2. Understanding the impacts of Fetal Alcohol Spectrum Disorder (FASD) on child mental health

What is this resource about?

This resource is intended to highlight the significance of Fetal Alcohol Spectrum Disorder (FASD) to practitioners working in child, family and/or adult-focused services. In particular, this resource outlines emerging understanding about the association between FASD and common mental health difficulties in children and young people. It is part of a series of Emerging Minds resources on FASD and its impact on children and families.

Who is this resource for?

This resource is suited to practitioners working in both child and adult-focused services, as well as general practitioners and allied health professionals working with pregnant women.

This resource may be of particular interest to practitioners who provide mental health support to children and young people. It is important for these practitioners to understand the likely impact of FASD on the mental health and wellbeing of children’s lives.

What is FASD?

Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term used to describe a range of distinct but related developmental disorders caused by exposure of the developing foetus to alcohol in utero. There are a range of possible diagnoses associated with prenatal alcohol exposure; therefore, the umbrella term FASD is typically used^*. FASD is sometimes referred to as an invisible disability, as the disorder is not always accompanied by any discernible physical characteristics.

Understandings about the probable impact of FASD on child wellbeing and mental health have grown in recent years. It appears likely that exposure to alcohol during key fetal developmental phases can result in a range of physical and functional difficulties in the developing child (‘primary difficulties’). When placed in the context of a child’s caregiving environment, particularly an unsupportive environment, these difficulties contribute to the child’s risk of developing mental health and behavioural difficulties later in life (‘secondary difficulties’). Despite this growing knowledge, the pathways through which this risk is conveyed are still not fully understood.

It is likely that the mental health and wellbeing outcomes for children living with FASD reflect a combination of primary factors related to the severity of prenatal influences; and secondary, (postnatal) factors related to a child’s complex family environment and the inability of wider social environment and services to support them adequately (Clarke & Gibbard, 2003).

Since these factors all vary between children, it is not surprising that the impact of FASD on children’s mental health and developmental trajectories can vary. Early diagnosis, access to appropriate interventions, and placement in a stable, nurturing and structured environment are all believed to minimise the likelihood of poor mental health outcomes over time (Clarke & Gibbard, 2003; McLean & McDougall, 2014; Parkinson & McLean 2013b Streissguth et al., 2007).

Recent estimates place the prevalence of FASD in Western societies as ranging from 1 per 100 live births (Stade et al., 2008; Thanh, Jonsson, Salmon, & Sebastianski, 2014) to as high as 2-5% of the population (May et al., 2009; Roozen et al., 2016) – a variation partly due to research methodology. Based on a synthesis of research conducted in Western countries, the most recent estimate proposed a community prevalence of 4% in Western countries* (Flannigan, Unsworth & Harding, 2018).

In addition to being more common than previously acknowledged, there is also increasing awareness that FASD is associated with a range of mental health difficulties. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM, 2013) has flagged the neurodevelopmental impact of prenatal alcohol exposure as a condition that warrants further consideration for inclusion as a mental health condition in its own right (DSM, 2013).

FASD appears to be almost as common as more well-known mental health conditions. If the suggestion that the prevalence of FASD may be as high as 4% in the community is to be accepted, FASD appears to occur at a similar rate to many other mental health conditions (e.g. prevalence of anxiety disorders has been estimated at 6.9%; depression at 2.8%; and ADHD at 7.4% [Lawrence et al., 2015]).

Indeed, FASD is actually more common than many other significant health conditions in Western societies. It is approximately two-and-a-half times more common than Autism (estimated to occur in 1.52% of the population) and 28 times more common than Downs Syndrome (estimated to occur in 0.14% of the population) (Flannigan et al., 2018; Nash & Davies, 2017; Popova 2017). These figures suggest FASD should be a priority for community-focused efforts directed at early intervention and prevention.

There are some populations in which FASD appears more common. Children living in foster and residential care (Fuchs & Burnside, 2014; Lange et al., 2013) and young people in forensic and youth justice settings (Bower et al., 2018; Fast, Conry & Loock, 1999) have shown higher rates of both FASD and mental health concerns. There is also considerable overlap between the two groups, with children who are living in care also being more likely to come into contact with the justice system.

Children and adolescents living with FASD are more likely to come into contact with the legal system, either as perpetrators or victims (Parkinson & Mclean, 2013). Early work in this area indicated that 60% of adolescents over the age of 12 who were living with FASD had had contact with the legal system; and 40% of adults living with FASD had experienced incarceration (Streissguth et al., 1996).

It has been estimated that within child and adult correctional facilities, between 11-23% of residents meet criteria for FASD (Fast and Conry, 2011); but more recent research suggests that this may be as high as 36% (Bower et al., 2018). Children and adolescents living with FASD were 19 times more likely to have been incarcerated compared to those without FASD (Popova, Lange, Bekmuradov, Mihic, & Rehm, 2011).

This population also displays significant mental health concerns. A recent study of lower risk juvenile offenders on diversionary programs found that 17.1% had a current mood, anxiety or psychotic disorder (Kang et al., 2017). A recent meta-analysis of research conducted on this issue found that overall, children in the youth justice system experienced mental health conditions at approximately six times the rate of adolescents in the general population (Na & Cho, 2019).

Children and adolescents living with FASD may also be less able to effectively navigate and understand child welfare and forensic systems, due to their underlying neuropsychological issues. In particular, language, memory and planning difficulties can disadvantage children in counselling and mediation environments; settings in which they are required to express their views, generate a coherent narrative, set abstract goals, and engage in verbal contracts (McLean, McDougall & Russell, 2014; Parkinson & McLean, 2013a).

Similarly, the cognitive, language and mental health difficulties of these children may mean that they are unable to participate effectively in legal decision making; and neurodevelopmental impairments may predispose them to ongoing contact with the forensic system (Bower et al., 2018; Lansig et al., 2014; Parkinson & Mclean, 2013a).

FASD appears to co-occur with a range of persistent mental health difficulties. Adults living with FASD reported a significant retrospective history of mental health concerns (over 90% of these adults reported experiencing mental health concerns at some stage of their life; Streissguth, Barr, Kogan, & Bookstein, 1996), making mental health concerns the most commonly experienced ‘secondary disability’ associated with FASD (Streissguth, et al., 1996).

Although the relationship between FASD and mental health problems is not yet fully understood, some aspects of this relationship are clear:

FASD is associated with cognitive vulnerabilities, that are also known to contribute to mental health conditions:
FASD results in cognitive difficulties and inefficient brain processes, leading to less flexible and adaptive social information processing and emotional regulation. Poor executive functioning has been associated with a range of common mental health conditions, including conduct disorder, ADHD, depression and anxiety (e.g., Diamond, 2013; Malloy-Diniz, Miranda, & Grassi-Oliveira, 2017). In other words, FASD may result in more profound damage to the pathways involved in executive control, rendering a child more likely to develop some form of mental health condition. This argument is consistent with a growing recognition amongst researchers of the association between underlying cognitive functioning, particularly executive functioning, and a range of mental health conditions (NIMH, n.d.)

There is considerable overlap between the features of FASD and some mental health difficulties:
The behavioural, attentional and social difficulties reported amongst children living with FASD share considerable overlap with other more well-understood childhood mental health conditions. The profiles of many children suspected of having FASD could meet the screening criteria for conditions such as Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD), language or communication difficulties, Autism Spectrum Disorder or learning difficulties (Anderson et al., 2017; APA, 2013; Nash, Koren, & Rovet, 2009; Nash et al., 2006).

Many children diagnosed by mental health practitioners with common childhood mental health disorders could also meet the diagnostic criteria for FASD. A study of 547 foster and adoptive children referred to a FASD clinic found that 80.1% met the criteria for FASD, but the diagnosis had previously been missed (Chasnoff, Wells, & King, 2015). In this same study the rate of misdiagnosis (i.e. children that had been incorrectly diagnosed with another mental health condition) was 6.4%. The flow-on implications of misdiagnosis may be considerable, as diagnosis will often determine the level and type of support offered to children and families throughout their lives (Anderson et al., 2017).

FASD co-occurs with a range of mental health disorders:
FASD is associated with a range of mental health and physical conditions that are also associated with poorer mental health. A recent systematic review of mental health comorbidity in this area showed that there was considerable comorbidity amongst those living with FASD (Weyrauch et al., 2017). For example, 50% of children living with FASD diagnosis also had a diagnosis of ADHD (10 times the expected population rate); 23% had an intellectual disability (ID) (23 times the expected population rate); and rates of other mental health disorders also occurred at rates that exceeded those expected in the community.

Following ADHD and ID, the most common comorbid diagnoses were:

• Learning Disorder (19.9%)
• Oppositional Defiant Disorder (ODD) (16.3%)
• Depression (14.1%)
• Psychotic Disorder (12.3%)
• Bipolar Disorder (8.6%)
• Anxiety Disorder (7.8%)
• Post-Traumatic Stress Disorder (PTSD) (6.0%)
• Obsessive Compulsive Disorder (OCD) (4.9%); and
• Reactive Attachment Disorder (4.7%) (Weyrauch et al., 2017).

The average age of the participants in these research studies in this systematic review was 10 years. Collectively, the rates of comorbid disorders in these children ranged between 1.5 times and 24.5 times those expected in the population, suggesting a significant, albeit not yet understood, relationship between prenatal alcohol exposure and early onset mental health difficulties.

FASD co-occurs with physical conditions that contribute to mental health difficulties:
FASD is also associated with a diverse range of physical health conditions and disabilities that may increase a child’s risk of developing mental health difficulties over time. Indeed, a recent meta-analysis of comorbid medical and associated conditions identified 428 conditions that could co-occur with FASD.

Amongst these were congenital malformations, deformities, chromosomal abnormalities, and a range of mental and behavioural disorders (Popova et al., 2016). Some of the most common were abnormalities of the peripheral nervous system and senses, conduct disorder, language disorders and chronic serious otitis media.

It appears, therefore, that FASD can also be associated with a range of medical conditions associated with significant stress that could contribute to the development of mental health difficulties over time.

One of the common outcomes of prenatal alcohol exposure is intellectual disability (ID). Many, although not all, children with FASD have significant and global cognitive impairment (McLean & McDougall, 2014). While the relationship between IQ and mental health difficulties has not been well explored in regard to FASD, the relationship between intellectual disability and mental health difficulties is generally well-established (Munir, 2016). A recent review concluded that around 40% of children and adolescents living with intellectual disability also experience a mental health condition, with 30% of these experiencing persistent mental ill health (Munir, 2016).

There are other serious mental health conditions associated with FASD. It is estimated that the rate of alcohol and substance use disorder in this group is five times higher than that expected in the community (Anderson et al., 2017; Streissguth et al., 1996; Yates, Cadoret, Troughton, Stewart, & Giunta, 1998). Studies suggest that 53% of males and 70% of females who were exposed to alcohol prenatally have substance use concerns as adults (Anderson et al., 2017; Streissguth et al., 1996).

It also appears that there is a strong correlation between diagnosis of FASD and suicidality (Anderson et al., 2017). Early research indicated that around 43% of adults living with FASD had threatened suicide and approximately 23% had attempted suicide sometime during their life (Streissguth et al., 1996). More recent research exploring the rate of suicidal attempt by age in the FASD population found that 3% of children aged 6–11 years, 12% of youths aged 12–20 years, and 23% of adults aged 21–51 years had attempted suicide (Huggins, Grant, & Streissguth, 2008).

Taken altogether, this body of work suggests it is critically important for practitioners to consider FASD as a possible contributor to or cause of a child’s current mental health difficulties; and that many behavioural and mental health presentations in affected children may in fact be influenced by underlying neurocognitive issues stemming from prenatal alcohol exposure. Diagnostic overshadowing is a potential concern, especially amongst high risk populations. Where mental health difficulties are significant, there is a risk the potential contribution of FASD may be overlooked; and where FASD is known, there may also be a risk of minimising any comorbid mental health concerns.

Therefore, it is always important for practitioners to be mindful of the potential for significant mental health concerns when working with children and families living with FASD.

There is considerable overlap of FASD with other issues of social and economic significance, such as lifelong mental health difficulties; suicidality and substance use; difficulty with meeting vocational or educational goals; and vulnerability to victimisation and/or offending behaviours. Given this, it is essential for all professionals working with children to have a good understanding of the impact FASD has on children’s lives.

There are factors to consider in order to make services more responsive to the needs of children living with FASD.

Asking about prenatal alcohol exposure

Practitioners need to consider the impact of prenatal factors as part of their assessment and formulation (McLennan, 2015). As a starting point, it seems important for all practitioners, whether in adult-facing or child and family-facing services, to be open to the possibility that prenatal alcohol exposure may be a contributor or companion to a child’s current mental health difficulties.

It is also important to record this information once obtained, as this information can be vital to a child’s ability to obtain a diagnosis later in life. This information can be useful in informing interventions, especially for those families with complex support needs; and for children and young people in out-of-home care, for whom accurate records may not otherwise be available (Anderson et al., 2017; McLean & McDougall, 2014).

Though there currently does not appear to be any way to reverse the impact of prenatal alcohol exposure for the developing fetus, there are nonetheless some important ways in which practitioners can support children. By helping to create a better ‘fit’ between a child’s ability and their social and learning environment, practitioners can minimise the risk of educational disengagement, social and peer relationship difficulties, and behavioural and emotional concerns. Two strategies for this – ‘universal accommodations’ and ‘targeted strategies’ – are discussed in more depth in the resource, 3. How to support children living with Fetal Alcohol Spectrum Disorder (FASD).

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