Burd, L. Getting an Early Start on Fetal Alcohol Spectrum Disorders. Head Start Newsletter. July, 2006.  

Burd, L., Cohen, C., Shaw, R., & Norris, J. A Court Team Model for Care of Young Children in Foster Care: The Role of Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorders. The Journal of Psychiatry and Law 2011 (in press) 

Burd, L., Fast, D.K., Conry, J., & Williams, A. Fetal Alcohol Spectrum Disorders as a Marker for Increased Risk of Involvement With Correction Systems The Journal of Psychiatry and Law 2011 (in press) 

Li, Q., Fisher, W.W., Peng, C.Z., Williams, A.D., & Burd. L. Fetal Alcohol Spectrum Disorders: A Population Based Study of Premature Mortality Rates in the Mothers. Maternal & Child Health 2011 (in press) 

Burd, L. and Christensen, T. Treatment of Fetal Alcohol Spectrum Disorders. Are We Ready Yet? Journal of Psychopharmacology. 2009. 29(1): 

Odendaal, H.J., Steyn, D. Wilhelm, Elliot, Amy, & Burd, L. Combined Effects of Cigarette Smoking and Alcohol Consumption on Perinatal Outcome. Gynecologic and Obstetric Investigation. 2009. 67: 1-8.

Burd, L. Response to Letter to the Editor. Birth Defects Research (Part A). 2009 85: 231-232.

Burd, L., Carlson, C., & Kerbeshian, J. Mental Health Disorders Comorbid With Fetal Alcohol Spectrum Disorders. In: Alcohol-Related Cognitive Disorders, L. Sher, I. Kandel, and J. Merrick (Eds), 2009 Nova Science Publishers, Inc. 111-123.

Burd, L., Klug, M.G., Li, Q., Kerbeshian, J., & Martsolf, J.T. Diagnosis of Fetal Alcohol Spectrum Disorders: A Valididy Study of the Fetal Alcohol Syndrome Checklist. Alcohol 2009  1-10.

Herrick, K., Hudson, L., & Burd. L. The Elephant in the Cradle Zero to Three 2009 2001, January. 44-50

Hofer, R. & Burd, L. Review of published Studies of Kidney, Liver, and Gastrointestinal Birth Defects in Fetal Alcohol Spectrum Disorders Birth Defects Research (Part A) 2009 85: 179-183.

Burd, L. and Hofer, R. Biomarkers for Detection of Prenatal Alcohol Exposure: A Critical Review of Fatty Acid Ethyl Esters in Meconium. Birth Defects Research (Part A). 2008. 82: 487-493.

Burd, L., Klug, M.G., Bueling, R, Martsolf, J., Olson, M., & Kerbeshian, J. Mortality Rates in Subjects with Fetal Alcohol Spectrum Disorders and Their Siblings. Birth Defects Research (Part A). 2008. 82(4): 217-223.

Burd, L., Carlson, C., & Kerbeshian, J. Fetal Alcohol Spectrum Disorders and Mental Illness. Int. J. Disabil. Human Dev. 2007. 6(4): 383-396.

Burd, L., Deal, E., Rios, R., Adickes, E., Wynne, J., & Klug, M.G. Congenital Heart Defects and Fetal Alcohol Spectrum Disorders. Congenital Heart Dis. 2007. 2: 250-255.

Burd, L., Roberts, D., Olson, M., & Odendaal, H. Ethanol and the Placenta: A Review. Journal of Maternal-Fetal & Neonatal Medicine. 2007. 20(5): 361-375.

Odendaal, H.J., Elliott, A., Signore, C., Burd, L. The adverse effects of alcohol consumption during pregnancy on the developing fetus. J Perinat Med. 2007. (Suppl. II) 

Burd, L Commentary: Intervention in FASD: We Must Do Better. Child: Care, Health and Development. 2006. 33(4): 398-400.

Burd, L., Klug, M.G., Martsolf, J., Martsolf, C., Deal, E., & Kerbeshian, J. A Staged Screening Strategy for Prenatal Alcohol Exposure and Maternal Risk Stratification. Journal of The Royal Society for the Promotion of Health. 2006. 126(2): 86-94.

Peng, C. Z., Burd, L. An introduction to screening instruments and diagnostic criteria for fetal alcohol spectrum disorder. Chinese Journal of Clinical Psychiatry. 2006. 5: 452-454.

Burd, L. Introduction: Fetal Alcohol Syndrome. Addiction Biology. 2004. 9: 115-118.

Burd, L. Introduction: Fetal Alcohol Syndrome. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 1-2.

Burd, L. & Wilson, H. Fetal, Infant, and Child Mortality in a Context of Alcohol Use. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 51-58.

Burd, L., Klug, M.G., & Martsolf, J.T. Increased Sibling Mortality in Children with Fetal Alcohol Syndrome. Addiction Biology. 2004. 9: 179-186.

Burd, L., Martsolf, J.T., & Juelson, T. Fetal Alcohol Spectrum Disorder in the Corrections System: Potential Screening Strategies. Journal of Fetal Alcohol Syndrome International. 2004. 2(e1): 1-10.

Burd, L., Selfridge, R.H., Klug, M.G., & Bakko, S.A. Fetal Alcohol Syndrome in the United States Corrections System. Addiction Biology. 2004. 9: 169-176.

Lupton, C., Burd, L., & Harwood, R. Cost of Fetal Alcohol Spectrum Disorders Cost of Fetal Alcohol Spectrum Disorders. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 42-50.

Burd, L. & Juelson, T. Community Based Screening for Fetal Alcohol Syndrome. In: Encyclopedia on Early Childhood Development [online].(Eds.) Tremblay, R.E., Barr, R.G., Peters, R.DeV. 2003. Montreal, Quebec: Centre of Excellence for Early Childhood Development. 1-6. Available at: http://www.excellence-earlychildhood.ca/documents/Burd-JuelsonANGxp.pdf.

Burd, L., Cotsonas-Hassler, T.M., Martsolf, J.T., & Kerbeshian, J Recognition and Management of Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 681-688.

Burd, L., Klug, M.G., Martsolf, J.T., & Kerbeshian, J. Fetal Alcohol Syndrome: Neuropsychiatric Phenomics. Neurotoxicology and Teratology. 2003. 25(6): 697-705.

Burd, L., Martsolf, J.T., Klug, M.G., & Kerbeshian, J. Diagnosis of FAS: A Comparison of the Fetal Alcohol Syndrome Diagnostic Checklist and the Institute of Medicine Criteria for Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 719-724.

Burd, L., Martsolf, J.T., Klug, M.G., O’Connor, E., & Peterson, M. Prenatal Alcohol Exposure Assessment: Multiple Embedded Measures in a Prenatal Questionnaire. Neurotoxicology and Teratology. 2003. 25(6): 675-679.

Burd, L., Selfridge, R.H., Klug, M.G., & Juelson, T. Fetal Alcohol Syndrome in the Canadian Corrections System. Journal of FAS International . 2003. 1(e14): 1-10.

Klug, M.G. & Burd, L. Fetal Alcohol Syndrome Prevention: Annual and Cumulative Cost Savings. Neurotoxicology and Teratology. 2003. 25(6): 763-765.

Klug, M.G. & Burd, L., Martsolf, J.T., & Ebertowski, M. Body Mass Index in Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 689-696.

Klug, M.G., Burd, L., Kerbeshian, J., Benz, B., & Martsolf, J.T. A Comparison of the Effects of Parental Risk Markers on Pre- and Perinatal Variables in Multiple Patient Cohorts with Fetal Alcohol Syndrome, Autism, Tourette Syndrome, and Sudden Infant Death Syndrome: An Enviromic Analysis. Neurotoxicology and Teratology. 2003. 25(6): 707-717.

Poitra, B.A., Marion, S., Dionne, M., Wilkie, E., Dauphinais, P., Wilkie-Pepion, M., Martsolf, J.T., Klug, M.G., & Burd, L. A School Based Screening Program for Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 725-729.

Burd, L. Maternal Risk Assessment. 2001.  

Burd, L. Fetal Alcohol Syndrome: A Handbook for Parents and Teachers. 2001.  

Burd, L., Cox, C., Fjelstad, K., & McCulloch, K. Screening for Fetal Alcohol Syndrome: Is It Feasible and Necessary? Addiction Biology. 2000. 5: 127-139.

Burd, L. The FAS Screen. 1999.  

Burd, L., Cox, C., Poitra, B., Wentz, T., Ebertowski, M., Martsolf, J.T., Kerbeshian, J., & Klug, M.G. The FAS Screen: A Rapid Screening Tool for Fetal Alcohol Syndrome. Addiction Biology. 1999. 4: 329-336.

Bagheri, M., Burd, L., Martsolf, J.T., & Klug, M.G. Fetal Alcohol Syndrome: Maternal and Neonatal Characteristics. Journal of Perinatal Medicine. 1998. 26: 263-269.

Burd, L. & Wentz, T. Fetal Alcohol Syndrome: The North Dakota Experience. North Dakota Journal of Human Services. 1997. 1(3): 14-20.

Burd, L., Martsolf, J.T., & Klug, M Children with Fetal Alcohol Syndrome in North Dakota: A Case Control Study Utilizing Birth Certificate Data. Addiction Biology. 1996. 1: 181-189.

Burd, L., Martsolf, J.T., Kerbeshian, J., Mohr, P., Mohr, T., & Ebertowski, M. Fetal Alcohol Syndrome: Delineation and Management. Clinical Advances in the Treatment of Psychiatric Disorders. 1996. 10(4): 1-8.

Burd, L. & Moffatt, M.E.K. Epidemiology of Fetal Alcohol Syndrome in American Indians, Alaskan Natives, and Canadian Aboriginal Peoples: A Review of the Literature. Public Health Reports. 1994. 109(5): 688-693.

Burd, L. & Martsolf J.T. Fetal Alcohol Syndrome: Diagnosis and Syndromal Variability. Physiology and Behavior . 1989. 46: 39-43.

Kerbeshian, J. & Burd L. Asperger's Syndrome and Tourette Syndrome: The Case of the Pinball Wizard. British Journal of Psychiatry. 1986. 148: 731-736.

Burd, L Prenatal Alcohol Use Assessment booklet  

Burd, L Assessment of Alcohol Exposure (Prior to Pregnancy )  

Burd, L Prenatal Blood Alcohol Concentration Calculator (.xlsx format)  

Burd, L. Assessment of Alcohol Exposure (During Pregnancy )  

Burd, L. Prevalence & Cost Calculator  

Burd, L. Adverse Outcomes from Prenatal Alcohol Exposure  

Burd, L. FAS  

Burd, L. Fetal Alcohol Syndrome in North Dakota (PDF)  

Burd, L. Fetal Alcohol Syndrome in North Dakota (PowerPoint)  

Burd, L. Rating Behavior Scale  

Burd, L. AD-HD Rating Scale  

Burd, L. Risk Marker Score  

Burd, L. FAS Epidemiologic Exposure Model  

Burd, L. Assessment of Smoking Exposure ( During Pregnancy )  

Burd, L. Prenatal Risk Assessment Questionnaire  

Burd, L. Calculate Maternal Risk Score.  

Burd, L. Epidemiology - Number Needed to Treat Calculator  

Burd, L. Epidemiology - Risk Calculator  

Burd, L. Epidemiology - Diagnostic Test Calculator  

Burd, L. Community Based Assessment  

Burd, L. Assessment of Smoking Exposure (Prior to Pregnancy )  

Burd, L. Getting an Early Start on Fetal Alcohol Spectrum Disorders. Head Start Newsletter. July, 2006.  

Burd, L., Cohen, C., Shaw, R., & Norris, J. A Court Team Model for Care of Young Children in Foster Care: The Role of Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorders. The Journal of Psychiatry and Law 2011 (in press) 

• Prenatal alcohol exposure (PAE) is common with about 80,000 women continuing to drink through all three trimesters of pregnancy each year. PAE is also associated with postnatal adversities including abuse and neglect which increase risk for foster care placement. Each day 700 children enter the foster care system. A diagnosis of Fetal Alcohol Spectrum Disorders (FASD) also increases the risk for foster care placement. Among children diagnosed with an FASD 70% are or have been in foster care. FASD prevalence rates are increased 10 to 15 fold in foster care systems. Foster care is an important opportunity to detect FASD; and provided services to infants and children with FASD. The FASD are the third most common identifiable cause of mental retardation in the United States. We describe a court team based model of care developed to improve management of children with PAE or FASD entering foster care. The programmatic objectives include: enhancing detection of PAE; screening for FASD; increase consideration of FASD as a potential issue in treatment planning with foster parents; improve entry into treatment; and increase surveillance for parents with an FASD.

Burd, L., Fast, D.K., Conry, J., & Williams, A. Fetal Alcohol Spectrum Disorders as a Marker for Increased Risk of Involvement With Correction Systems The Journal of Psychiatry and Law 2011 (in press) 

• Fetal alcohol spectrum disorders (FASDs) may be common in adolescents and adults in the corrections systems. However, current prevalence estimates for FASD suggest that nearly all affected people are undiagnosed in corrections systems. In this paper we provide an overview of our experience with FASD in corrections populations and present strategies for screening, assessment and intervention. We conclude with a plan to provide training to corrections staff in response to identified preferences and needs identified by Canadian and American corrections staff.

Li, Q., Fisher, W.W., Peng, C.Z., Williams, A.D., & Burd. L. Fetal Alcohol Spectrum Disorders: A Population Based Study of Premature Mortality Rates in the Mothers. Maternal & Child Health 2011 (in press) 

• OBJECTIVES: Fetal alcohol spectrum disorders (FASD) are associated with an increase in risk for mortality for people with an FASD and their siblings. In this study we examine mortality rates of birth mothers of children with FASD. METHODS: A retrospective case control methodology. We utilized the North Dakota FASD Registry to locate birth certificates for children with FASD which we used to identify birth mothers. We then searched for mothers death certificates. We then compared the mortality rates of the birth mothers with an age standardized control group comprised of all North Dakota women who were born and died in the same year as the birth mother. RESULTS: The birth mothers of children with FASD had a mortality rate of 15/304 = 4.93%; (95% CI 2.44% to 7.43%). The mortality rate for control mothers born in same years as the FASD mothers was 126/114,714 = 0.11% (95% CI 0.09% to 0.13%). Mothers of children with an FASD had a 44.82 fold increase in mortality risk and 80% of the deaths occurred in women under the age of 50. Three causes of death (cancer, accidents, and alcohol related disease) accounted for 67% of the deaths in the mothers of children with FASD. CONCLUSIONS: A diagnosis of FASD is an important risk marker for premature death in the mothers of children diagnosed with an FASD. These women should be encouraged to enter substance abuse treatment.

Burd, L. and Christensen, T. Treatment of Fetal Alcohol Spectrum Disorders. Are We Ready Yet? Journal of Psychopharmacology. 2009. 29(1): 

Odendaal, H.J., Steyn, D. Wilhelm, Elliot, Amy, & Burd, L. Combined Effects of Cigarette Smoking and Alcohol Consumption on Perinatal Outcome. Gynecologic and Obstetric Investigation. 2009. 67: 1-8.

Burd, L. Response to Letter to the Editor. Birth Defects Research (Part A). 2009 85: 231-232.

Burd, L., Carlson, C., & Kerbeshian, J. Mental Health Disorders Comorbid With Fetal Alcohol Spectrum Disorders. In: Alcohol-Related Cognitive Disorders, L. Sher, I. Kandel, and J. Merrick (Eds), 2009 Nova Science Publishers, Inc. 111-123.

Burd, L., Klug, M.G., Li, Q., Kerbeshian, J., & Martsolf, J.T. Diagnosis of Fetal Alcohol Spectrum Disorders: A Valididy Study of the Fetal Alcohol Syndrome Checklist. Alcohol 2009  1-10.

Herrick, K., Hudson, L., & Burd. L. The Elephant in the Cradle Zero to Three 2009 2001, January. 44-50

Hofer, R. & Burd, L. Review of published Studies of Kidney, Liver, and Gastrointestinal Birth Defects in Fetal Alcohol Spectrum Disorders Birth Defects Research (Part A) 2009 85: 179-183.

Burd, L. and Hofer, R. Biomarkers for Detection of Prenatal Alcohol Exposure: A Critical Review of Fatty Acid Ethyl Esters in Meconium. Birth Defects Research (Part A). 2008. 82: 487-493.

Burd, L., Klug, M.G., Bueling, R, Martsolf, J., Olson, M., & Kerbeshian, J. Mortality Rates in Subjects with Fetal Alcohol Spectrum Disorders and Their Siblings. Birth Defects Research (Part A). 2008. 82(4): 217-223.

Burd, L., Carlson, C., & Kerbeshian, J. Fetal Alcohol Spectrum Disorders and Mental Illness. Int. J. Disabil. Human Dev. 2007. 6(4): 383-396.

Burd, L., Deal, E., Rios, R., Adickes, E., Wynne, J., & Klug, M.G. Congenital Heart Defects and Fetal Alcohol Spectrum Disorders. Congenital Heart Dis. 2007. 2: 250-255.

Burd, L., Roberts, D., Olson, M., & Odendaal, H. Ethanol and the Placenta: A Review. Journal of Maternal-Fetal & Neonatal Medicine. 2007. 20(5): 361-375.

Odendaal, H.J., Elliott, A., Signore, C., Burd, L. The adverse effects of alcohol consumption during pregnancy on the developing fetus. J Perinat Med. 2007. (Suppl. II) 

Burd, L Commentary: Intervention in FASD: We Must Do Better. Child: Care, Health and Development. 2006. 33(4): 398-400.

Burd, L., Klug, M.G., Martsolf, J., Martsolf, C., Deal, E., & Kerbeshian, J. A Staged Screening Strategy for Prenatal Alcohol Exposure and Maternal Risk Stratification. Journal of The Royal Society for the Promotion of Health. 2006. 126(2): 86-94.

Peng, C. Z., Burd, L. An introduction to screening instruments and diagnostic criteria for fetal alcohol spectrum disorder. Chinese Journal of Clinical Psychiatry. 2006. 5: 452-454.

Burd, L. Introduction: Fetal Alcohol Syndrome. Addiction Biology. 2004. 9: 115-118.

Burd, L. Introduction: Fetal Alcohol Syndrome. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 1-2.

Burd, L. & Wilson, H. Fetal, Infant, and Child Mortality in a Context of Alcohol Use. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 51-58.

Burd, L., Klug, M.G., & Martsolf, J.T. Increased Sibling Mortality in Children with Fetal Alcohol Syndrome. Addiction Biology. 2004. 9: 179-186.

• We compared the rate of all cause mortality in siblings of children diagnosed with fetal alcohol syndrome (FAS) with the siblings of matched controls. The siblings of children with FAS had increased mortality (11.4%) compared to matched controls (2.0%), a 530% increase in mortality. Age of death in case sibling deaths occurred later (between one day to seven years) compared to the controls (age of death was one day to four years) OR = 2.4 (0.4 to 15.6). Siblings of children with FAS had increased deaths due to infectious illness OR = 13.7 (1.2 to 361) and death due to SIDS in cases compared to controls was increased OR = 10.2 (1.2 to 75.1). A diagnosis of FAS is an important risk marker for mortality in the siblings of the proband even if they do not have FAS. Maternal alcoholism appears to be a useful risk marker for increased mortality risk in diagnosed cases and their siblings. This has important implications in the management of family members of children with FAS.

Burd, L., Martsolf, J.T., & Juelson, T. Fetal Alcohol Spectrum Disorder in the Corrections System: Potential Screening Strategies. Journal of Fetal Alcohol Syndrome International. 2004. 2(e1): 1-10.

Burd, L., Selfridge, R.H., Klug, M.G., & Bakko, S.A. Fetal Alcohol Syndrome in the United States Corrections System. Addiction Biology. 2004. 9: 169-176.

• Background Prenatal alcohol exposure can result in fetal alcohol syndrome (FAS), which may increase the risk of confinement in the corrections system. Methods Each state and four major cities’ corrections systems were asked to complete a questionnaire on the prevalence of FAS and ARND in the offender population, the availability of screening and diagnostic services to identify offenders with FAS and staff training needs related to FAS. Results The total population in the 54 entities was 3,080,904 inmates. Completed questionnaires were obtained from 42 entities (78%). The mean rate of reported substance abuse in offenders was 60.1%. Specialized programs for persons with mental retardation were reported for 44.4% of corrections facilities and 25.9% of community corrections facilities. Programs for pregnant women were reported for 46.3% of corrections facilities and 29.6% of community facilities. One program (1.9%) reported having a screening program for FAS in the corrections system. Only four programs (7.4%) reported having access to diagnostic services for FAS in the corrections facilities. Of the 3,080,904 offenders, only one offender was reported to have a diagnosis of FAS. Reported staff training needs were very large. Conclusion Corrections systems have high unmet needs to screen, identify, and treat offenders with FAS and ARND. Staff training needs are substantial.

Lupton, C., Burd, L., & Harwood, R. Cost of Fetal Alcohol Spectrum Disorders Cost of Fetal Alcohol Spectrum Disorders. American Journal of Medical Genetics Part C (Semin. Med. Genet.). 2004. 127C: 42-50.

Burd, L. & Juelson, T. Community Based Screening for Fetal Alcohol Syndrome. In: Encyclopedia on Early Childhood Development [online].(Eds.) Tremblay, R.E., Barr, R.G., Peters, R.DeV. 2003. Montreal, Quebec: Centre of Excellence for Early Childhood Development. 1-6. Available at: http://www.excellence-earlychildhood.ca/documents/Burd-JuelsonANGxp.pdf.

Burd, L., Cotsonas-Hassler, T.M., Martsolf, J.T., & Kerbeshian, J Recognition and Management of Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 681-688.

• Fetal alcohol syndrome (FAS) is a common cause of developmental disability, neuropsychiatric impairment and birth defects. The disorder is identified by the presence of growth impairment, central nervous system dysfunction, and a characteristic pattern of craniofacial features. The reported prevalence of the disorder varies widely and recent estimates approach one percent of live births. Expression of these features varies by age. People with FAS have high rates of comorbid conditions: attention deficit hyperactivity disorder (40%), mental retardation (15 20%) learning disorders, (25%) speech and language disorders (30%) sensory impairment (30%) cerebral palsy (4%) epilepsy (8-10%). Birth defects are common. In the United States the annual birth cohort of persons with FAS could be as high as 39,000 cases annually. Cause-specific-mortality is 6% for patients with FAS. The disorder is expensive to treat and most patients have lifelong impairment. The annual cost of care in the United States would approach $5.0 billion. Early recognition and entry into appropriate treatment programs appear to improve outcome. Prevention efforts should involve screening for alcohol use prior to pregnancy and at the first prenatal care visit.

Burd, L., Klug, M.G., Martsolf, J.T., & Kerbeshian, J. Fetal Alcohol Syndrome: Neuropsychiatric Phenomics. Neurotoxicology and Teratology. 2003. 25(6): 697-705.

• Fetal Alcohol Syndrome (FAS) is a common developmental disorder with impairments in multiple neuropsychiatric spheres of varying severity. Few population-derived studies of the behavioral phenotype are available. The purpose of this study was to estimate the prevalence of neuropsychiatric disorders in three groups: subjects who met criteria for FAS (n=152); subjects who met criteria for partial FAS/ARND (n=150); and referred subjects who did not meet criteria for either FAS, or partial FAS/ARND (n = 86). Each subject had a standardized evaluation by a medical geneticist. All subjects were from North Dakota. We found increases in the prevalence rates of neuropsychiatric disorders in subjects with FAS compared to subjects with partial FAS/ARND and the lowest rates in the group that did not meet criteria for either FAS or partial FAS/ARND. Comorbid attention deficit hyperactivity disorder occurred in 73% of cases with FAS, in 72% cases with partial FAS/ARND and in 36% subjects who did not meet criteria for either. For other neuropsychiatric disorders a similar distribution of comorbidity was found. This study supports the concept of a continuum of impairment resulting from prenatal alcohol exposure. Conclusions: The presence of complex cognitive, behavioral and physical symptomatology in affected subjects with prenatal alcohol exposure would seem to fit well under the diagnostic rubric of fetal alcohol spectrum disorder (FASD). Diagnosis and long-term management will require increasing access to multidisciplinary child development teams including mental health professionals who treat children and adolescents. Adults will require care primarily from teams with expertise in mental health and developmental disabilities.

Burd, L., Martsolf, J.T., Klug, M.G., & Kerbeshian, J. Diagnosis of FAS: A Comparison of the Fetal Alcohol Syndrome Diagnostic Checklist and the Institute of Medicine Criteria for Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 719-724.

• Fetal alcohol syndrome (FAS) is a common cause of neuropsychiatric and growth impairment and craniofacial abnormalities. The syndrome may be more common than has been previously reported. Considerable controversy exists over the approaches for diagnosis of the syndrome. Method: In this study we examined the rate of agreement for three diagnostic schema using 385 subjects that had been referred for assessment of possible FAS. Cases had initially been diagnosed using the Fetal Alcohol Syndrome Diagnostic Checklist (FASDC). We then reviewed the chart of each of the 385 subjects referred and assigned a score from the 4-Digit Diagnostic Code. Finally we assigned each subject to a category from the Institute of Medicine Criteria or to a NOFAS category. We then compared the IOM categories with the Fetal Alcohol Syndrome Diagnostic Checklist (FASDC) score and the 4-Digit Diagnostic Code (4-Digit) score. Results: Rates of agreement with the IOM Criteria ranged from 44% to 63% using the 4-Digit Diagnostic Code and 59% to 71% using the FASDC. Poorest agreement was found in conjunction with partial FAS/ARND. Removal of exposure data from the scores greatly affected accuracy for both the 4-Digit and the FASDC scores. Discussion: The three schema had only modest rates of agreement for classification of subjects with a diagnosis of FAS. This study does not determine if the diagnosis used in the development of the cohort was accurate. Further study utilizing multiple diagnostic schema in a single population will help examine the rates of diagnostic agreement between differing diagnostic schema. A study utilizing a single cohort and applying multiple diagnostic criteria at the same time would be useful. A valuable cohort to study would be the subjects in the CDC surveillance system.

Burd, L., Martsolf, J.T., Klug, M.G., O’Connor, E., & Peterson, M. Prenatal Alcohol Exposure Assessment: Multiple Embedded Measures in a Prenatal Questionnaire. Neurotoxicology and Teratology. 2003. 25(6): 675-679.

• Alcohol exposure during pregnancy is a well-recognized public health problem. Accurate assessment of prenatal alcohol exposure is especially important to identify women in need of intervention. In this study a 36 item prenatal questionnaire was utilized to survey a representative sample of prenatal care providers to examine prevalence rates of exposure. The questionnaire included three common screening tools for alcohol use during pregnancy and the items necessary to establish a maternal risk profile. In North Dakota 1,081 pregnant women were included in the sample. Eighty (7.4% were Native American) and 952 (88%) were white. The TWEAK screening tool was positive for 253 (23.4%) of women. Native American women had a 71% increase in positive TWEAK screenings compared to white women. Logistic regression was used to develop a high-risk model. The data from prenatal care can also be used for maternal risk stratification. Early identification can provide opportunity for early interventions to decrease total exposure during pregnancy and to improve the outcome for the child.

Burd, L., Selfridge, R.H., Klug, M.G., & Juelson, T. Fetal Alcohol Syndrome in the Canadian Corrections System. Journal of FAS International . 2003. 1(e14): 1-10.

Klug, M.G. & Burd, L. Fetal Alcohol Syndrome Prevention: Annual and Cumulative Cost Savings. Neurotoxicology and Teratology. 2003. 25(6): 763-765.

• Fetal Alcohol Syndrome (FAS) is a common developmental disability. FAS is thought to be 100% preventable. While this is a theoretical truth a prevention rate of 100% appears unlikely in the near future. However, several prevention strategies are available. In this paper we examine the potential cost savings from prevention of one case of FAS each year in the state of North Dakota. We utilized the North Dakota Health Claims Database to examine annual cost of health care for children birth through 21 years of age with FAS and controls. The mean annual cost of health care for children birth through 21 years of age with FAS was $2,842 (n = 45). This is $2,342 per capita more than the annual average cost of care for children in North Dakota who do not have FAS ($500 per year). Prevention of one case of FAS per year in North Dakota would result in a cost savings of $128,810 in 10 years and $491,820 after 20 years. After 10 years of prevention the annual savings in health care costs alone for one case of FAS would be $23,420.

Klug, M.G. & Burd, L., Martsolf, J.T., & Ebertowski, M. Body Mass Index in Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 689-696.

• Prenatal alcohol exposure is an important cause of growth impairment. In this study we examined the stability of the growth measurements, including height, weight, and body mass index (BMI) percentiles, from birth to age at the time of diagnosis for subjects who were referred for evaluation to determine if they had fetal alcohol syndrome. Methods: We utilized subjects from the North Dakota Fetal Alcohol Syndrome Registry. Each person referred for assessment was provided a standardized assessment completed by a medical geneticist. We also examined differences in the diagnostic schema from the Institute of Medicine. The population consisted of 315 subjects with paired weight measurements, 234 subjects with paired height measurements, and 322 subjects with current BMI measurements. Results: Increases in weight percentiles and decreases in height percentiles were found. Children with FAS had consistently lower growth measurements. There was significant movement in and out of lower 5th and 10th percentiles by partial and no FAS children from birth to diagnosis. Discussion: The requirement for growth impairment needs to be broad rather than narrow, if most subjects with a diagnosis of FAS and partial FAS/ARND are to be captured

Klug, M.G., Burd, L., Kerbeshian, J., Benz, B., & Martsolf, J.T. A Comparison of the Effects of Parental Risk Markers on Pre- and Perinatal Variables in Multiple Patient Cohorts with Fetal Alcohol Syndrome, Autism, Tourette Syndrome, and Sudden Infant Death Syndrome: An Enviromic Analysis. Neurotoxicology and Teratology. 2003. 25(6): 707-717.

• The prevalence and magnitude of effect of individual risk markers for specific developmental varies widely across diagnostic category. The four study cohorts for this project were patients from four diagnostic registries in North Dakota for fetal alcohol syndrome, autism, sudden infant death syndrome (SIDS), and tourette syndrome. These four cohorts were used to estimate prevalence and magnitude of effect of parental risk markers in patients with developmental disabilities. Cases with North Dakota birth certificates were matched with controls. Using birth certificate data, we then examined five parental risk markers for each cohort and estimated direct and indirect effects for each risk marker by cohort. The authors found two significant paternal risk markers (age in SIDS and education in fetal alcohol syndrome.) Significant maternal markers were (age in SIDS, education in fetal alcohol syndrome, autism and SIDS). Marital status was a significant risk marker in fetal alcohol syndrome. Effect size using paired t-tests, odds ratios, and population attributable risk for both direct and indirect effects for each marker. We estimated to allow for direct comparisons of the differential effect estimates of each of these markers. The direct effect of parental markers differs across diagnostic cohorts of patients. Use of cohorts from similar denominator populations primarily obtained from prevalence studies of the cohort is a useful methodologic tool for estimating the prevalence and magnitude of effect of risk markers

Poitra, B.A., Marion, S., Dionne, M., Wilkie, E., Dauphinais, P., Wilkie-Pepion, M., Martsolf, J.T., Klug, M.G., & Burd, L. A School Based Screening Program for Fetal Alcohol Syndrome. Neurotoxicology and Teratology. 2003. 25(6): 725-729.

• Fetal alcohol syndrome (FAS) is a common cause of birth defects and neuropsychiatric impairment. Identification of affected people is crucial for early entry into intervention programs and for the development of prevalence estimates. The objective of this project was to determine if screening for FAS in a community elementary school based setting was feasible, to estimate prevalence in the screened population and to determine if a screening program for FAS can be implemented using available personnel from the community. The FAS Screen was used to screen kindergarten students enrolled in a school system. Students with scores on the FAS screen above the cutoff for a positive screen (?20) were referred to one of several diagnostic clinics for evaluation. Over a 9-year period, 1,384 students were screened and 69 (5%) had a positive screen (20 or above). These 69 children were then seen in a genetics/dysmorphology diagnostic clinic and 7 (10%) were found to have FAS n=6 or partial FAS n=1. The prevalence of affected children (FAS and partial FAS) was 1 per 198 students or 4.3 per 1,000. The FAS screen was completed annually by school staff, teachers, social workers, and psychologists. The test has acceptable epidemiologic performance characteristics in a community setting. The screening takes about 8-10 minutes. The procedure was well accepted in the community. This screening strategy was inexpensive to implement (less than $8.00 per student), and can be easily included with the other screens completed at kindergarten entry.

Burd, L. Maternal Risk Assessment. 2001.  

Burd, L. Fetal Alcohol Syndrome: A Handbook for Parents and Teachers. 2001.  

Burd, L., Cox, C., Fjelstad, K., & McCulloch, K. Screening for Fetal Alcohol Syndrome: Is It Feasible and Necessary? Addiction Biology. 2000. 5: 127-139.

• The relevant issues involved in community-based screening for fetal alcohol syndrome (FAS) are presented. The disorder is expensive and people with FAS have poor outcomes as adults with less than 10% living independently. Currently two screening tools for FAS are available. These could form the basis of prevention programs to reduce new cases of FAS and secondary disabilities in people with FAS. Screening for FAS in children of school age would be a useful target population. Community-based screening of this group and high risk populations should be considered as an option to increase the completeness of ascertainment and to develop prevalence estimates. Screening could also be an important strategy to improve services for affected persons. Determination of efficacy, efficiency and effectiveness studies of FAS screening programs would be important before implementing widespread screening.

Burd, L. The FAS Screen. 1999.  

Burd, L., Cox, C., Poitra, B., Wentz, T., Ebertowski, M., Martsolf, J.T., Kerbeshian, J., & Klug, M.G. The FAS Screen: A Rapid Screening Tool for Fetal Alcohol Syndrome. Addiction Biology. 1999. 4: 329-336.

• Fetal alcohol syndrome (FAS) is an important cause of mental retardation and developmental disabilities. A population based screening tool would allow for early diagnosis and entry into intervention programs. Objective To develop a brief screening tool for use in population based settings to improve the identification of children with FAS. Method The FAS Screen was developed and tested in six sites. These were sites that served children and all were located in North Dakota. Results Screening was completed on 1013 children, 65 were found to have a positive screening score and were referred. Forty were seen for evaluation by a medical geneticist and six were diagnosed with FAS. The estimated values for the screening tool were: specificity 94.1%, sensitivity 100%, positive predictive value 9.1% and negative predictive value 100%. The cost of screening was $13.00 per child and the cost per case identified was $4,100. Conclusion The FAS Screen is a brief screening test with acceptable performance characteristics and is cost effective.

Bagheri, M., Burd, L., Martsolf, J.T., & Klug, M.G. Fetal Alcohol Syndrome: Maternal and Neonatal Characteristics. Journal of Perinatal Medicine. 1998. 26: 263-269.

• Alcohol is the most common identifiable teratogenic cause of mental retardation in North America. Fetal Alcohol Syndrome (FAS) is a major public health problem, which is frequently under diagnosed by physicians. Objective: To identify and quantify the maternal risk factors and neonatal characteristics of children with FAS. Design: a retrospective case-control study using birth certificate data of North Dakota children diagnosed with FAS. Five controls were selected for each patient. Controls were selected from the computerized birth registry and matched by gender, year and month of birth. Subjects and setting: A list of all the children diagnosed with FAS from the North Dakota FAS Registry was sent to the State Health Department. We were able to locate the birth certificates for 132 (56%) of the 228 cases on the registry. Results: Of the 132 FAS cases, 106 (80.3%) were Native Americans and 24 (18.2%) were Caucasians. In this sample 51(38.6%) of the cases were male and 81 (61.4%) were female. Statistically significant maternal characteristics at p<0.01 were: older mother's age, lower education level, fewer months of prenatal care, fewer prenatal visits, lower gestational age at time of delivery and less prenatal weight gain. Significant neonatal differences at p<0.01 were lower birth weight and Apgar scores and higher incidence of congenital malformations. Conclusion: FAS is a completely preventable developmental disability. Consumption of alcohol during pregnancy can result in lifelong physical and mental impairments on the fetus. All pregnant women should be screened for alcohol use during prenatal visits. Women with positive screens or at high risk should be identified early by the primary care physician and referred for treatment and counseling.

Burd, L. & Wentz, T. Fetal Alcohol Syndrome: The North Dakota Experience. North Dakota Journal of Human Services. 1997. 1(3): 14-20.

• Fetal Alcohol Syndrome (FAS) is the leading identifiable cause of mental retardation in the United States. Prevalence rates in the US for FAS range from 1.0 to 1,900 per 10,000 live births. North Dakota has 12-18 infants born each year with FAS. The lifetime of care required by these people is expensive. Service delivery systems need additional coordination in order to appropriately serve this population. Suggestions for needed changes are discussed.

Burd, L., Martsolf, J.T., & Klug, M Children with Fetal Alcohol Syndrome in North Dakota: A Case Control Study Utilizing Birth Certificate Data. Addiction Biology. 1996. 1: 181-189.

• A retrospective case-control study utilizing birth certificate data in a population of children with Fetal Alcohol Syndrome (FAS) or Fetal Alcohol Effect (FAE) and controls in North Dakota was completed. Using the North Dakota FAS registry, 97 cases of FAS and FAE aged birth-18 years of age were identified. The North Dakota Department of Vital Records then searched for the child's birth certificates. For each case child, four controls were selected from the birth records. The controls were of the same race, sex, month and county of birth as the cases. Birth certificates for 68 children were identified, 44 with FAS and 24 with FAE. When compared with the FAE group, the FAS group had lower birth weights and mothers who began prenatal care later in pregnancy. The FAS/FAE group combined had mothers who were older, were more likely to be unmarried, had less weight gain during pregnancy, started prenatal care later in pregnancy and had fewer prenatal visits compared to controls. The FAS/FAE children had lower birth weights and higher rates of sibling deaths. The use of birth certificate data is a useful data source to compare maternal, paternal and prenatal characteristics for a population of children with FAS/FAE.

Burd, L., Martsolf, J.T., Kerbeshian, J., Mohr, P., Mohr, T., & Ebertowski, M. Fetal Alcohol Syndrome: Delineation and Management. Clinical Advances in the Treatment of Psychiatric Disorders. 1996. 10(4): 1-8.

• Fetal Alcohol Syndrome (FAS) is a common neuropsychiatric developmental disorder with wide ranging implications for development in multiple areas. The presence of complex cognitive, behavioral and physical symptomatology in patients with FAS will require increasing contact with psychiatrists who treat children, adolescents and adults. Psychiatry will play an important role in the evaluation and development of comprehensive treatment plans for persons with FAS.

Burd, L. & Moffatt, M.E.K. Epidemiology of Fetal Alcohol Syndrome in American Indians, Alaskan Natives, and Canadian Aboriginal Peoples: A Review of the Literature. Public Health Reports. 1994. 109(5): 688-693.

• A critical review of available reports on the epidemiology of Fetal Alcohol Syndrome in Indian, Eskimo and Native peoples was completed. A search of Medline, the National Institute Alcoholism and Alcohol Abuse Database and other relevant databases was conducted. The reference lists of several publications on Fetal Alcohol Syndrome were reviewed and four prominent researchers and four government agencies were contacted to identify unpublished articles. This identified ten studies eight of which were cross-sectional. Four of these studies utilized primary data from the authors evaluation of children suspected of having Fetal Alcohol Syndrome, the other six studies utilized secondary data. The prevalence of Fetal Alcohol Syndrome in the Indian and Native population of the United States and Canada was consistently high across the ten studies. These studies have significant limitations which limit both the confidence in the rates reported and the generalizability of the results. Three studies utilized data from the province of British Columbia. No study evaluated all children in the study area. Only two studies reviewed death certificates. Blinding of examiners to maternal alcohol use was included in only one study and no study presented evidence on the sensitivity and specificity of either the screening efforts or diagnostic criteria. This is especially important in studies of secondary data and in studies which report rates from newborn populations. Studies of the sensitivity and specificity of the diagnostic criteria for Fetal Alcohol Syndrome are required. Other study designs including longitudinal cohort studies are needed. Additional studies of populations of Indian and Natives where low rates of Fetal Alcohol Syndrome are suspected should be completed. Reviews of death certificates would also be a potentially important source of cases.

Burd, L. & Martsolf J.T. Fetal Alcohol Syndrome: Diagnosis and Syndromal Variability. Physiology and Behavior . 1989. 46: 39-43.

• The diagnostic criteria for Fetal Alcohol Syndrome (FAS) are reviewed and the authors suggest a new diagnostic schema to allow for a more adequate description of the range of FAS. FAS is also reviewed by topic area. Associated problems believed to be caused by maternal alcohol ingestion are discussed.

Kerbeshian, J. & Burd L. Asperger's Syndrome and Tourette Syndrome: The Case of the Pinball Wizard. British Journal of Psychiatry. 1986. 148: 731-736.

• yndrome (AS), with particular reference to diagnostic criteria and differentiation from infantile autism and personality disorders, and describe six cases seen in practice: all met DSM-III criteria for atypical pervasive developmental disorder'. Three also developed Tourette syndrome: the co-occurrence of the two disorders, and methods of intervention, are discussed.

Burd, L. Fetal Alcohol Syndrome in North Dakota (PowerPoint)  

Burd, L. Fetal Alcohol Syndrome in North Dakota (PDF)  

Burd, L. FAS  

Burd, L. Adverse Outcomes from Prenatal Alcohol Exposure