Arizona Department of Economic Security
Division of Developmental Disabilities
Fetal Alcohol Resource Center
4710 E. 29th Street, Tucson, Arizona 85711
(520) 638-2625
Child’s Name: ______DOB: ______Age: ______
Name of Person Interviewed: ______Date: ______
Screening for Alcohol Related Neurodevelopmental Disorder
(for children from 7 months through 2 years)
Although the cause of most developmental disabilities cannot be detected, alcohol remains the leading known cause of preventable intellectual and developmental disabilities. Fetal Alcohol Syndrome (FAS) or Alcohol Related Neurodevelopmental Disorder (ARND) can be present in the following conditions: Seizure disorders, Cerebral Palsy, Autism Spectrum Disorders, or developmental disabilities.
This screening tool is not a diagnostic instrument. It is intended to guide and inform individuals as to the potential risk for Fetal Alcohol Spectrum Disorders (FASD). If in doubt, follow through with a formal diagnostic process with healthcare professionals who are familiar with FASDs.
The following symptoms are common in toddlers with Fetal Alcohol Spectrum Disorders (FASD), some of whom may have developmental disabilities and some of whom have no apparent disabilities at all:
oDelay in developmental milestones for communication (baby talk, simple words)oDelay in developmental milestones in other areas (refer to developmental checklist)
oGaps between skill levels (gross motor skills better than fine motor skills)
oPoor weight gain or “failure to thrive”
oStrong gag reflex or frequent vomiting
oFeeding difficulties (extremely picky eater)
oOverly active compared to peers
oCannot stay focused on interesting stimuli
oOverly irritable
oDoes not initiate interaction with caregiver
oLack of sustained eye contact with others
oDoes not cuddle easily / oEasily over-stimulated by noise or crowds
oDifficulty learning self-soothing behaviors
oProblems falling asleep or staying asleep
oStrong startle reflex
oLack of healthy separation anxiety
oLack of healthy fear of strangers
oOverly fearful of people or noises
oDiscomfort with clothing or car seat
oFrequent screaming or prolonged crying
oIntense response to stressful situation
oTakes a long time to recover from stress
oPrenatal exposure to alcohol or other drugs (certain or suspected)
oBirth mother ever in treatment for or referred for treatment of substance abuse problems
Score: ______A score above 10/25 indicates a recommendation for referral for a diagnostic evaluation.
A low score does not rule out a possible Fetal Alcohol Spectrum Disorder in a child under the age of 5.
_____ I have determined that this child is at risk of having a Fetal Alcohol Spectrum Disorder (FASD).
Screener: Teresa Kellerman, FASD State Coordinator, Director of the Fetal Alcohol Resource Center
Revised 1/30/2014