J. COMMUN. DISORD. 24 (1991), 123-134
PERFORMANCE OF AMERICAN INDIAN CHILDREN WITH FETAL ALCOHOL SYNDROME ON THE TEST OF LANGUAGE DEVELOPMENT LAURA J. CARNEY and GAIL D. CHERMAK Department of Speech and Hearing Sciences, Washington State University
Alcohol is a teratogen known to have deleterious effects on the developing embryo and fetus. Language deficits secondary to central nervous system dysfunction are among the sequelae of Fetal Alcohol Syndrome (FAS). Limited information is available regarding the language deficits associated with FAS, particularly among the population of American Indians in whom FAS is highly prevalent. The TOLD-P and TOLD-I were administered to 27 American Indian children: 10 with FAS and 17 normally developing control subjects. Puretone screening, immittance measurement, and vision screening preceded language testing. The older FAS children presented syntactic deficits while the younger FAS subjects presented more global language deficits.
INTRODUCTION Alcohol is a teratogen known to have deleterious effects on the developing embryo and fetus (Chernoff, 1980; Church and Gerkin, 1988; Johnson, Knight, Marmer, and Steele, 1981; Jones, Smith, Ulleland, and Streissguth, 1973; Smith, 1981). Jones and Smith (1973) referred to the pattern of congenital malformations frequently seen in children born to mothers who ingested excessive amounts of alcohol during pregnancy as Fetal Alcohol Syndrome (FAS). The prevalence of FAS is similar to that of Down syndrome, between 1 in 500 to I in 1000 births (Smith, 1982). It has been estimated that between one third and one half of children born to chronic alcoholic mothers present some of the characteristics of FAS (Hanson, Streissguth, and Smith, 1978; Jones and Smith, 1973). FAS is associated with growth deficiencies, central nervous system dysfunction, and anomalies of internal organs and the skeletal system (Jones and Smith, 1973). Among the sequelae of particular concern to speech and hearing professionals are the major features of central nervous system dysfuncAddress Correspondence to Gail D. Chermak, Ph.D., Department Sciences, Washington State University, Pullman, WA 99164-2420.
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tion, including mental retardation and hyperactivity, tures of otitis media and cleft lip and palate.
and associated fea-
Language and Auditory Function Limited information is available regarding the speech, language, and hearing impairments of children with (FAS). High incidence of otitis media has been reported in FAS children (Johnson et al., 1981; Streissguth, Clarren, and Jones, 1985); however, evaluation of hearing function was an ancillary objective, and criteria for determination of otitis media were not delineated. Iosub, Fuchs, Bingol, and Gromisch (1981a) reported a high incidence (80%) of speech and language problems among 63 FAS patients, a developmental delay not previously reported in FAS. In reviewing the general developmental histories of three siblings diagnosed with FAS, Iosub, Fuchs, Bingol, Stone, and Gromisch (1981b) observed voice dysfunction, disorders of articulation, and fluency problems. Iosub et al. (1981a) asserted that speech and language deficits associated with FAS are the result of central nervous system damage due to the teratogenie effect of alcohol on the brain. However, Larsson, Bohlin, and Tune11 (1985) attributed the speech delays to postnatal environmental influences, not a consequence of alcohol in utero: his subjects were language-delayed children who presented no other features characteristic of FAS, but who had been born to mothers diagnosed as excessive drinkers. Gusella and Fried (1984) administered the Bayley Scales uflnfunt Development to 84 13-month-old infants born to women classified as social drinkers. Although these infants were never diagnosed with FAS, a significant negative correlation was found between amount of alcohol consumed by the mother during pregnancy and both expressive and receptive language skills of the infants. Hedrick, Prather, and Tobin (1975) observed a two-year and a three-year delay in receptive and expressive language in two 6-year-old boys with FAS. Becker, Leeper, and Warr-Leeper (1985) found significant deficits in 6 FAS children who were tested on the Test of Auditory Comprehension of Language (TACL) (Carrow, 1973), Token Test for Children (Disimoni, 1978), and the Developmental Sentence Scoring (DDS) (Lee, 1974). No significant differences were observed between the FAS and normal controls on the expressive portion of the Northwestern Sentence Screening Test (NSST) (Lee, 1971) or for selected subtests of the Illinois Test of Psycholinguistic Abilities (ITPA) (Kirk, McCarthy, and Kirk, 1968). Hamilton (1981) compared language performance of 10 5-year-old FAS children with three groups: (1) 10 normally developing 5-year-old children; (2) 10 3-year-old children matched in mean-length utterance (MLU) to the FAS group; and (3) 10 5-year-old children diagnosed with Prader-Willi syndrome whose cognitive level matched that of the FAS group. FAS children produced less complex and
FETAL ALCOHOL SYNDROME
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less complete grammatical forms than the normal and MLU matched groups; however, they produced more complex grammatical sentences than the Prader-Willi group. Normal controls surpassed the FAS group on expressive and receptive semantic measures; however, no significant differences were revealed between the FAS and MLU matched group. FAS children performed better than the Prader-Willi group on expressive semantic measures. Hamilton (1981) concluded that language skills cannot be predicted based solely on cognitive function, as FAS children frequently performed better than the intellectually matched Prader-Willi group. Characteristics of each syndrome may uniquely impact speech and language capabilities beyond the factors responsible for a general cognitive delay (Hamilton, 1981). A high prevalence of hearing disorders might be anticipated in the FAS population based upon the frequency with which craniofacial anomalies, which are often associated with hearing disorders, are observed in FAS children. Data regarding hearing function among FAS children are limited because few studies have been conducted to systematically investigate auditory function. Few investigators have ascertained hearing (or visual function) of FAS subjects prior to assessment of language skills. The potentially confounding role of auditory or visual dysfunction (viz., picture pointing or viewing) for language assessment speaks to the necessity to precede such testing with adequate sensory screening. [Congenital abnormalities of the eyes are frequently seen in FAS children (Garber, 1984; Miller, Epstein, and Sugar, 1984; Pettigrew, 1986; Stromland, 19831. Information regarding hearing function in FAS children is essential considering the potential impact of otitis media and fluctuating hearing loss on speech and language development (Silva, Chalmers, and Stewart, 1986; Teele, Klein, Rosner, and The Greater Boston Otitis Media Study Group, 1984) and the importance of early identification and implementation of audiologic habilitative measures to maximize the opportunity for the FAS child to attain full potential. Church and Gerkin (1988) used otoscopy, pure tone audiometry, speech thresholds, immittance measures, and auditory brain stem testing to evaluate auditory function in 14 children recently diagnosed with FAS. Thirteen of the 14 children presented a history of hearing disorders including bilateral recurrent serous otitis media. Four children (29%) also presented with a variety of bilateral sensorineural hearing loss: Two children had high-frequency deficits and two presented predominantly flat audiograms. The incidence of sensorineural hearing loss in this group was significantly greater than the incidence of 2% reported for the general pediatric population (Kileny and Robertson, 1984). The incidences of recurrent otitis media and sensorineural hearing loss were more comparable to those rates seen in children with craniofacial anomalies including Down
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syndrome and cleft palate (Bergstrom and Hemenway, 1971; Church and Gerkin, 1988; Downs, 1980; Downs, Jafek, and Wood, 1981). Plan for the Present Study FAS has been reported in many ethnic and racial groups around the world; however, FAS appears with a disproportionately high frequency in American Indian offspring (Aase, 1981). Alcohol abuse (and consequent FAS) is a major health problem among American Indians living in both the southwestern U.S. and Canada (Arizona Department of Health Services, 1979; Aase, 1981; Mitchell and Patch, 1981; Robinson, Conry, and Conry, 1987). Robinson et al. (1987) identified 22 of 116 children with FAS in one American Indian community in British Columbia. Cultural, social, environmental, and biologic factors may interact to increase the risk for FAS among American Indians (Aase, 1981). Permissive attitudes toward alcohol consumption are seen in several American Indian populations (Levy and Kunitz, 1974). Existing alcohol rehabilitation programs are directed primarily to the male American Indian alcoholic, with few provisions for women alcoholics (Aase, 1981). The common preconception that American Indians drink more alcohol than other groups is incorrect: Only 42% of adult Navajo Indians drink alcohol compared to 70% of all U.S. adults, and only 15%-20% of Navajo women drink alcohol compared to 40% of all U.S. women (Aase, 1981; Levy and Kunitz, 1974). However, American Indians who do drink, do so in excess: Alcohol-related deaths are 20 times higher in American Indians than in the general U.S. population (Aase, 1981). Physiologic and dietary factors may also predispose American Indians to alcoholism and FAS. American Indians may present a deficit in the ability to metabolize acetaldehyde, a primary product of alcohol degradation (Wolff, 1973), and zinc, which is a necessary coenzyme in alcohol dehydrogenase, is deficient in diets of some American Indians (Aase, 1981). Despite the high prevalence of FAS among American Indian children, language skills of this culturally and racially distinctive subgroup of FAS children have not been reported in the literature. The present study was undertaken to examine and compare the expressive and receptive language abilities of normally developing and FAS American Indian children. Hearing sensitivity, middle ear function, and near and far visual acuity were assessed in each subject prior to language testing to minimize the impact of potentially confounding variables on language performance. The experimental objectives were (1) to compare the expressive and receptive language skills of American Indian children presenting FAS with culturally similar, normally developing controls; (2) to conduct a preliminary examination of language skills of younger and older FAS subjects; and (3) to compare the language skills of the normally developing American
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Indian children with the standardization sample of the TOLD-P and TOLD-I. Results of statistical and clinical significance are discussed. METHOD Subjects Ten American Indian children (M = 8 : 6; SD = 2: 3) with diagnosed FAS and 17 normal American Indian controls (M = 9: 2; SD = 3 : 5) served as subjects. All children had been placed in English-speaking adoptive or foster homes between birth and age 3 years and resided in the vicinity of Saskatoon, Saskatchewan, Canada. Seven of the FAS children were of the Cree Indian Nation and 3 of the Dene Indian Nation. Records documenting tribal affiliations of the control subjects were not available; however, informal interviews with teachers and children suggest that 15 controls were of the Cree Indian Nation and 2 children were of the Dene Indian Nation. FAS children presented physical and behavioral characteristics associated with the syndrome including short palpebral fissures, hypoplastic philtrum, thinned upper vermilion border, anomalies of the maxilla or mandible, growth retardation, and hyperactivity or irritability. All FAS children had been identified early, placed in infant stimulation and preschool programs, and were now receiving special education services in the public schools. No child presented a history of secondary neurological insult or trauma. The FAS group demonstrated a range of cognitive function spanning borderline normal to a moderate degree of mental retardation: mean full scale IQ score was 79 (range = 50-91) derived from the Wechsler Intelligence Scale for Children-Revised. The 17 children comprising the control group had never received special education services and were reported by their teachers to be functioning at grade level. Equipment Maico audiometers S3.6-1969 standards tensity, and digital 5A) were calibrated
(models MA 19 and MA 41) were calibrated to ANSI prior to use. The pressure, probe frequency and indisplay of a Teledyne Impedance Meter (mode1 TAto manufacturer’s specifications prior to testing.
Procedure Prior to experimental participation, subjects met the following criteria: (1) pure-tone air conduction thresholds no poorer than 15 dB HL (ANSI, 1970) bilaterally at octave frequencies between 0.25 and 8 kHz; (2) tympanometric width, static admittance, and ear canal volume within normal
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Table 1. Means and Standard Deviations for TOLD-P Standard Scores Achieved by FAS and Control Groups and T Test Values for Differences
Between Groups,
N
=
Subtest
Picture Vocabulary Oral Vocabulary Grammatical Understanding Sentence Imitation Grammatical Completion Word Discrimination
16 Group
X
SD
t
Control FAS Control FAS Control FAS Control FAS Control FAS Control
8.33 5.00 9.55 5.00 10.33 1.43 10.66 5.42 9.66 6.14 12.44 5.71 10.44 8.00
2.95 3.16 2.74 3.11 1.50 3.69 3.46 1.71 1.58 1.86 2.00 3.72 2.40 3.16
2.17“
FAS
Word Articulation Up
< 0.05,
df
=
Control FAS
3.11” 1.96” 3.65“ 4.09” 4.65”
I .76
14
limits (Asha, 1989) bilaterally; (3) unremarkable otoscopic examination bilaterally; and (4) far and near visual acuity of 20/20 as assessed by the Snellen and Nearpoint Tests. Each subject was tested on two occasions within a two-week period: auditory and visual acuity were assessed during the first session and language testing was accomplished during the second session. Language was assessed using the Test of Language Development-Primary (TOLD-P) and the Test of Language Development-Intermediate (TOLD-I). Both tests provide data regarding phonologic, semantic, and syntactic aspects of both expressive and receptive language skills, have received extensive psychometric analysis, and present the same composite profiles, thereby facilitating comparisons across the age groups represented in this study (McCauley and Swisher, 1984). The TOLD-P was administered to 16 children between the ages of 4:0 and 8 : 1I (7 FAS and 9 controls) and the TOLD-I was administered to I1 subjects between the ages of 9:0 and 12: 11 (3 FAS and 8 controls) (Newcomer and Hammill, 1982; Hammill and Newcomer, 1982).
RESULTS Means and standard deviations of standard scores achieved by FAS and control groups on the TOLD-P and TOLD-I, and T-test values for differences between groups are presented in Tables 1 and 2. Mean performance of the FAS group was significantly poorer than the control group
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Table 2. Means and Standard Deviations for TOLD-I Standard Scores Achieved by FAS and Control Groups and T Test Values for Differences Between Groups, N = 11
Sentence
Subtest
Group
X
SD
Combining
Control FAS Control FAS Control FAS Control FAS Control FAS
8.63 4.33 10.00 6.00 9.38 4.33 7.50 7.00 9.13 5.33
2.50 1.15 5.01 1.00 2.97 2.08 1.60 4.58 1.36 1.53
Characteristics Word Ordering Generals Grammatical
Op
< 0.05,
Comprehension
df
=
1 2.79” 1.33 2.66” 0.18 4.01”
9.
on all subtests of the TOLD-P except the word articulation subtest. Mean performance of the FAS group was signiticantly poorer than the control group for 3 of 5 TOLD-I subtests: Sentence combining, word ordering, and grammatical comprehension. Means and standard deviations for composite scores achieved by the FAS and control groups on the TOLD-P and TOLD-I are presented in Table 3. Pearson product-moment correlation coefficients were computed to examine association among language measures. Correlations were not computed for FAS subjects’ performance on subtests of the TOLD-I due to the small sample (N = 3). Of 52 correlations, only 6 were significant (p < 0.05), and a few of these may be spurious given the large number of correlations performed on the data set. For the FAS group, significant correlations among TOLD-P measures were found between picture and oral vocabulary, picture vo-
Table 3. Means and Standard Deviations for TOLD-P and TOLD-I Composite Scores Achieved by FAS and Control Groups Composite Spoken Listening Speaking Semantics Syntax
Language
Control-P 48.78 6.85 18.67 3.74 30.00 6.12 17.89 4.51 30.67 4.56
FAS-P
Control-I
FAS-I
29.00 10.69 12.43 6.65 16.57 4.69 10.00 5.94 19.00 5.66
43.38 7.07 17.75 2.34 25.63 6.16 16.13 1.89 27.25 5.50
27.00 7.81 Il.33 1.53 15.67 7.77 13.00 3.61 14.00 4.36
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cabulary and grammatical understanding, grammatical understanding and grammatical completion, and sentence imitation and word discrimination (Y = 0.80, 0.89, 0.79, 0.79, respectively). For the control subjects, significant correlations were found between oral vocabulary and grammatical understanding and oral vocabulary and sentence imitation subtests of the TOLD-P (v = 0.80, 0.75, respectively). No significant correlations were seen among subtests of the TOLD-I. Five two-way Analyses of Variance (Winer, 1971) for factors group and age revealed a significant (p < 0.005) group effect for all mean composite scores (viz., spoken language, F1,23 = 27.52; listening, F1,23 = 12.26; speaking, F1,23 = 21.58; semantics, F1.23= 33.00; and syntax, F1,23= 9.20). Raw scores were converted to percentile scores. Of 7 FAS children administered the TOLD-P, performance poorer than the sixteenth percentile was seen in all 7 subjects for sentence imitation, 6 subjects on word discrimination, 5 subjects on picture vocabulary, 4 subjects for oral vocabulary and grammatical completion, 3 subjects for grammatical understanding, and 1 subject for word articulation. Performance below the sixteenth percentile was observed infrequently among the 9 control subjects: 1 subject on picture vocabulary, oral vocabulary, sentence imitation, and word articulation. Of the 3 FAS children administered the TOLD-I, performance poorer than the sixteenth percentile was seen in all 3 subjects on characteristics and word ordering, 2 subjects on grammatical comprehension, and 1 subject on generals. Performance below the sixteenth percentile was observed infrequently among the 8 control subjects: 2 subjects on characteristics, word ordering, and generals. DISCUSSION The overall pattern of results is consistent with previous reports of expressive and receptive language deficits among FAS children. Statistical analysis revealed depressed performance for the FAS children relative to their normally developing peers on all subtests of the TOLD-P, with the exception of the word articulation subtest, and on 3 of 5 subtests of the TOLD-I: sentence combining, word ordering, and grammatical comprehension. All composite scores were depressed for the FAS group. Although the FAS group presented depressed performance on all subtests of the TOLD-P except word articulation, implicating both expressive and receptive semantic and syntactic difficulties among the younger children, depressed performance on the TOLD-I was seen primarily on subtests requiring syntatic manipulation, both receptive and expressive. Notwithstanding the absence of a significant age x group interaction effect in the present study, it appears that the older FAS children present primarily syntactic deficits while the younger FAS subjects present more global
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language deficits. These outcomes support Hamilton’s (1981) results, which demonstrated delayed semantic development and disordered syntactic development among FAS children: Hamilton’s FAS group performed much like the younger MLU matched subjects on semantic measures but they produced less complete and grammatical forms than the MLU matched group. The cross-sectional design of the present study, however, provides only a preliminary look at specific linguistic deficits across age. Longitudinal studies should be conducted to examine further the semantic and syntactic development in FAS children. Although statistics allow one to test experimental questions, examination of data from a clinical perspective may provide insights directly applicable to the design of therapeutic objectives and intervention programming. Comparison of the groups’ performance with normative data (Newcomer and Hammill, 1982, p. 21; Hammill and Newcomer, 1982, p. 11) affords such insights. FAS group performance fell below 1 SD (3) of the mean (10) on all TOLD-P subtests except grammatical understanding and word articulation and for all TOLD-I subtests except generals. Despite statistically significant poorer mean performance relative to the control subjects, younger FAS subjects exhibited less global syntactic difficulty when compared with the standardization sample. Statistical results suggest that older FAS subjects performed more poorly than normal controls on 3 of 5 subtests of the TOLD-I; however, comparison with test norms revealed more pervasive difficulty. Somewhat different patterns of performance uncovered by clinical and statistical analyses of the data demonstrate the limitation of statistics, and the value of alternate approaches to data analysis, particularly when management decisions are at issue. It must be noted that differences in cultural and environmental experiences and perhaps, cognitive abilities, make a definitive interpretation of the present results difficult. Although FAS and control groups were comprised of proportionately equal numbers of subjects from the Cree and Dene Indian Nations, two Indian Nations with similar sociolinguistic environments, individual differences in language exposure may have influenced TOLD performance differences. Of more serious concern is the variability of adoptive placements: cultural and language experiences may have differed markedly as a function of age of placement in foster or adoptive English-speaking homes, placements that occurred over the children’s critical first three years of life. In addition, because standardized intelligence measures were not available to confirm teachers’ impressions of the normally developing children, observed language differences between groups may reflect differences in cognitive abilities. Hence, it is unclear whether FAS causes language deficits or whether language deficits are but one of a cluster of symptoms resulting from depressed cognitive function.
L. J. CARNEY and G. D. CHERMAK Finally, it is interesting to speculate why a few of the normally developing control subjects performed below norms on particular subtests of the TOLD-P and TOLD-I. Surely, such an outcome might be expected in any control group and even among normative groups of the standardization sample. Alternatively, some of these children may have subtle, persistent language disorders that do not impede grade level progress. Perhaps differences in teachers’ interpretations of “grade level” performance when recommending subjects for the control group may explain this outcome. It is also possible that the depressed performance of some control subjects may have resulted from cultural bias often attributed to standardized tests used with minority populations. The latter interpretation underlies the recommendation of Harris and Bayles (1984) to establish local norms when working with the American Indian population. In conclusion, the results of the present study are consistent with previous reports of expressive and receptive language deficits among FAS children. Greater control of environmental, cultural, and cognitive variables is required, however, to clarify the relationship between FAS and language deficits. Further investigations are planned to examine the influence of such variables on language development in FAS children. The authors wish to acknowledge
Irene Clark for assistance in subject selection.
REFERENCES Aase, J. M. (1981). The fetal alcohol syndrome in American Indians: A high risk group. Neurobehav. Toxicol. Teratol. 3:153-156.
American National Standards Institute (1970). American National Standards Institute specifications for audiometers. New York: ANSI S.3.6-1969. American Speech-Language-Hearing Association (1989). Guidelines for screening for hearing impairment and middle ear disorders. ASHA 31:71-77. Arizona Department of Health Services, Bureau of Vital Record and Information Services (1979). Health Znf. Special report No. 4. Bayley, N. (1969). Bayley Scales of Infant Development. ical Corp.
New York: Psycholog-
Becker, M., Leeper, H. A., and Warr-Leeper, G. A. (1985). Fetal alcohol syndrome: A description of short-term memory and grammatical and semantic abilities. Presented at the meeting of the Canadian Speech and hearing Association, Toronto. Bergstrom, L., and Hemenway, W. G. (1971). Otologic problems in submucous clefts. South. Med. J. 64: 1172-l 177. Carrow, E. (1973). Test for Auditory Comprehension of Language. Austin, TX: Learning Concepts. Chernoff, G. F. (1979). Introduction: A teratologist’s view of the Fetal Alcohol Syndrome. Curr. Alcoholism 7~7-13.
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SYNDROME
133
Church, M. W., and Gerkin, K. P. (1988). Hearing disorders in children with Fetal Alcohol Syndrome: Findings from case reports. Pediatrics 82: 147-154. Disimoni, F. (1978). The Token Test for Children. Hingham, sources. Downs, M. P. (1980). The hearing of Down’s individuals. Hear. 1:25-38.
MA: Teaching ReSem. Speech. Lung.
Downs, M. P., Jafek, B., and Wood, R. P. (1981). Comprehensive treatment of children with recurrent serous otitis media. Otolaryngol. Head Neck Surg. 89:658-665. Dunn, L. M. (1980). Peabody Picture Vocabulary Test. Circle Pines, MN: American Guidance Service. Ewing, J. A., Rouse, B. A., and Pellizzari, E. D. (1974). Alcohol sensitivity ethnic background. Am. J. Psychol. 131:206-210. Garber, J. M. (1984). Steep cornea1 curvature: J. Am. Optometric Assoc. 55~595-598.
and
A fetal alcohol syndrome landmark.
Gusella, J. L., and Fried, P. P. (1984). Effects of maternal social drinking and smoking on offspring at thirteen months. Neurobehav. Toxicol. Tetratol. 6: 1317. Hamilton, M. A. (1981). Linguistic abilities of children with Fetal Alcohol Syndrome. Doctoral dissertation, University of Washington, Seattle. Hammill, D. D., and Newcomer, P. L. (1982). Test of Language DevelopmentIntermediate. Austin, TX: Empiric Press. Hanson, J. W., Streissguth, A. P., and Smith, D. W. (1978). The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. J. Pediat. 92:457-460. Harris, G. A., and Bayles, K. A. (1984). Speech-language pathology and audiology: A Native American perspective. Paper presented at the annual meeting of the American Speech-Language-Hearing Association, San Francisco, CA. Hendrick, D. L., Prather, E. M., and Tobin, A. R. (1975). Sequenced Inventory of Communication Development. Seattle, WA: University of Washington Press. Iosub, S., Fuchs, M., Bingol, N., and Gromisch, Syndrome revisited. Pediatrics 68~475-479.
D. S. (1981a). Fetal Alcohol
Iosub, S., Fuchs, M., Bingol, N., Stone, R. K., and Gromisch, D. S. (1981b). Long-term follow-up of three siblings with Fetal Alcohol Syndrome. Alcoholism: Clin. Exp. Res. 5:523-527. Johnson, S., Knight, R., Marmer, D., and Steele, R. W. (1981). Immune deliciency in Fetal Alcohol Syndrome. Ped. Res. 15:908-911. Jones, K. L., and Smith, D. W. (1973). Recognition of the Fetal Alcohol Syndrome in early infancy. Lancet 2:999-1001. Jones, K. L., Smith, D. W., Ulleland, C., and Streissguth, A. P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1: 1267-1271.
L. J. CARNEY and G. D. CHERMAK
134
Kileny, P., and Robertson, C. M. T. (1984). Neurological assessment. J. Otolaryngol. 14(suppl. 14):34-39. Kirk, S. A., McCarthy, cholinguistic
Abilities.
aspects of infant hearing
J. J., and Kirk, W. D. (1968). The Illinois Urbana, IL: University of Illinois Press.
Test of Psy-
Larrson, G., Bohlin, A. B., and Tune& R. (1985). Prospective study of children exposed to variable amounts of alcohol in utero. Arch. Dis. Childhood 60:316321. Lee, L. (1971). Northwestern University Press. Lee, L. (1974). Development University Press. Levy, J. E., and Kunitz, Anglo-American
Test. Evanston,
Syntax Screening Sentence
Analysis.
Evanston,
IL: Northwestern IL: Northwestern
S. J. (1974). Indian Drinking: Navajo New York: Wiley Intersciences.
Practices
and
Theories.
McCauley, R. J., and Swisher, L. (1984). Psychometric review of language and articulation tests for preschool children. J. Speech Hear. Disord. 49~34-42. Miller, M. T., Epstein, R. J., and Sugar, J. (1984). Anterior segment anomalies associated with the fetal alcohol syndrome. .I. Pediatric Ophthalmol. Strabismus 21:8-18.
Mitchell, Indian
W., and Patch, K. (1981). Indian alcoholism
and education.
J. Am.
Ed. 6:31-33.
Newcomer, Primary.
P. L., and Hammill, D. D. (1982). Test ofLanguage Austin, TX: Empiric Press.
Development-
Robinson, G. C., Conry, J. L., and Conry, R. F. (1987). Clinical profile and prevalence of fetal alcohol syndrome in an isolated community in British Columbia. Can. Med. Assoc. J. 137:203-207. Smith, D. W. (1981). Fetal alcohol syndrome behav.
Toxicol.
Teratol.
and fetal alcohol effects. Neuro-
3: 127.
Smith, D. W. (1982). Recognizable Philadelphia, PA: Saunders.
Patterns
of Human
Malformation,
3rd edition.
Streissguth, A. P., Clarren, S. K., and Jones, K. L. (1985). Natural history of the fetal alcohol syndrome: A lo-year follow-up of eleven patients. Lancet 2:8591.
Silva, P. A., Chalmers, D., and Stewart, I. (1986). Some audiological, psychological, educational and behavioral characteristics of children with bilateral otitis media with effusion: A longitudinal study. J. Learn. Disabil. 19:165-169. Stromland,
K. (1985). Ocular abnormalities
Ophthalmol.
63(suppl.
in the fetal alcohol syndrome.
Acta
171):1-50.
Teele, D. W., Klein, J. O., and Rosner, B. A., and The Greater Boston Otitis Media Study Group. (1984). Otitis media with effusion during the first three years of life and development of speech and language. Pediatrics 74:282-287. Wechsler, D. L. (1974). Wechsler Intelligence Scale for Children-Revised. New York: Psychological Corp. Wolff, P. H. (1973). Vasomotor sensitivity to alcohol in diverse mongoloid populations. Am. J. Hum. Genet. 25:193-199.
PERFORMANCE OF AMERICAN INDIAN CHILDREN WITH FETAL ALCOHOL SYNDROME ON THE TEST OF LANGUAGE DEVELOPMENT LAURA J. CARNEY and GAIL D. CHERMAK Department of Speech and Hearing Sciences, Washington State University
Alcohol is a teratogen known to have deleterious effects on the developing embryo and fetus. Language deficits secondary to central nervous system dysfunction are among the sequelae of Fetal Alcohol Syndrome (FAS). Limited information is available regarding the language deficits associated with FAS, particularly among the population of American Indians in whom FAS is highly prevalent. The TOLD-P and TOLD-I were administered to 27 American Indian children: 10 with FAS and 17 normally developing control subjects. Puretone screening, immittance measurement, and vision screening preceded language testing. The older FAS children presented syntactic deficits while the younger FAS subjects presented more global language deficits.
INTRODUCTION Alcohol is a teratogen known to have deleterious effects on the developing embryo and fetus (Chernoff, 1980; Church and Gerkin, 1988; Johnson, Knight, Marmer, and Steele, 1981; Jones, Smith, Ulleland, and Streissguth, 1973; Smith, 1981). Jones and Smith (1973) referred to the pattern of congenital malformations frequently seen in children born to mothers who ingested excessive amounts of alcohol during pregnancy as Fetal Alcohol Syndrome (FAS). The prevalence of FAS is similar to that of Down syndrome, between 1 in 500 to I in 1000 births (Smith, 1982). It has been estimated that between one third and one half of children born to chronic alcoholic mothers present some of the characteristics of FAS (Hanson, Streissguth, and Smith, 1978; Jones and Smith, 1973). FAS is associated with growth deficiencies, central nervous system dysfunction, and anomalies of internal organs and the skeletal system (Jones and Smith, 1973). Among the sequelae of particular concern to speech and hearing professionals are the major features of central nervous system dysfuncAddress Correspondence to Gail D. Chermak, Ph.D., Department Sciences, Washington State University, Pullman, WA 99164-2420.
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123 0021.9924/91/$3..50
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L. J. CARNEY and G. D. CHERMAK
tion, including mental retardation and hyperactivity, tures of otitis media and cleft lip and palate.
and associated fea-
Language and Auditory Function Limited information is available regarding the speech, language, and hearing impairments of children with (FAS). High incidence of otitis media has been reported in FAS children (Johnson et al., 1981; Streissguth, Clarren, and Jones, 1985); however, evaluation of hearing function was an ancillary objective, and criteria for determination of otitis media were not delineated. Iosub, Fuchs, Bingol, and Gromisch (1981a) reported a high incidence (80%) of speech and language problems among 63 FAS patients, a developmental delay not previously reported in FAS. In reviewing the general developmental histories of three siblings diagnosed with FAS, Iosub, Fuchs, Bingol, Stone, and Gromisch (1981b) observed voice dysfunction, disorders of articulation, and fluency problems. Iosub et al. (1981a) asserted that speech and language deficits associated with FAS are the result of central nervous system damage due to the teratogenie effect of alcohol on the brain. However, Larsson, Bohlin, and Tune11 (1985) attributed the speech delays to postnatal environmental influences, not a consequence of alcohol in utero: his subjects were language-delayed children who presented no other features characteristic of FAS, but who had been born to mothers diagnosed as excessive drinkers. Gusella and Fried (1984) administered the Bayley Scales uflnfunt Development to 84 13-month-old infants born to women classified as social drinkers. Although these infants were never diagnosed with FAS, a significant negative correlation was found between amount of alcohol consumed by the mother during pregnancy and both expressive and receptive language skills of the infants. Hedrick, Prather, and Tobin (1975) observed a two-year and a three-year delay in receptive and expressive language in two 6-year-old boys with FAS. Becker, Leeper, and Warr-Leeper (1985) found significant deficits in 6 FAS children who were tested on the Test of Auditory Comprehension of Language (TACL) (Carrow, 1973), Token Test for Children (Disimoni, 1978), and the Developmental Sentence Scoring (DDS) (Lee, 1974). No significant differences were observed between the FAS and normal controls on the expressive portion of the Northwestern Sentence Screening Test (NSST) (Lee, 1971) or for selected subtests of the Illinois Test of Psycholinguistic Abilities (ITPA) (Kirk, McCarthy, and Kirk, 1968). Hamilton (1981) compared language performance of 10 5-year-old FAS children with three groups: (1) 10 normally developing 5-year-old children; (2) 10 3-year-old children matched in mean-length utterance (MLU) to the FAS group; and (3) 10 5-year-old children diagnosed with Prader-Willi syndrome whose cognitive level matched that of the FAS group. FAS children produced less complex and
FETAL ALCOHOL SYNDROME
125
less complete grammatical forms than the normal and MLU matched groups; however, they produced more complex grammatical sentences than the Prader-Willi group. Normal controls surpassed the FAS group on expressive and receptive semantic measures; however, no significant differences were revealed between the FAS and MLU matched group. FAS children performed better than the Prader-Willi group on expressive semantic measures. Hamilton (1981) concluded that language skills cannot be predicted based solely on cognitive function, as FAS children frequently performed better than the intellectually matched Prader-Willi group. Characteristics of each syndrome may uniquely impact speech and language capabilities beyond the factors responsible for a general cognitive delay (Hamilton, 1981). A high prevalence of hearing disorders might be anticipated in the FAS population based upon the frequency with which craniofacial anomalies, which are often associated with hearing disorders, are observed in FAS children. Data regarding hearing function among FAS children are limited because few studies have been conducted to systematically investigate auditory function. Few investigators have ascertained hearing (or visual function) of FAS subjects prior to assessment of language skills. The potentially confounding role of auditory or visual dysfunction (viz., picture pointing or viewing) for language assessment speaks to the necessity to precede such testing with adequate sensory screening. [Congenital abnormalities of the eyes are frequently seen in FAS children (Garber, 1984; Miller, Epstein, and Sugar, 1984; Pettigrew, 1986; Stromland, 19831. Information regarding hearing function in FAS children is essential considering the potential impact of otitis media and fluctuating hearing loss on speech and language development (Silva, Chalmers, and Stewart, 1986; Teele, Klein, Rosner, and The Greater Boston Otitis Media Study Group, 1984) and the importance of early identification and implementation of audiologic habilitative measures to maximize the opportunity for the FAS child to attain full potential. Church and Gerkin (1988) used otoscopy, pure tone audiometry, speech thresholds, immittance measures, and auditory brain stem testing to evaluate auditory function in 14 children recently diagnosed with FAS. Thirteen of the 14 children presented a history of hearing disorders including bilateral recurrent serous otitis media. Four children (29%) also presented with a variety of bilateral sensorineural hearing loss: Two children had high-frequency deficits and two presented predominantly flat audiograms. The incidence of sensorineural hearing loss in this group was significantly greater than the incidence of 2% reported for the general pediatric population (Kileny and Robertson, 1984). The incidences of recurrent otitis media and sensorineural hearing loss were more comparable to those rates seen in children with craniofacial anomalies including Down
126
L. J. CARNEY and G. D. CHERMAK
syndrome and cleft palate (Bergstrom and Hemenway, 1971; Church and Gerkin, 1988; Downs, 1980; Downs, Jafek, and Wood, 1981). Plan for the Present Study FAS has been reported in many ethnic and racial groups around the world; however, FAS appears with a disproportionately high frequency in American Indian offspring (Aase, 1981). Alcohol abuse (and consequent FAS) is a major health problem among American Indians living in both the southwestern U.S. and Canada (Arizona Department of Health Services, 1979; Aase, 1981; Mitchell and Patch, 1981; Robinson, Conry, and Conry, 1987). Robinson et al. (1987) identified 22 of 116 children with FAS in one American Indian community in British Columbia. Cultural, social, environmental, and biologic factors may interact to increase the risk for FAS among American Indians (Aase, 1981). Permissive attitudes toward alcohol consumption are seen in several American Indian populations (Levy and Kunitz, 1974). Existing alcohol rehabilitation programs are directed primarily to the male American Indian alcoholic, with few provisions for women alcoholics (Aase, 1981). The common preconception that American Indians drink more alcohol than other groups is incorrect: Only 42% of adult Navajo Indians drink alcohol compared to 70% of all U.S. adults, and only 15%-20% of Navajo women drink alcohol compared to 40% of all U.S. women (Aase, 1981; Levy and Kunitz, 1974). However, American Indians who do drink, do so in excess: Alcohol-related deaths are 20 times higher in American Indians than in the general U.S. population (Aase, 1981). Physiologic and dietary factors may also predispose American Indians to alcoholism and FAS. American Indians may present a deficit in the ability to metabolize acetaldehyde, a primary product of alcohol degradation (Wolff, 1973), and zinc, which is a necessary coenzyme in alcohol dehydrogenase, is deficient in diets of some American Indians (Aase, 1981). Despite the high prevalence of FAS among American Indian children, language skills of this culturally and racially distinctive subgroup of FAS children have not been reported in the literature. The present study was undertaken to examine and compare the expressive and receptive language abilities of normally developing and FAS American Indian children. Hearing sensitivity, middle ear function, and near and far visual acuity were assessed in each subject prior to language testing to minimize the impact of potentially confounding variables on language performance. The experimental objectives were (1) to compare the expressive and receptive language skills of American Indian children presenting FAS with culturally similar, normally developing controls; (2) to conduct a preliminary examination of language skills of younger and older FAS subjects; and (3) to compare the language skills of the normally developing American
FETAL ALCOHOL SYNDROME
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Indian children with the standardization sample of the TOLD-P and TOLD-I. Results of statistical and clinical significance are discussed. METHOD Subjects Ten American Indian children (M = 8 : 6; SD = 2: 3) with diagnosed FAS and 17 normal American Indian controls (M = 9: 2; SD = 3 : 5) served as subjects. All children had been placed in English-speaking adoptive or foster homes between birth and age 3 years and resided in the vicinity of Saskatoon, Saskatchewan, Canada. Seven of the FAS children were of the Cree Indian Nation and 3 of the Dene Indian Nation. Records documenting tribal affiliations of the control subjects were not available; however, informal interviews with teachers and children suggest that 15 controls were of the Cree Indian Nation and 2 children were of the Dene Indian Nation. FAS children presented physical and behavioral characteristics associated with the syndrome including short palpebral fissures, hypoplastic philtrum, thinned upper vermilion border, anomalies of the maxilla or mandible, growth retardation, and hyperactivity or irritability. All FAS children had been identified early, placed in infant stimulation and preschool programs, and were now receiving special education services in the public schools. No child presented a history of secondary neurological insult or trauma. The FAS group demonstrated a range of cognitive function spanning borderline normal to a moderate degree of mental retardation: mean full scale IQ score was 79 (range = 50-91) derived from the Wechsler Intelligence Scale for Children-Revised. The 17 children comprising the control group had never received special education services and were reported by their teachers to be functioning at grade level. Equipment Maico audiometers S3.6-1969 standards tensity, and digital 5A) were calibrated
(models MA 19 and MA 41) were calibrated to ANSI prior to use. The pressure, probe frequency and indisplay of a Teledyne Impedance Meter (mode1 TAto manufacturer’s specifications prior to testing.
Procedure Prior to experimental participation, subjects met the following criteria: (1) pure-tone air conduction thresholds no poorer than 15 dB HL (ANSI, 1970) bilaterally at octave frequencies between 0.25 and 8 kHz; (2) tympanometric width, static admittance, and ear canal volume within normal
128
L. J. CARNEY
and G. D. CHERMAK
Table 1. Means and Standard Deviations for TOLD-P Standard Scores Achieved by FAS and Control Groups and T Test Values for Differences
Between Groups,
N
=
Subtest
Picture Vocabulary Oral Vocabulary Grammatical Understanding Sentence Imitation Grammatical Completion Word Discrimination
16 Group
X
SD
t
Control FAS Control FAS Control FAS Control FAS Control FAS Control
8.33 5.00 9.55 5.00 10.33 1.43 10.66 5.42 9.66 6.14 12.44 5.71 10.44 8.00
2.95 3.16 2.74 3.11 1.50 3.69 3.46 1.71 1.58 1.86 2.00 3.72 2.40 3.16
2.17“
FAS
Word Articulation Up
< 0.05,
df
=
Control FAS
3.11” 1.96” 3.65“ 4.09” 4.65”
I .76
14
limits (Asha, 1989) bilaterally; (3) unremarkable otoscopic examination bilaterally; and (4) far and near visual acuity of 20/20 as assessed by the Snellen and Nearpoint Tests. Each subject was tested on two occasions within a two-week period: auditory and visual acuity were assessed during the first session and language testing was accomplished during the second session. Language was assessed using the Test of Language Development-Primary (TOLD-P) and the Test of Language Development-Intermediate (TOLD-I). Both tests provide data regarding phonologic, semantic, and syntactic aspects of both expressive and receptive language skills, have received extensive psychometric analysis, and present the same composite profiles, thereby facilitating comparisons across the age groups represented in this study (McCauley and Swisher, 1984). The TOLD-P was administered to 16 children between the ages of 4:0 and 8 : 1I (7 FAS and 9 controls) and the TOLD-I was administered to I1 subjects between the ages of 9:0 and 12: 11 (3 FAS and 8 controls) (Newcomer and Hammill, 1982; Hammill and Newcomer, 1982).
RESULTS Means and standard deviations of standard scores achieved by FAS and control groups on the TOLD-P and TOLD-I, and T-test values for differences between groups are presented in Tables 1 and 2. Mean performance of the FAS group was significantly poorer than the control group
FETAL ALCOHOL
SYNDROME
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Table 2. Means and Standard Deviations for TOLD-I Standard Scores Achieved by FAS and Control Groups and T Test Values for Differences Between Groups, N = 11
Sentence
Subtest
Group
X
SD
Combining
Control FAS Control FAS Control FAS Control FAS Control FAS
8.63 4.33 10.00 6.00 9.38 4.33 7.50 7.00 9.13 5.33
2.50 1.15 5.01 1.00 2.97 2.08 1.60 4.58 1.36 1.53
Characteristics Word Ordering Generals Grammatical
Op
< 0.05,
Comprehension
df
=
1 2.79” 1.33 2.66” 0.18 4.01”
9.
on all subtests of the TOLD-P except the word articulation subtest. Mean performance of the FAS group was signiticantly poorer than the control group for 3 of 5 TOLD-I subtests: Sentence combining, word ordering, and grammatical comprehension. Means and standard deviations for composite scores achieved by the FAS and control groups on the TOLD-P and TOLD-I are presented in Table 3. Pearson product-moment correlation coefficients were computed to examine association among language measures. Correlations were not computed for FAS subjects’ performance on subtests of the TOLD-I due to the small sample (N = 3). Of 52 correlations, only 6 were significant (p < 0.05), and a few of these may be spurious given the large number of correlations performed on the data set. For the FAS group, significant correlations among TOLD-P measures were found between picture and oral vocabulary, picture vo-
Table 3. Means and Standard Deviations for TOLD-P and TOLD-I Composite Scores Achieved by FAS and Control Groups Composite Spoken Listening Speaking Semantics Syntax
Language
Control-P 48.78 6.85 18.67 3.74 30.00 6.12 17.89 4.51 30.67 4.56
FAS-P
Control-I
FAS-I
29.00 10.69 12.43 6.65 16.57 4.69 10.00 5.94 19.00 5.66
43.38 7.07 17.75 2.34 25.63 6.16 16.13 1.89 27.25 5.50
27.00 7.81 Il.33 1.53 15.67 7.77 13.00 3.61 14.00 4.36
130
L. J. CARNEY and G. D. CHERMAK
cabulary and grammatical understanding, grammatical understanding and grammatical completion, and sentence imitation and word discrimination (Y = 0.80, 0.89, 0.79, 0.79, respectively). For the control subjects, significant correlations were found between oral vocabulary and grammatical understanding and oral vocabulary and sentence imitation subtests of the TOLD-P (v = 0.80, 0.75, respectively). No significant correlations were seen among subtests of the TOLD-I. Five two-way Analyses of Variance (Winer, 1971) for factors group and age revealed a significant (p < 0.005) group effect for all mean composite scores (viz., spoken language, F1,23 = 27.52; listening, F1,23 = 12.26; speaking, F1,23 = 21.58; semantics, F1.23= 33.00; and syntax, F1,23= 9.20). Raw scores were converted to percentile scores. Of 7 FAS children administered the TOLD-P, performance poorer than the sixteenth percentile was seen in all 7 subjects for sentence imitation, 6 subjects on word discrimination, 5 subjects on picture vocabulary, 4 subjects for oral vocabulary and grammatical completion, 3 subjects for grammatical understanding, and 1 subject for word articulation. Performance below the sixteenth percentile was observed infrequently among the 9 control subjects: 1 subject on picture vocabulary, oral vocabulary, sentence imitation, and word articulation. Of the 3 FAS children administered the TOLD-I, performance poorer than the sixteenth percentile was seen in all 3 subjects on characteristics and word ordering, 2 subjects on grammatical comprehension, and 1 subject on generals. Performance below the sixteenth percentile was observed infrequently among the 8 control subjects: 2 subjects on characteristics, word ordering, and generals. DISCUSSION The overall pattern of results is consistent with previous reports of expressive and receptive language deficits among FAS children. Statistical analysis revealed depressed performance for the FAS children relative to their normally developing peers on all subtests of the TOLD-P, with the exception of the word articulation subtest, and on 3 of 5 subtests of the TOLD-I: sentence combining, word ordering, and grammatical comprehension. All composite scores were depressed for the FAS group. Although the FAS group presented depressed performance on all subtests of the TOLD-P except word articulation, implicating both expressive and receptive semantic and syntactic difficulties among the younger children, depressed performance on the TOLD-I was seen primarily on subtests requiring syntatic manipulation, both receptive and expressive. Notwithstanding the absence of a significant age x group interaction effect in the present study, it appears that the older FAS children present primarily syntactic deficits while the younger FAS subjects present more global
FETAL ALCOHOL SYNDROME
131
language deficits. These outcomes support Hamilton’s (1981) results, which demonstrated delayed semantic development and disordered syntactic development among FAS children: Hamilton’s FAS group performed much like the younger MLU matched subjects on semantic measures but they produced less complete and grammatical forms than the MLU matched group. The cross-sectional design of the present study, however, provides only a preliminary look at specific linguistic deficits across age. Longitudinal studies should be conducted to examine further the semantic and syntactic development in FAS children. Although statistics allow one to test experimental questions, examination of data from a clinical perspective may provide insights directly applicable to the design of therapeutic objectives and intervention programming. Comparison of the groups’ performance with normative data (Newcomer and Hammill, 1982, p. 21; Hammill and Newcomer, 1982, p. 11) affords such insights. FAS group performance fell below 1 SD (3) of the mean (10) on all TOLD-P subtests except grammatical understanding and word articulation and for all TOLD-I subtests except generals. Despite statistically significant poorer mean performance relative to the control subjects, younger FAS subjects exhibited less global syntactic difficulty when compared with the standardization sample. Statistical results suggest that older FAS subjects performed more poorly than normal controls on 3 of 5 subtests of the TOLD-I; however, comparison with test norms revealed more pervasive difficulty. Somewhat different patterns of performance uncovered by clinical and statistical analyses of the data demonstrate the limitation of statistics, and the value of alternate approaches to data analysis, particularly when management decisions are at issue. It must be noted that differences in cultural and environmental experiences and perhaps, cognitive abilities, make a definitive interpretation of the present results difficult. Although FAS and control groups were comprised of proportionately equal numbers of subjects from the Cree and Dene Indian Nations, two Indian Nations with similar sociolinguistic environments, individual differences in language exposure may have influenced TOLD performance differences. Of more serious concern is the variability of adoptive placements: cultural and language experiences may have differed markedly as a function of age of placement in foster or adoptive English-speaking homes, placements that occurred over the children’s critical first three years of life. In addition, because standardized intelligence measures were not available to confirm teachers’ impressions of the normally developing children, observed language differences between groups may reflect differences in cognitive abilities. Hence, it is unclear whether FAS causes language deficits or whether language deficits are but one of a cluster of symptoms resulting from depressed cognitive function.
L. J. CARNEY and G. D. CHERMAK Finally, it is interesting to speculate why a few of the normally developing control subjects performed below norms on particular subtests of the TOLD-P and TOLD-I. Surely, such an outcome might be expected in any control group and even among normative groups of the standardization sample. Alternatively, some of these children may have subtle, persistent language disorders that do not impede grade level progress. Perhaps differences in teachers’ interpretations of “grade level” performance when recommending subjects for the control group may explain this outcome. It is also possible that the depressed performance of some control subjects may have resulted from cultural bias often attributed to standardized tests used with minority populations. The latter interpretation underlies the recommendation of Harris and Bayles (1984) to establish local norms when working with the American Indian population. In conclusion, the results of the present study are consistent with previous reports of expressive and receptive language deficits among FAS children. Greater control of environmental, cultural, and cognitive variables is required, however, to clarify the relationship between FAS and language deficits. Further investigations are planned to examine the influence of such variables on language development in FAS children. The authors wish to acknowledge
Irene Clark for assistance in subject selection.
REFERENCES Aase, J. M. (1981). The fetal alcohol syndrome in American Indians: A high risk group. Neurobehav. Toxicol. Teratol. 3:153-156.
American National Standards Institute (1970). American National Standards Institute specifications for audiometers. New York: ANSI S.3.6-1969. American Speech-Language-Hearing Association (1989). Guidelines for screening for hearing impairment and middle ear disorders. ASHA 31:71-77. Arizona Department of Health Services, Bureau of Vital Record and Information Services (1979). Health Znf. Special report No. 4. Bayley, N. (1969). Bayley Scales of Infant Development. ical Corp.
New York: Psycholog-
Becker, M., Leeper, H. A., and Warr-Leeper, G. A. (1985). Fetal alcohol syndrome: A description of short-term memory and grammatical and semantic abilities. Presented at the meeting of the Canadian Speech and hearing Association, Toronto. Bergstrom, L., and Hemenway, W. G. (1971). Otologic problems in submucous clefts. South. Med. J. 64: 1172-l 177. Carrow, E. (1973). Test for Auditory Comprehension of Language. Austin, TX: Learning Concepts. Chernoff, G. F. (1979). Introduction: A teratologist’s view of the Fetal Alcohol Syndrome. Curr. Alcoholism 7~7-13.
FETAL ALCOHOL
SYNDROME
133
Church, M. W., and Gerkin, K. P. (1988). Hearing disorders in children with Fetal Alcohol Syndrome: Findings from case reports. Pediatrics 82: 147-154. Disimoni, F. (1978). The Token Test for Children. Hingham, sources. Downs, M. P. (1980). The hearing of Down’s individuals. Hear. 1:25-38.
MA: Teaching ReSem. Speech. Lung.
Downs, M. P., Jafek, B., and Wood, R. P. (1981). Comprehensive treatment of children with recurrent serous otitis media. Otolaryngol. Head Neck Surg. 89:658-665. Dunn, L. M. (1980). Peabody Picture Vocabulary Test. Circle Pines, MN: American Guidance Service. Ewing, J. A., Rouse, B. A., and Pellizzari, E. D. (1974). Alcohol sensitivity ethnic background. Am. J. Psychol. 131:206-210. Garber, J. M. (1984). Steep cornea1 curvature: J. Am. Optometric Assoc. 55~595-598.
and
A fetal alcohol syndrome landmark.
Gusella, J. L., and Fried, P. P. (1984). Effects of maternal social drinking and smoking on offspring at thirteen months. Neurobehav. Toxicol. Tetratol. 6: 1317. Hamilton, M. A. (1981). Linguistic abilities of children with Fetal Alcohol Syndrome. Doctoral dissertation, University of Washington, Seattle. Hammill, D. D., and Newcomer, P. L. (1982). Test of Language DevelopmentIntermediate. Austin, TX: Empiric Press. Hanson, J. W., Streissguth, A. P., and Smith, D. W. (1978). The effects of moderate alcohol consumption during pregnancy on fetal growth and morphogenesis. J. Pediat. 92:457-460. Harris, G. A., and Bayles, K. A. (1984). Speech-language pathology and audiology: A Native American perspective. Paper presented at the annual meeting of the American Speech-Language-Hearing Association, San Francisco, CA. Hendrick, D. L., Prather, E. M., and Tobin, A. R. (1975). Sequenced Inventory of Communication Development. Seattle, WA: University of Washington Press. Iosub, S., Fuchs, M., Bingol, N., and Gromisch, Syndrome revisited. Pediatrics 68~475-479.
D. S. (1981a). Fetal Alcohol
Iosub, S., Fuchs, M., Bingol, N., Stone, R. K., and Gromisch, D. S. (1981b). Long-term follow-up of three siblings with Fetal Alcohol Syndrome. Alcoholism: Clin. Exp. Res. 5:523-527. Johnson, S., Knight, R., Marmer, D., and Steele, R. W. (1981). Immune deliciency in Fetal Alcohol Syndrome. Ped. Res. 15:908-911. Jones, K. L., and Smith, D. W. (1973). Recognition of the Fetal Alcohol Syndrome in early infancy. Lancet 2:999-1001. Jones, K. L., Smith, D. W., Ulleland, C., and Streissguth, A. P. (1973). Pattern of malformation in offspring of chronic alcoholic mothers. Lancet 1: 1267-1271.
L. J. CARNEY and G. D. CHERMAK
134
Kileny, P., and Robertson, C. M. T. (1984). Neurological assessment. J. Otolaryngol. 14(suppl. 14):34-39. Kirk, S. A., McCarthy, cholinguistic
Abilities.
aspects of infant hearing
J. J., and Kirk, W. D. (1968). The Illinois Urbana, IL: University of Illinois Press.
Test of Psy-
Larrson, G., Bohlin, A. B., and Tune& R. (1985). Prospective study of children exposed to variable amounts of alcohol in utero. Arch. Dis. Childhood 60:316321. Lee, L. (1971). Northwestern University Press. Lee, L. (1974). Development University Press. Levy, J. E., and Kunitz, Anglo-American
Test. Evanston,
Syntax Screening Sentence
Analysis.
Evanston,
IL: Northwestern IL: Northwestern
S. J. (1974). Indian Drinking: Navajo New York: Wiley Intersciences.
Practices
and
Theories.
McCauley, R. J., and Swisher, L. (1984). Psychometric review of language and articulation tests for preschool children. J. Speech Hear. Disord. 49~34-42. Miller, M. T., Epstein, R. J., and Sugar, J. (1984). Anterior segment anomalies associated with the fetal alcohol syndrome. .I. Pediatric Ophthalmol. Strabismus 21:8-18.
Mitchell, Indian
W., and Patch, K. (1981). Indian alcoholism
and education.
J. Am.
Ed. 6:31-33.
Newcomer, Primary.
P. L., and Hammill, D. D. (1982). Test ofLanguage Austin, TX: Empiric Press.
Development-
Robinson, G. C., Conry, J. L., and Conry, R. F. (1987). Clinical profile and prevalence of fetal alcohol syndrome in an isolated community in British Columbia. Can. Med. Assoc. J. 137:203-207. Smith, D. W. (1981). Fetal alcohol syndrome behav.
Toxicol.
Teratol.
and fetal alcohol effects. Neuro-
3: 127.
Smith, D. W. (1982). Recognizable Philadelphia, PA: Saunders.
Patterns
of Human
Malformation,
3rd edition.
Streissguth, A. P., Clarren, S. K., and Jones, K. L. (1985). Natural history of the fetal alcohol syndrome: A lo-year follow-up of eleven patients. Lancet 2:8591.
Silva, P. A., Chalmers, D., and Stewart, I. (1986). Some audiological, psychological, educational and behavioral characteristics of children with bilateral otitis media with effusion: A longitudinal study. J. Learn. Disabil. 19:165-169. Stromland,
K. (1985). Ocular abnormalities
Ophthalmol.
63(suppl.
in the fetal alcohol syndrome.
Acta
171):1-50.
Teele, D. W., Klein, J. O., and Rosner, B. A., and The Greater Boston Otitis Media Study Group. (1984). Otitis media with effusion during the first three years of life and development of speech and language. Pediatrics 74:282-287. Wechsler, D. L. (1974). Wechsler Intelligence Scale for Children-Revised. New York: Psychological Corp. Wolff, P. H. (1973). Vasomotor sensitivity to alcohol in diverse mongoloid populations. Am. J. Hum. Genet. 25:193-199.
