Evaluation of the Psychotropic Medication Algorithm for Fetal Alcohol Spectrum Disorder

Dr. Mela and a team of 12 multidisciplinary international experts have spent over 2 years developing a decision-tree style medication algorithm to guide prescribers as they see patients with Fetal Alcohol Spectrum Disorder/Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (FASD/ND-PAE). This algorithm is the first-ever treatment recommendation for psychotropic medications for FASD/ND-PAE. It is based on all available evidence (albeit very limited), which was consolidated in a recently published systematic review (Mela M, Okpalauwaekwe U, Anderson T, Eng J, Nomani S, Ahmed A, Barr AM. The utility of psychotropic drugs on patients with Fetal Alcohol Spectrum Disorder (FASD): a systematic review. Psychiatry and Clinical Psychopharmacology. 2018:1-10). From there, the algorithm was developed by considering the evidence and incorporating the clinical perspective of the expert panel. Now that the algorithm is developed, it needs to be evaluated to understand the effectiveness and allow for improvements for future iterations.


This medication algorithm is intended for individuals with a primary diagnosis of:

Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure

Fetal Alcohol Syndrome Disorder (with or without sentinel facial features)

Alcohol-related Neurodevelopmental Disorder

As a clinician, it is important to identify the primary “clusters” (domains) to target treatment. The first line of treatment is reserved for the cluster with the most impairing effect on functioning. After an adequate trial of the medications from the first line, medications from the second line can be tried, followed by other traditional guidance. Finally, if the first or second line medications are not effective, the adjunct treatment may be considered from the list in the algorithm.

The clusters include:

  • Hyper-arousal (with hypervigilance, aggression, insomnia, irritability, agitation, anger, anxiety, tension, reduced pain threshold)
  • Emotional dysregulation (with mood swings, excitability, anxiety, depression)
  • Hyperactivity/Neurocognitive (with restless movements, impulsiveness, inattention, distractibility and executive dysfunction)
  • Cognitive inflexibility with impaired perspective taking, poor abstraction, low frustration tolerance, poor social skills and impaired reasoning and reality testing