following criteria must be fully met for an fas diagnosis: growth deficiency: prenatal or postnatal height or weight (or both) at or below the 10th percentile fas facial features: all three fas facial features present central nervous system damage: clinically significant structural neurological, or functional impairment prenatal alcohol exposure: confirmed or unknown prenatal alcohol exposure fetal alcohol syndrome (fas) is the first diagnosable condition of fasd that was discovered. fas is the only expression of fasd that has garnered consensus among experts to become an official icd-9 and icd-10 diagnosis. to make this diagnosis or determine any fasd condition, a multi-disciplinary evaluation is necessary to assess each of the four key features for assessment. generally, a trained physician will determine growth deficiency and fas facial features. while a qualified physician may also assess central nervous system structural abnormalities and/or neurological problems, usually central nervous system damage is determined through psychological, speech-language, and occupational therapy assessments to ascertain clinically significant impairments in three or more of the ten brain domains. prenatal alcohol exposure risk may be assessed by a qualified physician, psychologist, social worker, or chemical health counselor. these professionals work together as a team to assess and interpret data of each key feature for assessment and develop an integrative, multi-disciplinary report to diagnose fas (or other fasd conditions) in an individual. partial fas partial fas (pfas) was previously known as atypical fas in the 1997 edition of the "4-digit diagnostic code". people with pfas have a confirmed history of prenatal alcohol exposure, but may lack growth deficiency or the complete facial stigmata. central nervous system damage is present at the same level as fas. these individuals have the same functional disabilities but "look" less like fas. the following criteria must be fully met for a diagnosis of partial fas: growth deficiency: growth or height may range from normal to deficient fas facial features: two or three fas facial features present central nervous system damage: clinically significant structural, neurological, or functional impairment in three or more of the ten brain domains prenatal alcohol exposure: confirmed prenatal alcohol exposure fetal alcohol effects fetal alcohol effects (fae) is a previous term for alcohol-related neurodevelopmental disorder and alcohol-related birth defects. it was initially used in research studies to describe humans and animals in whom teratogenic effects were seen after confirmed prenatal alcohol exposure (or unknown exposure for humans), but without obvious physical anomalies. smith (1981) described fae as an "extremely important concept" to highlight the debilitating effects of brain damage, regardless of the growth or facial features. this term has fallen out of favor with clinicians because it was often regarded by the public as a less severe disability than fas, when in fact its effects can be just as detrimental. alcohol-related neurodevelopmental disorder alcohol-related neurodevelopmental disorder (arnd) was initially suggested by the institute of medicine to replace the term fae and focus on central nervous system damage, rather than growth deficiency or fas facial features. the canadian guidelines also use this diagnosis and the same criteria. while the "4-digit diagnostic code" includes these criteria for three of its diagnostic categories, it refers to this condition as static encephalopathy. the behavioral effects of arnd are not necessarily unique to alcohol however, so use of the term must be within the context of confirmed prenatal alcohol exposure. arnd may be gaining acceptance over the terms fae and arbd to describe fasd conditions with central nervous system abnormalities or behavioral or cognitive abnormalities or both due to prenatal alcohol exposure without regard to growth deficiency or fas facial features. the following criteria must be fully met for a diagnosis of arnd or static encephalopathy: growth deficiency: growth or height may range from normal to minimally deficient fas facial features: minimal or no fas facial features present central nervous system damage: clinically significant structural, neurological, or functional impairment in three or more of the ten brain domains prenatal alcohol exposure: confirmed prenatal alcohol exposure alcohol-related birth defects alcohol-related birth defects (arbd), formerly known as possible fetal alcohol effect (pfae), was a term proposed as an alternative to fae and pfae. the iom presents arbd as a list of congenital anomalies that are linked to maternal alcohol use but have no key features of fasd. pfae and arbd have fallen out of favor because these anomalies are not necessarily specific to maternal alcohol consumption and are not criteria for diagnosis of fasd. exposure prenatal alcohol exposure is determined by interview of the biological mother or other family members knowledgeable of the mother's alcohol use during the pregnancy (if available), prenatal health records (if available), and review of available birth records, court records (if applicable), chemical dependency treatment records (if applicable), chemical biomarkers, or other reliable sources. exposure level is assessed as confirmed exposure, unknown exposure, and confirmed absence of exposure by the iom, cdc and canadian diagnostic systems. the "4-digit diagnostic code" further distinguishes confirmed exposure as high risk and some risk: high risk: confirmed use of alcohol during pregnancy known to be at high blood alcohol levels (100 mg/dl or greater) delivered at least weekly in early pregnancy. some risk: confirmed use of alcohol during pregnancy with use less than high risk or unknown usage patterns. unknown risk: unknown use of alcohol during pregnancy. no risk: confirmed absence of prenatal alcohol exposure. confirmed exposure amount, frequency, and timing of prenatal alcohol use can dramatically impact the other three key features of fasd. while consensus exists that alcohol is a teratogen, there is no clear consensus as to what level of exposure is toxic. the cdc guidelines are silent on these elements diagnostically. the iom and canadian guidelines explore this further, acknowledging the importance of significant alcohol exposure from regular or heavy episodic alcohol consumption in determining, but offer no standard for diagnosis. canadian guidelines discuss this lack of clarity and parenthetically point out that "heavy alcohol use" is defined by the national institute on alcohol abuse and alcoholism as five or more drinks per episode on five or more days during a 30-day period. "the 4-digit diagnostic code" ranking system distinguishes between levels of prenatal alcohol exposure as high risk and some risk. it operationalizes high risk exposure as a blood alcohol concentration (bac) greater than 100 mg/dl delivered at least weekly in early pregnancy. this bac level is typically reached by a 55 kg female drinking six to eight beers in one sitting. unknown exposure for many adopted or adults and children in foster care, records or other reliable sources may not be available for review. reporting alcohol use during pregnancy can also be stigmatizing to birth mothers, especially if alcohol use is ongoing. in these cases, all diagnostic systems use an unknown prenatal alcohol exposure designation. a diagnosis of fas is still possible with an unknown exposure level if other key features of fasd are present at clinical levels. confirmed absence of exposure confirmed absence of exposure would apply to planned pregnancies in which no alcohol was used or pregnancies of women who do not use alcohol or report no use during the pregnancy. this designation is relatively rare, as most people presenting for an fasd evaluation are at least suspected to have had a prenatal alcohol exposure due to presence of other key features of fasd. biomarkers evidence is insufficient for the use of chemical biomarkers to detect prenatal alcohol exposure. biomarkers being studied include fatty acid ethyl esters (faee) detected in the meconium (first feces of an infant) and hair. faee may be present if chronic alcohol exposure occurs during the second and third trimester since this is when the meconium begins to form. concentrations of faee can be influence by medication use, diet, and individual genetic variations in faee metabolism however. ten brain domains a recent effort to standardize assessment of functional cns damage has been suggested by an experienced fasd diagnostic team in minnesota. the proposed framework attempts to harmonize iom, 4-digit diagnostic code, cdc, and canadian guidelines for measuring cns damage vis-à-vis fasd evaluations and diagnosis. the standardized approach is referred to as the ten brain domains and encompasses aspects of all four diagnostic systems' recommendations for assessing cns damage due to prenatal alcohol exposure. the framework provides clear definitions of brain dysfunction, specifies empirical data needed for accurate diagnosis, and defines intervention considerations that address the complex nature of fasd with the intention to avoid common secondary disabilities. the proposed ten brain domains include: achievement adaptive behavior attention cognition executive functioning language memory motor skills multisensory integration or soft neurological problems social communication the fetal alcohol diagnostic program (fadp) uses unpublished minnesota state criteria of performance at 1.5 or more standard deviations on standardized testing in three or more of the ten brain domains to determine cns damage. however, the ten brain domains are easily incorporated into any of the four diagnostic systems' cns damage criteria, as the framework only proposes the domains, rather than the cut-off criteria for fasd. differential diagnosis the cdc reviewed nine syndromes that have overlapping features with fas; however, none of these syndromes include all three fas facial features, and none are the result of prenatal alcohol exposure: aarskog syndrome williams syndrome noonan syndrome dubowitz syndrome brachman-delange syndrome toluene syndrome fetal hydantoin syndrome fetal valproate syndrome maternal pku fetal effects other disorders that have overlapping behavioral symptoms and/or that might be comorbid to fetal alcohol spectrum disorder might include: attention deficit hyperactive disorder autism spectrum disorder reactive attachment disorder oppositional defiant disorder sensory integration dysfunction bipolar disorder depression most people with an fasd have most often been misdiagnosed with adhd due to the large overlap between their behavioral deficits. prevention the only certain way to prevent fas is to avoid drinking alcohol during pregnancy. in the united states, the surgeon general recommended in 1981, and again in 2005, that women abstain from alcohol use while pregnant or while planning a pregnancy, the latter to avoid damage even in the earliest stages (even weeks) of a pregnancy, as the woman may not be aware that she has conceived. the centers for disease control and the american college of obstetricians and gynecologists also recommend no alcohol during pregnancy. in the united states, federal legislation has required that warning labels be placed on all alcoholic beverage containers since 1988 under the alcoholic beverage labeling act. there is some controversy surrounding the "zero-tolerance" approach taken by many countries when it comes to alcohol consumption during pregnancy. the assertion that moderate drinking causes fas is said to lack strong evidence and, in fact, the practice of equating a responsible level of drinking with potential harm to the fetus may have negative social, legal, and health impacts. in addition, special care should be taken when considering statistics on this disease, as prevalence and causation is often linked with fasd, which is more common and causes less harm, as opposed to fas. treatment there is no current cure for fasd, but treatment is possible. early intervention from birth to age 3 has been shown to improve the development of a child born with fasd. because cns damage, symptoms, secondary disabilities, and needs vary widely by individual, there is no one treatment type that works for everyone. between 2017 and 2019 researchers made a breakthrough when they discovered a possible cure using neural stem cells (nscs); they propose that if applied to a newborn, the damage can be reversed and prevent any lasting effects in the future. medication psychoactive drugs are frequently tried as many fasd symptoms are mistaken for or overlap with other disorders, most notably adhd. behavioral interventions behavioral interventions are based on the learning theory, which is the basis for many parenting and professional strategies and interventions. along with ordinary parenting styles, such strategies are frequently used by default for treating those with fas, as the diagnoses oppositional defiance disorder (odd), conduct disorder, reactive attachment disorder (rad) often overlap with fas (along with adhd), and these are sometimes thought to benefit from behavioral interventions. frequently, a person's poor academic achievement results in special education services, which also utilizes principles of learning theory, behavior modification, and outcome-based education. developmental framework many books and handouts on fas recommend a developmental approach, based on developmental psychology, even though most do not specify it as such and provide little theoretical background.