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The Impact of FASD on the Field of Mental Health - June 2014

The field of mental health often does not recognize the impact of FASD on behavioral health issues and mental health treatment. When the brain damage due to an FASD is not recognized, and the FASD is not considered as a co-occurring issue, typical approaches often will not be effective. Individuals with an unrecognized FASD are often labeled as non-compliant and unmotivated. They may be viewed as “difficult” individuals or “treatment failures” because they do not respond to typical treatment approaches and do not follow through with instructions. They may not follow rules, may repeat negative behaviors in treatment settings, or may not complete treatment.

As individuals with an FASD are at higher risk for co-occurring mental health disorders for a number of reasons, we can potentially reduce the incidence of mental illness if we can reduce the incidence of FASD. This interview with the FASD Center's Dan Dubovsky examines this issue, and the role that the mental health field can play in preventing and addressing FASD.

Question: Does mental health have a role to play in the prevention of FASD?

Answer: Absolutely. As individuals with mental health disorders may use substances, introducing prevention strategies in treatment settings is essential in reducing the incidence of alcohol-exposed pregnancies. Information about the effects of alcohol on a fetus is important for both women and men to hear. Men have an important role in supporting women in not consuming alcohol during pregnancy, as well as recognizing the possible effects of their alcohol use prior to conception. Additionally, if we accurately identify women in treatment who may have a co-occurring FASD and modify our treatment approaches, we can improve outcomes for them and for their families.

Question: Why are individuals with an FASD at higher risk for mental health disorders?

Answer: There are several paths by which this can occur. One is reflected in a study that was completed by Dr. Susan Astley at the University of Washington. Dr. Astley studied 40 mothers who gave birth to children with Fetal Alcohol Syndrome (FAS), and found that over 95% of them had between one and ten mental health disorders. Seven percent had a diagnosis of schizophrenia, for example, which is seven times the average among the general population (1%). As schizophrenia has a strong genetic vulnerability, at least seven percent of their children with FAS had a genetic vulnerability for schizophrenia. The percent may well have been higher if the children’s fathers had schizophrenia. Research has shown that what causes underlying genetic vulnerabilities to develop into full blown disorders is the number of stressors the person experiences and the ability to cope with stressors. Individuals with an FASD experience many stressors throughout their life and have poor coping mechanisms.

Research has also shown that prenatal exposure to alcohol affects the hypothalamic-pituitary-adrenal axis that controls stress and anxiety, leading to a higher possibility that, if a person has a genetic vulnerability for a mental illness, they are more likely to develop that disorder. We also know that individuals with certain mental illnesses, including those with a strong genetic vulnerability such as schizophrenia, major depression, and bipolar disorder, have a significant risk of a co-occurring substance use disorder. Substances may be used to self-medicate, as these disorders can be extremely emotionally painful. Therefore, if women with one of these disorders uses substances while pregnant, her child may have an FASD as well as the genetic vulnerability for the mental health disorder. With this information, it is clear that a significant percentage of people in the mental health treatment system may have a co-occurring FASD.

Question: Why are typical treatment approaches (including many evidence-based practices) not effective for many people with an FASD?

Answer: The areas of the brain that are damaged in individuals with an FASD impact behaviors and responses to various situations. For example, damage in the dorsolateral prefrontal cortex--which is responsible for working memory--results in individuals with an FASD having difficulty following multiple directions or rules. Any time we give a person multiple instructions or tasks, we are relying on that person’s working memory to be able to complete the tasks. Damage in the frontal lobes of the brain, in an area that is responsible for abstract thinking, results in more literal thinking for individuals with an FASD across the I.Q. span. Behaviorally, this manifests as a person having difficulty with reward and consequence systems, which rely on a concept of historical time and future time. As level and privilege systems are the basis of many treatment programs, people with an FASD, especially if not diagnosed, may well fail in those programs.

The brain damage seen in FASD also results in impairment in verbal receptive language processing. This manifests in difficulty in any auditory approach. Evidence-based practices such as motivational interviewing and cognitive behavioral therapy rely on verbal approaches, as do group therapy, AA, and NA. Although a person with an FASD can participate in these, they often cannot take what they heard in a session and think about how that applies to their life and what they need to change. Damage in the areas of the brain that control stress and anxiety results in individuals with an FASD being seen as overreacting to minor stressful situations. They often get into difficulty for these behaviors, as they are seen as willful behaviors within their control. However, understanding the brain basis of FASD, we recognize that these behaviors are not in their control, and therefore utilizing consequences will not help them change their behavior.

Question: What is the significance of this information for the field of mental health?

Mental Health Disorder

Answer: The significance of this is that the approach to treatment for individuals with a co-occurring FASD is different than treatment for a person who does not have an FASD. As can be seen in this first Venn diagram (right), the typical approach to co-occurring disorders is that all need to be treated simultaneously. However, typically they are treated in parallel. In this concept, even if a co-occurring FASD was recognized, it would be treated simultaneously. Unfortunately, when it comes to someone with an FASD (most of whom will not be diagnosed), this is not the most appropriate view.

As is seen in the second Venn diagram (below), whatever is occurring in the person’s life, if the person has an FASD, that impacts all interventions with the person. For example, if a person has an FASD and bipolar disorder, treatment for the bipolar disorder must be modified. Mental Health Disorder Talk therapy approaches such as cognitive behavioral therapy cannot be employed the way it was designed, as it is a verbal process and verbal receptive language processing is significantly impaired in FASD. Similarly, if a person has a co-occurring substance use disorder with an FASD, motivational interviewing and insight-oriented psychotherapy cannot be utilized the way they were developed, as they too are verbal approaches where the individual is expected to think about what they heard, how that impacts them, and decide to make changes in their behavior. Additionally, if a person has an FASD and is homeless, housing approaches need to be modified if we want the person to succeed in maintaining housing.

In addition to the co-occurring mental health issues that individuals with an FASD may experience, those with an FASD may be misdiagnosed with some mental health disorders, as the behaviors that we see in FASD are similar to those we see in mental health disorders such as ADHD, Autism, Oppositional Defiant Disorder, Antisocial Personality Disorder, and Borderline Personality Disorder. Once an FASD is identified, it is very important to ascertain whether other diagnoses that a person has received over the years are accurate.

Our mental health system often seems to be reluctant to recognize FASD as an issue they need to address. Part of the reason may be that people think that FASD only affects infants or young children, or that people with an FASD have low I.Q.s and recognizable physical features. Neither of these is accurate. Another reason may well be that understanding FASD challenges the basic tenets of what we have been taught as professionals. That is, that people learn by experiencing the consequences of their actions and need to take responsibility for their actions in order to learn. This is the basis of reward and consequence systems that often are not effective for those with an FASD.

About the Expert

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 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.

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.