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FASD: A guide for mental health professionals

By Jerrod Brown July 10, 2017

Fetal alcohol spectrum disorders (FASD), which researchers have estimated affect 2 to 5 percent of the U.S. population, are lifelong conditions that result from exposure to alcohol in utero. Kenneth L. Jones, David W. Smith and colleagues are credited with discovering the birth defects and long-term impacts on cognitive and social functioning caused by fetal alcohol syndrome in 1973.

Prenatal alcohol exposure can result in a host of issues related to:

  • Cognitive functioning (e.g., impulse control, attention, executive functioning)
  • Social functioning (e.g., communication skills, recognition of social cues)
  • Adaptive functioning (e.g., problem-solving, ability to adapt to new situations)

Furthermore, several neurological issues characterize FASD, including stunted cell and nerve growth, elevated rates of cell mortality, neurotransmitter interruptions and migration issues in organic brain growth. Complicating matters, the overwhelming majority of individuals with FASD experience an array of psychiatric disorders, increasing the likelihood that these individuals will need specialized services from mental health care providers.

Unfortunately, many of these providers and professionals lack the necessary training and expertise to accurately identify and effectively treat the unique and complex symptomatology of this population. The goal of this article is to provide a basic introduction of FASD to mental health professionals in six key areas: FASD symptoms, diagnostic comorbidity, memory impairments, tips for interacting with individuals who may have FASD, screening and assessment, and treatment.

FASD symptoms

A diverse range of symptoms characterizes FASD.

Executive functioning deficits: Impairments associated with executive functioning are a hallmark deficit of FASD, impacting the majority of individuals affected by these disorders. Executive functioning deficits are often associated with impulsivity, diminished ability to learn from consequences and impairments in planning, verbal reasoning, emotional regulation, memory and learning.

Social skills deficits: Individuals with FASD often have pervasive impairments in the domain of social functioning. Misinterpretation of social cues is not uncommon. This can lead to boundary violation concerns (e.g., inappropriately touching another person), which can in turn result in involvement in the criminal justice system. Such social skill deficits can also increase the individual’s level of vulnerability to manipulation by others and an inability to detect unsafe situations and people.

Attachment problems: Consistent with these deficits in social skills, poor attachment with the primary caregiver is relatively common in children with FASD. Poor attachment with the primary caregiver can increase the likelihood of misdiagnosis in a child. Common misdiagnoses may include attention-based (e.g., attention-deficit/hyperactivity disorder [ADHD]) or behavior-based disorders (e.g., conduct and oppositional defiant disorders). In fact, it is not uncommon for these disorders to co-occur with a diagnosis of FASD. Given that reality, mental health professionals who work with individuals impacted by FASD should familiarize themselves with commonly co-occurring disorders such as those just mentioned.

Adaptive functioning: Adaptive functioning involves an individual’s practical, social and mental capacities to deal with everyday challenges and problems (e.g., personal hygiene, personal finances, navigating social interactions). In light of the executive functioning problems outlined earlier, as well as struggles with processing abstract information and solving problems, individuals with FASD have difficulty in the realm of adaptive functioning. The consequences can range from difficulty maintaining employment to struggles with caring for one’s self. Because of these deficits in adaptive functioning, a high percentage of individuals with FASD are dependent on the support of family and social services.

Learning problems: One of the key issues related to adaptive functioning among individuals with FASD is difficulty learning from past experiences. Furthermore, individuals with FASD often struggle to use past experience to prospectively avoid dangerous people and situations. These deficits are exacerbated by impulsivity and an inability to think strategically about decisions. Hence, FASD affects an individual’s ability to understand society’s norms and to behave within those norms.

Diagnostic comorbidity

Increasing the likelihood of negative short- and long-term outcomes, individuals with FASD often have co-occurring disorders and other issues.

Diagnostic comorbidity: It has been estimated that the overwhelming majority of individuals with FASD experience comorbid psychiatric conditions. ADHD is the most prevalent comorbid disorder observed among those affected by FASD. Other disorders frequently observed among adolescents with FASD include conduct disorder and oppositional defiant disorder. Finally, individuals with FASD are also at an elevated risk to abuse substances later in life.

Physical complications: A number of physiological symptoms can suggest the possibility of FASD. For example, prenatal alcohol exposure can result in cardiovascular (e.g., septal defects, hypoplastic pulmonary arteries) and kidney (e.g., pyelonephritis, hydronephrosis, hypoplasia) irregularities. Prenatal alcohol exposure has also been linked to orthopedic irregularities in the structure of bones in the upper body (e.g., radioulnar synostosis), fingers and toes (e.g., camptodactyly, brachydactyly, clinodactyly).

Other brain-based injuries: Individuals with FASD may be more prone to traumatic brain injuries throughout the life span. This could contribute to the underdiagnosis and misdiagnosis of FASD. Furthermore, these traumatic brain injuries may exacerbate other secondary conditions, including ADHD, executive functioning impairments, mental health and substance use disorders, and so on.

Other life adversities: As a function of FASD and these other co-occurring disorders and impairments, individuals with FASD are disproportionately likely to be afflicted with problematic life experiences. For example, individuals with FASD often come from unstable homes, experience neglect and abuse (verbal, physical or sexual), and are exposed to substance use, mental illness and criminal justice involvement by their families and household members. As such, mental health professionals should view these co-occurring disorders and other negative life experiences as potential indicators of FASD, necessitating a need for further assessment and evaluation.

Memory

One of the most devastating cognitive deficits of FASD is short- and long-term memory impairment.

Poor memory: Individuals with FASD typically have problems associated with memory. In some instances, these issues can lead to over- and underendorsement of symptoms, contributing to missed and misdiagnosis. In other instances, these individuals can struggle with retrieving and communicating their memories, contributing to issues such as suggestibility, confabulation, fabricating stories and incorrect storytelling.

Suggestibility: The suggestibility of individuals with FASD can be detrimental in at least two ways. First, these individuals may be manipulated into participating in criminal activity by peers. Second, these individuals may be prone to falsely confessing to criminal activities that they did not commit. As such, mental health professionals must take care to verify the accuracy of statements made by individuals with FASD. Mental health professionals should also take the topic of suggestibility into account when phrasing and asking questions during the initial intake and diagnostic assessment process.

Confabulation: FASD and other disorders characterized by memory deficits often co-occur with confabulation issues. Confabulation occurs when new memories are created by filling gaps in recall with one’s real memories, imagination or environmental cues. Incidents of confabulation may occur spontaneously or be prompted. For example, confabulation is particularly likely in situations in which professionals ask leading questions or pressure the interviewee. As such, confabulation can contribute to inaccurate self-reports by the client, resulting in possible misdiagnosis and the development of an ineffective treatment plan.

Interacting with clients

The pervasive symptoms of FASD have important implications for how mental health professionals should interact with clients who may have these disorders.

Importance of simplicity: Individuals with FASD tend to perform better when tackling one task at a time. This is especially true of tasks that do not involve reliance on previous experience to complete. Multistep and complex questioning can result in individuals with FASD shutting down emotionally or responding with factually incorrect or incomplete responses. Mental health professionals should take this into account when screening, assessing and developing treatment plans for this population.

Superficial talkativeness: The propensity for individuals diagnosed with FASD to be charming and talkative may lead mental health professionals to overestimate their level of competence and comprehension of treatment goals. It is important for clinicians to have these individuals demonstrate understanding and knowledge of the question being asked by explaining it back to the professional in their own words. Overuse of yes-or-no questioning can also mask the individual’s true level of impairment.

Misinterpretation of callousness: In some cases, behaviors resulting from FASD symptoms might be mistaken as a choice rather than as a result of the disorders. The social and cognitive deficits of individuals with FASD can contribute to problematic behaviors being misinterpreted as premeditated or manipulative. In fact, many of the behaviors exhibited by individuals with FASD are the direct result of deficits caused by prenatal alcohol exposure.

Screening and assessment

The combination of nuanced symptomatology and diagnostic comorbidity makes the screening and diagnosis process for FASD difficult.

Diagnostic terminology: FASD is an all-encompassing term that includes fetal alcohol syndrome, partial fetal alcohol syndrome, alcohol-related neurodevelopmental disorder and alcohol-related birth defects. In the fifth edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), neurodevelopmental disorder-associated with prenatal alcohol exposure has been added as a condition for further study. This is the first appearance of FASD-related symptoms in the DSM, which means mental health professionals can now diagnose prenatal alcohol exposure.

Missed and misdiagnosis: Missed and misdiagnoses of FASD may explain, at least in part, the limited awareness of the disorders among medical and mental health professionals. A lack of systematic education and training on FASD contributes to this situation. As a result, many children, youth and adults go unidentified and are subsequently unable to take advantage of advanced medical and psychological treatment and services that could render a better quality of life.

Detection difficulties: Another factor that likely contributes to the missed and misdiagnoses of FASD is the fact that these disorders are difficult to identify. Why is that? Visible indicators such as morphological signs are not always present, whereas cognitive deficits are difficult to detect using standardized intelligence measures. This is problematic because individuals with FASD who present with no outward signs of facial feature abnormalities can still possess severe neurobehavioral deficits. In fact, diagnosis of prenatal alcohol exposure becomes increasingly difficult as children grow into adolescence and adulthood. Specifically, many of the physical features of prenatal alcohol exposure fade as children grow physically. Furthermore, the availability of birth mothers and records decrease with time. As a result, many professionals and researchers have called FASD a “hidden disability.”

Importance of identification: Assessment and identification of FASD are essential because the likelihood of impairment related to alcohol exposure increases significantly with each subsequent pregnancy. Identification of these disorders in a first pregnancy provides a viable point of intervention to help prevent alcohol use in future pregnancies.

Treatment

Even in cases in which the individual has been accurately diagnosed with FASD, treatment can be challenging.

Problems with cognitive-based treatments: Individuals with FASD have cognitive (e.g., memory, understanding cause-and-effect), social (e.g., comprehending social cues) and adaptive (e.g., problem-solving ability, generalizing skills) deficits that complicate their participation in cognitive-based treatment. Likewise, insight-based therapy approaches are not encouraged with this population. Therapeutic approaches that incorporate modeling, coaching, teaching and skill building may be most effective with these individuals.

Problems with treatment adherence: Individuals with FASD may benefit more from treatment in structured residential facilities than in outpatient facilities because of the cognitive deficits associated with FASD. Should an outpatient program be the only option, odds of treatment success may be improved by maximizing program structure and tailoring treatment plans to the individual.

Conclusion

The disorders under the FASD umbrella are complex and lifelong. They are characterized by an array of adaptive, behavioral, emotional, executive, physical and social impairments. Considering the prevalence rates of FASD in the United States, it is highly likely that mental health professionals will come into frequent contact with individuals impacted by these disorders. Unfortunately, these disorders often go unrecognized and undiagnosed by many mental health professionals.

Other than simply improving identification of individuals with FASD, another essential step for mental health professionals is to better understand the various challenges and deficits faced by this population on a daily basis. To combat the status quo, mental health professionals are encouraged to seek training on this complex topic and consult with FASD experts when necessary. Taking this path forward will minimize the likelihood of negative short- and long-term outcomes for this population.

 

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Jerrod Brown is the treatment director for Pathways Counseling Center Inc., which provides programs and services benefiting individuals affected by mental illness and addictions. He is also the founder and CEO of the American Institute for the Advancement of Forensic Studies and the editor-in-chief of Forensic Scholars Today. He holds graduate certificates in autism spectrum disorder, other health disabilities and traumatic brain injuries, and is certified as a fetal alcohol spectrum disorders trainer. Contact him at Jerrod01234Brown@live.com.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

16 Comments

  1. barry stanley

    It is my observation, over twenty years, that Psychiatry is simply unable to acknowledge the correlations and relationship between pae/fasd and mental illnesses

    Reply
  2. Richard Willier

    It is the hope that a public outcry will encourage clinicians in the Psychiatric/Forensics field to examine FASD, and incorporate FASD into the assessments and counselling they do. It only makes sense not to dismiss a condition, when public safety and accommodations for the patient are paramount and must be used in determining any mental health or any brain based issue -along with any healthy follow-up suggestions.

    Reply
  3. Paul Novotny

    It seems that FASD is a condition that is largely out of the awareness of mental health professionals. Learning about FASD and incorporating such knowledge into mental health professionals’ daily practice can go a long way in effectively identifying and treating those with FASD.

    Reply
  4. Rebecca Tillou

    I was diagnosed witj FAS at 34 years old. My whole,childhood into adulthood put into perspective!!!

    Reply
  5. Kimberly D. Dodson, Ph.D.

    The connection between mental illness and FASD is clear. The long-term consequences can be devastating to mothers and infants. Many will unfortunately end up in the criminal justice system. I will use this article to educate my students about FASD. Great article!

    Reply
  6. Dr. Diane Harr

    Excellent article! Developing an understanding of the prevalence of FASD and recognizing the impact it has on children is crucial for mental health professionals and educators alike. Awareness of both identification and intervention can provide positive outcomes for students who face a myriad of challenges associated with this disorder.

    Reply
  7. Cody C

    An excellent encapsulation of the field’s understanding of FASD. Clear, concise, and to the point. Only through increasing awareness of FASD disorders will recognition by forensic clinicians become commonplace when appropriate.

    Reply
  8. barry stanley

    The Justice System is confronted with the consequences of prenatal and pre conceptual alcohol exposure on a daily basis.
    Unlike other institutions, such as education, the justice system has little opportunity to evade the issues that it is presented with; at least at the higher levels of the system.
    Psychiatry provides the Justice System with the experts to testify when issues concerning mental conditions occur.
    With few exceptions such expert forensic psychiatrists / psychologists witnesses have had no training or acquired knowledge of FASD.
    The increasing awareness and understanding of FASD by Judges and court lawyers is in conflict with the testimony of such witnesses, whom the courts rely on in cases involving persons who have FASD. The one situation that exemplifies the issue more than any is the charge of murder. This is because the crime and the consequences for all are so severe and tragic.
    In such cases when FASD is raised in mitigation it is the Forensic Psychiatrist or Psychologist who is the witness for the crown. With few exceptions they know little about fasd. Yet the judicial system is increasingly becoming more aware of FASD.
    This contrary situation will likely be the one that will eventually force Psychiatry to recognize the nature of FASD and the role of prenatal and pre conceptual alcohol in the development of psychiatric conditions. [ behaviours ]. This will mean a profound shift away from behaviour as the criteria for psychiatric diagnosis, to where such behaviours arise – the brain.
    It will also mean that the justice system, psychiatry and society as a whole will have to redefine the meaning of culpability and responsibility.
    This is the point to which we should be directing all our effort. We need to focus on educating the legal profession about FASD and appropriately challenge any erroneous testimony relating to FASD.
    Barry Stanley

    Reply
  9. Cameron Wiley

    Very interesting and comprehensive article. It’s unfortunate that a diagnosis with this many implications is flying so under the radar. I really hope this topic continues to be recognized and addressed with in-depth research.

    Reply
  10. Hal Pickett, Psy.D., LP, ABPP

    Jerrod Brown’s article is such an important professional topic because it starts to shed light on the difficult topic of diagnosing and treating FASD. I feel so many have gone undetected because we have relied so much on the mother identifying her use. We have to take steps to move beyond and have distinct diagnostic criteria and diagnostic tools. It can be such a subtle but lifetime roadblock for those effected.

    Reply
  11. JW

    A terrific article and one I am sharing with colleagues. This is a hot-topic for First Responders, in particular, Law Enforcement Officers. We have daily contact with a diverse population who are typically in a crisis. It is imperative for officers to expand awareness and enhance their observation skills involving behaviors complicated by physical and mental health factors, one of which FASD. Additionally, prenatal exposure to alcohol has ill effects on children and is seen as they age into adults. Many of those observations involve learning disabilities, socially immature, difficulty with judgment, reasoning and decision making, inhibits their memory and clouds their understanding of consequences to the decisions and behaviors they make. They are also prone to confabulate (filling in the gaps) due to their memory impairment. Adversely, over 60% of these people with FASD come into contact with law enforcement, thereby are also subsequently arrested and incarcerated. This is an important topic, one in which frontline responders could greatly benefit from additional research and practical training to enhance their observation and communication skill-sets when handling an individual with FASD.

    Reply
  12. Hannah Tong

    This topic is so important, not only for mental health professionals, but for future opportunities for research in the field.

    Reply
  13. Pamela Oberoi

    This is a a very important topic and I believe that the cultural aspects of FASD require more in depth research. In any case, it is important to understand the impact drinking during pregnancy causes, but of course also, as professionals we need to be trained and understand how we can be helpful and support clients affected by FASD. This is very important work, thank you for the good article.

    Reply
  14. SB

    This is an important topic that needs more attention in the mental health field for improved assessment and treatment outcomes.

    Reply
  15. Lori Borschke

    Our major “people systems” – Criminal Justice, Education, and Medical (both physical and mental health) – are all significantly impacted by FASD. Increased awareness, education, and treatment competency appear to be key in achieving successful outcomes related to this complicated disorder. Let’s assign funding resources to the front-end of addressing FASD, instead of trying to solve the problems that result from a lack of knowledge and understanding. This will require intentional, informed, and culture-specific action by professionals and involved persons within all of our people systems.

    Reply

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