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Ask the Expert

Screening for FASD among women in substance abuse treatment programs - April 2014

Identification of FASD could help modify treatment and improve outcomes

Experts: Therese Grant, Ph.D., and Dan Dubovsky, M.S.W.

Only about half of the women who enter inpatient treatment for substance abuse complete the program, according to information from SAMHSA. In outpatient settings, the figure is even lower – a 2009 report found that only 31 percent of female outpatients completed their treatment program. Some women may have difficulty in standard treatment because they are affected by a co-existing medical condition related to fetal alcohol spectrum disorders (FASD), which result from prenatal exposure to alcohol. Such exposure can impair the early development of the brain, leading to a wide range of subtle, lifelong behavioral and intellectual problems.

If not detected in childhood, FASD often goes unrecognized in adults. Studies have found that individuals affected by FASD are at an increased risk for substance abuse as they enter adolescence and adulthood. Furthermore, according to FASD experts Therese Grant, Ph.D., and Dan Dubovsky, M.S.W., these individuals often have specific problems with learning and information processing that interfere with their ability to benefit from the usual forms of treatment. Thus, they may struggle not because they lack motivation or commitment, but because the treatment programs do not provide the interventions and support they need to succeed.

Dr. Grant and Mr. Dubovsky are part of a team of researchers and clinicians working on an FASD screening tool called the Life History Screen (LHS), for women undergoing treatment for substance abuse. This tool examines life history patterns that are common in individuals with an FASD, such as having been raised by different caregivers, having difficulty in school, being inattentive and forgetful, or being unable to hold a job. A positive screen should alert treatment counselors to conduct a more thorough follow-up assessment for an FASD, and then modify treatment approaches accordingly. Proper identification of FASD promises to be a crucial step toward helping these women succeed in treatment and improve their lives.

We asked Dr. Grant and Mr. Dubovsky to give us their thoughts on the benefits of screening for FASD, the impact of FASD on women in substance abuse treatment, and ways to enhance treatment outcomes.

Q and A

Q: How common is FASD among women in treatment for substance abuse?

No one knows for sure. However, research has shown that individuals with prenatal alcohol exposure (PAE), a risk factor for FASD, are predisposed to develop alcohol and drug problems as they mature into adolescents and adults. As a result, FASD is likely an issue for many women in substance abuse treatment programs. In addition, since women with an FASD often have difficulty with typical treatment programs, they may enter treatment multiple times.

Q: What effects of FASD place these women at high risk of substance abuse, or impact their treatment?

The long-term effects of FASD include difficulties in organizing information, planning, regulating behavior, understanding abstract concepts, linking cause and effect, and making good judgments. These are all basic skills in day-to-day functioning. Even mild deficiencies in these areas can have a serious impact on the life course of an individual with an FASD, particularly in making decisions about alcohol and drug use or benefitting from treatment.

Other individual factors such as genetic vulnerability, peer pressure, a strong desire to “fit in” and have friends, difficulty predicting the consequences of one’s actions, and the pain of living with a hidden disability contribute to the possibility of alcohol and drug use.

Q: How can screening for FASD contribute to improved treatment for substance abuse?

Most substance abuse treatment programs do not screen patients for FASD or other forms of possible brain damage. We would recommend that treatment programs include routine screening, along with diagnostic referrals as indicated.

Individuals with an FASD often have trouble understanding the consequences of their actions and have little sense of historical or future time, which form the basis of reward and consequence systems of many treatment programs. These individuals also have deficiencies in verbal language processing and working memory, which impair their ability to understand and follow multiple rules or directions. Identifying individuals with an FASD through effective screening would allow clinicians to modify treatment approaches to address the way these individuals process information, in order to improve their chance for successful outcomes.

Q: What are some of the steps that substance abuse counselors and other clinicians can take to modify treatment plans to improve the chance of success for those affected by FASD?

For individuals diagnosed with an FASD, some of the possible treatment modifications include:

  • Breaking down directions, instructions, and rules to one at a time
  • Using other approaches than verbal instructions, e.g., visual diagrams or role play
  • Providing positive reinforcement
  • Recognizing the need for consistency, simplicity, and repetition

Q: What are the limitations of screening?

The LHS uses self-reported information. The accuracy of this information could be substantially reduced when coming from individuals who may have an FASD. These individuals are subject to memory difficulties, suggestibility, and other cognitive deficits. While we understand that self-reported data from individuals with FASD or other possible brain damage may produce inaccurate histories, such information is often the only data available at the time of treatment.

Q: What are the next steps your group plans to take to improve screening for FASD?

With regard to the LHS, our team is in the process of further developing the instrument’s psychometric properties. We are working with colleagues to compare LHS results with results of FASD diagnostic evaluations to assess the tool’s accuracy and determine the optimal screening cut-off points to improve the tool’s effectiveness.

About the Experts

Therese M. Grant, Ph.D., is an Associate Professor and the Ann Streissguth, Ph.D., Endowed Professor in Fetal Alcohol Spectrum Disorders, and Director, Fetal Alcohol and Drug Unit, in the Department of Psychiatry and Behavioral Sciences, at the University of Washington School of Medicine. Dr. Grant received her Ph.D. in epidemiology at the University of Washington in 1999. Her expertise is in the area of perinatal substance abuse and the teratogenic effects of prenatal alcohol exposure. She has a deep and long-standing commitment to serving individuals affected by substance abuse and is skilled in the research and science-based aspects of substance abuse, as well as meeting the challenges of community-based prevention and intervention. Dr. Grant publishes and lectures nationally and internationally on these topics. She works closely with community leaders to advance programs and policies that address problems of families affected by substance abuse.

Mr. Dan Dubovsky, M.S.W., has been the FASD Center’s FASD Specialist for more than 10 years and has a wide variety of experience in the field. Mr. Dubovsky has presented training sessions on FASD and its related secondary disabilities to individuals, organizations, treatment programs, systems of care, SAMHSA grantees, communities, states, and the federal government. He has authored and reviewed curricula on topics including Fetal Alcohol Syndrome (FAS), Child and Adolescent Development, Disturbances in Development, Child Sexual Abuse, Loss and Grief, Psychopharmacology, Attention-Deficit/Hyperactivity Disorder, Anger Management, and Impulse Control Disorders. Mr. Dubovsky has co-authored several articles on FASD prevention and treatment that have been published in peer-reviewed journals, and given more than 200 presentations on FASD at regional, national, and international meetings.


Grant, T. M., Brown, N. N., Dubovsky, D., Sparrow, J., Ries, R. (2013). The impact of prenatal alcohol exposure on addiction treatment. Journal of Addiction Medicine, 7(2), 87-95.

Grant, T. M., Brown, N. N., Graham, J. C., Whitney, N., Dubovsky, D., Nelson, L. A. (2013). Screening in treatment programs for Fetal Alcohol Spectrum Disorders that could affect therapeutic progress. The International Journal of Alcohol and Drug Research, 2(3), 37-49.

Grant, T. M., Brown, N. N., Graham, J., Ernst, C.C. (2014). Substance abuse treatment outcomes in women with Fetal Alcohol Spectrum Disorder. The International Journal of Alcohol and Drug Research, 3(1), 43-49.

Reference for 2009 data on women in outpatient settings, from SAMHSA Treatment Episode Data Set (TEDS):

DISCLAIMER: The views, opinions, and content of this column are those of the authors/experts and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS.