Fetal Alcohol Spectrum Disorder: A Review for Mental Health Professionals

Jerrod Brown, Adam L. Piccolino, Anthony Wartnik, Anne Russell & Tina Andrews

Fetal Alcohol Spectrum Disorder (FASD) affects the lives of millions of individuals in North America and is associated with a vast array of physiological, psychiatric, and neurological consequences that can significantly impair behavioral, emotional, developmental, and social functioning.  Our experience tells us that individuals with suspected or confirmed FASD are likely to come in contact with mental health inpatient and outpatient providers on a regular basis. As such, mental health professionals are strongly recommended to participate in continuing education on FASD. A more comprehensive understanding of FASD among mental health professionals should lead to improvements in identification, intervention, and treatment strategies, as well as an informed perspective when making recommendations on child welfare, custody assessments, competency to stand trial evaluations, and diagnostic and treatment planning. The overall goal of this article is to provide a review of FASD for mental health professionals.

Fetal Alcohol Spectrum Disorder (FASD) is a serious and complex disorder characterized by a range of deficits stemming from prenatal alcohol exposure (PAE; Chudley, Conry, Cook, Loock, Rosales, & LeBlanc, 2005; Sokol, Delaney-Black & Nordstrom, 2003). While the most recent Diagnostic and Statistical Manual-5th Edition (American Psychiatric Association, 2013) has added the specific designation of Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure (ND-PAE), the ND-PAE criteria requires further study and is not yet ready to be employed for diagnostic use at this time. In the meantime, individuals with FASD continue to require medical diagnosis to receive clinical acknowledgment and treatment of their condition, which can be difficult to obtain. Therefore, a multidisciplinary diagnostic approach is recommended when feasible. We speculate that an inevitable refinement of new diagnostic criteria will allow mental health professionals the opportunity to diagnose ND-PAE in the absence of specific medical input. However, the scope of the diagnosis is yet to be determined. However, the DSM-5 does provide a specifier for diagnosticians to note if prenatal alcohol exposure is suspected.  Mental health professionals may choose to diagnose using the DSM-5 code, 315.8 (F88)–Other Specified Neurodevelopmental Disorder, which is not specific to ND-PAE, citing specific reasons in support of the diagnosis of prenatal alcohol exposure (i.e., neurodevelopmental disorder associated with prenatal alcohol exposure).

The following information is offered to assist in the assessment and development of individualized rehabilitation/treatment plans for individuals with FASD:

  • FASD is believed to be significantly under-identified, missed entirely, or misdiagnosed in many mental health settings.
  • Early diagnosis and appropriate therapeutic intervention increases the potential for positive outcomes and either prevention or reduction of secondary disabilities.
  • There are no universal sets of FASD deficits and behaviors. While there are some identifiable core deficits related to FASD, because PAE affects the part of the fetus and fetal brain that is developing at the time of exposure, each case can be quite different depending on the time of exposure. The disabilities or symptoms associated with FASD are commonly divided into Primary and Secondary categories.
  • Primary Disabilities refer to the impaired mental function of persons with Fetal Alcohol Spectrum Disorders (FASD) directly resulting from damage to the developing brain caused by alcohol exposure.  Some examples of Primary Disabilities include: Learning issues, executive functioning issues, sensory integration dysfunction, memory issues, and level of adaptive functioning.
  • Individuals with FASD usually experience or are diagnosed with a number of secondary conditions or disabilities (i.e., mental health disorders, substance use disorders, trouble with the police, early school dropout, inappropriate sexual behavior, incarceration in prison or mental health institutionalization). Often these Secondary Disabilities result directly from a lack of understanding, support, and accommodation of the primary disabilities associated with FASD.
  • Although FASD is a leading cause of Intellectual Disability (previously termed mental retardation), most individuals with FASD present with average or even above average intelligence. Nevertheless, cognitive deficits are usually present (e.g., learning disabilities, deficits in executive functioning).
  • In identifying FASD, assessment of adaptive functioning is critical. This is especially important when IQ is also assessed, since IQ does not correlate well with adaptive behaviors (Streissguth, 1997) in this population. Thus, an individual with FASD with an IQ in the normal range may still have significant trouble living independently, parenting, or maintaining employment. Assessment of adaptive functioning is, therefore, critical.
  • FASD associated deficits may be evident only after several appointments. In some individuals, these deficits may be successfully masked at initial encounters with service providers. Because FASD is an “invisible” disability, those affected have often been judged harshly as capable but unwilling and neurological deficits are often seen as moral failings.  Affected individuals, especially youth and adults without a formal diagnosis, often developed a wide range of strategies (adaptive and maladaptive) to disguise their differences and avoid such judgments.
  • Mental health professionals should be aware of the possibility of confabulation (honest lying), since this is a common secondary consequence associated with FASD.
  • Obtaining a full case history is imperative and requires individual interviews as well as access to case files (e.g., court, medical, social services, employment histories) in an attempt to gain clear insight into the impact of Prenatal Alcohol Exposure (PAE) on the individual’s neurological functioning, with the caveat that persons with FASD may be unable to describe their own condition or circumstances.
  • Red flags, such as out-of-home placements, chemical dependency, criminal justice involvement, and immature social behavior, may be observed in case history and may warrant additional questioning when making determinations for treatment and intervention strategies.
  • Differential diagnosis of FASD can be challenging and complex when there is no confirmed prenatal exposure to alcohol.
  • FASD is often misdiagnosed with comorbid conditions and it can be considerably difficult to separate primary disability symptoms from secondary symptoms arising from lack of support. To minimize this risk of misdiagnosis; mental health professionals must develop a working familiarity with the overlapping conditions and behaviors associated with FASD along with typical comorbid disorders.
  • Misdiagnosis of FASD may result in the use of inappropriate pharmacological therapies and treatment techniques. Implementation of such therapies and techniques are both counterproductive to successful outcomes and initiate or exacerbate otherwise unnecessary and debilitating secondary disabilities associated with FASD.
  • Mental health professionals working with FASD-affected individuals should have an understanding of the complexities associated with treating comorbid substance abuse problems.
  • Individuals with FASD tend to experience higher rates of trauma compared to the general population. Thus, trauma-informed assessment and treatment methods are strongly encouraged.
  • Mental health professionals should consider incorporating elements of safety education, self-advocacy, social skills, behavioral regulation, and dual diagnosis treatment into treatment and intervention approaches.
  • Individualized rehabilitation/treatment plans should be concrete, developmentally appropriate, and repetitiously delivered over longer than usual periods.
  • Many individuals with FASD will need ongoing rehabilitation planning and monitoring throughout their lives.


Mental health professionals play a crucial role in the identification and treatment of individuals with FASD. Proper identification of FASD can be difficult since it presents differently to some degree in almost every affected individual. This task is often further confounded by secondary disabilities and/or comorbid characteristics often related to cognitive functioning in FASD-affected individuals. Appropriate and effective responses to individuals with FASD require a thorough understanding of the areas of development affected by prenatal exposure.  Finally, an understanding of the unique strengths and coping mechanisms used by an individual with FASD will provide greater opportunities to create an effective treatment or intervention plan.

Jerrod Brown, MA, MS, MS, MS, is the Treatment Director for Pathways Counseling Center, Inc. Pathways provides programs and services benefitting individuals impacted by mental illness and addictions. Jerrod is also the founder and CEO of the American Institute for the Advancement of Forensic Studies (AIAFS) and the lead developer and program director of an online graduate degree program in Forensic Mental Health at Concordia University, St. Paul, Minnesota. Jerrod is currently pursuing his doctorate degree in psychology. Email: [email protected]

Adam L. Piccolino, Psy.D., ABN, is a board-certified neuropsychologist with over 18 years of experience in providing direct clinical services in correctional settings. Dr. Piccolino has lectured locally and nationally on a variety of topics including the identification and management of traumatic brain injury, dementia, and other neurocognitive disorders within offending populations.

Judge Anthony P. (Tony) Wartnik served as a trial judge for 34 years, nine of which were with the Bellevue District Court, a limited jurisdiction court, and almost 25 years on the King County, Washington Superior Court, a general jurisdiction court. In the latter capacity, he presided over involuntary mental illness treatment commitment cases, juvenile offender and dependency cases, adult criminal cases, and family law cases. He chaired a task force in the mid-1990s to establish protocols in Juvenile Court for determining the competency of youth with organic brain damage and chaired the Governor’s Advisory Panel on Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE). Since retirement from the court in 2005, Tony has served as a consultant to the Fetal Alcohol and Drug Unit, University of Washington, School of Medicine, and as the Legal Director/Liaison for FASD Experts, a multidisciplinary Forensic Assessment and Diagnostic Team, and has presented at workshops and conferences throughout the United States, in Canada, New Zealand and Australia. In addition, he has authored numerous articles involving Fetal Alcohol related issues, mental health, and other subjects as they relate to the law and the court.

Anne Russell, is the biological mother of two adult children with Fetal Alcohol Spectrum Disorder (FASD).  Since 2000, Anne has worked to raise awareness in Australia about alcohol use during pregnancy and FASD. In 2005, she published the first of three books and is currently preparing the second edition of Alcohol and Pregnancy – My Responsible Disturbance. In 2007, she founded the Russell Family Fetal Alcohol Disorders Association (RFFADA), which provides support for over 200 parents both nationally and internationally.

Tina Andrews, MBA, M.Ed., is the co-founder and member of the Board of Directors for Families Affected by FASD, the author of a blog, Ten Second Kids in a Two Second World, and works full time in quality and statistical analysis in addition to her FASD advocacy efforts.

Reference List

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders  (5th ed., text rev.). Washington, DC: Author.

Chudley, A. E., Conry, J., Cook, J. L., Loock, C., Rosales, T., & LeBlanc, N.  (2005). Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. Canadian Medical Association Journal, 172, S1-S21. doi:10.1503/cmaj.1040302

Sokol, R.J., Delaney-Black, V., & Nordstrom, B. (2003). Fetal alcohol spectrum disorder. Journal of American Medical Association, 290, 2996-2999. doi: 10.1001/jama.290.22.2996

Streissguth, A. P. (1997). Fetal Alcohol Syndrome: A guide for families and communities. MD: Pearl H. Brooks Publishing Company.

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