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Fetal Alcohol Syndrome: How you can help

“The baby has Fetal Alcohol Syndrome,” the voice on the phone said.
“The baby has what?” Ms. Sanders asked, not sure her cell phone was getting a clear signal.
“Fetal Alcohol Syndrome,” the nurse repeated. “It’s a set of birth defects caused by drinking alcohol during pregnancy.”
As the nurse described the condition, Ms. Sanders began to understand. She had been concerned about baby Jonathan from the minute his mother had enrolled him in her child care program. Jonathan was smaller than other 6-month-olds and had not developed enough to push up or roll over. His feedings were a struggle, and his naps were short and fitful.
At Ms. Sanders’ urging, the mother had taken Jonathan to a doctor several weeks ago. Now the tests were completed, and the doctor had made the diagnosis. The nurse, at the mother’s request, was calling Ms. Sanders to explain.
“Now that we know what the problem is, we can get Jonathan some help,” the nurse said.
“Yes,” Ms. Sanders said. “Let’s suggest that his family get in touch with our local ECI program.”

What is Fetal Alcohol Syndrome?
Fetal Alcohol Syndrome (FAS) is a set of mental, physical, and behavioral birth defects that are a direct result of alcohol use during pregnancy. If a woman drinks wine, beer, or liquor during pregnancy, her baby could be born with FAS.
During pregnancy, a mother’s diet is her baby’s diet. When a woman drinks, the alcohol travels from her stomach to her bloodstream. It crosses the placenta and enters the fetus’ bloodstream. Alcohol can interfere with normal fetal development and cause life-long defects in major organs and the central nervous system.
Any amount of alcohol is a danger during all stages of pregnancy. During the first three months, cells divide to form a baby’s heart, brain, and other organs. Alcohol can interfere with cellular division and the development of these vital organs. During the second trimester, alcohol interferes with a baby’s physical growth. During the final trimester, a baby’s brain and nervous system mature. Drinking alcohol at this stage can harm a baby’s brain and result in neurological and behavioral difficulties.
After the child is born, the effects of alcohol are apparent in three areas:
Slowed growth. Babies born with FAS are typically underweight at birth. They usually stay thinner and shorter than others their age throughout life.
Physical features. Babies born with FAS may have characteristic facial features including short eye openings, no grooves between the nose and upper lip, a thin upper lip, impaired hearing and vision, limited flexibility in joints, and defects in some organs.
Central nervous system damage. Results of this damage can include mental retardation, learning difficulties, and problems with memory, perception, reasoning, organization, coordination, and abstract thinking. Social interactions are also often affected.

Behaviors in the classroom
The behaviors of infants and toddlers may signal FAS. Babies are often tired and irritable because of poor sleep/wake cycles. Some are medically fragile, have poor weight gains, and difficulty nursing and sucking. Chronic ear infections and speech delays are common. There can be delays in motor development like rolling over, crawling, and walking.
Preschool children with FAS continue to be affected by motor delays (including toilet learning) and medical challenges. Additionally, FAS impacts social interactions and behavior. Children tend to be easily distracted, fidgety, and unfocused. They sometimes have trouble identifying friends and engaging in cooperative play. They often have difficulty with reasoning, memory, and judgment.
Difficulties continue to compound in school-age children. Often children with FAS have trouble making and keeping friends, become isolated and lonely, and give up on positive social interactions. Attention deficits magnify academic problems. Boundaries are challenged and behaviors tend to be impulsive and unpredictable. Children are easily frustrated and may resort to tantrums, manipulation, and other destructive behaviors.

What you can do
If you suspect a child is affected by FAS, get help. Don’t rely on a child’s physical characteristics. Many children with FAS and other alcohol-related birth defects don’t have physical symptoms.
Instead, document your day-to-day behavioral observations in writing. Remember, you job is to teach, not to diagnose. Your observations will help you provide the best care, in the best learning environment.
Share your observations, gently, with the child’s parents. Again, don’t diagnose, just share what you see. When parents understand that you aren’t being judgmental—or feel that you are accusing them of being unfit or negligent parents—they are more likely to share their own observations and concerns with you. This is the beginning of cooperative problem solving.
Encourage parents to seek the help of a specialist. Early Childhood Intervention (ECI) programs can help you and the child’s parents with early identification of disabilities. ECI can also support the child and the family with appropriate therapies.
Children with FAS—and other alcohol-related birth defects—need the guidance of attentive, responsive, consistent, and compassionate adults. Because they lack internal controls, you need to provide external supports that help them grow and learn. The following tips are appropriate to all young children. They are key needs of children with FAS.

Routine and consistency
Establish routines so children can learn to predict coming events. For example, lunch is always followed by toothbrushing and nap time.
Do not debate rules and routines already established. Consistency is essential to security.
Build calming, sensory activities into the schedule, especially to precede significant transitions—outdoors, mealtime, or a large group activity, for example.
Give children five- and then one-minute warnings before a transition.
Avoid flickering lights or loud timers to signal transitions. If necessary, click the classroom light off completely to direct children’s attention to you. Turn the light back on as the group moves to a new activity.
Encourage children to use transitional objects—a toy, meaningful picture, or even a blanket—to minimize stress.
Use colored tape to create floor paths that guide children from one activity to another.
Set limits and follow them consistently.
Focus on teaching daily living skills.
Avoid frequent changes in the environment. Children with FAS need guidance in learning to negotiate through the classroom and the rest of the facility—getting to the bathroom, the kitchen, or outdoors—without getting lost.

Concrete and specific expectations
Remember to set expectations to the child’s developmental level—not age. Adapt materials as needed.
Break activities and tasks down into small, specific steps.
Be concrete when teaching a new concept. Show—rather than just tell.
Provide a beanbag chair, rocker, or hammock to use for self-soothing. Some children find a headset and quiet music calming and relaxing.
Avoid overstimulating activities and events. Create a quiet, peaceful learning place.
Help children learn to be friends. Encourage pairing with one other child rather than the large group.

Simplicity and repetition
Get children’s attention before giving directions. Use gestures, voice, and eye contact.
Make directions short, concise, clear, and one step at a time.
Use rebus charts, pictures, and signs to make directions concrete. Have children repeat directions back to you.
Let the environment help you teach by making materials accessible and learning centers engaging.
Be attentive to food sensitivities and eating behaviors. Serve small portions of lukewarm foods that have some texture. Don’t hurry meals and minimize mealtime distractions.
Consider using songs to reinforce and repeat directions.
Try to limit sensory overload—strong smells, hanging mobiles, and strong air currents, for example.
Children with FAS require lots of repetition with materials and learning activities to build a knowledge base. Often things learned one day are gone the next. Avoid rotating materials too quickly. Instead, offer slow and subtle variations—different colored paper for an art activity, for example.

Offer simple choices and encourage decision making.
Be realistic in your expectations. Don’t set up situations (field trips, for example) that are too challenging. It’s unfair and unproductive to set a child up for failure.
Establish a few simple rules. Use identical language to remind children of the rules. “Throwing toys is not acceptable. Please go and get the puzzle piece. I’ll sit with you while you finish the puzzle.”
Redirect inappropriate behavior. Intervene immediately—before behaviors get out of control.
Develop and share consequences for misbehavior. Impose consequences immediately and consistently.
Reinforce positive behaviors with private words of encouragement and congratulations.
Watch for signs of frustration and stress—clenched fists, reddened face, restlessness, and inability to attend to tasks. Evaluate the situation and respond immediately.
Provide areas that help children relax and “turn off” stimulation. Include pictures of relaxation techniques and earphones and soothing music that can block out other classroom sounds.
Help children learn to think by making thinking as concrete as possible. Use facial expressions, body language, charts, and self-talk to reinforce the need to think before acting. Encourage and reinforce thinking behaviors.
Use rebus figures or photographs to chart the sequence “Stop-Calm-Think.” For example, you can use a picture of a stop sign, a quiet forest scene, and a child’s picture with a hand on the head.

Centers for Disease Control and Prevention.
Duckworth, Susanna and Terry Norton. 2000. Fetal alcohol syndrome and fetal alcohol effects—Support for teachers and families. 28 (3): 19-23.
Mitchell, Kathleen T. 2002. Washington, D.C.: National Organization on Fetal Alcohol Syndrome.
National Institute on Alcohol Abuse and Alcoholism.
Rattray, Jennifer. 2002. Canadian Broadcasting System.

Special thanks to Carolyn A. Smith, executive director, Texas Office for Prevention of Developmental Disabilities, for assistance with this article.