fetal alcohol syndrome and Teratology, 10: l-2.

in families. Neurotoxicology

Abel, E., and Sokol, R. (1986) Fetal alcohol syndrome is now the leading cause of mental retardation. Lancet, 15: 1222. Abel, E., and Sokol, R. (1987) Incidence of fetal alcohol syndrome and economic impact of FAS-related anomalies. Drug & Alcohol Dependency,

19:51-70.

Becker, M., Warr-Leeper, G., and Leeper, H. (1990) Fetal alcohol syndrome: A description of oral motor, articulatory, short term memory, grammatical, and semantic abilities. Journal of Communication Disorders,

23:97-124.

Burgess, D., and Streissguth, A. (1990) Educating students with fetal alcohol syndrome or fetal alcohol effects. Pennsylvania Reporter, 22: l-6.

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Communication effects of prenatal alcohol exposure.

This paper surveys the literature on prenatal alcohol exposure. The focus is on studies of speech, language, and communication skills evidenced by chi...
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