Mental Health Resource and Practice Guide

Everyone has their own unique sets of strengths and challenges and there are a variety of additional factors that contribute to the distinctive complexities associated with FASD, including the social determinants of health, intergenerational impacts, compounding stigma, environmental adversity, co-occurring mental health issues, and unique caregiver and family experiences¹. Understanding some of the common challenges and strengths associated with this disability can help us to work from an FASD-informed perspective. However, when supporting an individual with FASD, it is important to come to understand each person’s individual needs and capabilities. This section will discuss:

Areas of Strengths

Beyond simply recognizing that individuals with FASD have areas of strength (although this is an important first step given the prominent deficit-focused perspective in care), we must also build upon and leverage these strengths. When we do not explore and utilize these strengths, it can continue to reinforce challenges for individuals with FASD with self-esteem and can exacerbate the shame that many individuals with FASD already experience.

In the following video, Myles Himmelreich discusses the focus that is typically faced on deficits when discussing FASD and expresses that his difficulties and diagnosis do not define him.

Flannigan and colleagues (2021) highlighted the following strengths for people with FASD in their research, which are important considerations in the context of mental health support:

• Strong self-awareness
• Receptiveness to support
• Capacity for human connection
• Perseverance through challenges
• Hope for the future

These capabilities are vitally important in the context of mental health therapy and support and can be built upon and used to increase wellbeing. Creating opportunities to actualize these strengths may help to support a heightened sense of wellbeing and happiness.

For additional information on working from a strengths-based perspective, see Section 7.

Reframing Behaviour

When supporting individuals with FASD it is important to be informed about the strengths and challenges people may have. Reframing challenging behaviour can be an integral part of adapting one’s practice to the unique needs of each person with FASD. Mental health professionals may initially perceive difficulties or a lack of change as intentional, a lack of motivation, or a lack of effort instead of seeing needs that require support and flexibility of approach. Reframing challenging behaviour allows you to assess needs, strengths, and strategies to better support someone.

FASD Throughout the Lifespan

Prenatal alcohol exposure and a diagnosis of FASD can have impacts on a person throughout their life. It is important to understand that as we all grow up our capacities and goals will change. FASD can have impacts from birth, with biological and genetic vulnerabilities that can then be exacerbated by behavioural, social, and environmental factors as one grows up¹². As mental health professionals, reflecting on the specific developmental capacities of our clients, as well as how this continues to be influenced by one’s life experiences, is important in adapting our practices for success. We need to consider the individual holistically and across time⁹_.

The following are areas of challenges and behaviours that people with FASD may experience across their lifespan.

Childhood

• Developmental delays (e.g., in language, motor skills, physical growth, etc.)
• Issues with emotional and behavioural regulation, activity level, and response to overstimulation
• Social difficulties (e.g., being overly friendly, not understanding social cues, communication challenges, difficulty making friends)
• Challenges moving from concrete to abstract concepts
• Lack of focus, and hyperactivity (e.g., difficulty with unstructured time)
• Not learning from consequences

Without the understanding of brain-based differences as well as the vulnerability to negative life experiences, unrealistic/inappropriate expectations of behaviour and ability can continually set children up for failure. It is important to take a life course approach and recognize that transitions and experiences can greatly impact the trajectories for children and youth¹³. Appropriate support and interventions that consider the influence of adverse experiences, cognitive, behavioural, and socio-emotional functioning is important to respond appropriately and effectively¹².

In childhood, challenges within cognition, learning and memory, attention, and academic achievement may begin to be observed¹⁴. It has also been found that children with FASD may have an increased rate of mood disturbances such as depressive symptoms as well as oppositional defiant disorder, conduct disorder, and ADHD⁷.

It is also important to recognize that children with FASD are more vulnerable to experience abuse, neglect, challenges in education, involvement with the criminal justice system, co-occurring mental health conditions, alcohol and substance use, and are also overrepresented in the child welfare system^13. In 2019, Cook and colleagues reported that at least 3-11% of children in the child welfare system have FASD (the general population rate of FASD is 2-4%). It is a common adverse experience for people with FASD to have unstable home placements and caregiver disruptions¹³. However, having a stable and nurturing home environment is an integral protective factor for individuals with FASD^13,15. It is therefore important to consider the larger caregiver/familial environment when working with children with FASD.

Adolescence

• Increasing behavioural and emotional regulation difficulties
• Challenges with critical thinking, abstract thinking and judgment skills
• A lack of connection between thoughts, feelings and actions
• Potential challenges in school (e.g., disruption, getting in trouble), involvement with the law, and/or sexually inappropriate behaviour
• Issues with self-esteem, impulsivity, and motivation
• Heightened risk of mental health challenges and substance use concerns
• Difficulty resisting negative peer influences
• May have trouble with accurately interpreting social cues (e.g., words, actions, non-verbal cues)

Adolescence and teenage hood present its own unique challenges for individuals, families, and caregivers. Without identification and support, challenges from childhood are likely to be exacerbated and impacted by changing biology and social expectations. It is also important to remember that, as mentioned previously, FASD can result in uneven development, and so an adolescent may be skilled, and talented in some areas but need significant support in others. This discrepancy can sometimes result in a misinterpretation of teenage behaviour as lazy or unmotivated rather than seeing it as an area of need.

Adolescents also have significant strengths and have a desire for their unique characteristics to be recognized and appreciated¹⁶. Children and adolescents have reported challenges with anxiety which can impact independence and confidence and may lead to becoming socially isolated or struggling to engage in school¹⁶. Therefore, promoting positive relationships and developing coping mechanisms for anxiety may be important practice considerations for mental health professionals. When supporting teenagers and adolescents, it may also be important to engage with the family and/or caregivers.

Adults

• Potential difficulties with education (e.g., attainment, disruption) as well as employment
• Challenges with independent living and adaptive skills (e.g., self-care, money management, social communication, relationships)
• Social skill issues (e.g., difficulties with communication and/or developing relationships)
• Co-occuring mental health challenges/diagnoses are likely (e.g., anxiety, depression, ADHD)
• Potential to withdraw or self-isoalte

People with FASD when not supported or provided with appropriate interventions can have an increased vulnerability to encounter negative life experiences as adults such as challenges with independent living and employment, involvement with the law, confinement due to mental health, and problems with sexually inappropriate behaviour¹⁵. For example, 11-23% of youth and 10-18% of adults in correctional settings were reported to have FASD (compared to 2-4% in general population)¹⁷. It is important to consider the intersecting challenges and life experiences that may affect adults with FASD who are accessing mental health support. The variation of difficulties in multiple areas also speaks to the need for a multidisciplinary and collaborative approach to care.

Becoming a Parent

Becoming a parent is a pivotal moment for anyone, filled with demands and a need for support. The skills and abilities of parents are constantly evolving, including for parents with FASD⁹. Canadian estimates of the number of parents living with FASD are generally around 300,000¹⁸. People with FASD who become parents may also face a variety of personal challenges that impact their ability to parent such as difficulties with memory, organization, and integrating sensory cues as well as systemic barriers such as societal attitudes, scrutiny of parenting, and subsequent anxiety and feelings of inadequacy⁹.

These challenges may also be exacerbated by adverse life experiences (e.g., trauma, abuse, entanglement with criminal justice or child welfare systems), lack of support, and isolation^{19, 11}. Mental health providers should consider the ways in which the social determinants of health, access to health care, education, and employment also impact individuals with FASD¹⁹_.

Abraham (2005) identified the most pressing needs of parents with FASD to be²⁰:

• Support with the practical and domestic skills required to care for children
• Training on parental skills and child development
• Assistance with obtaining public and social service
• Formal and informal relational support

Some strategies to support parents may include developing appropriate coping mechanisms, discussing parenting strategies, and identifying a safety net of support for the individual and family (including people, programs, resources)^11. Parents have also identified effective strategies including the frequent use of a calendar, highly detailed instructions, having a consistent routine, taking time for themselves, and focusing on positive behaviours of their children¹⁸. In addition, it may be important for a parent with FASD to have a relationship with a parental mentor who can support navigating common behaviours and experiences as it can be helpful to understand and see how other people navigate parenting and relationships.

However, it is also important to consider that although improving parenting skills may be an important goal for parents with FASD, this improvement should be considered in the context of first addressing urgent needs such as safety, stable housing, food security, financial stability, and mental health and substance use treatment^{21, 19}_.

Sex-Related Differences

Considering the sex and gender related differences in health and wellbeing can be important in understanding and supporting people with developmental disabilities. There is limited research on sex and gender related differences for people with FASD, as well as research that highlights the experiences and lived realities of FASD for gender-diverse people.

A recent study aimed to inform the practice of service providers working with people with FASD/prenatal alcohol exposure, with attention on exploring the overlapping and differing needs and experiences of males and females. The findings highlighted that there were no significant differences for FASD diagnostic outcomes or physical indicators of prenatal alcohol exposure²².

However, there were important differences with males experiencing significantly more neurodevelopmental impairment, high rates of ADHD, conduct disorder, and oppositional defiance disorder, and females experiencing higher rates of endocrine problems, anxiety, and depressive/mood disorders²².

There were also differences in terms of adversity, with males experiencing more difficulties with school and offending/incarceration and females experiencing higher rates of trauma and legal problems with victimization and custody²².

However, the authors also note that, “the dichotomous distinction between male and female can oversimplify the complex, nuanced, and dynamic interactions between sex and gender and related life experiences, as well as the broader…sociocultural factors^”22. As such, additional research is needed that explores the intersections of sex, gender, and FASD. Unfortunately, there is currently limited evidence and research regarding the experiences of people with FASD and those who identify as having diverse sexual orientations, gender identities, and gender expressions. See Gap Analysis: Sexual Orientation, Gender Identity, Gender Expression, and FASD.

As a mental health professional, it is important to consider and reflect on how the sex and gender identity of the client you are supporting may impact their experiences of violence, trauma, mental and physical health.

FASD and Families

There is a vast spectrum of family types who are raising youth with FASD, as many children with FASD may not reside with their birth families but may be raised in adoptive or foster settings, with grandparents or great-grandparents, with other extended family members, kinship networks, etc. and FASD can have a large impact on everyone in the family unit^23,1. Receiving a diagnosis of FASD can be difficult to access (especially as an adult), may be costly, and common challenges of FASD may not be prominent enough to seek out a diagnosis²³. Without a diagnosis children and families can be left without the help they require, and many caregivers will continue to play a support role for their children well into adulthood because of the lack of services¹.

Parents of children with FASD can experience a range of emotional reactions and challenges including stress, social isolation, feeling misunderstood, and being blamed by service providers for the challenges of their children^23,1. Parents have also reported that having a child with FASD can impact their other children, as well as relationships with extended family members²³. There is generally a lack of understanding and knowledge regarding FASD in society, as well as in social services and support, which can result in a lack of assistance and understanding for parents²³.