Commentary: Addressing Fetal Alcohol Spectrum Disorders in Addiction Treatment

Addiction treatment professionals can play a vital role in preventing the leading known cause of intellectual disabilities, birth defects and neurobehavioral disorders in the world, Fetal Alcohol Spectrum Disorders (FASD).

Each year 125,000 American newborns are prenatally exposed to heavy or binge alcohol consumption, 20 times the number exposed to methamphetamine and inhalants. Alcohol is a teratogen—a substance known to be toxic to developing babies. Of the most common substances of abuse, including marijuana, cocaine and heroin, alcohol produces by far the most serious neurobehavioral effects in the offspring of substance-using women.

FASD is not typically included in addiction treatment curriculum. One problem is that there is not a code for it in the DSM manual of mental health disorders, and as a result, psychiatrists and psychologists are not informed about FASD.

FASD may also be an unexamined cause for high recidivism in addiction treatment. There are several reasons why this may be:
•    Women may have used alcohol and drugs while pregnant and be afraid to discuss in group;
•    Women may have children with undiagnosed FASD, and may not be educated on appropriate parenting techniques; and
•    Clients themselves may have been prenatally exposed to alcohol and have unidentified learning and behavioral disorders as a result.

Preventing FASD in Addiction Treatment
If a woman drinks while she is pregnant, there is a risk for having a child with FASD regardless of ethnicity, education or socio-economic status. A woman does not have to be an alcoholic to have a child with effects; however, women that suffer with alcoholism are at the highest risk. Women who use other drugs are also at high risk for having a child with FASD, since many use alcohol as well. Women who drink should be counseled about using effective contraception to avoid pregnancy.

Since FASD is preventable, all clients and their families receiving addiction treatment should be educated on the hazards of drinking while pregnant. Men may not cause FASD directly, but they have a very important role in prevention. They can encourage and support women not to drink while pregnant, or at risk for pregnancy.

Treatment is an appropriate time to learn about FASD. If clients realize that some of their children may have effects from prenatal alcohol exposure, a counselor is there to provide them with support and resources. Treatment professionals should provide opportunities for women to discuss many of the difficult issues around mothering and parenting. They can provide women with language to talk to their pediatricians and other health care providers about possible exposures to ensure that the children are receiving assessments and appropriate services.

Recognizing FASD in Clients
People with FASD often go unnoticed as having a brain disorder because the majority of individuals have borderline intelligence or above. This is a lifelong disability and the cognitive, behavioral, emotional and social difficulties can each appear across a continuum of severity, from mild to profound. They may experience a daily fluctuation of attention and focus. Many will struggle with understanding cause and effect relationships or the ability to predict future behaviors. Individuals are typically naïve and are easily led into situations. They may have problems in judgment, memory and social skills, but because they have strong expressive language skills they appear higher functioning than they are. It is not uncommon for a client with FASD to be unsuccessful and sometimes terminated from treatment. These individuals need structure, support and understanding. If counselors better understood the typical behavioral profile of a client with FASD, and how to modify treatment, treatment outcomes could improve.

Recognizing that a person “can’t” perform, rather than “won’t” perform, immediately changes the dynamic in a service relationship. By recognizing the disability of FASD and modifying systems of care, we can improve outcomes for clients. Adults often need lifelong transitional and behavioral support.

Below are suggestions for improving treatment for individuals with FASD:   
•    Train staff to modify treatment plans and treatment;
•    Plan for long-term treatment and aftercare options;
•    Include the entire family in treatment;
•    Assist clients with housing, vocational, educational, day-care, respite, recreational and other services;  
•    Assist clients with Supplemental Security Income, public assistance, food stamps, Medicaid/Medicare and other disability programs;
•    Counselors should consider the possibility of past victimization in these clients;
•    Counselors should know best treatment practices and recommendations for clients with FASD; and
•    Addiction treatment agencies should pursue assessments and diagnosis for clients (and/or children of clients) when they suspect a person has FASD.

There is much that can be done to address FASD in addiction treatment. The National Organization on Fetal Alcohol Syndrome (NOFAS), founded in 1990 as a voice for individuals, families and caregivers living with FASD, disseminates information and resources, provides referrals to specialists, and offers a 22-unit certification program for addiction professionals (

Kathleen Tavenner Mitchell, MHS, LCADC

Kathleen T. Mitchell is currently the Vice President and International Spokesperson for the National Organization on Fetal Alcohol Syndrome and a noted speaker/author on Fetal Alcohol Spectrum Disorders (FASD) and Women and Addictions. She founded the Circle of Hope (COH), an international peer mentoring network for women who have used substances while pregnant.

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    Lisa Bara

    February 5, 2013 at 10:31 AM

    As a Youth Addictions Counsellor in Canada, I found the training “Addictions Treatment Design for FASD” extremely helpful for the exact reasons you have outlined here. Understanding and recognizing the complex needs of individuals with this diagnosis is imperative. Liz Lawryk and the OBD Triage Institute have been leaders is advocacy and education in this area. I would highly recommend this training to anyone interested in furthering their knowledge in this area.

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    Richard Solomon, PhD

    February 4, 2013 at 4:54 PM

    I am a retired psychologist who `failed` to help many adolescent and child clients over the years because of my not knowing about FASD. And I was quite experienced with/`expert` at diagnosing and treating alcohol abuse. The last few years of my career I began to learn about, evaluate clients for, and teach parents and fellow professionals about FASD. It is great that Ms, Mitchell is providing input to the professional and the client communities about this very important element of alcohol abuse.

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    Liz Lawryk

    February 3, 2013 at 10:45 AM

    Thank you for this excellent article. Ms. Mitchell has clearly, and accurately identified essential issues surrounding the complications of treatment for those living with FASD and their families. In Canada, we also acknowledge the need for FASD specific training in all areas of addictions prevention and treatment. Clinical Certification training programs in Addictions Treatment for Individuals Living with FASD are also available in Canada. It is hopeful that with enhanced services, prevention of FASD and addictions will go hand in hand worldwide.

    Liz Lawryk
    OBD Triage Institute
    Calgary, Alberta, Canada

    Clincal T

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    Fr. Jack Kearney

    February 2, 2013 at 9:10 PM

    Thank you! Excellent article….

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    kathryn page

    February 1, 2013 at 11:40 AM

    Thank you Join Together and Kathy Mitchell!!! FASD so often flies under the radar, looking just like “addictive behavior”, or even “Post-Acute Withdrawal Syndrome”, when the symptoms have been there since (before!) birth. What a frustrating mess results from treatment efforts to “return to former functioning”, and then mature past that point–when the brain damage of FASD is really the basic culprit to begin with (in addictive-looking behavior and immaturity) Given that there are some 5% of us with FASD, and that trouble with substances is a common outcome, it’s safe to say that a great many “treatment failures” can be traced to prenatal alcohol.

    The State of California Department of Alcohol and Drug Programs has published a manual for addressing FASD in perinatal treatment programs:

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