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A Neurodevelopmental Paradigm for Fetal Alcohol Spectrum Disorder

Natlie Novick BrownSusan RichNatalie Novick Brown, PhD (pictured left)
Susan D. Rich, MD, MPH (pictured right)

Summary: This article provides an overview of how FASD is diagnosed in the new DSM-5 in order to empower judges and other legal professionals for decision making involving afflicted individuals.

Neurodevelopmental disorder associated with prenatal alcohol exposure (ND-PAE; DSM-5, 2013) is a preventable condition that can predispose individuals to early onset criminal behavior and, in many cases, to violent and impulsive aggression. With a 400% increase in moderate-to-heavy maternal alcohol use from 1991-1995 (MMMW, April 25, 1997), an epidemic proportion of 15–20 year olds with ND-PAE is now transitioning into adulthood. Since brain damage and other sequellae of prenatal alcohol exposure (PAE) can occur as early as the late third to early fourth week of pregnancy, the problem has reached a critical threshold from an epidemiological perspective. Given recent increases in alcohol use among reproductive-age women and a 50% unplanned pregnancy rate in the US, millions of young women and their offspring are unknowingly vulnerable to inadvertent PAE prior to pregnancy awareness. For this reason, the US Surgeon General updated the alcohol use advisory among childbearing age and pregnant women in February 2005.

What is ND-PAE?

ND-PAE is a mental health diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that is associated with fetal alcohol spectrum disorders (FASD). For the first time in its 60-plus year history, the DSM has now recognized the neurodevelopmental sequellae of FASD under the diagnostic category “Specified Other Neurodevelopmental Disorder” (315.8). A summary of this perspective is presented in a recent international book chapter on autism spectrum disorder. We believe exclusive use of the DSM-5 diagnostic criteria and code for this population will allow better epidemiologic understanding of affected individuals and help clinicians recognize and treat this tragic but preventable condition. Toward that end, children and adolescents with PAE histories should be assessed by a psychiatrist, psychologist, or social worker to determine the presence of ND-PAE deficits in three overlapping domains:

1. Impaired Neurocognitive Functioning
Intellectual and executive function (EF) deficits and learning and memory problems, which are commonly identified in ND-PAE, can have a debilitating effect on afflicted individuals, leading to substantially impaired adaptive functioning across the lifespan. Intellectual impairment does not always mean intellectual deficiency. In fact, most individuals with FASD have IQs that fall in the average to borderline ranges, and some even have IQs in the superior range.[1] EF skills include problem-solving in novel situations, strategic planning, working memory, response inhibition, emotion and urge control, and cognitive flexibility. EF deficiency is nearly ubiquitous in this population. As we cannot consistently control our moods, urges and behavior without intact executive functioning, individuals with ND-PAE are extraordinarily disabled.

2. Impaired Self-Regulation
Problems in self-regulating mood, attention, impulse control and behavior are primary impairments in ND-PAE. For example, impairments in focusing, sustaining and flexibly shifting attention, and in inhibiting strong feelings and impulsive urges, create a vulnerability to mood problems and “fight or flight responses.” Such difficulties lead to random episodes where afflicted individuals are easily provoked, frustrated, irritated and enraged. Lacking a functioning neurocognitive “rheostat” to appropriately adjust emotional output and curtail urges, these persons may lash out impulsively, unpredictably and aggressively during emotionally charged situations. Many have witnessed or experienced abuse, which not only “models” inappropriate behavior but increases anxiety and mood disorders, thereby exacerbating the underlying tendency to experience rage in times of stress. The tragic consequences that result from these “automatic responses” are too often associated with violent and impulsive criminal behavior (see Figure 1).

Figure 1 bFigure 1. Links between ND-PAE/FASD and criminal behavior.

3. Impaired Adaptive Functioning
It has long been observed in FASD that affected children and adults display arrested development in terms of adaptive behaviors (e.g., language, daily living skills, social skills and moral development).[2],[3] Language skills include ability to understand others’ verbal communication and ability to communicate socially with others in a manner that accurately represents one’s thoughts. Daily living skills include routine tasks within the community as well as at home. Social skills include accurately perceiving and understanding social information, relating to others in an appropriate way, and coping with unexpected events. Socially, individuals with ND-PAE tend to be unsophisticated and naïve and lack the cognitive resources to engage in appropriate social problem-solving. Thus, this population does not understand social responsibility and the importance of following rules/laws. Because of their social vulnerability and gullibility, they are often victimized (American Association on Intellectual and Developmental Disabilities). In childhood, adaptive dysfunction involves academic difficulties and failure, childhood behavior problems, and eventually, early-onset delinquency (see Figure 1). In adolescence and beyond, adaptive dysfunction involves mental health problems and failures in work, relationships and independent living, as well as criminal conduct and substance abuse.

Why Incarceration?

With approximately 40,000 infants born each year in the US with ND-PAE since recognition of fetal alcohol syndrome in the United States in 1973,[4] there now are an estimated 1,600,000 individuals age 40 and below with this preventable neurodevelopmental disorder. Mistaken emphasis on the obvious “FAS face” and/or infrequently encountered intellectual deficiency as criteria for diagnosis and service eligibility has led to children with significant adaptive and neurodevelopmental deficits falling through the cracks in our fragmented systems of care (e.g., education, mental health, medical services, social welfare, juvenile/criminal justice). Hospitals have become revolving doors for "acute stabilization," but when brain-damaged individuals break the law, they tend to be confined immediately and receive few if any services. Deinstitutionalization of the mental health system and lack of community services has led to a default system of care for this vulnerable population (i.e., detention and youth facilities, jails, and prisons). Thus, it is not surprising that the rate of deinstitutionalization since the 1950s mirrors the rate of incarceration (Figure 2).[5]Figure 2

Figure 2. Deinstitutionalization versus incarceration, 1934-2000.

Intervention and Prevention: Upstream Solutions
Given the prevalence rates of ND-PAE, we advocate that all youth entering the criminal justice system be screened routinely for histories of PAE, referred for diagnosis by mental health professionals if screening is positive, and if diagnosed with ND-PAE, provided appropriate services and supports (e.g., case management, structured residential placements, medical and mental health services, school/work supports) upon re-entry into the community. There are currently few stopgap primary preventive measures in our society for the ubiquitous problem of ND-PAE, which may have occurred by the time most women learn they are pregnant. However, the first step toward ameliorating the situation is awareness of the neurodevelopmental sequellae in FASD so that legal and social service professionals can make decisions affecting this population within an informed context.

Author biographies:

Natalie Novick Brown is a licensed psychologist in Washington State and Florida. In her 20-year practice, she has specialized in fetal alcohol spectrum disorders, developmental disabilities and child development. She obtained her doctorate in clinical psychology from the University of Washington in Seattle, which included an 18-month internship in forensic evaluation. She then completed a post-doctoral fellowship in fetal alcohol spectrum disorders (FASD) with Ann Streissguth, pioneer researcher in the field. Brown is the founder and program director for FASDExperts, a multidisciplinary group of professionals that conducts forensic FASD evaluations throughout the United States. She is a clinical assistant professor in the University of Washington’s School of Medicine, Department of Psychiatry and Behavioral Sciences, where she consults with the Fetal Alcohol and Drug Unit on secondary disabilities and conducts research on FASD. Brown has published numerous articles and book chapters on FASD and conducted national and international trainings for legal, criminal justice, government, and mental health professionals.

Dr. Susan Rich is a board certified child/adolescent psychiatrist who has worked in the field of fetal alcohol spectrum disorder (FASD) prevention and treatment since 1993. She has developed a number of programs for women in recovery and their dependent children in North Carolina and evaluates and treats children and adults with FASD in her private practice in Maryland. Since 1998, Rich has advocated for inclusion of FASD/ARND in the Diagnostic and Statistical Manual (DSM) and presented an action paper on the topic to the American Psychiatric Association (APA) assembly in 2005. On several occasions, she has served as an expert in criminal cases on behalf of individuals with FASD. She holds medical licenses in Maryland, the District of Columbia, Pennsylvania, Georgia, and Tennessee.


[1] Streissguth, A., Barr, H., Kogan, J., & Bookstein, F. (1996). Understanding the occurrence of secondary disabilities in clients with fetal alcohol syndrome (FAS) and fetal alcohol effects (FAE). Final Report: Centers for Disease Control and Prevention Grant No. R04/CCR008515.

[2] Schonfeld, AM, Mattson, SN, & Riley, EP (2005). Moral maturity and delinquency after prenatal alcohol exposure. Journal of Studies in Alcohol, 66, 545-554.

[3] Roebuck, T. M., Mattson, S. N., & Riley, E. P. (1999). Behavioral and psychosocial profiles of alcohol-exposed children. Alcohol Clinical and Experimental Research, 23, 1070-1076.

[4] Jones, KL, Smith, DW, Ulleland, CN, & Streissguth, AP (1973). Pattern of malformations in offspring of alcoholic mothers,” The Lancet, 1, 1267–71.

[5] Harcourt, BE (2011). Reducing mass incarceration: Lessons from the deinstitutionalization of mental hospitals in the 1960s. Ohio State Journal of Criminal Law, 9, 53-88.


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