A TREATMENT IMPROVEMENT PROTOCOL

Addressing Fetal Alcohol 

Spectrum Disorders 

(FASD)

TIP 58
A TREATMENT IMPROVEMENT PROTOCOL

Addressing Fetal Alcohol 

Spectrum Disorders 

(FASD)

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Prevention

1 Choke Cherry Road

Rockville, MD 20857

TIP 58
Addressing Fetal Alcohol Spectrum Disorders (FASD)

Acknowledgments

This publication was produced by Northrop Grumman under the FASD Center for Excellence 

contract number HHSS283201200017I/HHSS28342002T with the Substance Abuse and 

Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human 

Services (HHS). Patricia B. Getty, Ph.D., Jon Dunbar-Cooper, M.A., C.P.P., CDR Josefine 

Haynes-Battle, R.N., B.S.N., M.S.N., and LCDR Daniel A. Bailey, M.S., M.B.A., served as 

the Center for Substance Abuse Prevention (CSAP) FASD Center for Excellence Contracting 

Officer Representatives, with Dr. Getty providing guidance, comments, and contributions 

throughout the development and review of this publication.

Disclaimer

The views, opinions, and content of this publication are those of the authors and do not 

necessarily reflect the views, opinions, or policies of SAMHSA or HHS. 

Public Domain Notice

All materials appearing in this volume except those taken directly from copyrighted sources are 

in the public domain and may be reproduced or copied without permission from SAMHSA/

CSAP. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of 

Communications, SAMHSA, HHS. 

Electronic Access and Copies of Publication

This publication may be ordered from SAMHSA’s Publications Ordering Web page at 

http://store.samhsa.gov/home. Or, please call SAMHSA at 1-877-SAMHSA-7 

(1-877-726-4727) (English and Español). 

Recommended Citation

Substance Abuse and Mental Health Services Administration. Addressing Fetal Alcohol Spectrum 

Disorders (FASD). Treatment Improvement Protocol (TIP) Series 58. HHS Publication No. 

(SMA) 13-4803. Rockville, MD: Substance Abuse and Mental Health Services Administration, 

2014.

Originating Office

Quality Improvement and Workforce Development Branch, Division of Services Improvement, 

Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services 

Administration, 1 Choke Cherry Road, Rockville, MD 20857.

HHS Publication No. (SMA) 13-4803

Printed 2014

ii
Contents

Consensus Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix 

What Is a TIP? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii 

How This TIP Is Organized . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv 

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii 

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of 

Childbearing Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

Professional Responsibility to Screen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 

Risk Factors for an AEP [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 

Drinking Rates Among Pregnant Women [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 

Procedures for Screening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

A Screening Decision Tree for AEP Prevention [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 

Selecting An Appropriate Prevention Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 

What’s a Standard Drink? [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 

Universal Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 

Universal AEP Prevention Statement and Possible Follow-Up Questions [box] . . . . . . . . . 7 

Selective Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

F.L.O. (Feedback, Listen, Options) [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 

FRAMES [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 

Indicated Prevention: Alcohol Screening & Brief Intervention (SBI) . . . . . . . . . . . . . . . . . . . . . 9 

Providing Intervention/Treatment: Additional Factors to Consider . . . . . . . . . . . . . . . . . . . . . 10 

Ensuring Effective Contraception [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 

Approaches to Resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

Procedures for Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

Resistant, Reluctant, Resigned, or Rationalizing [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 

Targeted Referral Options [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 

Providing a Referral: Additional Factors to Consider . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 

Helping Your Client Receive Culturally Competent Services [box] . . . . . . . . . . . . . . . . . . 14 

Working with Women Who May Have an FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 

Chapter 2: Addressing FASD in Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 

Value of Addressing FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Be Willing... [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

Identifying the Need for FASD Assessment, Diagnosis, and Services: Suggested Steps . . . . . . 18 

iii
iv

Addressing Fetal Alcohol Spectrum Disorders (FASD)

1. The Starting Point: Observing Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

Identifying Barriers and Causes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 

2. Functional Observation and History/Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 

An Appropriate Approach to Observation and Interviewing . . . . . . . . . . . . . . . . . . . . . . . . . . 20 

The FASD 4-Digit Code Caregiver Interview Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

The FASD 4-Digit Code Caregiver Interview Checklist [box] . . . . . . . . . . . . . . . . . . . . . 21 

3. Assessment (External or Through an In-House Assessment Team) . . . . . . . . . . . . . . . . . . . 22 

Risk Assessment Questions [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 

In-House Assessment: The Essential Elements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 

In-House Assessment: An Ideal Core Team [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 

External: Assessment and Diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 

Overview of the Diagnostic Process (As Performed by the FAS DPN) [box] . . . . . . . . . . 25 

When the Client Already Has a Diagnosis of an FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 

4. Tailoring Treatment for Individuals with an FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 

General Principles for Working with Individuals Who Have or May Have an FASD . . . . . . . 27 

Suicide Intervention/Prevention for Individuals with an FASD [box] . . . . . . . . . . . . . . . . 29 

The Navigator [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 

Special Considerations for Adolescents Who Have or May Have an FASD . . . . . . . . . . . . . . 38 

Treatment Tips From the Field [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 

Adolescent Development Issues in FASD [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 

Counselor Self-Assessment [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 

5. Working with the Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 

Top Unmet Needs for Caregivers Raising Children who have FASD and Behavior 

Problems [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 

6. Transition and Connection to Community Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 

Transitional Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 

Connection to Community Supports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 

Chapter 3: Clinical Vignettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

The Culturally Competent Counselor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Areas of Clinical Focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 

Attitudes and Behaviors of Culturally Competent Counselors [box] . . . . . . . . . . . . . . . . . 50 

Organization of the Vignettes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 

Vignette 1: Intervention with a woman of childbearing age who suffers from depression, is 

consuming alcohol, and may become pregnant (AEP Prevention) . . . . . . . . . . . . . . . . . . . 51 
v

Vignette 2: Examining alcohol history with a woman of childbearing age in substance abuse 

treatment for a drug other than alcohol (AEP Prevention) . . . . . . . . . . . . . . . . . . . . . . . . . 54 

Vignette 3: Intervention with a woman who is pregnant (AEP Prevention) . . . . . . . . . . . . . . . 57 

Vignette 4: Intervention with a woman who is pregnant and consuming alcohol, and who is 

exhibiting certain triggers for alcohol consumption, including her partner 

(AEP Prevention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 

Vignette 5: Interviewing a client for the possible presence of an FASD 

(FASD Intervention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Vignette 6: Interviewing a birth mother about a son who may have an FASD and is having 

trouble in school (FASD Intervention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 

Vignette 7: Reviewing an FASD diagnostic report with the family 

(FASD Intervention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 

Vignette 8: Making modifications to treatment for an individual with an FASD 

(FASD Intervention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 

Vignette 9: Working with an adoptive parent to create a safety plan for an adult male 

with an FASD who is seeking living independence (FASD Intervention) . . . . . . . . . . . . . 82 

Vignette 10: Working with a birth mother to develop strategies for communicating with a 

school about an Individualized Education Plan for her daughter, who has an FASD 

(FASD Intervention) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 

Part 2: Administrator’s Guide to Implementing FASD Prevention and Intervention . . . . . 93 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 

Chapter 1: The Administrative Response to FASD in Behavioral Health Settings . . . . . . . 95

Why SAMHSA Created an Implementation Guide as Part of This TIP . . . . . . . . . . . . . . . . 95 

Why Address FASD Prevention and Intervention? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 

Thinking About Organizational Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Key Elements of Assessment and Planning [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 

Key Principles of Implementation [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 

Resistance/Response [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 

The Role of the Administrator in Introducing and Supporting New Clinical Practices . . . . . 102 

Key Elements of Leadership [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency . . . . . . . . . 105 

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 

Assessment and Planning Before Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106 

Figure 2.1 How to Decide Whether to Implement a Policy for Addressing FASD . . . . . 106

How-To 2.1: How to Identify the Issue or Need [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

How-To 2.2: How to Assess Current Capacity to Address FASD [box] . . . . . . . . . . . . . 107 

How-To 2.3: How to Organize a Team to Address the Problem [box] . . . . . . . . . . . . . . . 108 

How-To 2.4: How to Identify a Specific Outcome to Target for Change [box] . . . . . . . . 109 

How-To 2.5: How to Assess the Agency’s Organizational Readiness for 

Implementation [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 

Contents
vi

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Addressing Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 

Sample Policy 1a: Clinical staff training and competency [FASD intervention] [box] . . . 112 

Sample Policy 1b: Clinical staff training and competency [FASD prevention] [box] . . . . 112

Sample Policy 2a: Recruitment, training, and supervision of FASD-capable clinical 

staff [FASD intervention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 

Sample Policy 2b: Recruitment, training, and supervision of clinical staff capable of 

screening women of childbearing age (whether pregnant or not) for alcohol 

consumption [FASD prevention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114 

Sample Policy 3a: Observation and referral of clients exhibiting signs of an FASD 

[FASD intervention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 

Sample Policy 3b: Screening and referral of female clients of childbearing age 

exhibiting signs of an alcohol use/abuse [FASD prevention] [box] . . . . . . . . . . . . . . . . . . 115 

Sample Policy 4a: Treatment planning, service recording, discharge planning, and 

continuity of care [FASD intervention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Sample Policy 4b: Treatment planning, service recording, discharge planning, and 

continuity of care [FASD prevention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Sample Policy 5a: Counselor performance appraisal [FASD intervention] [box] . . . . . . . 118

Sample Policy 5b: Counselor performance appraisal [FASD prevention] [box] . . . . . . . . 118

Sample Policy 6a: Evaluation of service effectiveness and quality assurance 

[FASD intervention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Sample Policy 6b: Evaluation of service effectiveness and quality assurance 

[FASD prevention] [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Addressing Relevant Regulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 

Addressing Staff Competence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123

How-To 2.6: How to Assess the Frontline Staff and Clinical Supervisors for 

Change [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 

Checklist 1: Characteristics and Competencies of Administrative and Support 

Staff [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 

Checklist 2: Characteristics and Competencies of All Clinical Staff [box] . . . . . . . . . . . . 126 

Checklist 3: Characteristics and Competencies of Counselors [box] . . . . . . . . . . . . . . . . . 127 

Checklist 4: Characteristics and Competencies of Clinical Supervisors [box] . . . . . . . . . . 129 

Figure 2.2 Recommended Credentials for Individuals Providing Training in FASD . . . . 131

How-To 2.7: How to Select a Trainer [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 

How-To 2.8: How to Continue the Learning After the Initial Training is 

Completed [box] . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 

Addressing Community Relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133 

Addressing Financial Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 

Addressing Continuity and Fidelity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 

Figure 2.3 Avenues for Communicating Organizational Commitment to Delivering 

Services to Address FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
vii

Appendix A—Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 

Appendix B—Selected Screening Instruments for Identifying Alcohol Use Among 

Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Appendix C—Public and Professional Resources on FASD . . . . . . . . . . . . . . . . . . . . . . . . . 161

Appendix D—The FASD 4-Digit Code Caregiver Interview Checklist: Profiles 

of FASD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166

Appendix E—Comparison of Current FASD Diagnostic Systems . . . . . . . . . . . . . . . . . . . . 168

Appendix F—Sample Crisis/Safety Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Appendix G—Services and Supports Checklist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Appendix H—Operational Standards for Fetal Alcohol Spectrum Disorders (FASD): 

A Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

Appendix I—Stakeholder Meeting Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Appendix J—Field Reviewers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Appendix K—Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

Contents

ix

Consensus Panel

Chairs, Part 1 and Part 2 

Consensus Panels 

Sterling K. Clarren, M.D., FAAP

Chief Executive Officer and Scientific 

Director

Canada NW FASD Research Network, 

Vancouver, British Columbia

Clinical Professor of Pediatrics

University of British Columbia, Vancouver, 

British Columbia

Clinical Professor of Pediatrics

University of Washington, Seattle, Washington

Melinda Ohlemiller, M.A.

Chief Executive Officer

Nurses for Newborns Foundation

St. Louis, Missouri

Part 1 Consensus Panel 

Members 

Susan Adubato, Ph.D. 

Director

Northern New Jersey FAS Diagnostic Center, 

Newark, New Jersey

Director

New Jersey/North East FASD Education and 

Research Center

University of Medicine and Dentistry of New 

Jersey

New Jersey Medical School, Newark, New 

Jersey

Mercedes Alejandro 

FASD Prevention Advocate

The Arc of Greater Houston

Houston, Texas

Mary C. DeJoseph, D.O. 

Adjunct Faculty

Philadelphia College of Osteopathic Medicine

Palmyra, New Jersey

Norma Finkelstein, Ph.D., LICSW

Executive Director

Institute for Health and Recovery

Cambridge, Massachusetts

Therese Grant, Ph.D. 

Ann Streissguth Endowed Professor in Fetal 

Alcohol Spectrum Disorders

University of Washington School of Medicine

Director, Washington State Parent-Child 

Assistance Program

Seattle, Washington

Patricia Moran 

Program Manager

White Earth Substance Abuse Program

Ponsford, Minnesota

Mark B. Sobell, Ph.D., ABPP

Professor /& Co-Director

Healthy Lifestyles Guided Self-Change 

Program

Center for Psychological Studies

Nova Southeastern University

Fort Lauderdale, Florida
x

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Jasmine Suarez-O’Connor

Network Coordinator

Self Advocates with FASD in Action (SAFA)

Scotia, New York

Diane L. O’Connor 

FASD Prevention Initiative

Research Foundation of Mental Hygiene

Support Person

Self Advocates with FASD in Action

Albany, New York

Part 2 Consensus Panel 

Members 

Hortensia Amaro, Ph.D.

Hortensia Amaro, Ph.D.

Associate Dean and Distinguished Professor

Bouve College of Health Sciences

Director, Institute on Urban Health Research

Northeastern University

Boston, Massachusetts

L. Diane Casto, M.P.A.

Manager

Behavioral Health, Prevention & Early 

Intervention Services

Alaska Department of Health and Social 

Services

Juneau, Alaska

Deborah E. Cohen, Ph.D.

Director

Office for Prevention of Mental Retardation 

and Developmental Disabilities

State of New Jersey (Retired)

Norma Finkelstein, Ph.D., LICSW

Executive Director

Institute for Health and Recovery

Cambridge, Massachusetts

Sidney L. Gardner, M.P.A.

President

Children and Family Futures

Irvine, California

Pamela Gillen, N.D., R.N., CACIII

Director

Colorado FASD/ATOD Substances 

Prevention Outreach Project (COFAS)

University of Colorado at Denver

Aurora, Colorado

Logan Lewis, LMSW, CASAC

Clinical Director

Camelot Counseling

Jamaica, New York

Donna N. McNelis, Ph.D.

Director, Behavioral Healthcare Education

Vice-Chair, Program Development & 

Administration

Professor of Psychiatry

Drexel University College of Medicine

Philadelphia, Pennsylvania

Sara Messelt

Executive Director

Minnesota Organization on Fetal Alcohol 

Syndrome (MOFAS)

St. Paul, Minnesota

Heather Carmichael Olson, Ph.D.

Department of Psychiatry and Behavioral 

Sciences

University of Washington School of Medicine

Seattle Children’s Hospital Child Psychiatry 

Outpatient Clinic

Fetal Alcohol Syndrome Diagnostic and 

Prevention Network

Seattle Children’s Hospital Research Institute

Families Moving Forward Program

Seattle, Washington

Deborah Stone, Ph.D.

Social Science Analyst

Center for Mental Health Services (CMHS)

Rockville, Maryland (Retired)
xi

What Is a TIP?

The Treatment Improvement Protocol (TIP) series, which has been published by the Substance 

Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department 

of Health and Human Services (HHS) since 1993, has generally offered best-practices guidelines for the treatment of substance use disorders. For this TIP, the Center for Substance Abuse 

Prevention (CSAP), a sub-agency within SAMHSA, has drawn on the experience and knowledge of clinical, research, and administrative experts. As behavioral health disorders are increasingly recognized as a major problem, the audience for the TIPs is expanding beyond public and 

private treatment facilities to include practitioners in mental health, criminal justice, primary 

care, public health, and other healthcare and social service settings. 

The recommendations contained in each TIP are grounded in an evidence base. Evidence 

includes scientific research findings and the opinion of the TIP consensus panel of experts that 

a particular practice will produce a specific clinical outcome (measurable change in client status). In making recommendations, the consensus panel engages in a process of “evidence-based 

thinking” in which they consider scientific research, clinical practice theory, practice principles, 

and practice guidelines, as well as their own individual clinical experiences. Based on this thinking, they arrive at recommendations for optimal clinical approaches for given clinical situations. 

Relevant citations (to research outcome reports, theoretic formulations, and practice principles 

and guidelines) are provided. 

TIP Format 

This TIP is organized into three parts: 

•	 Part 1 for behavioral health practitioners focuses on providing appropriate counseling 

methods and frameworks. 

•	 Part 2 for program administrators focuses on providing administrative support to 

implement adoption of the counseling recommendations made in Part 1. 

•	 Part 3 for clinical supervisors, program administrators, and interested practitioners is an 

online literature review that provides an in-depth look at relevant published resources. 

Part 3 will be updated regularly following publication of the TIP. 

Ideally, it is envisioned that a supervisor might assemble a small group of counselors, distribute 

copies of this TIP (which are free), and begin a series of six or so meetings where the materials 

in the TIP would be reviewed, discussed, and in other ways used as an educational and training 

vehicle for the improvement of treatment skills (with the particulars of how this training would 
be done determined by the individual supervisor, based upon her or his unique situation, needs, 

and preferences). Thus, after a relatively short period of time and with only limited additional 

resources, this TIP could help to meet the challenge of fostering a specific kind of improvement 

in service delivery. 

Development Process

The need for this TIP was identified through a collaborative discussion with leadership from 

each of SAMHSA’s three Centers; CSAP, the Center for Substance Abuse Treatment (CSAT), 

and the Center for Mental Health Services (CMHS). Two consensus panels of experts were 

convened; one for clinical issues, and the other for administrative guidelines. The TIP was then 

field reviewed by an external group of subject matter experts, who provided suggestions for further refining the document (see appendix J).

TIPs Online

TIPs can be accessed via the Internet at http://store.samhsa.gov/home. The online Addressing 

Fetal Alcohol Spectrum Disorders: Part 3, A Review of the Literature, which will be updated periodically, is available at http://store.samhsa.gov/home.

Terminology

Throughout the TIP, the term “behavioral health” is used to refer to both substance abuse treatment and mental health settings. (The term can, in fact, refer to many types of health settings, 

but the primary audiences for this TIP are substance abuse treatment and mental health providers.) The term “substance abuse” has been used to refer to both substance abuse and substance 

dependence (as defined by the Diagnostic and Statistical Manual of Mental Disorders, 5th edition

[DSM-5] [American Psychiatric Association 2013]). This term was chosen partly because substance abuse treatment professionals commonly use the term “substance abuse” to describe any 

excessive use of addictive substances. In this TIP, the term refers to the use of alcohol as well as 

other substances of abuse. Readers should note the context in which the term occurs in order to 

determine what possible range of meanings it covers; in most cases, however, the term refers to 

all varieties of substance use disorders described by the DSM-V. 
xiii

Foreword

The Treatment Improvement Protocol (TIP) series supports SAMHSA’s mission of building 

resilience and facilitating recovery for people with or at risk for mental or substance use disorders by providing best practices guidance to clinicians, program administrators, and payors to 

improve the quality and effectiveness of service delivery and, thereby, promote recovery. TIPs are 

the result of careful consideration of all relevant clinical and health services research findings, 

demonstrated experience, and implementation requirements. Clinical researchers, clinicians, and 

program administrators meet to debate and discuss their particular areas of expertise until they 

reach a consensus on best practices. This panel’s work is then reviewed and critiqued by field 

reviewers. 

The talent, dedication, and hard work that TIP panelists and reviewers bring to this highly participatory process have helped bridge the gap between the promise of research and the needs of 

practicing clinicians and administrators to serve, in the most scientifically sound and effective 

ways, people who abuse substances. We are grateful to all who have joined with us to contribute 

to advances in the substance abuse treatment field.

Pamela S. Hyde, J.D. 

Administrator, Substance Abuse and Mental Health Services Administration 

Dr. H. Westley Clark, M.D., 

J.D., M.P.H., CAS, FASAM

Director

Center for Substance Abuse 

Treatment 

Substance Abuse and 

Mental Health Services 

Administration

Frances M. Harding

Director

Center for Substance Abuse 

Prevention 

Substance Abuse and 

Mental Health Services 

Administration

A. Kathryn Power, M.Ed.

Director

Center for Mental Health 

Services 

Substance Abuse and 

Mental Health Services 

Administration

xv

How This TIP Is Organized

This TIP is divided into three parts: 

•	 Addressing Fetal Alcohol Spectrum Disorders, Part 1: Background and Clinical Strategies for 

FASD Prevention and Intervention

•	 Addressing Fetal Alcohol Spectrum Disorders, Part 2: Administrator’s Guide to Implementing 

FASD Prevention and Intervention

•	 Addressing Fetal Alcohol Spectrum Disorders, Part 3: Literature Review

Parts 1 and 2 are presented in this publication; Part 3 is available only online, at 

http://store.samhsa.gov/home. Each part is described below. 

Part 1 of the TIP is for behavioral health providers and consists of three chapters:

•	 Chapter 1 discusses approaches to preventing FASD; that is, assisting women who are in 

treatment settings and are pregnant or may become pregnant to remain abstinent from 

alcohol. In providing these guidelines, this TIP adopts the Institute of Medicine (IOM) 

model for prevention, which sees prevention as a step along a continuum that also incorpo

rates treatment and maintenance.

•	 Chapter 2 discusses methods for identifying individuals in treatment who have or may 

have an FASD, referring them for diagnosis where possible, and providing appropriate 

interventions to meet their needs.

•	 Chapter 3 provides clinical vignettes designed to realistically portray the provider–client 

interactions that might take place when providing FASD prevention or interventions.

Part 2 is an implementation guide for program administrators and consists of two chapters. 

•	 Chapter 1 lays out the rationale for the approach taken in chapter 2 and will help readers 

understand how administrators can provide support for programs and counselors as they 

address FASD. It is hoped that this knowledge will enhance the ability of treatment 

programs to address FASD concurrently with other behavioral health needs; addiction, 

mental health issues, etc.

•	 Chapter 2 provides detailed information on how to achieve high-quality implementation of 

the recommendations in Part 1.

Part 3 of this TIP is a literature review on the topic of FASD and is available for use by clinical 

supervisors, interested counselors, and administrators. Part 3 includes literature that addresses 

both clinical and administrative concerns. To facilitate ongoing updates, the literature review will 

only be available online at http://store.samhsa.gov/home.

xvii

Preface

Giving Voice to a Hidden Population

•	 A woman gives birth to a child with a Fetal Alcohol Spectrum Disorder (FASD); no one 

told her that alcohol consumption during pregnancy could harm the baby.

•	 A man is repeatedly kicked out of various forms of treatment for noncompliance; he 

never means to be noncompliant, his special needs and lack of understanding are simply 

never recognized.

•	 A teen-aged girl doesn’t receive appropriate screening for alcohol use during her pregnancy; 

her child is removed when she’s identified with a substance use disorder, and her child is 

later found to have an FASD. 

•	 A man repeatedly loses jobs because he can’t “follow orders;” he ends up homeless and 

cycles repeatedly through the social service system.

These stories are not unusual. They are not “worst case scenarios.” They are the all-too-common 

realities of people with an FASD, or women who wanted to have a healthy child but weren’t 

given the basic help they needed before and during pregnancy. And sometimes these realities 

overlap.

Addressing Fetal Alcohol Spectrum Disorders was written to help you offer hope to these individuals when they present in your setting. This TIP will not ask you to implement a whole new way 

of treating clients, although you may discover alternative approaches that you want to explore. 

Rather, it asks you to see people who have or may have an FASD as you see any individual in 

your care with a significant co-occurring life issue that should be recognized and incorporated 

into treatment planning. This TIP also asks you to see pregnant women who consume alcohol 

not through a lens of judgment but as women in need, for whom even a few minutes of information and education can make a lifetime of difference for their health and the health of their 

babies.

This TIP is also about hope for you as a substance abuse or mental health treatment professional 

because it gives you another way to view the clients who “just don’t get it” or who seem to want 

to succeed in treatment but can’t follow directions, don’t make it to appointments, grow restless 

in group sessions, or generally seem “resistant” with no clear explanation. You can “reframe” your 

thinking about these clients. Not all of these cases will be explained by FASD, obviously, but 

making FASD awareness a part of the culture of your agency widens the net of understanding 

that you can offer to your clients and increases your staff ’s capabilities for achieving positive outcomes with a higher percentage of them.
xviii

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Ultimately, SAMHSA’s goal is to provide knowledge and assistance to help substance abuse and 

mental health treatment programs better serve their clients. Providing FASD-informed services 

is a part of that mission, and is the guiding principle behind the publication of this TIP. Thank 

you for taking the time to read this publication, and for potentially making a difference for a 

population that should not remain hidden any longer.
xix

Executive Summary

Introduction

About FASD

Overview

Fetal Alcohol Spectrum Disorders (FASD) 

is a non-diagnostic umbrella term describing 

the range of effects that can occur in an individual whose mother consumed alcohol during 

pregnancy. These effects may include physical, 

mental, behavioral, and/or learning disabilities with possible lifelong implications. As is 

discussed in greater detail later in this TIP, 

these disorders often co-occur with substance 

abuse and mental health issues, and generally 

require treatment modifications for successful 

outcomes. They are 100 percent preventable, 

however, if those at risk of consuming alcohol 

during pregnancy are identified and effective 

prevention strategies are used.

Possible diagnoses within the spectrum 

include Fetal Alcohol Syndrome (FAS), Partial 

Fetal Alcohol Syndrome (pFAS), AlcoholRelated Neurodevelopmental Disorder 

(ARND), Static Encephalopathy/AlcoholExposed (SE/AE), and Neurobehavioral 

Disorder/Alcohol Exposed (ND/AE). (See 

box, FASD: Key Terms, for a fuller description of the disorders within the spectrum and 

related terminology.)

FASD: Key Terms

•	Fetal Alcohol Spectrum Disorders (FASD): Umbrella term referring to a group of disorders

caused by prenatal exposure to alcohol; a particular condition on the fetal alcohol spectrum

is referred to as “an FASD.” Now generally considered to refer to Fetal Alcohol Syndrome

(FAS), partial FAS (pFAS), Alcohol-Related Neurodevelopmental Disorders (ARND), Static

Encephalopathy/Alcohol-Exposed (SE/AE), and Neurobehavioral Disorder/Alcohol Exposed

(ND/AE). See below for all. A variety of diagnostic approaches exist for the disorders within the

spectrum; the five most commonly used approaches are included in the key terms below, and

are summarized/compared in Appendix E.

Disorders currently or previously described as forms of FASD (in alphabetical order):

•	Alcohol-Related Birth Defects (ARBD): Term used to describe individuals who present with

congenital defects (including malformations and dysplasia), but not the growth or cognitive/

behavioral impairments typically seen in FAS (see definition below). Now less used, although

diagnostic guidelines still exist through the Institute of Medicine (IOM; see Fetal Alcohol 

Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment, below in this box). 

•	Alcohol-Related Neurodevelopmental Disorder (ARND): Term created by the IOM to describe

individuals with prenatal alcohol exposure and neurodevelopmental abnormalities, but no
xx

Addressing Fetal Alcohol Spectrum Disorders (FASD)

FAS facial phenotype. The neurodevelopmental abnormalities are characterized by a complex

pattern of behavioral or cognitive conditions inconsistent with developmental level and not

explained by genetic background or environment. Problems may include learning disabilities;

school performance deficits; inadequate impulse control; social perceptual problems; language

dysfunction; abstraction difficulties; mathematics deficiencies; and judgment, memory, and

attention problems. The term ARND presents with the same limitations as the discontinued term

Fetal Alcohol Effects (see definition below), as one cannot confirm that the neurodevelopmental

disorder present in a child with prenatal alcohol exposure was caused by the alcohol exposure in

the absence of the FAS facial phenotype. Some diagnostic systems replace the term ARND with

Static Encephalopathy/Alcohol-Exposed and Neurobehavioral Disorder/Alcohol Exposed (SE/AE

and ND/AE; see definitions below).

•	Fetal Alcohol Effects (FAE): Term introduced in the late 1970’s to describe less complete partial

expressions of FAS (see definition below) in individuals with prenatal alcohol exposure (Clarren

& Smith, 1978). Aase, Jones, and Clarren (1995) expressed concern about the validity of the

term FAE and proposed abandoning its clinical use, as it implied a causal association (between

prenatal alcohol exposure and abnormalities observed in an individual patient) that could not

actually be confirmed.

•	Fetal Alcohol Syndrome (FAS): Term for what is generally considered to be the most recognizable

form of FASD. These individuals exhibit the FAS facial phenotype, impaired growth, and

cognitive and behavioral abnormalities.

•	Neurobehavioral Disorder/Alcohol Exposed (ND/AE): Term used to describe individuals with

prenatal alcohol exposure, moderate cognitive/behavioral impairment (equivalent to moderate

ARND), and no FAS facial phenotype.

•	Partial FAS (pFAS): Term applied to individuals who exhibit FAS without growth deficiency, or

exhibit FAS with most but not all of the facial features.

•	Static Encephalopathy/Alcohol Exposed (SE/AE): Term used to describe individuals with prenatal

alcohol exposure and severe cognitive/behavioral impairment (equivalent to severe ARND), but

no FAS facial phenotype.

Additional terms are presented in alphabetical order:

•	Alcohol-Exposed Pregnancy (AEP): Any pregnancy during which the woman drinks any amount

of alcohol at any time during the pregnancy. This exposure does not mean the offspring has

been affected in any way, but it does place the offspring at some degree of risk for an array of

developmental difficulties, including damage to the brain and central nervous system, retardation

of growth and other physical effects, and cognitive and behavioral impairments.

•	Diagnosis: In the context of this TIP, “diagnosis” refers to the formal identification of an FASD

by a qualified team and/or dysmorphologist (someone who specializes in structural, or birth,

defects). When the TIP discusses the primary diagnosis that brought the client into your

substance abuse or mental health setting, or for which your setting is primarily assessing or

treating the client, it will be referred to as the “primary treatment issue.”

•	Diffuse Brain Damage: Damage to the brain that is not localized or necessarily the result of a

specific traumatic incident to one part of the brain. Such damage can arise from other sources

besides alcohol or occur from multiple sources including alcohol. As an AEP (see definition

above) can impair the development of multiple parts of the brain of the fetus over the period of

pregnancy, an FASD can be considered a manifestation of diffuse brain damage. However, not

all diffuse brain damage is the result of alcohol and its expression does not always qualify as an

FASD.

•	FASD 4-Digit Diagnostic Code (Astley, 2004b): Comprehensive, reproducible method for

diagnosing the full spectrum of outcomes of patients with prenatal alcohol exposure. First
xxi

developed in 1997 by the Washington State FAS Diagnostic and Prevention Network (FAS DPN),

the Code was revised in 1999 and again in 2004. Summarized in Appendix E.

•	Fetal Alcohol Spectrum Disorder: Canadian Guidelines for Diagnosis (Chudley et al., 2005):

Canadian guidelines for the diagnosis of FAS, pFAS, and ARND. Summarized in Appendix E.

•	Fetal Alcohol Syndrome: Diagnosis, Epidemiology, Prevention, and Treatment (Stratton, Howe,

Battaglia, & the Committee to Study Fetal Alcohol Syndrome, 1996): Diagnosis and treatment

guidelines developed by the IOM and published in 1996. These guidelines would be revised

by Hoyme, May, and Kalberg (2005) in A Practical and Clinical Approach to the Diagnosis of 

Fetal Alcohol Spectrum Disorders: Clarification of the Institute of Medicine Criteria. Each is

summarized in Appendix E.

•	Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis (Bertrand et al., 2004): FAS

diagnosis and referral guidelines developed by the Centers for Disease Control and Prevention

(CDC). Summarized in Appendix E.

•	Intervention: In the context of this TIP, ‘intervention’ describes 1) a brief methodology for

informing women of childbearing age about the results of alcohol screening and the dangers

of alcohol use during pregnancy, or 2) the selection of an appropriate treatment methodology

to best meet the needs of a client who has or may have an FASD, and any accompanying

modifications or accommodations in treatment planning.

•	Screening: ‘Screening’ is a familiar term in mental health and substance abuse treatment settings.

Validated screening instruments for identifying alcohol use among women are available, and no

modification to the basic understanding of screening is necessary for their use. To accomplish

the important goal of screening for an individual with an FASD in your setting, formalized tools

are limited. However, this TIP does provide indicators to look for, and screening may need to be

done more informally through guided observation and/or diagnostic interviewing. In most cases,

screening for an FASD will need to occur over time, rather than being a process that can be

completed through the use of a simple, brief instrument administered once (e.g., at intake).

•	Static Encephalopathy: Permanent or unchanging brain damage. Effects on development depend

on the part(s) of the brain involved and the severity of the damage.

•	Teratogen: Any substance that can damage a developing fetus. Common teratogens include

alcohol, tobacco, lead, radiation, and exposure to infectious disease.

Prevalence

The prevalence of FAS in the United States 

has been estimated at 1–3 per 1,000 live births 

among the general population (Stratton et al., 

1996) and 10–15 per 1,000 in some higherrisk populations, such as children residing in 

foster care (Astley, Stachowiak, Clarren, & 

Clausen, 2002; Astley, 2004a). The prevalence 

of the full spectrum of FASD in the general 

population is estimated at 9.1 per 1,000 live 

births, though a review of in-school screening 

and diagnosis studies suggest that the national 

rate could potentially be closer to 50 per 1,000 

(May et al., 2009). In addition, recent retrospective analyses of hospital admissions data 

indicate that under-reporting of alcohol misuse 

by women may further disguise true prevalence 

(Morleo et al., 2011). 

Although prenatal alcohol exposure has been 

clearly established as a causal factor for FASD 

in animal models, the amount of alcohol 

required to cause damage to the fetus remains 

in question, and may differ based on the individual. Factors such as dose of alcohol, pattern 

and timing of exposure, genetics, whether the 

mother also smoked and/or used other drugs, 

general health and nutrition of the mother, 

her level of stress and/or trauma, and her age 

all may play a role in the impact that alcohol 

has on the developing fetus (Guerri, Bazinet, 

& Riley, 2009). Animal studies do suggest that 

binge drinking (four or more drinks on one 

Executive Summary
xxii

Addressing Fetal Alcohol Spectrum Disorders (FASD)

occasion) is associated with more severe effects 

(Bonthius & West, 1988; Clarren, Astley, 

Gunderson, & Spellman, 1992), and it is 

generally asserted that there is no known ‘safe’ 

level of alcohol consumption during pregnancy 

(Office of the Surgeon General, 2005; Hicks 

& Tough, 2009; Feldman et al., 2012).

Not every woman who consumes 

alcohol during pregnancy will give 

birth to a child with an FASD. 

However, because science has not 

determined a safe level of alcohol 

that may be consumed during 

pregnancy, the possibility of an 

FASD is created any time a woman 

consumes alcohol while pregnant.

Due to the range of deficits—and variability 

in degree of severity of each deficit—within 

the diffusely damaged brain, FASD can present as functionally different in each individual

that is affected. However, certain cognitive, 

behavioral, and adaptive functioning problems

are common across the spectrum, including 

lower IQ, impaired learning ability, and difficulty processing information (such as not 

being able to remember or follow instructions,

or poor verbal receptive skills) (Streissguth, 

Barr, & Bookstein, 1996; Bertrand et al., 2004

Streissguth et al., 2004; Astley et al., 2009a; 

Astley, 2010). Physical abnormalities and facia

dysmorphology (i.e., congenital malformation)

are only common with FAS. Other functional 

issues regularly observed include attention def

icit (Nanson & Hiscock, 1990; Lee, Mattson, 

& Riley, 2004), decreased proficiency in cognitive planning (Kodituwakku, Handmaker, 

Cutler, Weathersby, & Handmaker, 1995; 

Kodituwakku, Kalberg, & May, 2001; 

Rasmussen, 2005), reduced working memory 

(Burden, Jacobson, Sokol, & Jacobson, 2005; 

Astley et al., 2009b; Green et al., 2009), 

;

l 

-

reduced response inhibition (Noland et al., 

2003; Mattson, Crocker, & Nguyen, 2011), 

socially inappropriate behaviors (Bishop, 

Gahagan, & Lord, 2007; Jirikowic, Kartin, & 

Olson, 2008; Mattson, Crocker, & Nguyen, 

2011), and deficits in fine motor (Kalberg et 

al., 2006; Jirikowic et al., 2008) and visualspatial functions (Chiodo, Janisse, DelaneyBlack, Sokol, & Hannigan, 2009; Mattson et 

al., 2010).

Cost Factors

Estimates of the cost to raise a child with an 

FASD vary depending on the source and the 

factors included in the analysis, and detailed 

cost estimates are generally only available 

in relation to the specific condition of FAS. 

Nonetheless, these costs are significant. In an 

analysis of medical expenditures for pediatric 

Medicaid enrollees, Amendah, Grosse, and 

Bertrand (2010) found that, for a child with 

identified FAS, incurred health costs were 

nine times higher than for children without 

an FASD. Astley, Bailey, Talbot, and Clarren 

(2000a) further isolated cost factors in a demonstration of primary FAS prevention in an 

FASD diagnostic clinic that targeted high-risk 

women; using this approach, the cost of raising 

a child with FAS was found to be roughly 30 

times higher than the cost of preventing FAS 

in the child.

The most widely acknowledged estimate of 

the lifetime cost of care for an individual with 

an FAS is that of Lupton, Burd, and Harwood 

(2004), who adjusted figures originating with 

Harwood and Napolitano (1985) for 2002 

dollars to suggest that the figure was roughly 

$2 million (including medical treatment, special education, residential care for persons with 

mental retardation, and productivity losses; in 

2012 dollars, this would be over $2.5 million). 

The overall annual cost of FAS to the U.S. 

healthcare system (based on an assumption of 

2 cases per 1,000 live births) is estimated at $5 

billion (Lupton et al., 2004).
xxiii

Part 3 of this TIP, the online Literature Review, 

contains additional information on FASD surveillance and cost factors, as well as the impact of 

alcohol on the brain and behavior.

Historical Background

FASD is often described as a ‘new’ or ‘recent’ 

discovery. In fact, references to the harmful 

effects of maternal drinking on infant outcome date back to biblical times: “Behold, 

thou shalt conceive, and bear a son; and now 

drink no wine or strong drink” ( Judges 13:7, 

as noted in Clarren & Smith, 1978). In addition, several comprehensive descriptions were 

compiled by physician groups in the 18th 

and 19th centuries (Royal College, 1726; 

Sullivan, 1899; Goodacre & Mercer, 1965). 

The more recent history commonly referred to 

begins in 1968, when Lemoine, Harousseau, 

Borteyni, and Menuet from France published 

an article describing children with distinctive 

facial features and other symptoms related to 

prenatal alcohol exposure. In 1970, unaware 

of the Lemoine publication, Ulleland and colleagues published similar observations describing a small group of alcohol-exposed infants 

admitted to several high-risk maternal-child 

health clinics at the University of Washington 

(Ulleland, Wennberg, Igo, & Smith, 1970; 

Ulleland, 1972). This work would eventually lead to a seminal, collaborative article 

describing the pattern of outcomes associated 

with prenatal alcohol exposure ( Jones, Smith, 

Ulleland, & Streissguth, 1973), as well as the 

publication that coined the term FAS ( Jones 

& Smith, 1973).

In the roughly 40 years that have followed, 

extensive study has been conducted on alcohol’s teratogenic effects, as well as on interventions for women of childbearing age who 

consume alcohol, leading to several significant 

federal milestones in addressing FASD. 

In 1996, the Institute of Medicine (IOM) 

published Fetal Alcohol Syndrome: Diagnosis, 

Epidemiology, Prevention, and Treatment

(Stratton et al., 1996), leading the National 

Institute on Alcohol Abuse and Alcoholism 

(NIAAA) to establish the Interagency 

Coordinating Committee on FASD (originally Interagency Coordinating Committee 

on FAS) to address that publication’s recommendations. Then, in 2000, Congress set forth 

mandates related to children’s health, including FASD, leading the Centers for Disease 

Control and Prevention (CDC) to establish 

the National Task Force on FAS and FAE 

(completed in 2007), and SAMHSA to establish the FASD Center for Excellence in 2001.

In the decade since the Congressional mandates, the research and knowledge base around 

FASD has expanded greatly. According to 

Goodlett (2010), a PubMed search of FAS-, 

FASD-, or fetal alcohol-specific terminology 

at the end of 2010 returned nearly 3,900 articles published since 1973, of which more than 

38 percent had been published since 2000. 

This growth is translating to practice: Since 

2001, the FASD Center for Excellence alone 

has funded more than 70 subcontractors across 

the United States to carry out pilot efforts to 

implement FASD-related services into existing 

programs, including substance abuse and mental health treatment settings.

This body of work has revealed an unfortunate 

paradox: Individuals with an FASD require 

more intensive and personalized services, and 

early diagnosis and intervention have been 

identified as critical to improved outcomes and 

minimized secondary disabilities (Streissguth 

et al., 2004; Astley, 2010). Yet, individuals with 

an FASD often go undiagnosed or are misdiagnosed (Greenbaum, Stevens, Nash, Koren, & 

Rovet, 2009), are difficult to identify early and 

may not receive appropriate early intervention 

(Olson, Jirikowic, Kartin, & Astley, 2007), and 

often receive services that do not account for 

their disabilities and thus may result in poor 

outcomes.

Executive Summary
xxiv

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Audience: Who Should Read This TIP?

This TIP is designed for use by behavioral 

health providers, particularly substance abuse 

and mental health treatment professionals, not only because these are the primary 

constituencies of SAMHSA but also because 

individuals with FASD experience higher 

rates than the general population of both 

substance abuse and mental health issues 

(Streissguth et al., 1996; O’Connor et al., 

2002; Streissguth et al., 2004; Clark, Lutke, 

Minnes, & Quellette-Kuntz, 2004; Astley, 

2010). In addition, individuals with an FASD 

exhibit higher rates of life problems commonly 

encountered in substance abuse and mental 

health treatment populations, including higher 

risk of suicide (Huggins, Grant, O’Malley, & 

Streissguth, 2008), exposure to multiple traumas throughout the lifespan (Henry, Sloane, 

& Black-Pond, 2007; Greenbaum et al., 2009), 

homelessness (Fryer, McGee, Matt, Riley, & 

Mattson, 2007), and increased interaction with 

the criminal justice system (Streissguth et al., 

1996; Streissguth et al., 2004).

This TIP is also important because there are 

great opportunities for FASD prevention in 

mental health and substance abuse treatment 

settings. According to the 2009 National 

Survey on Drug Use and Health (NSDUH), 

17.1 percent of women age 18 or over in the 

U.S. received mental health treatment or counseling in 2009, compared to only 9.2 of men 

in the same age group (Center for Behavioral 

Health Statistics and Quality [CBHSQ], 

2010), while the Treatment Episode Data Set

(TEDS) indicates that 33.0 percent of admissions to substance abuse treatment facilities 

in 2011 were female, more than half of whom 

(50.5 percent) indicated alcohol as a primary, 

secondary, or tertiary substance of abuse 

(CBHSQ, 2013). Thus, these settings provide 

ideal opportunities to implement brief, effective approaches to preventing an AEP.

Part 1 of this TIP is for frontline personnel 

and consists of three chapters:

•	 Chapter 1 discusses approaches to FASD 

prevention; that is, assisting women who 

are in treatment settings and are pregnant 

or may become pregnant to remain 

abstinent from alcohol. In providing 

these guidelines, this TIP adopts the 

IOM model for prevention, which 

sees prevention as a step along a 

continuum that also incorporates 

treatment and maintenance.

•	 Chapter 2 discusses methods for 

identifying individuals in treatment who 

have or may have an FASD, referring 

them for diagnosis where possible, and 

providing appropriate interventions to 

meet their needs. These clients are 

assumed to be adolescent or older,

as they would need to be capable of 

presenting in treatment on their own 

(although the TIP strongly recommends 

including the family in treatment, when 

possible).

•	 Chapter 3 provides clinical vignettes 

designed to realistically portray the 

provider–client interactions that might 

take place when providing FASD 

prevention or interventions.

Part 2 provides administrators with strategies and tools for undertaking the activities 

that will support treatment professionals and 

clients and for making the changes required 

to incorporate FASD prevention and/or intervention in daily practice. Part 2 also includes 

methods, materials, resources, and examples to 

assist administrators with quality improvement 

and ongoing evaluation of the necessary programmatic changes.

At the same time, the clinical and administrative guidance set forth in this TIP has strong 

applicability across healthcare and social 

service settings. While the client interactions 
xxv

described generally involve substance abuse 

and mental health treatment, any provider 

assisting women at risk of an AEP or assisting individuals who may have an FASD can 

implement the majority of these recommendations if they adapt them for that professional’s 

setting. This is particularly the case if the setting in question overlaps with the life issues 

that more frequently occur among individuals 

with an FASD, as discussed above (i.e., criminal justice, housing, primary care).

Barriers to Treatment: The Need for the TIP

For a variety of reasons, including the somewhat hidden nature of many of the symptoms, 

individuals with an FASD are frequently misdiagnosed or their condition is not recognized 

(Olson et al., 2007; Greenbaum et al., 2009). 

This, in turn, leads to care that is not matched 

to the patient’s needs and strengths, increasing 

the risk for secondary disabilities (Streissguth 

et al., 2004).

Added to this, recent statistics on drinking 

among pregnant women show that AEP prevention is as serious an issue as appropriate 

services for individuals who have an FASD 

(see box, Drinking Rates Among Pregnant 

Women, in the next chapter). AEP prevention 

may not be a familiar goal in mental health 

and substance abuse treatment settings. Yet 

these are ideal settings in which to prevent 

prenatal alcohol exposure, as behavioral health 

professionals routinely work with women of 

childbearing age (age 10–49 years). Treatment 

can then have a positive affect not only on the 

client, but on his or her family and generations 

to come.

Ideally, this TIP will help to alleviate many 

barriers to providing successful treatment for 

these two populations, including:

•	 The application of treatment approaches 

 that, while effective with general 

populations, may not be ideally suited to 

the needs of individuals with an FASD;

•	 A lack of awareness among treatment 

professionals of the rapid developments in 

the field of FASD services over the last 

decade; and

•	 Helping clients deal with feelings of 

shame, loss, or fear of discrimination.

Lack of Success With Typical Treatment 

Approaches

Prenatal exposure to alcohol has many teratogenic effects, among them that it can alter 

brain structure and function, meaning that 

people with an FASD do not process information in the same ways that those without an 

FASD do. These effects are permanent; an 

FASD cannot be ‘cured.’ Processing differences that may affect treatment can take many 

forms, including:

•	 Poor receptive language skills 

(difficulty with complex language and 

multiple instructions);

•	 Difficulty with social cognition and 

accurately understanding social cues;

•	 Difficulty taking in new information, 

and in generalizing learning to new 

settings; and

•	 Not always connecting cause and effect 

(particularly if the effect is delayed).

Expert consensus suggests that treatment 

approaches that rely on an assumption of ‘normal’ functioning of these cognitive processes 

are likely to be less effective with individuals 

with an FASD. This appears to be true for 

both mental health and substance abuse treatment settings.

Cognitive–Behavioral Therapy (CBT) models, 

for instance, are verbally based insight therapies designed to reduce target symptoms, and 

are based on the idea that inaccurate thoughts 

are linked to maladaptive feelings and behaviors. However, CBT approaches do not fit well 

Executive Summary
xxvi

Addressing Fetal Alcohol Spectrum Disorders (FASD)

given that individuals with an FASD have 

biologically based cognitive deficits (O’Connor 

et al., 2002). Behaviors of individuals with an 

FASD may result from errors in thinking that 

are difficult to change because of underlying 

diffuse brain damage. Modification to CBT, 

and adding other approaches, will be needed to 

maximize treatment efficiency and success.

The disease model of substance abuse treatment, which advocates lifelong abstinence 

from alcohol, also relies on the assumption that 

a client has normative function. Behavioral 

health professionals assume that the client can 

comprehend that he or she has a ‘disease’ and 

also that he or she can plan ahead to recognize 

why it is important to achieve abstinence. For 

an individual with an FASD, this link may be 

difficult to make, and so his or her substance 

abuse or mental health target symptoms may 

be harder to change (and change harder to 

maintain) because of the underlying diffuse 

brain damage.

Rapid Developments in the Field

The tremendous growth in FASD-related 

research and the establishment of the 

SAMHSA FASD Center for Excellence have 

practical implications for behavioral health 

professionals, in that the field of FASD-related 

practices is growing dynamically. Much of the 

practical guidance in this TIP has emerged 

only over the last 5 to 10 years. Even professionals who have had some form of FASD 

training in the past are likely to discover new 

and useful strategies in this TIP that can be 

effectively applied in their programs.

Treatment Barriers

Despite their unique treatment needs, clients 

with an FASD or pregnant women at risk 

of an AEP still share with any other client a 

significant, common barrier to treatment success: The impact of negative self-perception. 

An individual with an FASD or a woman who 

has consumed alcohol during pregnancy may 

perceive themselves negatively, either because 

of internal feelings of shame, a sense of not 

belonging, or due to experiencing external 

shaming or judgment. These internal feelings 

and external experiences can each become a 

barrier to treatment (Astley, Bailey, Talbot, & 

Clarren, 2000b; Salmon, 2008).

When implementing the practices recommended in this TIP, behavioral health professionals are urged to keep sight of the importance of addressing the client’s feelings and 

experiences, as well as the need for sensitivity 

to issues such as gender, ethnicity, cultural 

background, and sexuality, as these factors 

impact treatment success among individuals 

with an FASD and women of childbearing 

age as significantly as any other treatment 

population.

“We must move from viewing the 

individual as failing if s/he does not 

do well in a program to viewing 

the program as not providing what 

the individual needs in order to 

succeed.”

Dubovsky, 2000
1

1 Prevention of AlcoholExposed Pregnancies 

Among Women of 

IN THIS CHAPTER Childbearing Age

•	Introduction

•	Professional 

Responsibility to Screen

•	Procedures for Screening

•	Selecting An 

Appropriate Prevention 

Approach

•	Procedures for Referral

•	Working with Women 

Who May Have an FASD

One act of AEP prevention can 

positively impact the life of the 

mother and the life of the unborn 

child. One change in how services 

are provided can multiply that 

impact many times over.

Introduction

This TIP adopts 

the IOM continuum of care 

model, which 

sees prevention 

as a step along a 

continuum that 

also incorporates 

treatment and 

maintenance (see Figure 1.1, below). The IOM model defines three 

types of prevention: universal, selective, and indicated.

•	 Universal prevention “[a]ddresses [the] general public or [a] 

segment of [the] entire population with average probability, risk 

or condition of developing [a] disorder” (Springer & Phillips, 

2007). Universal prevention can take a variety of forms, 

including media campaigns, large-scale health initiatives 

(e.g., immunization), point-of purchase signage, and warning 

labels on products.

•	 Selective prevention is designed for a “[s]pecific sub-population 

with risk significantly above average, either imminently or over 

[his or her] lifetime” (Springer & Phillips, 2007), and can 

include “screening women for alcohol use, training healthcare 

professionals, working with family members of pregnant 

women who abuse alcohol, developing biomarkers, brief interventions, and referrals” (Grant, 2011).

•	 Indicated prevention “[a]ddresses identified individuals with 

minimal but detectable signs or symptoms suggesting a 

disorder” (Springer & Phillips, 2007), such as pregnant women 

who drink heavily, or women who have already given birth to a 
2

Addressing Fetal Alcohol Spectrum Disorders (FASD)

 child with FASD and continue to drink. 

For the purposes of the AEP prevention discussion in this chapter, women of childbearing 

age (i.e., females age 10–49) in your treatment 

setting should receive AEP prevention based 

on the following:

•	 Universal prevention: A woman who is 

not pregnant, and either reports no 

alcohol use or does not screen positive for 

at-risk alcohol use;

•	 Selective prevention: A woman of 

childbearing age who reports alcohol use 

but has only one of the two indicators for 

an indicated intervention; she is either 

pregnant but does not screen positive for 

at-risk alcohol use, or she screens positive 

for at-risk alcohol use but is not 

pregnant; or

•	 Indicated prevention: A woman of 

childbearing age who screens positive for 

at-risk alcohol use and is pregnant.

This chapter will first discuss screening, then 

appropriate brief interventions for AEP prevention in each of the three categories, before 

discussing treatment issues and referral. In 

each category, screening is a vital starting 

point before moving on to appropriate prevention, treatment, or referral.

Professional Responsibility to 

Screen

As the box “Risk Factors for an AEP” (next 

page) makes clear, a variety of factors can 

impact a woman’s consumption of alcohol during pregnancy. These and other factors make 

it critical to inquire about alcohol use among 

all women of childbearing age in behavioral 

health settings for alcohol consumption:

•	 There is no known safe level of alcohol 

consumption during pregnancy, and 

even low levels of prenatal alcohol exposure have been shown to negatively 

impact a fetus (Chang, 2001).

Figure 1.1: The IOM Continuum of Care Model

Source: Springer & Phillips, 2006; 2007.
3

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

•	 Screening facilitates the implementation 

of appropriate interventions, at the 

earliest possible point (Leonardson, 

Loudenburg, & Struck, 2007).

•	 Prevented AEP can result in significant 

cost savings through prevented cases of 

FASD and reduced use of the health and 

social services systems (Abel & Sokol, 

1991; Astley et al., 2000a; Lupton et al., 

2004; Astley, 2004a).

•	 Screening is an ethical obligation, one 

that should be conducted equally of men 

and women regardless of race and 

economic status, and which should be 

performed with women using instruments 

that are designed for women (Committee 

on Ethics of the American College of 

Obstetricians and Gynecologists 

[ACOG], 2008). Additionally, in an 

FASD prevention study assessing the 

feasibility of identifying high-risk women 

through the FASD diagnostic evaluation 

of their children, Astley and colleagues 

(2000a) concluded that these women 

are not only at high risk for producing 

more children damaged by alcohol 

exposure, but they themselves often face 

serious adverse social, mental, and 

physical health issues, as well. Thus, one 

could argue that it would be unethical to 

ignore their existence and ignore 

opportunities to provide them with 

advocacy support and primary prevention 

intervention.

•	 Awareness does create change: Statistics 

from SAMHSA’s NSDUH (May 21, 

2009) suggest that drinking rates among 

women drop considerably during 

pregnancy, particularly in the second and 

third trimesters when there is a much 

higher awareness of pregnancy status.

In addition, screening:

•	 Gives the client permission to talk about 

drinking;

•	 Helps to identify and or clarify 

co-occurring issues; 

•	 Minimizes surprises in the treatment 

process; and

•	 Can mean more effective treatment.

Risk Factors for an AEP

Substance Abuse/Mental Health Factors

•	History of alcohol consumption (NIAAA, 2000; Bobo, Klepinger, & Dong, 2007)

•	Family background of alcohol use (Stratton et al., 1996; Leonardson et al., 2007)

•	History of inpatient treatment for drugs or alcohol and/or history of inpatient mental health 

treatment (Project CHOICES Research Group, 2002)

Personal/Sexual/Family Factors

•	Previous birth to a child with an FASD (Kvigne et al., 2003; Leonardson et al., 2007)

•	Lack of contraception use/unplanned pregnancy (Astley et al., 2000b)

•	Physical/emotional/sexual abuse (Astley et al., 2000b)

•	Partner substance use/abuse (Stratton et al., 1996; Leonardson et al., 2007)

•	Multiple sex partners (Project CHOICES Research Group, 2002)

•	Smoking (CDC, 2002; Leonardson et al., 2007)

•	Never having been tested for HIV (Anderson, Ebrahim, Floyd, & Atrash, 2006)

•	Lack of education, income, and/or access to care (Astley et al., 2000a)
4

Drinking Rates Among Pregnant Women

According to SAMHSA’s 2010 NSDUH, “Among pregnant women aged 15 to 44, an estimated

10.8 percent reported current alcohol use, 3.7 percent reported binge drinking, and 1.0 percent

reported heavy drinking. These rates were significantly lower than the rates for non-pregnant

women in the same age group (54.7, 24.6, and 5.4 percent, respectively). Binge drinking during

the first trimester of pregnancy was reported by 10.1 percent of pregnant women aged 15 to 44”

(Office of Applied Studies [OAS], 2011). All of these estimates are based on data averaged over

2009 and 2010. (Binge drinking for women has been defined by NIAAA as four or more drinks on

one occasion [2004]).

In telephone interviews with 4,088 randomly selected control mothers from the CDC’s National

Birth Defects Prevention Study who delivered live born infants without birth defects during

1997–2002, Ethen and colleagues (2009) found even higher numbers: 30.3 percent of respondents

reported alcohol use during pregnancy, with 8.3 percent reporting binge drinking during

pregnancy (approximately 97 percent of those indicating binge drinking stating that it was during

the first trimester).

In addition, one study of stool and hair samples of neonates who had been prenatally exposed

to heavy ethanol use suggested that these children were also 3.3 times more likely to have been

exposed to amphetamines and twice as likely to have been exposed to opiates, both of which

can also impair long-term child development (Shor, Nulman, Kulaga, & Koren, 2010). Another

recent study found that, among 1,400 patients with prenatal alcohol exposure attending an FASD

diagnostic clinic in Washington state, 62 percent were prenatally exposed to tobacco, 37 percent

were prenatally exposed to marijuana, and 38 percent were prenatally exposed to crack cocaine

(Astley, 2010).

Statistics from SAMHSA’s TEDS and from SAMHSA’s NSDUH indicate a potentially greater need to

address the FASD issue specifically in substance abuse treatment settings: More than 22 percent

of pregnant women admitted into treatment from 1992 to 2006 indicated alcohol as their primary

substance of abuse (OAS, 2006).

Lastly, 49 percent of all pregnancies in the United States are unintended (Finer & Henshaw, 2006).

As a result, many women will consume alcohol without knowing that they are pregnant.

Procedures for Screening

Behavioral health settings are busy, and screening procedures must be efficient. Figure 1.2, 

Screening Decision Tree for AEP Prevention, 

provides a procedure for an opening question 

about alcohol use, moving on to screening (if 

necessary), suggested instruments for screening, and next steps. The goal of screening is to 

determine, as quickly and as accurately as possible, whether a client is at risk and therefore 

brief intervention and treatment or referral is 

warranted.

The screening instruments recommended in 

Figure 1.2 are not the only options available 

for determining client alcohol use, but are validated as indicated in the decision tree (Sokol 

& Clarren, 1989; Russell, 1994; Chang, 2001). 

Nonetheless, if your agency does not use 

these instruments or does not have a ‘perfect’ 

alternative, it is better to screen with what is 

available to your program than to not screen 

women of childbearing age at all.

Part 3 of this TIP, the online Literature Review, 

includes further discussion of these and other alcohol screening instruments for use with women.

Screening should be done with sensitivity 

to the client’s level of health literacy, or, “the 

degree to which people have the capacity to 
5

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

Figure 1.2: A Screening Decision Tree for AEP Prevention

AEP prevention can be simple and brief. The TIP consensus panel developed the following 

Screening Decision Tree for AEP Prevention to help behavioral health providers quickly touch upon 

the topic of alcohol use with all women of childbearing age, and then provide brief but effective 

prevention or intervention.

 

 

 

* The T-ACE and TWEAK are validated for use with pregnant women. The CRAFFT Interview may be more helpful when 

assisting adolescent clients. The AUDIT-C is validated for use with non-pregnant women. All of these instruments are reprinted in Appendix B of this TIP.
6

obtain, process, and understand basic health 

information and services needed to make 

appropriate health decisions” (Parker, Ratzan, 

& Lurie, 2003; Liechty, 2011). More than a 

third of adults in the United States do not 

have adequate health literacy (Kutner, 2006; 

Liechty, 2011), so the prevention message may 

need to be simplified and reinforced by asking 

the client on several occasions and in a variety 

of ways. This means that your agency will 

likely need to screen at several different points 

in time.

In addition, talking about alcohol use or seeking help for an alcohol-related problem can 

be potentially embarrassing or difficult for the 

client (NIAAA, 2005). Counselors should be 

conscious of this risk, and be respectful when 

raising the issue of alcohol use. Additional 

sources of information that can help to identify alcohol use include collateral reports from 

family and friends of the client, and client 

medical/court records.

Vignette #2 in Part 1, Chapter 3 incorporates 

discussion of drink size and the use of a visual aid 

with a client.

Selecting an Appropriate 

Prevention Approach

Based on the results of your client screening, 

the next step is to decide on an appropriate 

brief approach: Universal prevention message or selective or indicated brief intervention. Brief interventions are associated with 

sustained reduction in alcohol consumption 

by women of childbearing age, and those discussed have shown promise for being adaptable to various settings and needs (Fleming, 

Barry, Manwell, Johnson, & London, 1997; 

Manwell, Fleming, Mundt, Stauffacher, & 

Barry, 2000; Burke, Arkowitz, & Menchola, 

What Is a Standard Drink?

All	clients	being	screened	for	alcohol	consumption	should	be	given	a	clear	indication	of	what	

constitutes	a	‘standard	drink.’	A	standard	drink	in	the	United	States	is	any	drink	that	contains	

about	14	grams	of	pure	alcohol	(about	0.6	fluid	ounces	or	1.2	tablespoons).	Below	are	U.S.	

standard	drink	equivalents.	These	are	approximate,	since	different	brands	and	types	of	beverages	

vary	in	their	actual	alcohol	content.

Source: Helping Patients Who Drink Too Much: A Clinicians Guide (Updated 2005 Edition), NIAAA, p. 24. NIH Publication

No. 07-3769.
7

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

2003; Project CHOICES Intervention 

Research Group, 2003; Chang et al., 2005; 

Grant, Ernst, Streissguth, & Stark, 2005; 

O’Connor & Whaley, 2007).

When using these prevention approaches, 

counselors should remember that no intervention constitutes full treatment of a woman’s 

alcohol use. Each is designed simply to 

encourage a dialogue about alcohol and begin 

a process of change. Each should be the basis 

for ongoing evaluation and an informed 

approach to treatment or referral. For 

programs that do not have existing approaches 

to substance abuse treatment, procedures for 

appropriate referral are discussed after the 

brief interventions.

Universal Prevention

As indicated in Figure 1.2, Screening Decision 

Tree for AEP Prevention, a woman who is not 

pregnant, and either reports no alcohol use 

or does not screen positive for at-risk alcohol 

use, can receive a simple universal prevention message. Consider the following scripted 

messages.

Universal AEP Prevention Statement and Possible Follow-Up Questions

“It’s great that you’re choosing not to drink alcohol. I know you aren’t currently pregnant or 

planning to become pregnant, but you are in the primary childbearing years right now. If you 

change your mind about pregnancy or discover in the future that you are pregnant, or you do 

begin to drink, please keep in mind that research has shown a link between drinking during 

pregnancy and the baby having an FASD. A child with an FASD can have physical and behavior 

problems, as well as cognitive problems (or, problems with the brain). These effects are caused by 

the alcohol, and they don’t go away, although they can be treated. There is no known safe amount 

of alcohol to consume during pregnancy, and any type of alcohol can cause FASD.

Can I give you a brochure [or	Web	address,	such	as	www.fasdcenter.samhsa.gov]	to take with 

you? This will explain more about FASD and how to have a healthy baby. Even if you aren’t 

planning to become pregnant, you could share it with a friend or family member who is.”

*****

If asked:	 Why	is	there	no	known	safe	amount	of	alcohol	that	a	woman	can	have	during		

	 	 pregnancy?

Answer:	 The	amount	of	alcohol	required	to	damage	an	unborn	baby	differs	based	on	the		

	 	 individual.	Things	like	how	much	alcohol	a	woman	drinks,	how	often	she	drinks	during		

	 	 pregnancy,	and	which	trimesters	she	drinks	in	all	play	a	part.	It	also	depends	on		

	 	 genetics,	whether	the	woman	smokes	or	uses	other	drugs,	her	general	health	and		

	 	 nutrition,	her	age,	and	her	levels	of	stress	or	trauma.	That’s	why	the	Surgeon	General		

	 	 recommends	that	pregnant	women	not	drink	any	alcohol	at	all.

If asked:	 What	kinds	of	alcohol	should	I	avoid?

Answer:	 All	alcohol	can	harm	a	baby	while	you’re	pregnant,	not	just	beer,	wine,	and	hard	liquor.		

	 	 Wine	coolers	and	‘alco-pops’	also	count.	Anything	with	alcohol.	Even	some	over-the-	

	 	 counter	medications	have	a	lot	of	alcohol	in	them;	if	you’re	pregnant	or	thinking	of		

	 	 becoming	pregnant,	you	should	be	careful	about	those,	too.

If asked:	 Where	can	I	find	more	information	about	FASD?

Answer:	 In	addition	to	the	SAMHSA	FASD	Center	for	Excellence	(www.fasdcenter.samhsa.gov),		

	 	 the	CDC	(http://www.cdc.gov/ncbddd/fasd/index.html)	provides	extensive		

	 	 information	about	FASD.
8

Whether asked for more information or not, 

the universal AEP prevention message should 

be accompanied by appropriate awareness 

materials, either in print or via a Web address. 

The SAMHSA FASD Center for Excellence 

provides a series of consumer fact sheets called 

What You Need to Know that provides helpful 

information about how to have a healthy baby. 

Appendix C, Public and Professional Resources

on FASD, has links to additional information 

resources.

At the same time, counselors should keep in 

mind with universal AEP prevention that, in 

some situations, women may deny using alcohol, but a combination of signs and symptoms 

suggest otherwise. In such cases, it may be 

prudent to re-screen frequently (Taylor, Bailey, 

Peters, & Stein, 2009).

Selective Prevention

The following section discusses two brief 

interventions for AEP prevention that are 

appropriate with women of childbearing age 

who report alcohol use but have only one of 

the two indicators for an indicated intervention; they are either pregnant but do not 

screen positive for at-risk alcohol use, or they 

screen positive for at-risk alcohol use but are 

not pregnant. These are organized in terms of 

the time required to perform the intervention 

effectively. As with universal prevention, each 

of these approaches should be accompanied 

by appropriate FASD information material, 

such as the What You Need to Know fact sheets, 

either in hard copy or through a Web link.

The first selective intervention, called ‘FLO’ 

for short, is a simple, three-step approach 

(see box below). An example of using the 

FLO approach with a client is illustrated in 

Vignette #1 in Part 1, Chapter 3 of this TIP.

The second selective intervention, FRAMES, 

is a more established and slightly more 

detailed method for motivating a client toward 

change, and has demonstrated positive results 

in brief intervention situations (Miller & 

Sanchez, 1994; Miller & Rollnick, 2002). See 

the box on the following page.

Each of these brief interventions discusses 

‘action plans’ or strategies for changing alcohol-related behaviors. For counselors who are 

not already well-versed in substance use-related change strategies, NIAAA has provided a 

brief guide to simple change strategies in the 

publication Helping Patients Who Drink Too 

Much (2007). Basic strategies to discuss with 

the client can include:

•	 What specific steps the client will take 

(e.g., not go to a bar after work, measure 

all drinks at home, alternate alcoholic and 

non-alcoholic beverages);

•	 How drinking will be tracked (diary, 

kitchen calendar);

•	 How the patient will manage high-risk 

situations; and

FLO (Feedback, Listen, Options)

1.	 Provide Feedback about screening

results. If possible, confirm the results

	 with additional screening and provide

	 information about recommended

	 drinking limits. (For women who are—

	 or are planning to become—

	 pregnant, the ideal goal is abstinence.)

2.	 Ask clients for their views about

	 their own drinking and Listen carefully

	 to encourage their thinking and

	 decision-making process.

3.	 Provide medical advice, and negotiate

	 a decision about Options clients can

	 pursue, including establishing a goal

	 and developing an action plan.

Source: Higgins-Biddle, J., Hungerford, D., & CatesWessel, K. (2009). Screening and brief interventions (SBI) 

for unhealthy alcohol use: A step-by-step implementation 

guide for trauma centers. Atlanta: Centers for Disease

Control and Prevention, National Center for Injury

Prevention and Control. [Parenthetical in #1 added.]
9

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

FRAMES

Source: Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. (2nd ed.) New York, NY: 

Guildford Press. [Italics in “Feedback” added.]

•	 Who might be willing to help the client

avoid alcohol use, such as a significant

other or a non-drinking friend.

Indicated Prevention: Alcohol Screening and 

Brief Intervention (SBI)

Alcohol Screening and Brief Intervention

(SBI) is a workbook-based brief intervention

that is appropriate with women of childbearing age who screen positive for at-risk alcohol

use and are pregnant. SBI generally takes

10 to 15 minutes to complete, and has been

shown to positively impact abstinence rates

and key subsequent health factors in the newborn, including higher birth weight/length

and lower mortality (O’Connor & Whaley,

2007).

The WIC Project Care: Health and Behavior 

Workbook was originally developed for Women,

Infants and Children (WIC) programs,

which provide support to current and expecting mothers, but the workbook can be used

across settings. It is crafted in very simple language and uses traditional brief intervention

techniques, including education and feedback,

cognitive–behavioral procedures, goal-setting,

and contracting. The care provider should

go through the workbook with the client. As

with both universal and selective prevention,

the SBI approach should be accompanied

by appropriate FASD print materials or a

relevant and reliable Web link for further

information.

The workbook can be downloaded for free in

multiple languages from the WIC Web site:

http://www.phfewic.org/Projects/Care.aspx
10

Providing Intervention/Treatment: Additional 

Factors to Consider

The following are factors to keep in mind 

when delivering a brief intervention for AEP 

prevention, as well as when delivering full substance abuse treatment (for agencies that are 

able to offer such care).

•	 Selective and indicated prevention services should be delivered by someone with 

motivational interviewing (MI) skills if at 

all possible. While a detailed discussion 

of MI techniques is outside the scope of 

this TIP, SAMHSA provides a Web site 

(http://www.motivationalinterview.

org/) that contains extensive materials 

and training resources for providers looking to develop their MI skills. See also 

TIP 35, Enhancing Motivation for Change 

in Substance Abuse Treatment (SAMHSA, 

1999).

•	 Consider the woman’s age and circumstances, and how these impact intervention/treatment. For example, life factors 

and obstacles to abstinence (family 

responsibilities, work, other children, etc.) 

will probably be very different for a teen 

vs. an older woman.

•	 Consider cultural context, as well; the cultural factors that impact treatment may be 

very different for an African-American, 

Hispanic/Latina, Asian-American, or 

Native-American woman (or a woman of 

any other minority) than for a Caucasian 

woman.

•	 Be willing to make modifications (e.g., 

frequency, duration) to maximize opportunities for prevention and recovery.

•	 Include and engage families in treatment, 

including significant others, grandparents, 

guardians, and custodians.

•	 Include relapse prevention.

•	 Include family support skills.

•	 Consider additional counseling factors:

− Parenting skills (that work for both 

the parent and the child)

− Trauma and abuse

− Co-occurring mental health issues

•	 Using a calendar with a client who is 

already pregnant may help her differentiate when she found out she was pregnant 

from when she actually became pregnant. 

She may have consumed alcohol for some 

time before knowing of the pregnancy, 

and showing that the drinking occurred 

even before she knew she was pregnant 

can help her feel less pressured and 

alleviate feelings of guilt. Clients may 

feel guilty and not tell the whole truth 

(or even withhold the truth). This means 

that getting an accurate picture of alcohol 

use may require multiple screenings. It is 

critical to build trust over several sessions. 

[Vignette #4 in Part 1, Chapter 3 demonstrates the use of a calendar with a client.]

•	 Watch for clients who ‘shut down’ on the 

topic of alcohol, and be understanding 

if the client experiences a sense of panic 

Ensuring Effective Contraception

A woman who drinks alcohol at risky levels may not always follow prescribed procedures for

effective contraception (Astley et al., 2000b). Review contraception use with her to ensure that

she has full contraceptive coverage every time she has sexual intercourse. This might include

providing secondary, back-up, or emergency contraception methods. For example, along with oral

contraceptives, advise her to use condoms, which have the added benefit of reducing sexually

transmitted diseases.

Source: Division of Women’s Health Issues. (2006). Drinking and reproductive health: A Fetal Alcohol Spectrum Disorders prevention tool kit. Washington, DC: American College of Obstetricians and Gynecologists.
11

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

about what she may have unintentionally 

done to her baby.

•	 If the client is not pregnant but is drinking, and is not resistant to talking about 

contraception, qualified professionals can 

consider adding a discussion of effective contraception (see box, “Ensuring 

Effective Contraception”) to discussions 

about drinking reduction.

Approaches to Resistance

With any approach to AEP prevention, 

counselors should keep in mind that, while a 

female client may feel safe enough to share 

about her alcohol use, she may not be ready 

to take the next step of comprehensive assessment and treatment (Astley et al., 2000b). A 

woman may present as resistant, reluctant, 

resigned, or rationalizing. The publication 

Substance Abuse During Pregnancy: Guidelines 

for Screening (Taylor et al., 2009) provides 

guidance on meeting these various forms of 

resistance. In addition, see the box below.

Procedures for Referral

If you believe, based on screening and interaction during intervention, that your client 

requires assistance that is best delivered in 

another care setting (or treatment in another 

setting becomes necessary due to factors such 

as criminal justice or social service involvement), you should discuss the benefits of 

treatment with the client and offer to provide 

her with a referral to a local substance abuse 

treatment center or other appropriate provider. 

A general list of treatment facilities can be 

searched through The SAMHSA Treatment 

Locator (http://findtreatment.samhsa.gov). 

Additional referral possibilities include the 

following:

•	 County substance abuse services;

Resistant, Reluctant, Resigned, or Rationalizing

• 

•

Resistant: “Don’t tell me what to do.” 

Provider Response: Work with the resistance. Avoid confrontation and try to solicit the woman’s

view of her situation. Ask her what concerns her about her use and ask permission to share what

you know, and then ask her opinion of the information. Accept that the process of change is a

gradual one and it may require several conversations before she feels safe about discussing her

real fears. This often leads to a reduced level of resistance and allows for a more open dialogue.

Try to accept her autonomy but make it clear that you would like to help her quit or reduce her

use if she is willing.

• Reluctant: “I don’t want to change; there are reasons.”

Provider Response: Empathize with the real or possible results of changing (for example, her

partner may leave). It is possible to give strong medical advice to change and still be empathetic

to possible negative outcomes to changing. Guide her problem-solving.

 Resigned: “I can’t change; I’ve tried.”

Provider Response: Instill hope, explore barriers to change.

• Rationalizing: “I don’t use that much.”

Provider Response: Decrease discussion. Listen, rather than responding to the rationalization.

Respond to her by empathizing and reframing her comments to address the conflict between

wanting a healthy baby and not knowing whether “using” is really causing harm.

Sources: Taylor, P., Bailey, D., Peters, R., & Stein, B. (2009). Substance abuse during pregnancy: Guidelines for screening.

Olympia, WA: Washington State Department of Health.

DiClemente, C. C. (1991). Motivational interviewing and stages of change. In W. R. Miller & S. Rollnick (Eds.), Motivational 

Interviewing: Preparing People to Change Addictive Behaviors (pp. 191- 206). New York: Guilford.
12

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Targeted Referral Options

Non-Pregnant Women: Project CHOICES

Project CHOICES is an evidence-based intervention (Project

CHOICES Intervention Research Group, 2003; Floyd et al., 2007)

that targets women at risk of having an AEP before they become

pregnant. The goal is to reduce drinking and/or prevent pregnancy

through contraception.

The target population for Project CHOICES is women ages 18

to 44 who are sexually active and drinking alcohol at risk levels.

The model uses a four-session intervention approach based in MI

methods, and discussions in each session are tailored to the client’s

self-rated readiness to change and interest in discussing alcohol use

or contraception.

Project CHOICES programs exist in multiple settings, including

residential and outpatient substance abuse treatment, community

mental health treatment, jails, and community-based teen

programs for girls. Eligibility criteria include 1) self-report of being

sexually active, 2) being non-pregnant (but able to conceive), 3)

high-risk drinking (8 or more drinks per week or 4 or more drinks

in one occasion) in the past 30 days, 4) ineffective use of or no

contraception, and 5) not currently trying to become pregnant or

planning to try in the next 6 months.

Intervention Components:

•	Four MI-based

counseling sessions,

including personalized

feedback of risk,

motivation to change

one or both risk

behaviors, decreasing

temptation to engage

in risk behaviors and

increasing confidence

to avoid them, goalsetting, and change

planning; and

•	One contraceptive

counseling visit.

The CDC provides additional information about Project CHOICES at

http://www.cdc.gov/ncbddd/fasd/research-preventing.html.

Pregnant Women: Parent-Child Assistance Program (PCAP)

The Parent-Child Assistance Program (PCAP) is a scientifically

validated (Grant et al., 2005) paraprofessional case management

model that provides support and linkages to needed services to

women for 3 years following enrollment. The goal is to reduce

future AEP by increasing abstinence from alcohol and drug use and/

or improving regular use of reliable contraception among enrollees.

The target population for PCAP is pregnant or post-partum women

(up to 6 months) who have had an AEP and will self-report drug

and/or alcohol use during the target pregnancy. The model is based

in Relational Theory, the Stages of Change, and harm reduction.

PCAP programs exist in a variety of settings, including substance

abuse treatment and family support centers. Eligibility criteria

include self-report of heavy alcohol or illicit drug use during

pregnancy and ineffective or non-engagement with community

social services.

Intervention Components:

•	Paraprofessional home

visitation;

•	Goal-setting;

•	Case management

targeting alcohol use

and contraception use;

and

•	Linkages to community

services and programs.

Case management is

provided at least twice

monthly for up to 3 years

following initial entry into

the program.

To learn more about PCAP, including contact information, background materials, an

implementation guide, and relevant forms and materials, visit

http://depts.washington.edu/pcapuw/.
13

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

•	 12-Step programs;

•	 Hospital treatment programs;

•	 Mental health programs; and

•	 Special pregnancy-related programs, 

which can be identified through your 

state health department by calling 800-

311-BABY (2229), or 800-504-7081 for 

Spanish. 

Programs throughout the United States have 

worked and are working directly with the 

SAMHSA FASD Center for Excellence to 

implement SBI (summarized above), Project 

CHOICES, or the Parent-Child Assistance 

Program (PCAP) (both summarized in the 

box ”Targeted Referral Options,” previous 

page). A program near you can be considered 

a source for possible referral or for guidance 

on locating a similar program. Please contact 

the FASD Center for Excellence for current 

program contact information 

(www.fasdcenter.samhsa.gov). Your local 

FASD State Coordinator may also be able 

to provide guidance on appropriate referrals. The National Association of FASD 

State Coordinators can be con¬tacted via the 

SAMHSA FASD Center for Excellence Web 

site: http://fasdcenter.samhsa.gov/statesys

temsofcare/nafsc.aspx.

The feasibility of fully implementing SBI, 

Project CHOICES, or PCAP in your agency 

will depend on your staff skill set, your collaborative network, your funding, and a variety 

of other factors that are examined in greater 

detail in the Administrative section (Part 2) of 

this TIP. 

Providing a Referral: Additional Factors to 

Consider

•	 Discuss possible strategies for the client 

to stop consuming alcohol; for example, 

individual counseling, 12-Step programs, 

and other treatment programs. Studies 

have shown that people given choices are 

more successful in treatment (Taylor et 

al., 2009).

•	 Use an advocate or special outreach 

services, if available, such as PCAP or 

Maternity Support Services (Taylor et 

al., 2009). Refer to Appendix C, Public 

and Professional Resources on FASD, for 

additional sources of information on 

community supports.

•	 Obtain information about costs, which 

health plans cover alcohol services (e.g., 

Medicaid, Medicare, state assistance, 

and public programs), who to contact to 

refer a patient, the phone numbers, and 

the necessary procedures for enrollment. 

This will allow you to tailor the referral 

to the client’s needs and health insurance 

coverage (Higgins-Biddle, Hungerford, & 

Cates-Wessel, 2009).

•	 Identify the types of services available 

in your area (e.g., cognitive–behavioral, 

12-Step, Motivational Enhancement 

Therapy) and the types of modalities 

(e.g., in-patient, outpatient), and prepare 

short descriptions of the available options 

so patients can understand the differences 

among alternative approaches (HigginsBiddle et al., 2009).

•	 If possible, help the client make an 

appointment while she is in your office. 

If the woman is unwilling to make that 

commitment, ask if she would like some 

information to take with her if she should 

change her mind. Schedule the next 

visit, continue to maintain interest in 

her progress, and support her efforts to 

change. Monitor and follow up on any 
14

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Helping Your Clients Receive Culturally Competent Services

This TIP, like all others in the TIP series, recognizes the importance of delivering culturally

competent care. Cultural competency, as defined by HHS, is...

“A set of values, behaviors, attitudes, and practices within a system, organization, program, or 

among individuals that enables people to work effectively across cultures. It refers to the ability 

to honor and respect the beliefs, language, interpersonal styles, and behaviors of individuals and 

families receiving services, as well as staff who are providing such services. Cultural competence 

is a dynamic, ongoing, developmental process that requires a long-term commitment and is 

achieved over time” (U.S. Department of Health and Human Services, 2003, p. 12).

This section discusses national information resources that are available on the topic of cultural

competence or for providing care to specific cultural groups (listed alphabetically). However,

the absence of a specific cultural group from this section is not meant to suggest that cultural

competency is not an issue for that population. Individuals from all cultural backgrounds deserve

respect and attention in a treatment environment, and the significance of culture needs to be

recognized in relation to many different areas of a person’s life; race, ethnicity, gender, sexual

orientation, age, socioeconomic status, language, etc.

Chapter 3 of this TP, Clinical Vignettes, contains additional information on the essential elements

of culturally competent counseling.

Hispanic/Latin Populations

If your agency is not fully capable in serving Hispanic/Latin clients or a Hispanic/Latin client

requests culturally specific services, the National Council of La Raza provides a search tool

(http://www.nclr.org/index.php/nclr_affiliates/affiliate_network/) that can direct clients to

over 300 community-based organizations that provide a variety of health and general services for

Hispanic/Latin populations.

In addition, SAMHSA’s National Hispanic & Latino Addiction Technology Transfer Center (ATTC)

offers a variety of products and resources focused on the health needs of Hispanics and Latinos.

Visit their Web site at http://www.attcnetwork.org/regcenters/index_nfa_hispaniclatino.asp.

Native Populations

If your agency is not fully capable in serving native clients or a native client requests culturally

specific services, the Indian Health Service (IHS) provides an interactive search map (http://www.

ihs.gov/findhealthcare/) that can be used to find an IHS, Tribal, or Urban Indian Health Program

(UIHP) facility. This search engine scans a variety of settings, including hospitals, behavioral

health settings, village clinics, and school health facilities.

If you are unable to locate services through the map, the Health Resources and Services

Administration (HRSA) provides the HRSA Health Center locator (http://findahealthcenter.hrsa.

gov/Search_HCC.aspx) to determine if there are other culturally specific services available in

your area.

Cultural Competency Training/Learning

The SAMHSA FASD Center for Excellence can provide training or technical assistance (TA) on

cultural competency topics, or can put your agency in touch with a nearby specialist. Training

and TA request forms can be accessed online (http://www.fasdcenter.samhsa.gov). Chapter 3

of this part of the TIP, Clinical Vignettes, also contains a checklist of core competencies for the

culturally sensitive counselor.

In addition, the HRSA’s Culture, Language and Health Literacy page (http://www.hrsa.gov/

culturalcompetence/index.html) provides links to a range of resources on cultural competence

when serving clients of differing cultures, genders, and sexual identities.
15

Chapter 1: Prevention of Alcohol-Exposed Pregnancies Among Women of Childbearing Age

co-existing psychiatric conditions (Taylor 

et al., 2009).

•	 Maintain communication with the sub-

stance abuse treatment or other provider 

to monitor progress (Taylor et al., 2009).

•	 If immediate substance abuse treatment 

or other support is not available, the 

counselor or designated staff might meet 

with the woman weekly or bi-weekly to 

express concern and to acknowledge the 

seriousness of the situation (Taylor et al., 

2009).

Working with Women Who May 

Have an FASD

When working with women of childbearing 

age, counselors may encounter clients who 

exhibit symptoms or characteristics suggesting 

that they themselves have an FASD. Research 

has identified intergenerational FASD as a 

pattern (Kvigne et al., 2003; May et al., 2005). 

Verifying the presence of an FASD is a pro-

cess of observation, interviewing, and addi-

tional screening that takes time. The guide-

lines provided in the next chapter, Addressing 

FASD in Treatment, can prove helpful for 

counselors who want to pursue verification of 

a possible FASD in the client, and/or wish to 

modify their approach to delivering prevention 

or treatment/referral accordingly.

For more information on AEP 

prevention...

Vignettes 1–4 in Part 1, Chapter3 illustrate

scenarios wherea counselor practices AEP

prevention approaches. In addition, Part 3,

the online literature review, also contains

further discussion of screening and prevention

interventions.

17

2 Addressing FASD in 

Treatment 

IN THIS CHAPTER

•	Introduction

•	1. The Starting Point: 

Observing Indicators

•	2. Functional 

Observation and 

History/Interviewing

•	3. Assessment (External 

or Through an 

In-House Assessment 

Team)

•	4. Tailoring Treatment 

for Individuals with 

an FASD

• 5. Working with the 

Family

• 6. Transition and 

Connection to 

Community Supports

Introduction

Value of Addressing FASD

Although the evidence base for effective substance abuse/mental 

health interventions with individuals who have or may have an 

FASD is limited (Premji, Benzies, Serrett, & Hayden, 2006; 

Paley & O’Connor, 2009), research has demonstrated that this 

population can and does succeed in treatment when approaches 

are properly modified, and that these modifications can lead to 

improved caregiving attitudes and reduced stress on family/caregivers as well as providers (Bertrand, 2009).

For the counselor, building competence with FASD has the 

obvious value of enhancing professional skills, as the counselor 

can provide FASD-informed care. For the client, addressing 

FASD has the potential to enhance the treatment experience 

for both the individual with an FASD and those around him or 

her, increase retention, lead to improved outcomes, reduce the 

probability of relapse (thus helping to break the cycle of repeated 

treatment, incarceration, displacement), and increase engagement 

rates in aftercare services. Access to FASD-informed interventions and accommodations, like those discussed in this chapter, 

has the potential to create protective factors for the client that 

can reduce secondary disabilities (Streissguth et al., 2004) and 

has been shown to lead to better outcomes (Bertrand, 2009).

For the client, addressing FASD provides an additional route 

to possible treatment success. Individuals with an FASD are 

a largely hidden population, yet these individuals frequently 

need services for substance abuse, and, especially, mental health 

(Streissguth et al., 1996). For every client that did not return for 

appointments, seemed noncompliant or resistant with no clear 

explanation of why, or just didn’t seem to ‘get it,’ a knowledge of 

FASD could be an extra clue that helps solve that puzzle and 

enable success for both the client and the program.
18

Be Willing...

To	effectively	serve	individuals	who	have	or	may	have	an	FASD,	what	is	needed	most	is	a	counselor	

who	is	willing.	For	many	individuals	with	an	FASD,	it	is	not	that	they	can’t	do	the	things	necessary	

to	succeed	in	treatment.	Rather,	it’s	that	no	one	is	willing	to	develop	the	understanding	needed	

to	help	them	succeed.	While	individuals	with	an	FASD	do	present	unique	challenges,	a	willing	

counselor	can	make	the	difference	between	treatment	success	and	treatment	‘failure.’

• Be willing	to	understand	the	brain-based	disabilities	that	are	characteristic	of	these	disorders:	

With	any	diffuse	brain	damage,	including	the	damage	that	can	result	from	prenatal	alcohol	

exposure,	some	of	the	effects	are	permanent,	and	one	cannot	assume	or	teach	the	usual	

decision-making	and	self-care	capabilities.

• Be willing	to	observe	physical	and	behavioral	factors	and	consider	possibilities	beyond	

defiance,	noncompliance,	or	other	more	commonly	diagnosed	symptoms.

• Be willing	to	meet	the	client	where	they	are	and	enable	their	growth.

•	Be willing	to	set	aside	the	false	view	that,	because	an	FASD	is	permanent,	“nothing	can	be	

done.”	Individuals	with	an	FASD	can	and	do	respond	positively	to	treatment	that	is	modified	

to	meet	their	unique	needs.

• Be willing	to	develop	treatment	plans	for	this	population	with	the	identification	and	

addressing	of	secondary	disabilities	as	a	built-in	expectation,	as	research	has	shown	that	

individuals	with	an	FASD	exhibit	a	unique	prevalence	of	co-occurring	disorders	(O’Connor	et	

al.,	2002;	Astley,	2010;	Pei,	Denys,	Hughes,	&	Rasmussen,	2011;	Kodituwakku	&	Kodituwakku,	

2011).

•	Be willing	to	redefine	success	and	consider	multiple	treatment	options	and	make	

modifications	(frequency,	duration,	cultural	issues,	client	strengths,	etc.)	to	maximize	the	client’s	

opportunities	for	recovery.

• Be willing	to	stretch	the	schedule.	Success	with	a	client	who	has	an	FASD	can	take	longer,	

but	it	is	achievable.	Interventions	should	aim	to	“...support	the	life	path	of	an	individual	with	

disabilities	in	a	positive	direction	over	time”	(Olson,	Oti,	Gelo,	&	Beck,	2009).

It is important to note that this TIP is not 

encouraging counselors to forego the primary 

treatment issue that brought the client to their 

setting in the first place, in favor of treating 

FASD. This chapter is only providing a process for identifying FASD as a possible barrier 

to successfully addressing the primary treatment issue, and making appropriate modifications to your treatment approach to maximize 

the potential for positive outcomes. Even if 

the cognitive or behavioral barriers that you 

identify through this process do not ultimately 

result in a diagnosis or positive assessment for 

an FASD, these are still functional impairments presenting barriers to treatment, and 

thus the process remains valuable. 

Identifying the Need for FASD Assessment, 

Diagnosis, and Services: Suggested Steps

The step chart on the next page illustrates a 

six-stage process that counselors can implement with clients for whom there are indications of an FASD. These steps will form the 

outline for the remainder of this chapter.

1. The Starting Point: Observing 

Indicators

Identifying Barriers and Causes

If there are indications of an FASD in the 

form of maladaptive behaviors, Step 1 represents a critical intermediate process: Be willing 

to consider the root cause of the behavior rather 

than just responding to the behavior. The 
19

Chapter 2: Addressing FASD in Treatment

1.	The	Starting	Point:	Observing	Indicators

2.	Functional	Observation	and	History/Interviewing

3.	Assessment	(External	or	Through	an	In-House	Assessment	Team)

4.	Tailoring	Treatment	for	Individuals	with	an	FASD

5.	Working	with	the	Family

6.	Transition	and	Connection	to	Community	Supports

easiest way to think of Steps 1 and 2 is that 

Step 1 is the observation of a treatment barrier 

or group of barriers, Step 2 is the examination 

of a possible root cause (or causes).

So, in Step 1, you have a client who is 

not doing well in treatment, and you have 

exhausted your normal protocol of approaches 

for improving the efficacy of the treatment 

relationship. Since individuals with an FASD 

are at an increased risk of having substance 

use or mental health issues in the first place 

(Streissguth et al., 1996; Astley, 2010), what 

this step asks you to do is take a step back and 

consider whether the maladaptive behaviors 

that you are observing (e.g., frequently missed 

appointments) match the profile of an individual who may have an FASD (i.e., poor time 

management skills, memory problems).

When working with an individual who has an 

FASD, a counselor would be likely to observe 

problem indicators in the following functional 

domains:

•	 Planning/Temporal Skills

•	 Behavioral Regulation/Sensory Motor 

Integration 

•	 Abstract Thinking/Judgment 

•	 Memory/Learning/Information 

Processing 

•	 Spatial Skills and Spatial Memory 

•	 Social Skills and Adaptive Behavior 

•	 Motor/Oral Motor Control 

Problems in these domains will likely show up 

as deficits that interfere with treatment success, including:

•	 Inability to remember program rules or 

follow multiple instructions. 

•	 Inability to remember and keep appointments, or to get lost on the way there. 

•	 Inability to make appropriate decisions 

by themselves about treatment needs and 

goals. 

•	 Inability to appropriately interpret social 

cues from treatment professionals or other 

clients. 

•	 Inability to observe appropriate boundaries, either with staff or other clients.

•	 Inability to attend to (and not disrupt) 

group activities. 
20

•	 Inability to process information readily or 

accurately.

•	 Inability to ‘act one’s age.’

When indicators occur in any these domains 

(and particularly when they occur across 

multiple domains), it is worthwhile to apply 

the FASD 4-Digit Code Caregiver Interview 

Checklist (Astley, 2004b) in Step 2 to determine if there is sufficient cause to 1) pursue 

evaluation for an FASD with this client, and 

2) modify treatment to account for the client’s 

functioning in these areas.

2. Functional Observation and 

History/Interviewing

An Appropriate Approach to Observation and 

Interviewing

If you have decided to move on to a fuller 

examination of the possible presence of an 

FASD based on indicators observed in Step 1, 

it is important to approach the topic with care 

and sensitivity. For the client, discussion of a 

possible FASD can cause feelings of shame, or 

possibly even anger or disbelief, about being 

identified with a “brain disorder.” For the family of the individual, particularly for a birth 

mother, suggesting the possible presence of an 

FASD can lead to feelings of guilt or a feeling 

of being ‘blamed,’ and a perception that service systems are unhelpful or even a negative 

experience. It is critical for a counselor to take 

a no-fault, no-shame approach to the topic 

of FASD, continually reassuring the individual and the family that you are examining 

the possibility of an FASD only as a way to 

achieve the best possible treatment outcome.

The FASD 4-Digit Code Caregiver Interview 

Checklist

The FASD 4-Digit Code Caregiver Interview 

Checklist provided below is from the FASD 

4-Digit Diagnostic Code (Astley, 2004b). The 

checklist is also reproduced in Appendix D, 

and can be considered for reproduction and 

inclusion in your treatment file for clients 

where you believe a form of FASD may be 

present.

However, please note: This checklist is not 

presented as a validated FASD screening 

instrument. It is simply provided as a tool 

that can be used over time to note typical 

problem areas for someone who might have an 

FASD (i.e., building a profile of FASD), and 

provides information that you can combine 

with your clinical judgment to make a betterinformed decision about whether to direct a 

client toward a more extensive FASD assessment or diagnosis.

It should also be noted that the behaviors 

identified on this checklist can indicate other 

disorders, as well. Individuals with an FASD 

are frequently misdiagnosed (Greenbaum 

et al., 2009). Given their symptoms, they 

may be described as meeting criteria for 

Attention Deficit/Hyperactivity Disorder 

(ADHD), Attention Deficit Disorder (ADD), 

Oppositional Defiant Disorder (ODD), adolescent depression, or bipolar disorder. It is 

possible for FASD to co-occur with any of 

these diagnoses, but it is also possible that a 

condition on the fetal alcohol spectrum may 

better describe the pattern of target symptoms 

than these other diagnostic terms. A differential and comprehensive diagnosis is essential, 

whether in-house or through referral, and the 

information gathered through this checklist 

can help to inform a diagnostic process.

In a profile of the first 1,400 patients to 

receive diagnostic evaluations for an FASD 

at the Washington State FAS Diagnostic & 

Prevention Network (FAS DPN), caregivers 

completing an interview with a professional 

based in part on this checklist demonstrated 

an impressive ability to differentiate the 

behavior profiles of children with FAS/pFAS, 

children with severe ARND (SE/AE), and 
21

Chapter 2: Addressing FASD in Treatment

The FASD 4-Digit Code Caregiver Interview Checklist

Severity Score: Severity of Delay/Impairment (Displayed along left margin) 

Circle: 0 = Unknown, Not Assessed, Too Young 1 = Within Normal Limits 2 = Mild to Moderate 

3 = Significant 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
22

Addressing Fetal Alcohol Spectrum Disorders (FASD)

 

 

 

 

 

 

 

 

Source: Astley, S. J. (2004). Diagnostic guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code, Third Edition. 

Seattle, WA: University of Washington. Accessed June 1, 2012 at http://depts.washington.edu/fasdpn/pdfs/FASD-2004-

Diag-Form-08-06-04.pdf. Used with permission from the author. 

children with moderate ARND (ND/AE) 

(Astley, 2010).

In addition, the box “Risk Assessment 

Questions” contains a group of questions 

developed at the FAS Community Resource 

Center in Tucson, Arizona. These questions 

can further assist providers seeking to determine whether an evaluation for an FASD is 

warranted.

3. Assessment (External or 

Through an In-House Assessment 

Team)

Assessment for the presence of an FASD is 

an interdisciplinary process best accomplished 

through a team approach. The sad reality is 

that the existing network of qualified assessment teams and facilities in the United States 

is insufficient to meet demand, and behavioral health experts have repeatedly observed 

the urgent need for an increase in FASD 

Risk Assessment Questions

 

 

 

Adapted from: Kellerman, T. (2005). Recommended assessment tools for children and adults with confirmed or suspected 

FASD. Tucson, AZ: FAS Community Resource Center. Accessed June 5, 2012 at 

http://come-over.to/FAS/AssessmentsFASD.htm. 
23

Chapter 2: Addressing FASD in Treatment

assessment, diagnosis, and treatment capacity (Institute of Health Economics, 2009; 

Interagency Coordinating Committee on 

FASD, 2011).

However, many substance abuse and mental 

health treatment settings may have an interdisciplinary staff team and/or sufficient referral relationships to attempt FASD assessment 

internally, creating an opportunity to help fill 

a gap in the behavioral health field. If this is 

the case with your agency, this section discusses some of the essential elements of FASD 

assessment, as well as available resources 

that can help your agency develop this staff 

capability. (The first interdisciplinary FASD 

diagnostic clinic [the Washington State FAS 

Diagnostic and Prevention Network (FAS 

DPN)] was established in Washington State 

in 1993 as part of a CDC-sponsored FASD 

prevention study [Clarren & Astley, 1997]. 

A comprehensive description of the interdisciplinary model used by the Washington 

State FAS DPN is presented by Clarren, 

Carmichael-Olson, Clarren, and Astley 

[2000]; see Appendix A: Bibliography). In 

addition, for sites that cannot provide FASD 

capacity internally, referral options do exist, 

and this section will provide information on 

accessing those resources.

In-House FASD Assessment: The Essential 

Elements

Effective in-house assessment for FASD is 

built on three core components: 1) building 

the right team, 2) accessing the right resources, 

and 3) gathering the right information.

Building the Right Team

FASD assessment, as will be explained below, 

involves gathering information and making 

evaluations in a variety of functional areas, 

and is an involved process that can overwhelm 

the client and his or her family. This necessitates a wide range of professional skill sets, 

not only to perform the various clinical and 

observational tasks, but also to help the client 

and family navigate the process smoothly. The 

box “In-House FASD Assessment: An Ideal 

Core Team” describes an ideal in-house FASD 

assessment team and its functions.

Part 2, Chapter 2 of this TIP outlines appropriate processes if these professionals need 

to be added and/or accessed through referral 

relationships.

Accessing the Right Resources

Appendix C, Public and Professional Resources 

on FASD, provides information and links for 

accessing FASD information and training 

from a variety of national and regional sources. 

In-House FASD Assessment: An Ideal Core Team

•	

•	

•	

•	

•	

•	
24

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Gathering the Right Information

•	

•	

•	

•	

•	

Based	on	TIP	consensus	panel	recommendations	and	Canadian Guidelines for Diagnosis	(Chudley,	Conry,	Cook,	Loock,	

Rosales,	&	LeBlanc,	2005).

1

	The	psychologist	should	be	trained	to	do	neuropsychological	testing.

Among these are two excellent resources for 

agencies seeking to develop FASD capabilities; the Washington State FAS DPN and 

the CDC’s FASD Regional Training Centers 

(RTCs).

•	 One of the primary sites for FASD 

assessment and diagnosis in the United 

States is the Washington State FAS 

DPN, based at the University of 

Washington in Seattle. Established 

in 1993 through Washington State 

Senate Bill 5688 and support from 

the CDC, March of Dimes, Chavez 

Memorial Fund, and the Washington 

State Department of Social and Health 

Services, the Washington State FAS 

DPN provides FASD diagnostic services 

as well as training in FASD. Training 

resources include the FASD 4-Digit 

Diagnostic Code Online Course and a 

2-day FASD Diagnostic Team training 

for interdisciplinary clinical teams (or 

individual clinical team members) seeking 

to establish FASD services in their community. Visit the FAS DPN’s homepage 

(http://depts.washington.edu/fasdpn/) 

to find out more about their services. 

•	 The CDC’s RTCs develop, implement, 

and evaluate educational curricula regarding FASD prevention, identification, 

and care, and incorporate the curricula 

into training programs at each grantee’s 

university or college, into other schools 

throughout their regions, and into the 

credentialing requirements of professional 

boards. Visit the CDC’s RTC homepage 

(http://www.cdc.gov/ncbddd/fasd/

documents/flyerfasd_rtcs.pdf) to find 

out about currently funded RTC sites and 

available services.

A useful tool that your team can use to 

gather and organize the necessary information to support a formal FASD diagnosis is 

the New Patient Information Form. This form 

was developed by the Washington State FAS 

DPN and is part of the Diagnostic Guide for 

Fetal Alcohol Spectrum Disorders: The 4-Digit 

Diagnostic Code (Astley, 2004b, Third Edition, 

pp. 103-114). If your agency decides to refer 

a client for an FASD diagnosis, this information will provide a necessary foundation 

for the diagnostic process. The New Patient 

Information Form can be downloaded for free 

from (http://depts.washington.edu/fasdpn/

htmls/diagnostic-forms.htm).

In addition to basic information about the 

client and your agency, the New Patient 

Information Form provides a template for 

gathering information in the critical areas of 

Growth; Physical Appearance and Health; 

Neurological Issues; Attention Deficit and 
25

Chapter 2: Addressing FASD in Treatment

Hyperactivity; Mental Health Issues; School 

Issues; Alcohol Exposure; Information About 

the Patient’s Biological Parents; Medical 

History of the Biological Family; Pregnancies 

of Birth Mother; Pregnancy, Labor, and 

Delivery of this Patient; List of Professionals 

Currently Involved in Patient’s Care; 

Placements (foster, adoptive, etc.); and What 

to Bring to the [diagnostic] Clinic.

To further ensure collection of appropriate 

information and build staff knowledge and 

capabilities related to FASD, it will be valuable for your team to become familiar with 

the basic guidelines of the most widely used 

diagnostic approaches to the various disorders 

in the spectrum. A comprehensive comparison 

of the current FASD diagnostic systems is 

presented in a chapter entitled “Diagnosing 

FASD” (Astley, 2011), and is reprinted 

in Appendix E, Comparison of Current 

FASD Diagnostic Systems with the author’s 

permission.

External: Assessment and Diagnosis

The reality for many programs will be that, 

for reasons of cost and/or lack of community 

resources, building an in-house FASD assessment team or diagnostic capability will be 

unrealistic. If this describes your agency, the 

FASD diagnosis and training sites discussed 

under Accessing the Right Resources, above, 

should be accessed so that you can refer your 

client to an appropriate provider. Agencies can 

also use the Resource Directory (http://www.

nofas.org/resource-directory/) provided by 

the National Organization on FAS (NOFAS) 

to help locate FASD-related services.

At the same time, referral for assessment and 

diagnosis should be paired with treatment 

modifications and accommodations that are 

discussed in the next section. This can be done 

with or without a formal diagnosis of a form 

of FASD. If you and your clinical team have 

identified symptoms indicating an FASD 

through Steps 1 and 2 of this chapter, the 

methods discussed in the next section can still 

help the treatment process.

Many providers will not have an existing 

relationship with the FASD assessment or 

diagnosis provider to whom they refer a client. In such cases, it is vital to actively assist 

the client through the transition and provide 

regular follow-up to ensure client satisfaction 

and full and open communication between 

agencies and with the client. (Also the client’s 

family, if they are involved in treatment.) The 

box “Overview of the Diagnostic Process (As 

Performed by the FAS DPN)” summarizes the 

phases of the diagnostic process as performed 

Overview of the Diagnostic Process (As Performed by the FAS DPN)

A comprehensive description of the FAS DPN interdisciplinary FASD diagnostic process is presented by 

Clarren et al. (2000).

•	

•	
26

Addressing Fetal Alcohol Spectrum Disorders (FASD)

•	

•	

•	

•	

•	

•	

•	

Table	originally	appeared	in	Jirikowic,	Gelo,	&	Astley	(2010)	with	minor	modifications.

by the Washington State FAS DPN. The 

phases of this process are likely to be similar 

in other interdisciplinary FASD diagnostic 

clinics.

When the Client Already Has a Diagnosis of an 

FASD

If a client has already been diagnosed with 

an FASD at the time of presentation to your 

setting, the guidelines in the next section 

should automatically be considered. In addition, as indicated in the table Overview of 

the Diagnostic Process in the previous section, 

the diagnosis report may also be a source of 

intervention and modification guidelines and 

should be thoroughly reviewed by the counselor with the client (and the family, if involved 

in the treatment process). A comprehensive 

summary of the types of intervention recommendations provided in relation to 120 youths 

following their FASD diagnostic evaluations 

at the Washington State FAS DPN is provided by Jirikowic et al. (2010).

At the same time, further assessment by medical, mental, and allied health professionals 

may still be needed to determine the client’s 

current level of function in important areas, 

particularly if the diagnosis occurred years 

earlier. “Refreshing” the functional information 

will help the counselor tailor the treatment 

plan and counseling strategies to the client’s 

strengths, needs, and preferences. Forms of 

re-testing and assessment can include the 

following:

•	 Being familiar with any medications the 

client is taking and observing any behaviors or physical symptoms that might 

indicate the need to reevaluate medication 

use or dosage; 

•	 Hearing and speech tests to identify any 

progress in communication or barriers 
27

Chapter 2: Addressing FASD in Treatment

that may affect the client’s treatment and 

ongoing recovery;

• Occupational therapy and physical 

therapy evaluations to assess the client’s 

daily living skills and motor function, 

vocational skills, and preferences and 

possibilities;

•	 Determining current achievement levels 

in reading, spelling, and math; and

•	 Use of an appropriate, standardized interview or questionnaire to determine how 

the client compares to peers in receptive, 

expressive, and written communication; 

personal, domestic, and community daily 

living skills; and interpersonal relationships, play and leisure time, and coping 

skills.

4. Tailoring Treatment for 

Individuals with an FASD

Introduction

This section will discuss appropriate 

approaches to modifying treatment and/or 

making necessary accommodations for clients 

who exhibit indicators suggesting an FASD, 

or who show cognitive and behavioral barriers 

to treatment success, as identified in Steps 1 

and 2 of this chapter.

This discussion is divided into two sections; 1) 

general principles for working with individuals who have or may have an FASD (regardless of age), and 2) specific considerations for 

adolescents who have or may have an FASD. 

The chapter then moves on to Step 5, Working 

With the Family, and Step 6, Transition and 

Connection to Community Supports.

As noted above, if the individual already 

has a diagnosis of an FASD, the diagnostic 

report may also include recommendations for 

appropriate interventions and modifications to 

treatment. The counselor should review this 

report thoroughly, if it is available.

General Principles for Working with 

Individuals Who Have or May Have an FASD

Safety Considerations

Safety is a primary health issue for individuals of all ages with an FASD ( Jirikowic et al., 

2010). Starting a treatment process without 

first addressing safety issues is futile and 

potentially dangerous: The clinician must first 

evaluate physical safety for the adolescent or 

adult with an FASD. This includes issues of 

violence, harm to self (such as self-mutilation) 

or others, victimization, adequate housing, and 

food. In typical adolescents and adults, psychiatric severity can be significantly reduced 

when co-occurring issues are treated together 

and mental health and substance abuse treatment are provided as an integrated program 

(Hser, Grella, Evans, & Huang, 2006).

For older individuals who have or may have 

an FASD, there are special safety considerations. This population has a number of risk 

factors for accidents and injury; poor decisionmaking, impulsivity, impaired motor coordination, working memory, attention, emotional 

and sensory regulation, and susceptibility to 

peer pressure. Even seemingly routine tasks 

like crossing the street safely may be impossible for those who are more severely affected. 

Other examples of possible safety and health 

concerns in adolescents and adults with an 

FASD are remembering medication schedules, 

decisions about legal and illegal substances, 

driving, and risk-taking situations in which 

poor social problem-solving (McGee, Fryer, 

Bjorquist, Mattson, & Riley, 2008), impulsivity, and peer pressure combine to compromise 

safety.

Vignette #9 in Part 1, Chapter 3 of this TIP 

elaborates the process of working with a caregiver to develop a personalized Safety Plan 

on behalf of an individual with an FASD. In 

addition, Appendix F, Sample Crisis/Safety 

Plan, contains a sample plan that has been 
28

Addressing Fetal Alcohol Spectrum Disorders (FASD)

adapted from the work of the Families Moving 

Forward Program (http://depts.washington.

edu/fmffasd/), and can be printed and used 

with a client and/or their family member(s)/

caregiver(s).

Risk for Abuse

Children with physical, psychological, and 

sensory disabilities—including FASD—are 

known to be more vulnerable to violence 

and maltreatment, or to be at a greater risk 

of these forms of abuse (Olivan, 2005). This 

vulnerability is brought about by a variety of 

factors, including dependence on others for 

intimate and routine personal care, increased 

exposure to a larger number of caregivers and 

settings, inappropriate social skills, poor judgment, inability to seek help or report abuse, 

and lack of strategies to defend themselves 

against abuse. Murphy and Elias (2006) report 

figures from the National Center on Child 

Abuse and Neglect indicating that children 

with disabilities are sexually abused at a rate 

2.2 higher than that for children without disabilities. The United States Department of 

Justice reports that 68 to 83 percent of women 

with developmental disabilities will be sexually assaulted in their lifetimes, and less than 

half of them will seek assistance from legal or 

treatment services (Pease & Frantz, 1994). In 

a study of 336 males and females in treatment 

for alcohol abuse or dependence, more than 56 

percent had also experienced childhood sexual 

or physical abuse (Zlotnick et al., 2006).

In one long-term study, 80 percent of young 

adults who had experienced abuse as a child 

met diagnostic criteria for at least one psychiatric disorder at age 21. These individuals 

exhibited many problems, including depression, anxiety, eating disorders, and suicide 

attempts (Silverman, Reinherz, & Giaconia, 

1996). Other psychological and emotional 

conditions associated with abuse and neglect 

include panic disorder, dissociative disorders, attention-deficit/hyperactivity disorder, 

depression, anger, posttraumatic stress disorder, 

and reactive attachment disorder (Teicher, 

2000; De Bellis & Thomas, 2003; Springer, 

Sheridan, Kuo, & Carnes, 2007). 

Astley (2010) has documented a high prevalence of abuse, neglect, and multiple home 

placements among 1,400 patients identified 

with an FASD—70 percent were in foster/

adoptive care and had experienced, on average, 

three home placements. In fact, in a separate 

study, Astley and colleagues (2002) identified a 

prevalence rate of FAS in foster care that was 

10-times higher—1/100—than in the general 

population—1/1000. Children in foster care 

face a risk of maltreatment, which can affect 

their physical health and lead to attachment 

disorders, compromised brain functioning, 

inadequate social skills, and mental health difficulties (Harden, 2004). Another study among 

young women with FASD found that they 

had poor quality of life scores and high levels 

of mental disorders and behavioral problems 

relative to standardization samples and other 

at-risk populations (Grant et al., 2005).

Risk for Suicide

In addition, individuals with an FASD are at 

significant risk of suicide at all ages studied 

(Huggins et al., 2008). A person with an 

FASD may not appear to plan or execute a 

suicide attempt effectively; this is not indicative of the seriousness of the intent.

High Risk of Repeated Involvement with the 

Legal System

People with an FASD can have specific types 

of brain damage that may increase engagement in criminal activity (Kodituwakku et 

al., 1995; Page, 2001; Mattson, Schoenfeld, 

& Riley, 2001; Page, 2002; Moore & Green, 

2004; Clark et al., 2004; Schonfeld, Mattson, 

& Riley, 2005; Schonfeld, Paley, Frankel, 

O’Connor, 2006; Brown, Gudjonsson, & 

Connor, 2011). These can include:
Chapter 2: Addressing FASD in Treatment

Suicide Intervention/Prevention for Individuals with an FASD

•	Standard	suicide	assessment	protocols	need	to	be	modified	to	accommodate	neuropsychological	

deficits	and	communication	impairments:

	 •	 Instead	of	“How	does	the	future	look	to	you?”	ask	“What	are	you	going	to	do	tomorrow?		

	 	 Next	week?”	(Difficulties	with	abstract	thought.)

•	 The	seriousness	of	the	suicidal	behavior	does	not	necessarily	equal	the	level	of	intent	to	die		

	 (lack	of	understanding	of	consequences).

• Obtain	family/collateral	input.

•	Be	careful	about	words	used	regarding	other	suicides	or	deaths.

•	Intervene	to	reduce	risk:

	 •	 Address	basic	needs	and	increase	stability.

	 •	 Treat	depression.

	 •	 Teach	distraction	techniques.

	 •	 Remove	lethal	means.

	 •	 Increase	social	support.

•	Do	not	use	suicide	contracts	(impulsivity	issues).

•	Monitor	risk	closely.

•	Reinforce	and	build	reasons	for	living.

	 •	 Be	literal.

•	 Strengthen	advocate-client	relationship.

Source:	Huggins,	J.	E.,	Grant,	T.,	O’Malley,	K.,	&	Streissguth,	A.	(2008).	Suicide	attempts	among	adults	with	Fetal	Alcohol	

Spectrum	Disorders:	Clinical	considerations.	Mental Health Aspects of Developmental Disabilities, 11(2),	33-42.

•	 Lack of impulse control and trouble 

understanding the future consequences of 

current behavior; 

• Trouble understanding what constitutes 

criminal behavior (for example, a youth 

with an FASD may not see any problem 

with driving a car he knows was stolen if 

he wasn’t the one who stole it);

•	 Difficulty planning, connecting cause 

and effect, empathizing (particularly 

if the experience is not explained in a 

very concrete way), taking responsibility, 

delaying gratification, and making good 

judgments; 

• Tendency toward explosive episodes, 

often triggered by sensory overload, 

slower rates of processing the information 

around them, and/or feeling “stupid;”

•	 Vulnerability to peer pressure and influence (e.g., may commit a crime to please 

friends), and high levels of suggestibility; 

and

•	 Lower level of moral maturity (due in 

part to social information processing 

deficits).

The number of people in the criminal justice 

system with an FASD has not specifically 

been determined. Data are limited, and populations vary by state. In addition, few systems 

conduct any screening or can provide diagnosis. Streissguth and colleagues (2004) conducted an evaluation of 415 clinical patients 

with FASD at the University of Washington. 

Trouble with the law (including arrest, conviction, or otherwise) was reported in 14 percent 

of children and 60 percent of adolescents and 

adults with an FASD. In addition, Fast, Conry, 

29
30

Addressing Fetal Alcohol Spectrum Disorders (FASD)

& Loock (1999) evaluated all youth referred 

to a forensic psychiatric assessment for FASD 

in Burnaby, British Columbia, Canada. Of 287 

youths assessed, 67 (or 23 percent) were found 

to have an alcohol exposure-related diagnosis. 

Although this result should not be generalized 

to the entire prison population, it does reveal 

a possible disproportionate representation of 

individuals with an FASD in the juvenile justice system.

It is important for counseling professionals 

to consider a client’s criminal history and 

any factors that place the client at risk for 

further criminal involvement. Because persons 

with an FASD have problems learning from 

experience, they may repeat crimes and cycle 

through the legal system multiple times.

Clinicians may encounter individuals with an 

FASD who are participating in court-ordered 

treatment. Such individuals need help navigating the legal system. The clinician can consult 

with the client’s attorney and assist in educating him or her about FASD. In addition, the 

clinician can assist in finding resources to 

help the client understand any legal proceedings and requirements. The National Legal 

Aid & Defender Association (http://www.

nlada100years.org/) or the American Bar 

Association (www.americanbar.org) may be 

able to identify resources at the local level.

Vulnerability of Individuals with an FASD

Individuals with an FASD are vulnerable not 

only to criminal activity but also to victimization (Freunscht & Feldman, 2011). Their poor 

judgment may lead them to associate with 

people who victimize them physically, emotionally, and financially. Their impulsivity may 

lead them into dangerous situations. Women 

with an FASD may get involved with negative associations for food, shelter, attention, or 

drugs (Page, 2003). In addition, their impaired 

sense of boundaries can lead to sexual victimization. Because of their unpredictable 

behavior, they may need 24-hour supervision 

(Streissguth, 1997).

Even with compensatory strategies, the person 

with an FASD may be less able to use judgment, consider consequences, or understand 

abstract situations (Kodituwakku, 2007; 

Astley, 2010; Freunscht & Feldman, 2011). 

Impulsivity is an ongoing issue. Social isolation and loneliness may drive the person to 

seek out any type of friendship and lead to 

victimization. A discussion or pursuit of safeguards for the person may be necessary:

• Recognize that victimization may occur, 

and keep vigilant for situations that may 

arise in the person’s life. 

•	 Role-play personal safety and specific 

scenarios that people face (e.g., who is a 

stranger vs. who is a friend) to allow the 

individual to practice taught skills and 

perhaps allow them to pursue safe activities (De Vos, 2003). Consider videotaping 

the client doing it right in the role-play, 

so he or she can watch it over and over, 

reinforcing the lesson. Watching the 

video also helps move the information 

from short-term memory to long-term 

memory. (In many cases, though certainly 

not all, long-term memory has been 

observed to function better than shortterm memory for individuals with an 

FASD).

•	 Establish written routines and structured 

time charts, and have these where they 

are easily seen throughout the day.

• Provide a buddy system and supervision to help decrease opportunities for 

victimization.

•	 Consider a guardianship of funds to protect the individual. A trustee can ensure 

that the necessities of life are covered, 

including rent, food, clothing, and finding 

an advocate. The clinician may want to 
31

Chapter 2: Addressing FASD in Treatment

include such provisions in the aftercare 

plan. 

•	 Help the client find a healthy, structured 

environment in aftercare to help them 

avoid criminal activity.

Family Safety and Support

For all families caring for an individual with 

an FASD, or when parents themselves have 

an FASD, establishing family safety and 

support is vital. A crisis/safety plan should 

always be put in place (see Appendix F for an 

example Crisis/Safety Plan form). To stay safe 

and well-supported, it is important to help 

the client (and caregivers) identify available 

services, determine which ones are effective 

for them or their children, and understand 

how to work productively with service providers (Streissguth, 1997). (See Appendix G for 

a Services and Supports Checklist that can be 

reviewed with clients as a worksheet.)

For birth families in recovery, the counselor 

can help families cope with FASD during the 

recovery process. This is best done by building a protective environment for clients and 

their children. This may include helping them 

obtain safe, stable housing, assisting with 

daily living skills (such as bill paying and food 

shopping), and overseeing home situations. 

It is also important to establish a network 

of community service providers who will be 

available for aftercare to promote ongoing 

recovery and avoid relapse (Millon, Millon, & 

Davis, 1993).

For more information about this topic, 

see Step 6, Transition and Connection to 

Community Supports).

Modifying a Treatment Plan

Factors to Consider

When modifying a treatment plan for an 

individual who has or may have an FASD, the 

following should be considered:

•	 Help the client adjust to a structured 

program or environment and develop 

trust in the staff. Individuals with an 

FASD tend to be trusting (Freunscht & 

Feldman, 2011) and need a great deal of 

structure, but may have trouble adapting 

to changes in routine and to new people. 

•	 Share the rules early and often. Put 

instructions in writing and remind the 

client often. Keep the rules simple and 

avoid punitive measures that most individuals with an FASD will not process. If 

a rule is broken, remind the client of the 

situation and help to strategize ways they 

can better follow the rule in the future. 

•	 Take a holistic approach, focusing on 

all aspects of the client’s life, not just the 

substance abuse or mental health issues. 

Include basic living and social skills, such 

as how to dress, groom, practice good 

hygiene, present a positive attitude, and 

practice good manners. Help the client 

develop appropriate goals within the context of his or her interests and abilities. 

•	 Provide opportunities to role-play or 

otherwise practice appropriate social 

behaviors, such as helping others. 

Areas of focus may include impulse 

control skills, dealing with difficult 

situations such as being teased, and 

problem-solving. 

•	 In an inpatient setting, allow time for 

the client to be stabilized and acquire 

the basic skills to cooperate with others 

before discussing his or her substance 

abuse or mental health issues. In an outpatient setting, it may help to develop a 

rapport with the client and establish trust 

and communication before addressing the 

primary treatment issue. 

•	 Assume the presence of co-occurring 

issues. It is likely that a high percentage 

of people with an FASD have at least one 

co-occurring mental disorder (O’Connor 
32

Addressing Fetal Alcohol Spectrum Disorders (FASD)

et al., 2002; Streissguth et al., 2004; Clark 

et al., 2004; Astley, 2010). In a study of 

1,400 patients with FASD, Astley (2010) 

documented that 75 percent had one or 

more co-occurring disorders, with the 

most prevalent being ADHD (54 percent). In a study of 80 birth mothers of 

children with FAS, 96 percent had from 

one to nine mental disorders in addition 

to alcoholism (Astley et al., 2000b); the 

most common was phobia (76 percent). 

Forty-four percent of the women had 

mental disorders diagnosed by the age of 

8 years.

•	 When possible, include the family or 

caregivers in activities, such as parent 

education about FASD and substance 

abuse and/or mental health, strategies for 

providing care for an individual with an 

FASD and a substance abuse or mental 

health problem (e.g., avoiding power 

struggles), and building the client’s selfesteem. Help family and caregivers practice positive communication skills such 

as active listening, use of literal language, 

and avoiding “don’t” (i.e., focusing on 

what needs to be done rather than what 

should not be done).

•	 Include the client in treatment planning/modification, and build family/

caregiver meetings into the plan as well, 

with a clear purpose and agenda. 

Recognize that some family members 

may also have an FASD, and work with 

them accordingly. 

•	 Incorporate multiple approaches to 

learning, such as auditory, visual, and 

tactile approaches. Avoid written exercises 

and instead focus on hands-on practice, 

role-playing, and using audio- or videorecording for playback/reinforcement 

of learning. Use multisensory strategies, 

The Navigator

A person who has impaired vision is given a seeing eye dog. A person with impaired hearing is

given an interpreter or a hearing aid. These external devices are necessary for the person with

physical impairments to be able to function to maximum potential in life.

The person with an FASD has a physical impairment in the area of the brain, particularly the

forebrain or frontal lobes, which regulate the executive functions. A navigator refers to the

presence of another responsible person (parent, teacher, job coach, sibling) who can mentor, assist,

guide, supervise, and/or support the affected person to maximize success (which may need to be

redefined as the avoidance of addiction, arrest, unwanted pregnancy, homelessness, or accidental

death).

Because some individuals with an FASD may appear to be bright and normal, the disability that is

brain damage may only be apparent in test results, or in actions that place the person at serious

risk. It is the risk of danger to the person and to others that makes a navigator such a useful

and important concept. A navigator can seem like a form of enabling or an encouragement

of co-dependency. More accurately, however, a navigator is an appropriate form of advocacy

to ensure that the individual receives whatever assistive devices are needed for him or her to

participate in life in as normal a capacity as reasonably possible.

For many individuals with an FASD, the navigator can be someone with whom they “check in” on a

regular basis, or vice versa. For others, the navigator will play a more constant advocacy role, and

may share the role with others. (See Vignette #9 for an example of a father playing the role of a

navigator, and sharing the role with a coach and one of his son’s relatives.)

Adapted from: Kellerman, T. (2003). External brain. Accessed June 5, 2012 at http://come-over.to/FAS/externalbrain.htm.
33

Chapter 2: Addressing FASD in Treatment

Counseling Strategies

such as drawing, painting, or music, to 

assist the client in expressing feelings. 

These strategies take advantage of skills 

that many individuals with an FASD 

have. They can also help the client share 

difficult feelings that may be hard to talk 

about, such as fear and anger.

• Consider sensory issues around lighting, equipment sounds, and unfamiliar 

sensations and smells. Individuals with 

an FASD can be very sensitive to these 

environmental factors.

•	 Arrange aftercare, and encourage family/

caregivers to participate in a support 

group to continue to learn parenting skills 

and to be encouraged in the recovery process (see Step 6, Transition and Connection 

to Community Supports).

Due to the cognitive, social, and emotional 

deficits seen in FASD, counseling clients with 

these conditions requires adaptability and flexibility. Research data, clinical observation, and 

caregiver reports all suggest that it is crucial 

to tailor treatment approaches. Traditional 

approaches may not prove optimally effective, and more effort may be needed to convey 

basic concepts and promote a positive therapeutic relationship and environment. The following are recommendations designed to help 

providers:

•	 Set appropriate boundaries;

•	 Be aware of the client’s strengths;

•	 Understand the impact of any abuse the 

client has experienced;

•	 Help the client cope with loss;

•	 Address any negative self-perception 

associated with an FASD;

•	 Focus on self-esteem and personal issues;

•	 Address resistance, denial, and acceptance;

•	 Weigh individual vs. group counseling;

•	 Consider a mentor approach; and

•	 Assess comprehension on an ongoing 

basis.

Boundaries

Establishing a trusting and honest relationship 

while maintaining boundaries is important 

with any client. Because persons with an 

FASD often lack social skills and have social 

communication problems (Kodituwakku, 

2007; Greenbaum et al., 2009; Greenspan, 

2009; Olson & Montague, 2011), they may 

breach boundaries by making inappropriate 

comments, asking inappropriate questions, 

or touching the counselor inappropriately. To 

set boundaries, it may help to have the client 

walk through the rules and expectations and 

demonstrate expected behavior. Frequent roleplaying can help the client learn to apply concepts and figure out how to respond to various 

situations.

Persons with an FASD frequently experience 

difficulty with memory (Rasmussen, 2005; 

Riggins et al., 2012). Added to this, they may 

be able to repeat rules but not truly understand them or be able to operationalize them. 

Thus, it is important to review rules regularly. 

It is much more effective to limit the number 

of rules, review them repeatedly, and role-play

different situations in which the person will 

need to recall the rules. Repetition is key.

Strengths

Many people focus on the deficits in persons 

with an FASD, but they also have many 

strengths. Some of these can be used in the 

treatment setting as part of counseling. Family 

may be a strength area: Parents report their 

children with FASD were engaged with 

their families and willing to receive—and 

even seek—help (Olson et al., 2009), as well 

as demonstrating a willingness to provide 

assistance with ordinary tasks ( Jirikowic et al, 

2008). Based on extensive clinical experience, 

Malbin (1993) identifies a number of other 

strength areas. For example, some people with 
34

Addressing Fetal Alcohol Spectrum Disorders (FASD)

an FASD are quite creative. They can express 

themselves through art and music, which may 

prove more effective than traditional talk therapy. Other approaches may involve storytelling 

and writing. These techniques can also be 

used for practical matters, such as developing a 

poster with treatment goals. In addition, visual 

aids can assist by drawing on areas of relative 

strength, so drawn or pictured goals may aid 

recall better than a written or spoken list of 

instructions.

History of Abuse

Given the risk of abuse among persons with 

an FASD and among individuals with substance abuse and/or mental health issues, it is 

likely that a client with a combination of these 

will have some personal abuse history (Astley 

et al., 2000b). The counselor working with 

persons with an FASD needs to be sensitive 

to the possibility of childhood abuse and other 

forms of victimization, and their impact on 

the counselor–client relationship. A common 

theme that counselors need to be attentive to 

is powerlessness, a theme often reflected in the 

following types of client communications and 

behaviors:

•	 Clients undervaluing their own 

competencies.

•	 Clients viewing others’ needs and goals as 

more important than their own.

•	 Clients’ inability to obtain nurturance and 

support for themselves.

•	 Clients’ feelings of depression, anger, and 

frustration about their lives.

•	 Clients’ low expectations for their own 

success.

Loss and Grieving

All individuals with an FASD have experienced losses in their lives. The fact that they 

are not like their peers is a loss of the ability 

to be like everyone else. Some have lost the 

hopes and dreams of what they wanted to be. 

Others lose their family or a secure future. 

Some lose the opportunity for meaningful 

peer relationships and friendships. These losses can affect people in many ways and need 

to be addressed. The counselor can help to 

address these areas of loss through a number 

of strategies:

•	 Use active listening strategies, such as 

repeating what the person has said; 

•	 Be honest; 

•	 Raise awareness of experiences of separation and loss; 

•	 Acknowledge and validate losses 

experienced; 

•	 Acknowledge the client’s feelings about 

loss;

•	 Avoid “good parent/bad parent” issues; 

•	 Encourage communication; and 

•	 Refer for further treatment (e.g., mental 

health) when necessary. 

Self-Perception

Self-perception is a major issue with FASD. 

Despite the advent of the disease model, many 

people still view alcohol problems as a sign 

of moral weakness or a character flaw. This 

negative stereotype can be particularly severe 

in relation to pregnant women who drink, 

making the topic difficult to discuss (Salmon, 

2008). Added to this, the negative judgment 

toward the mother may also be visited on the 

child. A counselor needs to be aware of this, 

and approach the issue carefully and sensitively if he or she suspects a client has an FASD.

Given their cognitive, social, and emotional 

deficits, persons with an FASD may think 

they are powerless to change. It is important 

to work through this issue with the client. 

They need to understand that they are not 

responsible for their disability and that they 

deserve respect. They also need to know that 

change is possible.
35

Chapter 2: Addressing FASD in Treatment

Self-Esteem and Personal Issues

The combination of abuse, loss, grief, and negative stereotypes can lead to self-esteem issues 

in any individual. Self-esteem is regularly an 

issue for individuals with an FASD (Olson, 

O’Connor, & Fitzgerald, 2001). Those who 

also have substance abuse or mental health 

problems face a double-edged sword: Their 

self-esteem can be damaged by their experience with an FASD and by their substance 

abuse or mental health issue. The clinician 

can use several strategies to help address selfesteem and personal issues:

•	 Use person-first language. An FASD 

may be part of who a person is, but it is 

not the person’s entire identity. Someone 

can have an FASD, but nobody is an 

FASD. 

•	 Do not isolate the person. Sending 

persons with an FASD out of the room 

to think about what they have done or 

responding to issues in a group session by 

simply ejecting them will often increase 

their sense of isolation and does not help 

them learn appropriate behaviors.

•	 Do not blame people for what they cannot do. Demanding that people repeatedly try to do things they cannot do is a 

lesson in frustration. It is important to 

have patience and understand individual 

limitations. People with an FASD may 

need something repeated several times 

because they have trouble remembering, 

not because they refuse to pay attention. 

•	 Set the person up to succeed. Measures 

of success need to be different for different people. It is important to identify 

what would be a measure of success 

for the individual with an FASD and 

reinforce successes in concrete terms (e.g., 

“You did a great job of being on time for 

our session today. Thank you.”) Training 

in social skills, anger management skills, 

and relaxation skills can help. In order for 

skills-building programs to be most successful for the person with an FASD, they 

need to be repeated periodically. 

Resistance, Denial, and Acceptance

Individuals who have or may have an FASD 

may deny that they have a disability. Although 

some are relieved to know the cause of their 

difficulties, others may struggle to confront 

or accept their situation. The counselor needs 

to take time to help the person cope with the 

lack of understanding that often surrounds 

FASD. Women with an FASD, for instance, 

may fear becoming like their mothers and 

having a child with an FASD. An individual 

with an FASD may have difficulty with forgiveness of the birth mother, or may feel that 

it is inevitable that they will pass on FASD to 

their children. Counselors should reassure clients that they are not responsible for their disability, help them resolve their feelings about 

the birth mother, and educate them about the 

science of their condition (i.e., that it is not 

inevitable that they would pass on the condition). This process may take awhile, and the 

person may drift back and forth from accepting the disability to denying it. Exploring the 

reasons for the denial and understanding the 

client’s fears can help.

Individual Counseling vs. Group Sessions

Individuals with an FASD may struggle to 

function in a group setting. Studies have 

shown increased levels of sensory sensitivities 

in this group, at least for children ( Jirikowic 

et al., 2008). Clinical observations suggest 

individuals with an FASD can become overwhelmed by sensory input from large groups, 

noise, small spaces that cause crowding and 

touching of others, and visual distractions. 

Given the executive function deficits that are 

common in this clinical population, individuals with an FASD may not be able to process 

everything in the discussion and become lost. 

They may also ‘talk too much,’ and/or not be 
36

Addressing Fetal Alcohol Spectrum Disorders (FASD)

able to effectively convey their feelings and 

ideas in group discussions.

Individual counseling may be needed to avoid 

some of the issues that arise in clients with 

an FASD who lack social skills and find 

group settings confusing or overwhelming. 

Talk therapy can be modified to incorporate 

role-playing, practice dialogues, play therapy, 

art therapy, and other methods that can draw 

on the strengths seen in individuals with an 

FASD. Printed material may be helpful, but 

should be written in simple language with a 

clear, non-distracting page layout.

If group work is necessary, the counselor 

can assist the client who has or may have an 

FASD by making some accommodations:

•	 Explain group expectations concretely and 

repeat these ideas often. 

• If a person monopolizes conversation or 

interrupts, use a talking stick as a concret

visual reminder of who should be speaking. Hand the stick to the person whose 

turn it is to speak and pass the stick to 

others as appropriate. 

e 

•	 Give the person time to work through 

material concretely within the group time 

so he or she can ask questions or you can 

check understanding of material. The 

client may need extra time to process 

information. Listen for key themes to 

emerge slowly through the person’s talk 

and behaviors. 

•	 Allow the client to get up and walk 

around if he or she gets restless.

•	 Use concrete representations, such as 

marking the floor, to show the concept of 

boundaries.

•	 Make adaptations for the whole group to 

avoid singling out the client.

Use of a Mentor

Programs that work with individuals with 

an FASD have found that mentoring can be 

effective, as it provides a consistent, stable, 

one-to-one relationship and allows for the 

development of a personal bond with a trained 

individual who has knowledge and experience working with those who have an FASD 

(Malbin, 1993; Schmucker, 1997; Grant et 

al., 2004; Denys, Rasmussen, & Henneveld, 

2011). A mentor can:

•	 Assist with the development of concrete 

and consistent rules and goals that will 

guide behaviors in specific situations; 

•	 Improve comprehension in discussions 

with others (e.g., providers or other 

clients); and

•	 Assist with the development of personal scenarios for the adult to work out 

responses and practice through role-play.

Ongoing Assessment for Comprehension of 

Information

Extensive clinical observations reveal that 

individuals with an FASD may appear to 

understand when they do not. Parents often 

say their family member with an FASD “just 

doesn’t get it.” This means that individuals 

with an FASD may repeat information without actually understanding the content, and so 

will be unlikely to follow through. Because of 

this, it is important to provide consistency and 

re-check the retention of information often:

•	 Ask the client to summarize what you 

have said.

•	 Review written material, such as rules, at 

each session.

•	 Do not assume that the client is familiar 

with a concept or can apply it simply 

because you have reviewed it multiple 

times; have discussions that explore their 

understanding beyond simply being able 

to repeat the concept.

Clinical wisdom holds that the only consistent thing about FASD is that those who are 

affected behave inconsistently. This means, 

for example, that a client may demonstrate 
37

Chapter 2: Addressing FASD in Treatment

that they know something on Monday, but 

have trouble recalling that same information on Tuesday. The clinician can benefit by 

following the rule to: REPEAT, REPEAT, 

REPEAT.

Sexual Abstinence, Contraception, and 

Pregnancy

Adolescents and adults with an FASD should 

be well informed and consulted about decisions regarding abstinence, contraception, and 

pregnancy. There are many ways to support 

pregnancy, delivery, and parenting by an individual with an FASD. The client may have 

questions about whether or not the FASD can 

be passed on to any offspring; caregivers must 

clarify that only prenatal exposure to alcohol 

can cause an FASD. If the client has children, 

the parenting skills taught to the client should 

account for the possible presence of an FASD 

in both parent and child; the skills learned 

must be appropriate to each of them and work 

for each of them.

Clinical experience reveals that women with 

an FASD can be vulnerable to exploitation 

and unintended pregnancy (Grant et al., 2004; 

Merrick, Merrick, Morad, & Kandel, 2006). It 

can be difficult for them to use contraception 

effectively due to memory lapses, problems 

following instructions, or difficulty negotiating 

contraceptive use with a partner. Counselors 

can help clients evaluate their family planning 

needs and assist in obtaining reliable, longterm birth control methods.

Although it may be unusual in a treatment 

setting, very practical and basic assistance may 

be important for a woman with an FASD. 

The counselor may need to accompany the 

client to a doctor’s appointment to help her 

understand her options and choose the best 

one. One study found improved use of contraception among young women with an FASD 

by implementing a community intervention 

model of targeted education and collaboration 

with key service providers, and by using paraprofessional advocate case managers as facilitators (Grant et al., 2004).

Clinical consensus based on evaluation of 

common behavioral characteristics of FASD 

suggests that the causal relationship between 

HIV/STDs/viral hepatitis and substance use 

disorders may be heightened among those 

who also have an FASD. Care plans for individuals with an FASD entering substance 

abuse treatment should include communicable 

disease assessment.

Medication Assessment

In some cases, medication options may be 

appropriate to treat some of the functional or 

mental health components of FASD (Coe, 

Sidders, Riley, Waltermire, & Hagerman, 

2001). The counselor may want to refer the 

client for an assessment to determine whether 

he or she can follow a regimen of taking a pill 

every day or getting a shot every few months. 

It is also important to consider the possible 

physical impact, since persons with an FASD 

may have health problems and be prone to 

side effects. Medications for individuals with 

an FASD may not work at rates similar to 

other populations and/or may require different dosages to work (O’Malley & Hagerman, 

1999). Including a mentor or supportive family member in the discussion may help the 

individual with an FASD to be more comfortable asking questions and better understand 

what is being said.

Job Coaching

In a study of 90 adults with a diagnosed form 

of FASD, most had some work experience 

but the average duration was only 9 months 

(Streissguth et al., 1996). Some of the general 

barriers to successful work for people with 

disabilities are external; discrimination by 

employers, co-workers, and family, transportation issues, completing applications and job 

testing, social skills, and the lack of support 
38

Addressing Fetal Alcohol Spectrum Disorders (FASD)

at interviews. Other barriers are internal, and 

need to be addressed early on in the vocational 

process; self-esteem and self-worth, fear of 

success, self-sabotage, and having a realistic 

view of strengths and career goals. All of 

these internal factors affect career choice, selfpresentation at the interview and the job, and 

ultimate vocational success (Fabian, Ethridge, 

& Beveridge, 2009; Leon & Matthews, 

2010). These issues should be addressed 

through counseling and skills-building prior to 

standard vocational tasks.

A job coach or vocational rehabilitation counselor may need to remain involved with an 

individual with an FASD beyond the time 

when he or she seems to “know” the job, and 

be understanding if the individual has days or 

situations in which he or she can’t remember 

what to do or gets overwhelmed. Individuals 

with an FASD may do well enough on a job 

that a coach or counselor decides they “get it” 

and stops providing support, when in fact it 

was the support that enabled success.

Vocational Rehabilitation

Vocational Rehabilitation should be viewed as 

an interdisciplinary team process. It may be up 

to a parent or caregiver to coordinate information. The team may include a physician for 

medical and health issues, an occupational/

physical therapist, a psychologist for counseling to address some of the above issues, teachers, case managers, and job placement agencies 

(Gobelet, Luthi, Al-Khodairy, & Chamberlain, 

2007). Some adults and families will choose 

sheltered workshops because of concerns about 

safety, transportation, long-term placement, 

work hours, maintaining disability benefits, 

social environment, and work skills issues 

(Migliore, Grossi, Mank, & Rogan, 2008). At 

the same time, the majority of adults with an 

intellectual disability prefer integrated employment over sheltered workshops, regardless of 

disability severity (Migliore, Grossi, Mank, & 

Rogan, 2007).

Special Considerations for Adolescents Who 

Have or May Have an FASD

It is important to remember that adolescents 

are quite different from adults, and adolescents 

with an FASD differ from teens that develop 

in typical fashion. Adolescents with an FASD 

may function at social and emotional levels 

well below their chronological age, with an 

uneven cognitive and physical profile (some 

skills less impaired than others). The treatment process must incorporate the nuances 

of the adolescent’s experience. In modifying 

treatment plans for adolescents with an FASD, 

it is important to consider cognitive, emotional, and social limitations, as well as risk factors 

that led to their substance abuse or mental 

health issue. Many youth with an FASD have 

grown up in less-than-ideal environments, 

facing parental substance abuse, economic 

deprivation, abuse, and multiple foster care 

placements. These situations can increase their 

risks for substance abuse and mental disorders.

A summary of clinical and empirical evidence 

shows that adolescents will commonly exhibit 

learning and behavior challenges, especially in 

adaptive function (getting along from day to 

day), and in remaining organized and regulated (Streissguth et al., 2004; Spohr, Willms, 

& Steinhausen, 2007). They often learn 

information slowly (especially what is said to 

them), tend to forget things they have recently 

learned, and make the same mistakes over 

and over. They can often have trouble shifting attention from one task to another. Like 

those with ADHD, they may be impulsive 

and find it hard to inhibit responses, and may 

be restless or even obviously hyperactive. In 

general, they may have trouble regulating their 

behavior. Even though adolescents with FASD 

may be talkative, they have social communication problems (such as leaving out important 

details or explaining things in a vague way). 

Adolescents with FASD tend to show poor 

judgment, are suggestible (and therefore easily 
39

Chapter 2: Addressing FASD in Treatment

Treatment Tips From the Field

In addition to the guidance provided in this chapter, providers in British Columbia provided the following 

anecdotal suggestions for effective programming for individuals who have or may have an FASD.

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	 

 

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

Source: Rutman, D. (2011). Substance using women with FASD and FASD prevention: Service providers’ perspectives on promising approaches in substance use treatment and care for women with FASD. Victoria, British Columbia: University of Victoria.

influenced by others), and show immature 

social skills. Because of this, they may be too 

friendly with people they do not know well, 

too trusting, and have difficulty recognizing 

dangerous situations. 

Treatment Plan Modification

It is generally believed that traditional forms 

of therapy, such as “talk therapy,” are not the 

most effective choice when working with 

adolescents with an FASD. Their cognitive 
40

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Ongoing Assessment for Comprehension of 

Information

Adolescent Development Issues in FASD

The following table outlines some of the more common developmental delays and deficits 

experienced by individuals with an FASD through the adolescent years (ages 12–21), and useful 

treatment approaches. This table is based on an expert clinical consensus.

deficits prevent them from developing insight 

or applying lessons to their real lives. However, 

with creativity and flexibility, a treatment plan 

can be developed that includes techniques 

counselors are familiar with and comfortable 

with, adapted to fit the needs of the client 

(Baxter, 2000). 

Addressing Peer Influences

Clinical observations indicate that adolescents with FASD are socially immature, and 

research documents that adults with FASD 

are more suggestible (Brown et al., 2011). 

Developmental literature makes clear that peer 

influences are important in the adolescent 

stage, and that deviant peer influences can lead 

to antisocial behavior. The counselor should 

address issues such as peer pressure in treatment to set the stage for less risky behavior 

outside treatment. Linking an adolescent with 

an FASD with a mentor is a sound treatment 

strategy.

As with adults, it is important to check often 

to make sure the adolescent client understands 

what has been said. Ask the client to summarize what you have said. Review written 

material, such as rules, at each session. Repeat, 

repeat, repeat, even if the client says, “You’ve 

told me this a hundred times.”

For adolescents, applying concepts can be 

difficult. Cognitive deficits, the frustration of 

having an FASD, and typical teen rebellion 

can make communication especially hard. 

Role-playing different situations, providing 

opportunities to share and process feelings, 

and giving the client time to process information is important. It also may help to use 

alternative methods of expression, such as 

drawing, to assist the client in sharing his or 

her understanding.
41

Chapter 2: Addressing FASD in Treatment

Educational Support (IDEA and FAPE)

The Individuals With Disabilities Education 

Act (IDEA) entitles every young person to a 

free and appropriate public education (FAPE) 

in the least restrictive environment. If the client is eligible, this can continue until age 21. 

If you have a client who has or may have an 

FASD and is in school, it is important to consult with the school regarding any provisions 

in that client’s individualized education plan 

(IEP), either those identified by the school 

that should be carried over to treatment or 

vice versa. In a study of 120 children undergoing FASD diagnosis at a Washington State 

FAS DPN clinic, Jirikowic and colleagues 

(2010) found that over 90 percent did require 

intervention recommendations associated with 

their educational plan.

In the outpatient setting and during aftercare, 

it is a good idea for the psychologist to consult 

with the school counselor or case manager 

(if the client has one) regarding educational 

needs. Areas such as social skills may be 

addressed in the IEP, and are important to 

address during treatment and as part of aftercare. It also helps to be aware of any academic 

issues that may affect the client’s treatment, 

such as stress about academic performance or 

difficulties with classmates.

Parents may not be aware of the laws regarding education of children with disabilities and 

may feel overwhelmed. They may be having 

problems dealing with their child’s school and 

wonder what to do. The counselor can help by 

informing the client and family about IDEA 

and FAPE requirements and helping outline 

possible interventions to suggest to the school.

The U.S. Department of Education provides 

an online overview (http://www2.ed.gov/

about/offices/list/ocr/docs/edlite-FAPE504.

html) of the stipulations of FAPE and who 

qualifies for educational support under its 

terms.

In addition, vignette #10 in Part 1, Chapter 3 

of this TIP discusses some of the key aspects 

of developing an IEP for an individual who 

has an FASD.

Psychosexual Development

Early and ongoing social experiences play 

a key role in psychosexual development. 

Adolescent tasks include having and maintaining intimate relationships, managing complex 

emotions and social situations, and developing 

independent thinking. The adolescent with an 

FASD may not achieve these milestones all at 

the same time, at the usual age range, or at all. 

Many adolescents with disabilities are delayed 

or prevented from achieving these goals by 

social isolation or a variety of functional limitations. Social skills may be broken down into 

manageable tasks, just as in every other area 

of instruction. This includes the basics first, 

such as mastering appropriate greetings, eye 

contact, body language, personal space, selfadvocacy skills, and telephone and computer 

skills. A foundation in some or all of these 

basic skills will allow for the development of 

more complex skills. Mentors and peers may 

be very effective in this regard.

Vocational Coaching

Young adults with a disability need advocacy 

and support with a variety of new agencies 

and support services throughout the transition 

and adult years. A life skills curriculum should 

include how to use the internet to search for 

employment and employment enhancement 

services, awareness of issues associated with 

safe work environments, interviewing strategies, appropriate use of medication, managing 

finances, dealing with workplace routines and 

expectations, being cautious about at-risk 

situations, and knowing when to ask for help 

(Winn & Hay, 2009). Role-playing each of 

these skills with the client will be beneficial.
42

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Counselor Self-Assessment

Working with clients with an FASD can raise issues for you, the counselor. You might feel resentment about 

being “stuck” with such challenging clients, or harbor negative attitudes toward women who drink while 

pregnant. The client with an FASD can trigger feelings of guilt and shame in a counselor who drank while 

pregnant or has a child with an FASD.

Understanding how to cope with clients with an FASD can help the counseling professional serve such clients 

more effectively. Olson and colleagues (2009) have underlined the importance of the need to Reframe, 

Accommodate, and Have Hope for caregivers raising those with FASD. These same strategies can help 

counselors, and are combined with the recommendations of Malbin (1993) and Schmucker (1997) to create 

the following recommendations for counselors providing FASD-related services.

REFRAME

Reframe your perception of the person’s behavior. He or she is not trying to make you mad

or cause trouble. He or she has brain damage and may have a history of abuse or other family

dysfunction. You need to explore behaviors, stay patient, and tolerate ambiguity.

•	Understand that FASD involves permanent brain changes.

•	The client is not refusing to do things. He or she can’t do them or does not understand what

you are asking him or her to do.

•	Clients often are not lying purposely. They are trying to fill in gaps in memory with their own

information.

•	Perseverating behaviors are an attempt to control or make sense of their own world.

•	Transition and change are very difficult for the person with an FASD. Acting out when things

change may be a reaction to fear of transitions or difficulty processing change.

ACCOMMODATE

•	Expect to repeat things many times in many ways. Clients with an FASD may ask the same

question every time you see them. Remember that these clients have cognitive deficits. They

are not asking just to test your patience. Be patient and avoid looking bored going over the

same information multiple times.

•	Use a written journal or goal sheets to remind people how far they’ve come and where they

are headed. Due to their memory difficulties, clients with an FASD will not always remember

what supports or programs have been developed with them or their goals. Keep a positive

attitude and focus on what the person has accomplished, rather than on goals yet to be met.

•	Realize that there is no set approach; what works one time may not work the next. As part of

the dysfunction of FASD, the client may experience things differently day to day or even hour

to hour, and variability is the norm. Keep an open mind and be flexible. Avoid statements such

as “But it worked last time.”

HAVE HOPE

•	Be good to yourself. Even with a realistic plan and an established routine, nothing is perfect.

Things change and setbacks occur. By expecting bumps in the road of a person’s journey

through life, we can learn to not take these dips personally. By offering the person with an

FASD nonjudgmental and informed support, we offer hope.

•	Know yourself, and take the time to reflect on your comfort level in dealing with issues 

surrounding FASD. Gain knowledge if needed. Gain comfort in tackling the subject by roleplaying with colleagues. Know your limits and get outside help or referrals as required. Plan to

connect to appropriate community resources.
43

Chapter 2: Addressing FASD in Treatment

Thinking Ahead and Planning for the Future

It is important to think ahead and plan for 

the future with adolescents and young adults 

with FASD. If they are able to build an independent life, counselors can help the client 

learn how to self-advocate and self-monitor, 

and should communicate these skills to the 

client’s caregivers, as well. It is important to 

think ahead about education on topics such 

as (1) safe sex; (2) communicating clearly 

with partners about consensual activity; (3) 

use of cigarettes and alcohol; (4) use of illicit 

substances, such as marijuana and drugs; (5) 

the consequences of criminal activity; and (6) 

ideas of what to safely do when the individuals goes through times of feeling irritable and 

negative (calming strategies).

5. Working with the Family

Introduction

Multiple studies have spoken to the value of 

involving the family in the treatment of an 

individual who has or may have an FASD, 

if possible (Schmucker, 1997; Grant, Ernst, 

Streissguth, & Porter, 1997; Olson et al., 

2009; Olson, Rudo-Stern, & Gendler, 2011). 

Involving the family in planning, choosing, and shaping services for the client has 

become a key intervention concept in the 

field of developmental disabilities, as greater 

family involvement has been linked to better 

outcomes (Neely-Barnes, Graff, Marcenko, 

& Weber, 2008). Family-centered care is 

also strongly advocated for individuals with 

co-occurring mental health issues and a developmental disability like an FASD (McGinty, 

Worthington, & Dennison, 2008).

As with many clients in substance abuse and 

mental health settings, it is advisable to take 

a broad view of family. Many individuals with 

an FASD will have resided with foster parents 

and/or in kinship care (foster and adoptive 

scenarios being the most common), and care 

scenarios may extend well beyond the more 

typical ages of independence, like 18 or 21. 

Ultimately, who the client chooses to see as 

family or as the important caregiver in their 

life should be incorporated into the process, if 

possible.

As the table on the next page makes clear, 

involving the family can be as much about 

meeting their needs as the client’s. The most 

frequently unmet family needs can be met 

with emotional support and, later in the counseling relationship, offering opportunities to 

“look forward” to the future and discuss both 

hopes and worries. Other frequently unmet 

needs can be met by helping caregivers find 

methods for self-care and respite. FASD 

education and appropriate intervention will 

meet other common needs, but may be less 

important (at the start) than support and 

direct assistance to help understand and meet 

caregivers’ own needs.

Approaching the Family

It is imperative to obtain permission to 

approach family on the topic of an FASD. 

If the birth mother is still involved in the 

individual’s care and is not aware of the possibility of an FASD, it is vitally important not 

to make her feel shamed or judged. The counselor should be prepared to address feelings of 

guilt. The family may also experience many of 

the feelings of anger, grief, and loss that the 

client experiences. All members of the family 

should be made to feel as comfortable as possible expressing these feelings.

If the family agrees to be involved, there are 

a number of ways that the counselor can 

support both them and the client. It is vital 

to use “reframing” to help the family better 

understand the client’s behaviors as being at 

least partly caused by brain-based disabilities 

(Olson et al., 2009). A positive view of the 

affected individual, of the relationship between 

the caregiver and the individual, and of the 

caregiver process has been associated with 
44

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Top Unmet Needs for Caregivers

Raising Children who have FASD and Behavior Problems

 

Source: Olson, H. C., Oti, R., Gelo, J., & Beck, S. (2009). “Family Matters:” Fetal Alcohol Spectrum Disorders and the family. 

Developmental Disabilities Research Reviews, 15, 235-249.

more positive outcomes for the individual and 

family (Blacher & Baker, 2007). The counselor 

can then help the family reach out to extended 

family and friends to help them reframe the 

situation. Reframing can help everyone more 

positively understand the client’s behavior, 

and appropriately adjust the home and school 

environments. Treatment approaches that 

stress problem-focused management and stress 

reduction may be a useful addition to parent 

training (Olson et al., 2009). Other suggestions include:

•	 As with the client, review the diagnostic 

report thoroughly with the family (if it 

is available). Chapter 3 of Part 1, Clinical 

Vignettes, contains a vignette illustrating 

this process. 

•	 Help the family arrange for respite care or 

a community support worker: Caregivers 

may feel stressed or burned out by the 

responsibilities of caring for someone 

with an FASD.

•	 Assist family in coming up with ways 

to educate extended family and friends 

about FASD to help them understand 

the client’s behaviors and adjust the home 

environment accordingly.

•	 Connect family and friends with support 

groups or other community resources (see 

Step 6). 

•	 Help find long-term mentors for clients. 

Family members or friends who have 

become exhausted or burned out dealing 

with an FASD may be willing to help 
45

Chapter 2: Addressing FASD in Treatment

after a mentor has stepped in for awhile 

and the client has made progress.

• Encourage parents and caregivers to 

maximize independence, even if they are 

used to “helping” or completing tasks for 

the client.

•	 Help the family access needed services 

and supports (see Appendix G, Services 

and Supports Checklist, for a list that can 

be used as a worksheet). 

The Families Moving Forward Program intervention is a scientifically-validated behavioral 

consultation program tailored for families 

raising preschool and school-aged individuals with FASD or confirmed prenatal alcohol 

exposure. The intervention includes methods 

and materials that appropriately trained counselors can use when working with families of a 

client who has an FASD, even if the client is 

older (http://depts.washington.edu/fmffasd). 

See Appendix F, Sample Crisis/Safety Plan, and 

Appendix G, Services and Supports Checklist, 

for materials that have been adapted from the 

Families Moving Forward Program for this 

TIP.

If the client had an existing diagnosis of 

an FASD before presenting in your setting, 

involving the family is still valuable. Caregivers 

are probably already well-versed in FASD and 

the difficulties of obtaining effective services, 

and can be as much of a resource of information for the counselor as the counselor is for 

the family.

6. Transition and Connection to 

Community Supports

Transitional Services

Part of the counselor’s role is to prepare for 

discharge of the client. This involves working 

to establish a network of community resources 

and providers of service who will continue to 

provide support and advocacy when your role 

is complete. Providing these supports with 

education about FASD and the client’s unique 

patterns of behavior is an important part of 

successful transitioning. See Appendix G, 

Services and Supports Checklist, for a worksheet 

that can be used to quickly identify linkages 

the counselor and client may want to explore.

Network of Providers

Counselors need to be familiar with available resources in the community, such as 

psychiatrists, social workers, developmental 

disability providers, and physicians. Counselors 

can include referrals to these resources in the 

transition plan and work with case managers at their facility as appropriate. For clients 

who are still in school, it is also important to 

consider the transition to school, and to work 

with school administrators and/or the school 

counselor to determine how best to address 

the client’s ongoing needs within the school 

setting.

It may also be necessary to consult an advocate 

or legal representative if the client has had any 

legal problems. Adolescents with an FASD 

can get pulled into illegal activity or manipulated into relapses. 

Mentorship

Locating a long-term mentor within the 

person’s sphere of relationships can be 

another way to support the transition process. 

Providing tips and strategies for things that 

have worked well with the client during treatment can enable the mentor to provide support in the future (Schmucker, 1997). There 

are also organized programs that can help to 

identify mentors, though these resources are 

scarce and differ by community.

If the family is involved in treatment and the 

client had an existing diagnosis of an FASD 

before treatment, it is likely that they will 

have developed relationships with a variety of 

providers and can thus potentially be a useful 
46

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Assessment of Living Skills/Planning for 

Safety

resource for information on services available 

in the community. There are a number of 

things that should happen during transition 

planning that a parent or caregiver could help 

to facilitate, such as introduction to the relevant service providers and transfer of information to those agencies.

Even if taught as part of treatment, basic 

functional living and social skills will need to 

be re-assessed before transition to help the client function more effectively and safely in the 

community. The provider should work with 

the client to:

•	 Assess ability to handle money, pay bills 

and rent, buy groceries, etc. The clinician 

can consider a representative payee, if 

necessary.

•	 Anticipate housing needs: Will the client live alone? With caregivers? With 

others in structured housing or a group 

setting? An individual with an FASD 

is likely to need dedicated, long-term 

caregiver support in any setting, but this 

is particularly vital if they will be living 

alone. Assistance is likely to be needed 

with negotiating public transportation, 

handling interpersonal relationships, 

grocery shopping, and structuring leisure 

time (Streissguth et al., 1996).

•	 Identify job desires and possibilities, as 

well as what is needed for job success.

• Review appropriate social interaction.

•	 Review processes for checking whenever 

the client is unsure of a situation or 

response, or is in trouble.

•	 Ensure that learned skills are practiced in 

the new environment.

•	 Continue supports at least until the client 

adjusts to the new environment.

If a mentor, family member, or other caregiver 

is identified for the client, Vignette #9 in Part 

1, Chapter 3 of this TIP walks through the 

process of working with that person or persons to develop a personalized Safety Plan on 

behalf of an individual with an FASD.

Connection to Community Supports

Both the client and the client’s family and 

caregivers (if involved) can benefit from connection to support systems in their community. As with referral for assessment or diagnosis, 

it is vital that the counselor actively assist the 

client through transition to other providers 

and follow up regularly to ensure client satisfaction and full and open communication 

between agencies and with the client (and the 

client’s family, if they are involved in the treatment process).

Appendix C, Public and Professional Resources 

on FASD, provides links to a number of support organizations for individuals with an 

FASD, including NOFAS (www.nofas.org), 

the Birth Mothers Network (also known as 

the Circle of Hope; visit the NOFAS Web site 

and the FAS Community Resource Center 

(http://www.come-over.to/FASCRC/).

NOFAS can be a particularly valuable 

resource, as it houses not only the Birth 

Mothers Network but also an extensive affiliate network whose members provide a broad 

range of FASD-related services to individuals and their families. In addition, NOFAS’s 

“Living With FASD” page (http://www.

nofas.org/living/) contains links to financial 

assistance programs such as Supplemental 

Security Income (SSI), Social Security 

Disability Insurance (SSDI), and Medicaid, as 

well as family and mother support programs 

such as Women, Infants and Children (WIC).

An emerging community resource for individuals with an FASD is the Self-Advocates with 

FASD in Action (SAFA) Network. Members 
47

Chapter 2: Addressing FASD in Treatment

Job Support

Self-Help Participation

include individuals with an FASD and their 

support persons. The SAFA Network provides 

speakers and training on living with an FASD, 

and also peer support for other individuals 

and families coping with these disorders. The 

SAFA Network can be contacted through 

SAMHSA’s FASD Center for Excellence 

(www.fasdcenter.samhsa.gov, or toll-free at 

1-866-STOP-FAS).

Your local One-Stop Center (www.

careeronestop.org) may provide links to your 

state Department of Labor and Workforce 

Development, the local division for vocational rehabilitation services, and/or specific 

state initiatives for development of customized employment for people with disabilities. 

For individuals with an FASD, customized 

employment should include a protocol that 

addresses their special needs.

The person with an FASD will need support 

to participate successfully in a 12-Step program. Many areas of the country have “Double 

Trouble” meetings; these are 12-Step self-help 

groups designed to meet the special needs of 

people with addiction and mental health issues 

(Vogel, Knight, Lauded, & Maura, 1998). 

Double Trouble meetings may be more flexible about impulsive behaviors than routine 

meetings. The counselor should be cautious 

about referring a client who has or may have 

an FASD into a self-help group, due to issues 

of victimization as well as the possibility that 

the individual’s special needs will not be met.

Another significant resource for people with 

an FASD and co-occurring issues is the 

recovery movement in the mental health field. 

Recovery centers (also known as “drop-in” 

centers) offer a variety of supports, groups, and 

meetings in some areas.

For more information on treatment 

approaches with individuals who 

have or may have an FASD...

Vignettes 5–10 in Part 1, Chapter 3 of this

TIP illustrate scenarios where a counselor

works with a client who has or may have

an FASD, or provides assistance to family

members/caregivers. In addition, Part 3, the

online Literature Review, also contains further

discussion of interventions, protective factors,

and co-occurring issues.

49

3 Clinical Vignettes

IN THIS CHAPTER

•	Introduction

• The Culturally 

Competent Counselor

•	Areas of Clinical Focus

•	Clinical Vignettes

Introduction

This chapter presents vignettes of counseling/intervention sessions between various service professionals and either 1) women 

of childbearing age where FASD prevention is warranted, and/

or 2) individuals who have or may have an FASD or their family members. The vignettes are intended to provide real-world 

examples and overviews of approaches best suited (and not suited 

to) FASD prevention and intervention.

The Culturally Competent Counselor

This TIP, like all others in the TIP series, recognizes the importance of delivering culturally competent care. Cultural competency, as defined by HHS, is...

“A set of values, behaviors, attitudes, and practices within a system, organization, program, or among individuals that enables 

people to work effectively across cultures. It refers to the ability 

to honor and respect the beliefs, language, interpersonal styles, 

and behaviors of individuals and families receiving services, as 

well as staff who are providing such services. Cultural competence is a dynamic, ongoing, developmental process that requires 

a long-term commitment and is achieved over time” (U.S. 

Department of Health and Human Services, 2003, p. 12). 

A critical element of this definition is the connection between 

attitude and behavior, as shown in the table on the next page.

Areas of Clinical Focus

In this chapter, you are invited to consider different methods and 

approaches to practicing prevention of an AEP and/or interventions and modifications for individuals who have or may have an 

FASD. The ten scenarios are common situations for behavioral 

health professionals and focus on: 
50

Addressing Fetal Alcohol Spectrum Disorders (FASD)

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

•	

This table originally appeared in TIP 48, Managing Depressive Symptoms in Substance Abuse Clients During Early Recovery

((SMA) 08-4353). The authors of this TIP gratefully acknowledge the authors of TIP 48.

1. Intervention with a woman of childbearing age who has depression, is consuming 

alcohol, and may become pregnant (AEP 

Prevention)

2. Examining alcohol history with a woman 

of childbearing age in substance abuse 

treatment for a drug other than alcohol 

(AEP Prevention)

3. Intervention with a woman who is pregnant (AEP Prevention)

4. Intervention with a woman who is pregnant and consuming alcohol, and who 

is exhibiting certain triggers for alcohol 

consumption, including her partner (AEP 

Prevention)

5. Interviewing a client for the possible presence of an FASD (FASD 

Intervention)
51

Chapter 3: Clinical Vignettes

6. Interviewing a birth mother about a son 

who may have an FASD and is having 

trouble in school (FASD Intervention)

7. Reviewing an FASD diagnostic report 

with the family (FASD Intervention)

8. Making modifications to treatment for 

an individual with an FASD (FASD 

Intervention)

9. Working with an adoptive parent to create a safety plan for an adult male with 

an FASD who is seeking living independence (FASD Intervention)

10.Working with a birth mother to develop 

strategies for communicating with a 

school about an Individualized Education 

Plan for her daughter, who has an FASD 

(FASD Intervention)

Organization of the Vignettes

To better organize the learning experience, each vignette contains an Overview of 

the general learning intent of the vignette, 

Background on the client and the setting, 

Learning Objectives, and Master Clinician 

Notes from an “experienced counselor or 

supervisor” about the strategies used, possible 

alternative techniques, timing of interventions, and areas for improvement. The Master 

Clinician is meant to represent the combined 

experience and expertise of the TIP’s consensus panel members, providing insights into 

each case and suggesting possible approaches. 

It should be kept in mind, however, that some 

techniques suggested in these vignettes may 

not be appropriate for use by all clinicians, 

depending on that professional’s level of 

training, certification, and licensure. It is the 

responsibility of the counselor to determine 

what services he or she can legally/ethically 

provide.

1. INTERVENTION WITH A 

WOMAN OF CHILDBEARING 

AGE WHO HAS DEPRESSION, IS 

CONSUMING ALCOHOL, AND 

MAY BECOME PREGANT (AEP 

PREVENTION)

Overview: This vignette illustrates how and 

why a counselor would address prevention of 

an AEP with a young woman who is being 

seen for depression.

Background: This vignette takes place in a 

college counseling center where Serena, 20, is 

receiving outpatient services for the depression 

that she’s been feeling for about 4 months. In 

her intake interview, Serena has indicated that 

she consumes alcohol, is not pregnant, and is 

sexually active. She has had two prior sessions 

with the counselor, during which they have 

discussed Serena’s general background, family 

interactions, social supports, and her outlook 

on school.

In today’s session, they have been discussing 

her boyfriend, Rob. A therapeutic relationship 

has begun to form between Serena and the 

counselor, and the counselor would now like to 

explore Serena’s alcohol use and whether it is a 

possible contributing factor in her depression. 

While doing this, the counselor will identify 

an opportunity to deliver an informal selective 

intervention to prevent a possible AEP.

Learning Objectives:

1. To illustrate that clients often have multiple issues that need to be addressed 

besides their primary reason for seeking 

counseling.

2. To demonstrate a selective intervention 

(“FLO”) for preventing an alcoholexposed unplanned pregnancy.

3. To recognize that prevention of an AEP 

can be accomplished by eliminating alcohol use during pregnancy or preventing 

a pregnancy during alcohol use; often 

the most effective route is to prevent the 

pregnancy.
52

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Vignette Start

The session is already in progress. Serena has been discussing how she and her boyfriend Rob tend 

to fight a lot, but she continues to spend time with him because they have fun at parties.

COUNSELOR:	 So, how long have you and Rob been together?

SERENA:	 About 7 months.

COUNSELOR:	 And you’ve said that the two of you are sexually active.

SERENA:	 Yeah, I usually sleep over on the weekend, after the parties.

COUNSELOR:	 Do these fights occur at any particular time?

SERENA:	 Not really. When we’re stressed, mostly, over school or work or whatever.

Then I feel more depressed cuz we’re fighting, and he gets upset because I’m

depressed. It’s like a circle. That’s why we go to the parties, to unwind and

forget about stuff.

COUNSELOR: 	 And then you tend to end up spending the night with him.

SERENA:	 Usually.

COUNSELOR: 	 Are you using any protection, or birth control?

SERENA: 	 No.

COUNSELOR: 	 And during these parties, are you drinking?

SERENA:	 Sure.

COUNSELOR: 	 About how many drinks do you have?

SERENA: 	 I don’t really know. My cup’s never empty, it just gets refilled at the keg.

COUNSELOR: 	 Are there other times when you drink alcohol?

SERENA: 	 No, it’s really just at the parties.

Master Clinician Note: Serena is presenting high-risk behavior by combining alcohol use and

unprotected sex. The counselor seeks to identify the link between alcohol, unprotected sex, and

pregnancy.

COUNSELOR:	 I know you’re not expecting this, but if you were to find out right now that you

were pregnant, how would that change things for you?

SERENA:	 Oh lord, that would totally turn my life upside down. And Rob’s. God, he’d

freak.

COUNSELOR:	 So, you do not want to get pregnant.

SERENA: 	 No, I definitely do not wanna get pregnant.

Master Clinician Note: Serena has made it clear that she does not want to become pregnant, so

the counselor shifts to addressing the gap between Serena’s behaviors (being sexually active but

not practicing safe sex) and her stated desire (to not get pregnant).
53

Chapter 3: Clinical Vignettes

COUNSELOR:	 I understand, and I’m concerned about your health and what you want for your

future. So, if you plan to keep attending these parties and being sexually active,

then maybe we can talk about contraception. Did you know that half of all

pregnancies in the U.S. are unplanned?

SERENA:	 Wow. No, I didn’t know that.

COUNSELOR:	 It’s true. It’s possible that you could get pregnant, and the drinking could

impact the health of that baby. Let’s talk about how we can avoid those things.

SERENA:	 Okay.

The counselor gives Serena a pamphlet that describes effective contraception.

COUNSELOR:	 Would you be willing to read this? It’s short, but it has good information.

Perhaps we can go over it when we meet next week.

SERENA:	 Okay. I thought I was here to talk about depression, though.

COUNSELOR:	 Yes, absolutely, our first goal is to help you stop feeling depressed. And as

you’ve said, you definitely don’t want to have a baby, so I think it’s important

for us to discuss ways to avoid getting pregnant, so that that’s not something

that adds to your worries.

SERENA:	 Oh, okay. I see what you mean.

COUNSELOR:	 So next week I can answer any questions you have about that material, and

then we can talk about some positive goals you want to lay out, like feeling less

depressed, or fighting with Rob less, or not getting pregnant. Does that sound

okay?

SERENA:	 Yeah, thanks.

Master Clinician Note:	This	vignette	does	not	“solve”	the	issue	of	Serena’s	depression.	

However,	as	part	of	examining	the	possible	causes,	Serena	has	talked	about	a	pattern	of	regular	

at-risk	drinking,	combined	with	unprotected	sex.	Because	of	this,	the	counselor—who	by	now	

has	established	a	good	rapport	with	Serena—has	taken	the	opportunity	to	carefully	include	a	

selective	intervention	for	preventing	an	AEP.

In	an	informal	way,	the	counselor	has	used	the	steps	of	the	“FLO”	intervention	discussed	in	

Part	1,	Chapter	1	of	this	TIP.	During	intake	and	again	at	this	visit,	Serena	has	indicated	that	she	

consumes	alcohol	and	is	sexually	active.	The	counselor	provides	Feedback	on	these	responses	

(by	discussing	the	possibility	of	an	AEP),	then	Listens	as	Serena	indicates	that	she	does	not	want	

to	become	pregnant.	The	counselor	thus	shifts	the	focus	of	medical	advice	to	the	Option	of	

contraception	and	provides	Serena	with	educational	material.

At	the	same	time,	the	counselor	has	not	lost	sight	of	depression	as	Serena’s	primary	treatment	

issue.	In	this	session,	the	counselor	has	laid	the	groundwork	for	continuing	to	discuss	Serena’s	

at-risk	drinking	and	her	problematic	relationship	with	Rob	as	possible	components	of	the	

depression,	but	in	the	context	of	positive	goals	that	Serena	can	aim	for	(i.e.,	finding	ways	to	feel	

less	depressed,	fight	with	Rob	less,	and	avoid	an	unwanted	pregnancy).
54

Addressing Fetal Alcohol Spectrum Disorders (FASD)

2. EXAMINING THE ALCOHOL 

HISTORY WITH A WOMAN 

OF CHILDBEARING AGE IN 

SUBSTANCE ABUSE TREATMENT 

FOR A DRUG OTHER THAN 

ALCOHOL (AEP PREVENTION)

Overview: This vignette illustrates the value 

of asking about alcohol use in a female substance abuse treatment client of childbearing 

age, even though her primary drug is not 

alcohol.

Background: Chloe is being seen at an outpatient treatment center for methamphetamine 

abuse. The counselor has the health history 

that was provided during intake. It indicates 

that Chloe reports as non-pregnant, but is 28 

(of childbearing age) and is sexually active. 

The counselor wants to explore whether Chloe 

is using other substances, as well as screening 

for a possible mental health problem. Given 

that the client is sexually active, there is a 

risk of an unplanned pregnancy, therefore the 

counselor begins with alcohol.

1. To emphasize the importance of probing 

for alcohol use even if it is not the primary drug.

2. To recognize that quantity of use is 

subjective. The use of a visual helps the 

client understand what a one-drink 

equivalent is.

3. To recognize that if a mental health issue 

presents itself, it will need to be addressed 

concurrently.

Learning Objectives:

Vignette Start

COUNSELOR:	 Hi, Chloe.

CHLOE:	 Hey.

COUNSELOR:	 Please have a seat. I have some questions that I would like to ask you, Chloe.

You’re in treatment for methamphetamines, correct?

CHLOE:	 Yes.

COUNSELOR:	 If it is okay with you, I would like to ask you first about your use of some other

drugs. I would like to start with alcohol. Do you know how much alcohol you

drink?

CHLOE:	 You mean, altogether? I don’t know.

COUNSELOR:	 Okay, in an average week, how much alcohol would you say you drink?

CHLOE:	 Well, usually I just drink enough to wash down my pills.

COUNSELOR:	 What pills are those?

CHLOE:	 The, whatayacallit, desoxyn.

COUNSELOR:	 And what do you wash these pills down with? What kind of alcohol?

CHLOE:	 Usually vodka. With some orange juice in it.

COUNSELOR:	 And do you do this every time you take the pills?

CHLOE:	 Not every time, but most times.
55

Chapter 3: Clinical Vignettes

COUNSELOR:	 Okay. And how much vodka do you drink to wash down the pills?

CHLOE:	 One drink.

COUNSELOR:	 Here, let me show you something real quick. This is a picture of different

glasses that people tend to use for drinking alcohol. Which one do you use?

Master Clinician Note: The counselor uses the visual below to help Chloe more concretely

understand her level of consumption. However, this visual does not reflect every available

drinking size or container, so any discussion of a standard drink should incorporate the client’s

personal experience (i.e., “If you don’t see your glass on here, what do you use?”).

CHLOE:	 None of them. Well (Chloe indicates the 8.5 ounce drinking glass), that looks

like what I use, but it’s not all vodka.

COUNSELOR:	 How much do you fill with vodka, and how much orange juice?

CHLOE:	 About half and half.

COUNSELOR:	 All the way to the top?

CHLOE:	 Yeah, but with ice in it.

COUNSELOR:	 Okay, so that’s going to be about three to four ounces of vodka, and an ounce

and a half of hard liquor is equal to one drink. So, it looks like you’re having the

equivalent of two to three drinks every time you wash down the pills.

CHLOE:	 Hmm. I didn’t know that.

COUNSELOR:	 Is there any other time when you use alcohol?

CHLOE:	 I may have some when I’m feeling bad. It takes the edge off.

COUNSELOR:	 Can you tell me more about how you feel when you “need to take the edge

off?”

CHLOE:	 I just feel very upset, worried. Sometimes sad.

COUNSELOR:	 That must be hard for you. About how often do you feel worried and/or sad?
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Master Clinician Note: The counselor expresses empathy for the client and how sad/worried she

is feeling. This expression of empathy assists in establishing more of a caring relationship, so that

further questions around alcohol use can be explored in a helpful manner. The counselor also

explores more with the client about how she is feeling when she talks about “taking the edge

off” to see what might be the result of her drug use and to see if she needs a mental health

evaluation. A mental health evaluation might explore whether medication is indicated that could

assist Chloe in reducing her alcohol use.

CHLOE (laughs):	 A lot.

COUNSELOR:	 It must be difficult to feel so sad and worried a lot. Can I ask you a few more

questions about this?

CHLOE:	 Okay.

COUNSELOR:	 Did you feel very sad or worried this week?

CHLOE:	 Yeah.

COUNSELOR:	 So, when you felt this way this week, did you need to use alcohol to feel

better? Or, as you said, to take the edge off?

CHLOE:	 (shrugs) Yeah, I had three or four drinks.

Master Clinician Note: The counselor does not assume that the client is deliberately underestimating, but keeps in mind that clients may minimize when self-reporting alcohol use (Taylor

et al., 2009).

COUNSELOR:	 Did you also feel like this last week?

CHLOE:	 Probably.

COUNSELOR:	 How about last month? Did you need to use alcohol to try to feel better then

also? That would have been August.

CHLOE:	 I’m sure I did.

COUNSELOR:	 So Chloe, you would say that you’re feeling sad and worried, and using alcohol

to help you feel better, has been going on for quite a while, is that right?

CHLOE:	 Yeah, most of this year.

Master Clinician Note: Given the frequency of poly-drug use among clients in substance abuse

treatment, this counselor did not assume that methamphetamine was the only substance that

Chloe was using. Through some simple probing, the counselor has identified that not only has

Chloe been drinking, she has been doing so at a high-risk rate. At a future time when dealing

more specifically with the amount Chloe is drinking, the counselor might show her a chart

with drinking frequencies to help Chloe see what level of drinking is defined as heavy and/or

problematic for women.

Chloe has also talked about a pattern of self-medication. The reason or trigger for this may be

depression; Chloe has said only that she drinks when she is “feeling like s&@*.” This will require

further exploration. For now, the counselor knows that a potential co-occurring mental health

issue, a co-occurring substance abuse issue, and prevention of a possible AEP should all be

factored into the treatment plan.
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Chapter 3: Clinical Vignettes

3. INTERVENTION WITH A 

WOMAN WHO IS PREGNANT 

(AEP PREVENTION)

Overview: This vignette illustrates that 

screening for alcohol use should be done at 

every visit with women who are—or are at an 

indicated likelihood for becoming—pregnant. 

Alcohol-exposed pregnancies occur in all 

demographics, regardless of socio-economic 

status, age, ethnicity, or marital status.

Background: April, 27, works full-time. She 

recently found out she is pregnant with her 

first child. She and her husband have relocated 

to a new city, and she is being seen at a private 

OBGYN office for the first time.

Learning Objectives:

1. To recognize that asking about alcohol 

use during the first visit only is not 

enough; screening should occur at every 

visit.

2. To identify that a woman could begin 

drinking during the pregnancy if she is 

experiencing a relapse. 

3. To highlight there is no known safe 

amount of alcohol use during pregnancy.

Vignette Start

1st Office Visit

PRACTITIONER:	 Hello, I’m Dr. Johnson. I see on the chart that you are pregnant.

Congratulations!

APRIL:	 Thank you.

PRACTITIONER:	 I have a number of questions that I need to ask you before the exam.

Practitioner inquires about health history and eating habits, recommending an increase in fruit 

consumption.

PRACTITIONER:	 A few other quick questions. How much do you smoke per day?

APRIL:	 I don’t smoke.

PRACTITIONER:	 That’s good! How much coffee and water do you drink?

APRIL:	 I have a cup of coffee in the morning, that’s about it. I try to drink water all the

time. I don’t know how much I have per day. Probably a few glasses worth.

PRACTITIONER:	 Okay, how often do you drink alcohol?

Master Clinician Note: The practitioner has included alcohol as part of a general health

exploration rather than asking the question by itself, which can make some clients nervous. Still,

April looks a little concerned.

APRIL:	 I don’t drink any alcohol.

PRACTITIONER:	 Okay, that’s good to hear. Not to worry, that’s just a general question that I

will be asking during all of our visits. There’s no safe time, amount, or kind of

alcohol to drink during pregnancy, so we recommend women not drink during

their pregnancy.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

2nd Office Visit: We pick up the conversation after the practitioner has again gone over the 

general health questions about smoking and level of intake of water and coffee.

APRIL:	 I’m actually trying to drink more water now, and less coffee. I carry a water

bottle around with me all the time.

PRACTITIONER:	 Okay, that’s good. How much alcohol have you had?

APRIL:	 None, really.

PRACTITIONER:	 Have you had any alcohol?

APRIL:	 One glass. We were having dinner with some friends.

Master Clinician Note: This interaction demonstrates the value of re-screening in relation to

alcohol. April stated in the first visit that she does not drink. However, during this second visit,

she has revealed that she does drink on occasion. It will be important for the practitioner to

repeat the benefits of abstinence during pregnancy and probe for level of alcohol use, while

remaining supportive and nonjudgmental.

PRACTITIONER:	 I see. Well, as we discussed at your last visit, no alcohol use during the

pregnancy is the best policy. We just want to take the best possible care of your

baby. About what size was that glass, would you say?

Master Clinician Note: The practitioner can use a visual aid, as in the previous vignette, to

help April understand how much really equals one drink. The practitioner has also repeated the

importance of abstinence during the pregnancy, and tied the guideline specifically to the health

of April’s baby.

3rd Office Visit: At this visit, April again indicates alcohol consumption, this time “a couple of 

drinks” at a dinner party. The practitioner explores further.

PRACTITIONER:	 How many drinks did you have?

APRIL:	 Well, my friend handed me a glass of cabernet when I arrived, because she

said I would love it. I reminded her that I was pregnant, but she said a couple

wouldn’t hurt and that she had a few when she was pregnant and her kids were

fine.

PRACTITIONER:	 So, you drank the cabernet. Did you have any others?

APRIL:	 Well, then I had some with dinner, too. I felt like I had been really good during

the pregnancy, so I just decided to have a few drinks this one night.

PRACTITIONER:	 So, you ended up having a few drinks that night.

APRIL:	 Yes, but just that one time. And it was only wine.

PRACTITIONER:	 I know that the temptation to have some drinks at a party or a celebration can

be great, but there are a couple things to keep in mind. One is that science has

shown that alcohol can harm the baby. We don’t know yet how much alcohol

consumption is too much, so it’s very important to avoid all alcohol during the

pregnancy.

The practitioner pauses for the client to process what has been said.
59

Chapter 3: Clinical Vignettes

APRIL:	 Okay.

PRACTITIONER:	 Also, it’s important to understand that any type of alcohol you drink can hurt

the baby, not just certain kinds. Wine, hard liquor, beer...any beverage with

alcohol in it. So it’s important to avoid all of them during the pregnancy.

APRIL:	 Gotcha.

Master Clinician Note: Given that April has continued to drink even after her first couple of

visits, the practitioner takes the educational process a step further this time, clearly noting that

science has established a risk and that there is no “acceptable” form or amount of alcohol. A

counselor or practitioner may also want to discuss the possibility of equipping April with some

tools to help her abstain during the pregnancy (e.g., relaxation techniques, recreation, avoiding

trigger situations such as parties). The need to continue to monitor April’s alcohol consumption

should be clearly noted in the medical record.

4. INTERVENTION WITH A 

WOMAN WHO IS PREGNANT 

AND CONSUMING ALCOHOL, 

AND WHO IS EXHIBITING 

CERTAIN TRIGGERS FOR 

ALCOHOL CONSUMPTION, 

INCLUDING HER PARTNER (AEP 

PREVENTION)

Overview: This vignette illustrates a method 

for obtaining the alcohol history of a pregnant 

woman.

Background: Isabel, 30, has been referred to 

an outpatient mental health treatment center 

for feelings of depression. She is Hispanic, 

married, and pregnant (in her third trimester), 

and has one other child. The counselor and 

client have completed the intake process and 

Isabel has participated in the development 

of her comprehensive treatment plan. This is 

their third meeting. The counselor and Isabel 

agreed at the end of their last session that this 

would be about potential health risks with the 

pregnancy.

Learning Objectives:

1. To learn how to use a practical visual tool 

(a calendar) to more accurately and effectively identify client drinking patterns and 

possible triggers for alcohol consumption.

2. To identify verbal cues that can indicate 

that a topic is becoming uncomfortable 

for a client, and apply effective techniques 

when a client becomes upset.

Vignette Start

COUNSELOR:	 Hi,	Isabel.	How	are	you?

ISABEL:	 Fine,	how	you	doing?

COUNSELOR:	 I’m	fine,	thanks.	When	we	met	last,	we	finished	working	on	your	treatment	plan.	

You	have	had	a	little	bit	of	time	to	think	about	the	plan	now.	Do	you	have	any	

thoughts	or	concerns	about	what	we	developed?

ISABEL:	 No,	not	really.

COUNSELOR:	 How	are	you	doing	with	the	pregnancy?
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

ISABEL:	 Pretty good. Things are going pretty well.

COUNSELOR:	 Great. Now, at the end of your last visit here, we said we would spend part

of today’s session talking about alcohol use during pregnancy. You indicated

during your intake that you drink socially, so let’s talk about that a little more.

Knowing about when and how much you drink will help us to see if there is any

need to be concerned about any health issues for you or the baby. Is that okay

with you?

ISABEL:	 [Sounding a little concerned.] What do you mean “concerned about health

issues?” I am not an alcoholic.

Master Clinician Note: The counselor wants to reassure Isabel that she has not formed a

negative opinion of her. The counselor now also needs to be aware that Isabel may try to

minimize the frequency and amount of alcohol consumed so that she is not viewed as an

alcoholic.

COUNSELOR:	 [Calmly and reassuringly.]	I	am	sorry,	Isabel.	I	wasn’t	trying	to	say	that	you	have	

an	alcohol	problem.	Nothing	you	have	told	me	during	our	previous	sessions	

would	lead	me	to	believe	that	you	are	an	alcoholic	or	have	a	drinking	problem.	

You	said	you	only	drink	socially,	correct?

ISABEL:	 Yes. I don’t drink every day or even every weekend.

COUNSELOR:	 Good. That’s just what I thought. I know, just from the short time we have been

seeing each other, that you would never do anything to hurt your child. But,

would you agree that drinking socially for one person might be different than

drinking socially for another?

ISABEL	 Of course.

COUNSELOR:	 Alcohol can have an influence on individuals who are anxious, depressed,

and even on women who are pregnant, and possibly their unborn child. That

influence can depend on the frequency and amount of alcohol consumed.

So knowing the social situations and how much you drink at those occasions

will help us determine if you need to make any changes between now and

when the baby is born. If it is okay with you, let’s see if we can identify those

situations.

ISABEL:	 Okay, I’ll give it a try.

COUNSELOR:	 Thanks. That’s great. So first let me ask you this: Normally, when you aren’t

pregnant, how often would you say you drink alcohol?

ISABEL:	 Well, most of the time I’m not normally a drinker.

COUNSELOR:	 Okay, that’s good. When you do drink, about how much do you have?

ISABEL:	 I can’t really say. It depends.

Master Clinician Note: The counselor wants to get an accurate picture of Isabel’s drinking

during pregnancy, so she brings out a calendar. The visual is helpful as it allows both client and

counselor to put their eye contact elsewhere, which can contribute to the ease of discussion. The

counselor explains that it also helps to trigger memory by looking at dates.
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Chapter 3: Clinical Vignettes

COUNSELOR:	 Okay, so let’s start by figuring out when you first found out that you were

pregnant.

ISABEL:	 I went to Dr. Murphy’s office and they did a pregnancy test. I had not had my

period. I can look at the calendar, but I am pretty sure it was sometime in May.

COUNSELOR:	 Do you think it was the beginning of May or the middle?

ISABEL:	 It was the middle, and then I went home and told Marco.

COUNSELOR:	 Ok, so you found out you were pregnant in the middle of May. [Counselor 

marks the calendar.] When did Dr. Murphy tell you your due date would be?

ISABEL:	 Around December 22.

COUNSELOR:	 Great, so we know you’re in your third trimester now. [The counselor circles 

the third trimester with a colored pencil, then circles the other trimesters with 

different colors.] It looks like you probably got pregnant somewhere around the

beginning of April. [The counselor also marks this on calendar.] Did your alcohol

drinking change after you found out you were pregnant in mid-May?

ISABEL:	 Yes, I pretty much quit drinking after that. But right before, around the

beginning of May [points to calendar], Marco had just gotten a job and we went

out with some friends. We went to party that one time, and I drank a little, but I

don’t think that would harm the baby. It wasn’t a lot.

COUNSELOR:	 You’re doing great. Do you remember what you were drinking?

ISABEL:	 I had one rum and Coke. Mostly Coke, with a little rum.

COUNSELOR:	 Was that all?

ISABEL:	 I had one wine cooler which I sipped for the rest of night. That wasn’t too

much, was it?

Master Clinician Note: The counselor senses that Isabel is getting a little anxious about this line

of questioning and tries to be reassuring and non-judgmental.

COUNSELOR:	 Two drinks in one night don’t sound like a lot to me. I’m only asking because

I want to help you do the best for the baby between now and the time you

deliver. So let’s see: It seems like you are saying that you mostly drink on special

occasions. Is that right?

ISABEL:	 Yes, those are the times I usually drink, and sometimes when Marco has friends

over to watch a game I might have a beer or two.

COUNSELOR:	 Okay. Can you remember any other occasions when you might have been

drinking during your pregnancy?

ISABEL:	 I drank a little on my birthday in July.

COUNSELOR:	 Did you go out for your birthday?

ISABEL:	 No. Marco surprised me when I got home. He made me dinner with flowers and

wine and everything.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

COUNSELOR:	 He sounds very thoughtful.

ISABEL:	 [Smiling, shrugs a little.] He can be.

COUNSELOR:	 So, do you remember how much wine you had that night?

ISABEL:	 I had maybe two or three glasses. I have read that drinking a little wine would

not hurt the baby. I try to be aware not to do anything that would hurt my baby.

I drank a little with my first child and he is healthy.

COUNSELOR:	 I know that, Isabel. No mother would do anything on purpose to hurt her baby.

I know how hard you’re working to take care of yourself during the pregnancy,

and that’s really important. Did Marco drink with you on your birthday?

ISABEL:	 Marco drinks all the time. He drinks beer every day. I’m sure that I’m okay,

because you know I’m not like Marco. I don’t come home and a have a six pack.

COUNSELOR:	 Okay. So, you drank these two times before you got pregnant. And right about

here is when you would have found out you were pregnant. [The counselor 

points to circled first trimester on calendar.] Are there any other days in these

months that you can think of, or any events?

ISABEL:	 [Pauses, squirms a little in her chair.] Well, there was one time Marco and I had

an argument about the amount of time he spends with his friends. He goes out

on Friday nights and drinks with his friends, doesn’t come home sometimes

until the next morning. He went out and I had some of my girlfriends over and

I wound up getting drunk. I was so bad I was throwing up. I was embarrassed. I

had to go to the bedroom and they had a bucket and they were saying “Isabel,

are you okay?” But that’s the only time I can think of.

COUNSELOR:	 And what were you drinking then?

ISABEL:	 We were drinking rum and Coke.

COUNSELOR:	 Okay, do you know how many drinks you had?

ISABEL:	 We were drinking and playing cards. I must have had three or four, at least.

COUNSELOR:	 How many drinks does it take to make you feel high?

ISABEL:	 It depends. A couple glasses of wine, or one rum and Coke, if it is strong.

Master Clinician Note: The counselor is gradually asking more detailed questions about Isabel’s

alcohol use. Although Isabel claims not to be a drinker, a pattern of usage is emerging through

the use of the calendar. Isabel is bringing up Marco often, so the counselor takes this cue and

probes further about her husband.

COUNSELOR:	 It sounds like whenever you drink it has something to do with Marco. Are there

times that you drink by yourself?

ISABEL:	 No.

COUNSELOR:	 Okay, so tell me about drinking with Marco.
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Chapter 3: Clinical Vignettes

ISABEL:	 [Sighs.] It’s	just	mostly	because	we’re	with	friends	and	I	like	to	do	what	everyone	

else	is	doing.	I	want	to	be	social.	I	don’t	drink	every	day	with	him.	He’ll	come	

home	with	a	six	pack	and	drink	beer	while	he	is	watching	TV	or	sports.	He	loves	

baseball	and	basketball.

COUNSELOR:	 So	he	drinks	when	he	comes	home	from	work.	Does	he	want	you	to	drink	with	

him?

ISABEL:	 He’ll	offer	me	a	beer	now	and	then,	ya	know,	but	that’s	his	thing.	That’s	what	

men	do.	I	have	too	many	other	things	going	on.	I	really	drink	just	a	little.	I	really	

don’t	think	that	I	am	doing	anything	that	is	going	to	hurt	the	baby.	I	don’t	want	

to	fight	with	Marco	about	his	drinking	or	his	friends.	I	have	to	come	here	to	

deal	with	my	other	problems.

COUNSELOR:	 Is	Marco	excited	about	the	baby?

ISABEL:	 [Relaxing a little at the change in subject.]	Oh	yeah.	Very.	I’m	excited,	too.	

We’re	looking	forward	to	this.

COUNSELOR:	 How	do	you	think	it’s	going	to	be	with	his	drinking	after	the	baby	is	born?

ISABEL:	 I	don’t	know.	I	doubt	he	will	change.

COUNSELOR:	 Are	you	worried	about	that?

ISABEL:	 No,	he’s	a	good	guy.	[She sniffles and wipes her nose.]	He	really	is.	I	know	you	

probably	think	he’s	an	alcoholic	or	something.	That’s	not	how	it	is.	We’re	not	

like	that.	[She starts crying.]	I	love	this	baby.	So	does	he.	We’re	trying	to	take	

care	of	it.	[Her crying continues, and she gets an anxious expression on her 

face.]

Master Clinician Note: Isabel is becoming anxious, and is shifting the topic away from alcohol.

This is a signal, or cue, to the counselor that the client is uncomfortable. The counselor needs to

acknowledge what Isabel is feeling and be careful about how much further she probes on this

issue during this visit.

COUNSELOR:	 I know you have a lot on your plate and I think you are handling it quite well.

You did quite a bit in today’s session, and you did very well. I would like to end

this session and talk a little about our next session. Would that be alright with

you?

ISABEL:	 Sure.

COUNSELOR:	 I heard you say you had read something that drinking small amounts of alcohol

was okay for a pregnant woman. Is that correct?

ISABEL:	 Yes, I read it on poster, I don’t remember where.

COUNSELOR:	 I would like to give you something to read. It’s short. It’s about what can

happen when babies are exposed to alcohol before being born. I would like

you to read it so we can discuss it in our next session. Is that okay with you?

ISABEL:	 Sure. The more I know, the more I can protect the baby, right?

COUNSELOR:	 Absolutely.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Master Clinician Note:		The	mental	health	counselor	is	in	a	difficult	position.	Her	use	of	the	

calendar	helped	to	reveal	a	pattern	of	alcohol	use	by	Isabel	and	her	husband	that	exceeds	

what	Isabel	first	admitted	and	is	unsafe	for	the	baby.	It	also	helped	to	establish	some	of	Isabel’s	

triggers	for	drinking	alcohol,	which	include	her	husband	and	being	angry.

At	the	same	time,	discussing	alcohol	use	and	how	it	can	hurt	a	baby	can	be	an	emotional	topic	

for	the	mother.	She	is	working	hard	to	take	care	of	her	baby,	and	the	topic	of	alcohol	may	have	

gone	further	than	she	is	comfortable	with.	At	the	same	time,	it	has	been	useful,	as	Isabel	seems	

to	be	reaching	a	point	where	she	has	begun	to	question	her	use	of	alcohol	during	pregnancy.	

This	is	a	learning	moment	for	the	counselor.	She	can	see	the	value	of	exploring	alcohol	use	with	

her	pregnant	patients,	but	she	also	knows	that,	in	the	future,	she	can	pay	closer	attention	to	

verbal	cues	that	indicate	a	client’s	discomfort;	in	Isabel’s	case,	the	changing	of	the	topic	and	the	

repeated	assertions	that	she	doesn’t	think	she	has	hurt	her	baby.	The	counselor	should	continue	

the	session	long	enough	to	bring	closure	to	the	topic	of	alcohol	use,	while	supporting	the	

positive	things	that	Isabel	has	done	to	take	care	of	her	baby.	The	door	should	be	left	open	to	

come	back	to	the	topic	of	alcohol	in	future	sessions.

If	Isabel	continues	to	show	a	pattern	of	alcohol	use	during	the	pregnancy,	the	counselor	can	

help	her	identify	other	ways	to	deal	with	her	anger	besides	drinking	(stress	management),	and	

help	her	identify	or	find	support	systems	in	her	life	other	than	her	husband	if	he	is	not	being	

supportive	of	her	abstinence	during	pregnancy	(e.g.,	a	pregnancy	peer	support	group).	If	a	

mental	health	counselor	does	not	feel	comfortable	addressing	these	issues,	referral	to	a	qualified	

substance	abuse	treatment	counselor	is	advisable.

5. INTERVIEWING A CLIENT FOR 

THE POSSIBLE PRESENCE OF AN 

FASD (FASD INTERVENTION)

Overview: This vignette illustrates the clues 

the health care worker is receiving that suggest 

an impairment and possible FASD. A client 

with an FASD, with brain damage, will not 

receive the information from the worker the 

same way someone without FASD will receive 

it. The client may not have a diagnosis and 

may not immediately present as someone with 

a disability. There are a number of questions 

the worker could ask to determine whether 

they need to operate in a different kind of 

therapeutic environment with the client. The 

main goal of this vignette is for the health care 

worker to consider the possibility of an FASD, 

not to diagnose an FASD, which can only be 

done by qualified professionals. A woman who 

has an FASD is at high risk for having a child 

with an FASD.

Background: Marta is a single woman, 19, 

who recently had a baby, and is being seen at 

a Healthy Start center by a health care worker. 

This is the first time they are meeting. The 

health care worker’s colleague asked her to 

meet with Marta as she knew that the health 

care worker was knowledgeable about FASD 

and was known as the office “FASD champion.” The colleague has begun to suspect 

that Marta may need an evaluation for FASD, 

as she has repeatedly missed appointments 

or been late, gotten lost on the way to the 

center, failed to follow instructions, spoken at 

inappropriate times, and has repeated foster 

placement and criminal justice involvement in 

her case history. The only information in the 

history about Marta’s biological mother is that 

she is dead. The colleague wants the health 

care worker to conduct an informal interview 

to assess the possibility of an FASD.
65

Chapter 3: Clinical Vignettes

Learning Objectives:

1. To learn how to identify behavioral and 

verbal cues in conversation with a client 

that may indicate that the client has an 

FASD.

2. To learn how to apply knowledge 

of FASD and its related behavioral 

problems, in order to reassess clients 

with troublesome behaviors or concerns for factors other than knowing 

noncompliance.

Vignette Start

HEALTH CARE WORKER:	 Hi Marta, how are you?	

MARTA:	 Good.

HEALTH CARE WORKER:	 Your regular counselor has asked me to meet with you today for a

few minutes to ask you a few questions, if that’s okay. [Marta nods in 

agreement.] Okay, so tell me how you got here today.

MARTA:	 [Shrugs.] I took the #10 bus, then I got off and walked.

HEALTH CARE WORKER:	 Where did you get off the bus?

MARTA:	 Madison Avenue.

HEALTH CARE WORKER:	 Did you know you could have taken the bus to Washington Street

instead of Madison Avenue? Then you would have been six blocks

closer.

MARTA:	 [Shaking her head.] I didn’t know that.

HEALTH CARE WORKER:	 Do you want me to write that down for you?

MARTA:	 Okay.

HEALTH CARE WORKER:	 [Writes down the information.] Here, you can keep this in your purse.

[Hands Marta the piece of paper.]

Master Clinician Note: Individuals with an FASD sometimes exhibit poor working memory. The

health care worker is not assuming that Marta has an FASD at this point. However, if she does, it

is unlikely that she will remember the information about the bus route, so the health care worker

writes it down.

HEALTH CARE WORKER:	 Did you pay for your bus ride with cash or a bus card?

MARTA:	 Today I paid with cash, but I don’t always have it.

HEALTH CARE WORKER:	 When are the times when you don’t have money?

MARTA:	 Sometimes friends borrow it, or other people.

HEALTH CARE WORKER:	 What other people?

MARTA:	 Well, like last time, a man on the corner asked me for money, so I

gave it to him. Then I didn’t have any for the bus.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Master Clinician Note: Marta has exhibited a double “red flag” for an individual with an FASD;

poor money management skills, and a lack of understanding of consequence (i.e., giving away

the money without understanding that she then wouldn’t be able to pay for the bus).

HEALTH CARE WORKER:	 Marta, I’d like to ask you a little more about some of the questions

that you were asked when you first came here.

MARTA:	 Okay, go ahead.

HEALTH CARE WORKER:	 You told us that your mother is not alive. How old was she when she

died?

MARTA:	 Twenty-five, I think.

HEALTH CARE WORKER:	 How old were you when she died?

MARTA:	 Four.

HEALTH CARE WORKER:	 I’m very sorry to hear that you’ve lost your mother.

MARTA:	 [Very matter-of-factly.] I didn’t lose her. She died.

Master Clinician Note: Marta is exhibiting very literal interpretation of language, which is

common among individuals with an FASD.

HEALTH CARE WORKER:	 You’re right, that’s what I should have said. That was probably a hard

time for you. [Marta nods.] Did you know much about her?

MARTA:	 [Shakes her head and shrugs.] Not really.

HEALTH CARE WORKER:	 Do you know if she ever had any kind of problem with alcohol?

MARTA:	 Like, being an alcoholic?

HEALTH CARE WORKER:	 Yes.

MARTA:	 [Shrugs.] I heard she drank, yeah.

HEALTH CARE WORKER:	 Do you know if she drank alcohol while she was pregnant with you?

MARTA:	 I don’t know. [Pauses for a moment.] That’s a weird question. Why are

you asking that?

HEALTH CARE WORKER:	 Did the question make you uncomfortable? Sometimes when women

drink during pregnancy their kids end up having extra challenges. Do

you know what I mean when I say challenges?

MARTA:	 Sure.

HEALTH CARE WORKER:	 Can you give me an example?

MARTA:	 [Shrugs]. I don’t know.

Master Clinician Note: Marta has stated that she understands when really she doesn’t. Any

young person might do this, but it is especially common for individuals with an FASD. Checking

for cognition is important with clients that have or may have an FASD.
67

Chapter 3: Clinical Vignettes

HEALTH CARE WORKER:	 Needing extra help in school is an example of a challenge.

MARTA:	 Right, okay.

HEALTH CARE WORKER:	 Is it okay to ask a few more questions?

MARTA:	 Yeah.

HEALTH CARE WORKER:	 Thanks. This will only take a couple more minutes, I promise. How

about you? Do you drink alcohol at all?

Master Clinician Note: Because this is an interview to see if there is reason to believe that

Marta has an FASD, the counselor is probing to see if perhaps Marta’s baby was also exposed to

alcohol before birth.

MARTA:	 No, I don’t like the taste of it.

HEALTH CARE WORKER:	 Me neither. So, you didn’t have any alcohol while you were pregnant?

MARTA:	 No, my foster mom and dad told me not to drink or smoke while I was

pregnant.

HEALTH CARE WORKER:	 That was very good advice. Tell me, where did you live when you were

growing up?

MARTA:	 First with my aunt, then lots of places. I was in foster care.

Master Clinician Note: It is not unusual for individuals with an FASD to no longer be in the care

of their parents, and to have been placed multiple times in foster care.

HEALTH CARE WORKER:	 Did you like school when you were growing up?

MARTA:	 [Looking down.] Umm... I guess it was okay.

HEALTH CARE WORKER:	 What classes did you like?

MARTA:	 I liked art. And I liked Ms. Norton.

HEALTH CARE WORKER:	 Who was Ms. Norton?

MARTA:	 Ms. Norton was in the resource room.

Master Clinician Note: Time spent in the “resource room,” while not a clear-cut clue, is certainly

a strong indicator that the child was identified in school as having special needs. This is often the

case with children who have an FASD. The counselor could further explore by asking a followup question like “Did you ever have extra help with your school work?” or “Did you ever have

special classes or tutoring in school?”

HEALTH CARE WORKER:	 How many students were in the class with you?

MARTA:	 Five, including Eddie.

HEALTH CARE WORKER:	 Who’s Eddie?
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

MARTA:	 [Laughing a little to herself as she remembers.]	Eddie	is	the	kid	that	I	

used	to	get	in	trouble	with	all	the	time.	He	was	always	coming	up	with	

ideas.

HEALTH	CARE	WORKER:	 What	do	you	mean	when	you	say	Eddie	“came	up	with	ideas?”	Can	

you	give	me	an	example?

MARTA:	 Well,	like,	one	time	we	were	walking	home	from	school,	and	he	saw	a	

bike	in	someone’s	yard	that	he	really	wanted.	So	he	told	me	to	go	get	

it	for	him.	I	did,	but	the	man	who	lived	there	caught	me	and	called	the	

cops.

HEALTH	CARE	WORKER:	 Did	you	realize	that	taking	the	bike	could	get	you	into	trouble?

MARTA:	 I	had	a	feeling.	I	wasn’t	sure,	but	I	wanted	Eddie	to	keep	liking	me.

Master Clinician Note:	Involvement	in	“trouble”	or	crime	as	an	unintentional	secondary	

participant	is	an	FASD	“red	flag,”	particularly	when	the	motivation	is	social	(i.e.,	to	make	friends).

Master Clinician Note:	Marta’s	case/vignette	is	oversimplified.	In	a	matter	of	minutes,	she	

has	exhibited	a	handful	of	behavioral	clues	that	suggest	that	she	may	have	a	disability.	Not	

all	individuals	who	may	have	an	FASD	will	be	this	easy	to	‘spot.’	This	conversation	is	provided	

simply	as	a	way	to	learn	how	such	“red	flags”	might	come	up	in	conversation	with	a	client.	

By	identifying	these	red	flags,	which	are	particularly	common	in	individuals	with	an	FASD,	the	

health	care	worker	will	be	able	to	manage	the	case	in	a	way	that	better	suits	the	needs	of	the	

client,	and	can	make	a	better-informed	decision	regarding	the	need	for	a	more	complete	FASD	

diagnostic	evaluation.	Additional	probing	questions	that	could	be	asked	include	the	following:

•	How	much	alcohol	did	your	mom	drink	when	she	was	pregnant?

•	Think	about	when	you	were	a	child.	How	did	you	do	in	school?

•	Do	you	ever	have	trouble	keeping	appointments?	How	do	you	do	with	telling	time?

Refer to Part 1, Chapter 2 for guidance on referring a client for a formal FASD diagnostic 

evaluation, and for strategies and treatment modifications that will improve treatment 

success with an individual who may have an FASD.

6. INTERVIEWING A BIRTH 

MOTHER ABOUT A SON WHO 

MAY HAVE AN FASD AND IS 

HAVING TROUBLE IN SCHOOL 

(FASD INTERVENTION)

Overview: Counseling professionals in mental 

health or substance abuse treatment may avoid 

talking to a female client or family member 

about their alcohol use during pregnancy, 

either to avoid communicating any shame or 

judgment to that individual, or out of a lack of 

knowledge about FASD. This case illustrates 

a scenario where such a discussion may prove 

fruitful, and the sensitivity required when 

starting the discussion.

Background: The vignette begins with a 

community mental health professional talking to Dixie Wagner, 35, about the behavior 

of Dixie’s 7-year-old biological son, Jarrod. 

( Jarrod is not present at this session.) Jarrod is 

in trouble again for hitting another child, and 

this is causing distress for the mother that the 

mental health professional wants to address, 

which leads into a discussion of FASD.
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Chapter 3: Clinical Vignettes

Learning Objectives: 

1. Cite methods to help the caregiver clarify 

the child’s issues and discover why the 

child is having problems.

2. Specify skills needed to follow the caregiver’s lead in asking probing questions.

3. Explore the negative perceptions surrounding prenatal alcohol exposure, and 

examine how lack of knowledge or fear 

of shaming may interfere with asking the 

right questions. 

Vignette Start

MENTAL HEALTH PROFESSIONAL:	 Dixie, we talked briefly on the phone about Jarrod’s school

issues. It sounds to me like you are concerned for him. Today

I’d like to hear more about your concerns, and then we can

work from there. How does that sound?

DIXIE:	 Yes, that’s fine. You’re right, I’m very concerned about him.

MENTAL HEALTH PROFESSIONAL:	 Is it okay that we talk about the kinds of behaviors that led

to Jarrod hitting a fellow student? Was the student a friend

of Jarrod’s?

DIXIE:	 That is exactly what’s so disturbing about this situation; it

was someone I thought was a good friend, a kid named

Garrett. Jarrod looks up to Garrett and talks about him all

the time. I was excited that he wanted to be friends with

Garrett. I was very surprised to get a call from the principal.

MENTAL HEALTH PROFESSIONAL:	 You’re right. Friends are so important for all children this

age. Has Jarrod been having problems with his peers?

DIXIE:	 [Sighs]. He’s always had a hard time getting along with kids

his own age. He starts off happy and friendly. He wants

everyone to like him. Sometimes I think his enthusiasm might

be too much for some kids. Sometimes he says such crazy

things. I don’t know if he thinks the kids will laugh at what

he says or if he is really being serious. Slowly I can see the

kids moving away from him. It breaks my heart. He ends

up playing by himself. He really wants everyone to like him.

He’ll talk to anyone! We always say Jarrod has never met a

stranger he didn’t like. I worry a little that he’ll listen to the

wrong person when he gets older. Most of the time he’s just

so sweet and loveable.

MENTAL HEALTH PROFESSIONAL:	 Okay, so what I’m hearing is that Jarrod has been having

problems making and keeping friends his own age, although

he really wants to have a friend. Is that right? [Dixie nods.] 

How about in the school setting? How do you think he is

doing in class and with his school work?

DIXIE:	 Well, he’s been labeled a “talker” in class, and we’ve gotten

plenty of notes from the teacher because Jarrod likes to chat

with his neighbors and that annoys them sometimes, and the

teacher. He has a lot of energy, and sometimes loses focus

on his work. He can get frustrated, and may have a hissy fit
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

at school when he doesn’t want to do his work. He likes to

do a good job. Sometimes he just won’t finish his work. So

the teacher will send it home for us to do with him. Every

night we sit down and spend a lot of time on homework, but

that usually ends up in Jarrod fighting and yelling at us.

MENTAL HEALTH PROFESSIONAL:	 So, Jarrod generally has a hard time focusing and sitting still.

These hissy fits, as you call them, how many of these will he

have in a typical school day? Can you tell me a little more

about that? Are you noticing any consistent struggles?

DIXIE:	 I guess he’s had several since starting school this year. The

hissy fits are like toddler temper tantrums. I can’t believe

he is still having tantrums. We never really know why he

has them, especially at school. I know he leaves every day

happy to be going to school, but when he gets home he’s

tired and cranky, and very angry. He doesn’t know where

his homework is in his backpack. This leads to raised voices,

either me or my husband. The teacher always tells us

Jarrod was given the homework, so he must be deliberately

misplacing it. If we do find the homework assignment,

Jarrod will sit and work really hard for awhile, but then

he starts to whine and cry that he is tired and doesn’t

remember what the teacher told him that day. My husband

and I review his spelling words with him every day. He sits

and really tries hard to remember them. But he never passes

the test on Friday. We spend lots of time with him on his

homework. It’s like we have to re-teach him everything he

learned from the day. Many times it ends in a hissy fit. It’s

not like we don’t help him. We’ve done this with him since

he was in first grade.

MENTAL HEALTH PROFESSIONAL:	 Jarrod sounds like he is facing some challenges with his

school work. Are there other times or activities when he

struggles?

DIXIE:	 Well, when he gets off the bus in the afternoon, he is out

of control. He runs around, bumping into furniture and

screaming. Sometimes he will knock down the dog. I am

sure he doesn’t mean to hurt the dog, though, because he

really loves it. The teacher says he has trouble standing in

line for lunch, and pushes the other students next to him.

She also says he has a hard time on the playground for

recess. He prefers to stay inside with her. And about 2pm

every day, Jarrod gets very sleepy.

MENTAL HEALTH PROFESSIONAL:	 I see. Is he getting enough sleep?

DIXIE:	 We start the bedtime routine about 7:30, right after dinner.

The kids will take showers, brush their teeth, and then we’ll

read a book together. We struggle to get Jarrod to brush his

teeth. He hates taking a shower, but once the water is in the

tub, he loves taking a bath. Everyone gets a chance to pick a

book when it’s their turn. Jarrod always picks a picture book
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Chapter 3: Clinical Vignettes

about Kermit the frog. But when it is time to go to bed,

Jarrod is wide awake, talking or playing his video games.

We’ve had to put him in his own room so my other children

can go to sleep. Jarrod is up before my husband, usually

before 5am, because he’s never needed much sleep.

MENTAL HEALTH PROFESSIONAL:	 So what I am hearing is that you and your husband have

set up a nighttime routine for all the children, but Jarrod

has a hard time with the routine. It sounds like Jarrod is

only getting a few hours of sleep at night. This may be a

reason why Jarrod is having problems in school, since he is

tired, but I would like to hear more from you. What else is

worrying you?

DIXIE:	 This isn’t school-related, but that boy can’t keep his room

clean! I run a tight ship, and an unmade bed is not welcome.

He can never find anything. I raise my voice, and still no

results. My other kids listen to me. I have no idea why Jarrod

disobeys me all the time.

MENTAL HEALTH PROFESSIONAL:	 Can you describe a typical room-cleaning episode?

DIXIE:	 I’ll say “Did you clean your room?” and he says “Yes” and

then I’ll go and check and nothing is put away. There are

clothes on the floor. Dirty and clean clothes will be in his

dresser drawers. The bed is unmade. He’ll leave wet bath

towels on the floor. And there he sits playing a video game.

Nothing is done and he still says “Yup, it’s clean!” He just

doesn’t listen. Sometimes I punish him. That doesn’t work,

either.

MENTAL HEALTH PROFESSIONAL:	 That can’t be easy, and I can see where that could be

frustrating for you and your husband. Do you think it’s a case

of Jarrod not having the organizational skills needed to keep

his room clean, or that he doesn’t understand what you’re

asking him to do?

DIXIE:	 I think he understands, he’s just resisting. I know he can do

it, but usually not until I stand over him and make him do it,

one thing at a time. It’s exhausting.

MENTAL HEALTH PROFESSIONAL:	 Well, That sounds like a lot of kids Jarrod’s age. But what

I’m getting at is when you break down the specific tasks for

Jarrod—one thing at a time, like you say—he does what he’s

told and does it correctly. Is that right?

DIXIE:	 Yes, we have found that there isn’t a better kid when you

work with him one-on-one.

MENTAL HEALTH PROFESSIONAL:	 You’re providing me with a lot of needed detail. Thank you.

Knowing his behaviors out of school really does help me

understand how we might be able to help him in school. I’d

also like to follow up on something you mentioned earlier,
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

about	Jarrod’s	friends.	How	is	he	with	kids	his	own	age,	

besides	Garrett?

DIXIE:	 Besides	the	kindergarten	twins	who	live	next	door,	Jarrod	

has	no	one	to	play	with.	We	tried	to	get	him	into	soccer,	

but	he	ran	after	the	soccer	ball	no	matter	what	side	had	it	

and	the	kids	made	fun	of	him.	We	tried	cub	scouts	with	my	

husband	helping	out	as	den	leader,	but	Jarrod	would	be	

very	bouncy	and	talkative,	grabbing	the	other	kids’	project,	

sometimes	breaking	them.	The	kids	would	be	polite,	but	

eventually	started	to	shun	him.	Eventually	he	would	go	off	

by	himself	and	play	with	a	toy.

MENTAL	HEALTH	PROFESSIONAL:	 This	must	be	hard	for	you	and	your	husband.	

DIXIE:	 We	were	told	last	year	that	Jarrod	was	immature	for	his	age,	

but	the	teacher	said	boys	tend	to	mature	later	than	girls.	

The	teacher	wanted	to	wait	and	see	if	Jarrod	matured	over	

the	year	before	we	did	any	official	school	testing.

MENTAL	HEALTH	PROFESSIONAL:	 So,	let’s	recap	what	we	have	talked	about.	Jarrod	tries	to	be	

social	and	verbal,	is	trusting,	and	wants	to	be	a	good	friend.	

He	also	has	trouble	cleaning	his	room,	staying	on	task,	

and	doing	his	school	work,	but	when	he	does	sit	down	for	

homework,	he	can	be	very	diligent	in	getting	his	work	done.	

Then	there	may	be	some	sensory	issues,	like	brushing	his	

teeth	or	taking	a	shower,	and	the	bus	tends	to	be	a	problem.	

Of	course,	we	cannot	forget	the	fight	with	Garrett.	Out	of	all	

these	things,	I	don’t	see	a	child	with	an	aggressive	nature.	

What	I	am	concerned	about,	though,	is	that	Jarrod	might	be	

facing	some	difficulties	that	will	lead	him	to	get	into	another	

fight.

DIXIE:	 This	isn’t	making	sense	to	me.

MENTAL	HEALTH	PROFESSIONAL:	 Well,	I	don’t	have	a	real	clear	picture	yet.	However,	one	of	

things	that	could	be	at	work	is	that	Jarrod	could	have	some	

cognitive	issues	that	are	creating	differences	in	the	way	he	

processes	information.	These	deficits	can	occur	for	a	whole	

range	of	reasons.	Sometimes	children	are	born	with	them,	

and	as	they	grow,	their	brains	are	different	from	most	kids.	

DIXIE:	 You	mean	like	ADHD?	We’ve	had	people	suggest	ADHD	

before.

MENTAL	HEALTH	PROFESSIONAL:	 ADHD	may	be	one	issue,	but	other	things	could	be	at	work,	

too.	Is	it	okay	that	we	talk	about	before	Jarrod	was	born?	

This	is	something	that	I’ve	asked	some	of	my	clients	before,	

and	it	may	be	helpful	here,	as	well.	I’d	like	to	ask	about	

Jarrod’s	birth,	and	when	you	were	pregnant	with	him.	It	will	

help	us	understand	Jarrod’s	environmental	background.	

Were	there	any	complications	during	your	pregnancy	with	

Jarrod?
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Chapter 3: Clinical Vignettes

DIXIE:	 No, everything was fine. In fact it was a pretty easy

pregnancy. I didn’t have much morning sickness.

MENTAL HEALTH PROFESSIONAL:	 Would you say that you planned your pregnancy with

Jarrod?

DIXIE:	 No, not really. He’s our third, and we weren’t really planning

on a third.

MENTAL HEALTH PROFESSIONAL:	 Now, many pregnancies are unplanned. About half in this

country, in fact. Were you pregnant for awhile before you

knew?

DIXIE:	 Yeah, I found out kind of late. [Starts to become defensive.] 

But I had a good doctor, and good prenatal care.

MENTAL HEALTH PROFESSIONAL:	 What did your doctor tell you about the use of alcohol

during your pregnancy?

DIXIE:	 My husband and I are social drinkers, but we always have

been. I don’t smoke. I drank during my other pregnancies.

My doctor even told me to do it sometimes, because I get

really stressed out and it’s how I used to relax. I really think

you’re way off here.

MENTAL HEALTH PROFESSIONAL:	 Your doctor told you that the occasional drink was okay?

That it would relax you?

DIXIE:	 Yes, he did, and why would he say that if it wasn’t true? He’s

a pediatrician, for god’s sake. Where is this going? Are you

saying I did something wrong to hurt Jarrod?

MENTAL HEALTH PROFESSIONAL:	 No I do not think you would do anything to hurt Jarrod.

Some doctors still give that advice, even though the

evidence now suggests that alcohol can harm a fetus. It

won’t necessarily harm every fetus, but it can hurt some.

I recognize that this is hard to talk about. I only want to

explore the possibility. We both have the same goal, to help

Jarrod. He has exhibited a pattern of behavior that makes an

FASD something worth examining, even if it’s just to rule it

out. Do you know about FASD?

DIXIE:	 [Sits forward in her chair, holding up her hands in a defensive 

manner.] So, wait. What you’re saying is that I drank alcohol

and hurt Jarrod while I was pregnant. Is that it?

MENTAL HEALTH PROFESSIONAL:	 Only experts can determine whether a person has an FASD.

Changes in the brain due to alcohol can only be identified

by certain professionals, but what I do suggest is that we

start to look at why Jarrod might be experiencing some of

the problems that you and his teacher have identified. I am

seeing a pattern of behavior that may suggest an FASD. We

all want the best for Jarrod, and knowing what is happening

in his head may help all of us meet his needs.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

DIXIE:	 [Leans back, crossing her arms, more relaxed but still wary.] 

What	is	this	stuff,	FASD?

MENTAL	HEALTH	PROFESSIONAL:	 It	stands	for	Fetal	Alcohol	Spectrum	Disorders.	See,	alcohol	

is	an	environmental	factor	that	can	affect	a	developing	fetus.	

I	mentioned	alcohol	because	some	women	are	unaware	

of	the	effects	that	alcohol	can	have	on	an	unborn	baby.	

Scientists	refer	to	the	effects	of	alcohol	on	the	fetus	as	

FASD.

DIXIE:	 I’ve	never	heard	of	it.	Are	you	saying	you	think	Jarrod	has	

that?	[Sits forward in her chair; tears well up in her eyes.]

What	you’re	saying	is	that	I	drank	alcohol	and	changed	

Jarrod’s	brain	while	I	was	pregnant.	Is	that	it?	This	is	my	

fault?

MENTAL	HEALTH	PROFESSIONAL:	 I’m	not	leaping	to	that	conclusion.	If	Jarrod	does	have	an	

FASD,	there	is	no	blame	here.	I	just	think	it’s	worthwhile	to	

discuss	the	possibility,	because	it	may	help	your	son,	which	is	

what	we	both	want.

DIXIE:	 [Sits back in her chair and slumps a little.]	Yeah,	I	wanna	

help	him.	I	want	nothing	more.	My	husband	and	I	have	done	

everything	we	can.	[She sniffles some more and shakes her 

head, considering; the counselor offers a box of tissues.]

This	has	been	so	hard.	It’s	been	going	on	so	long.	We’ve	

seen	so	many	doctors,	and	heard	so	many	diagnoses,	and	no	

one’s	ever	right.	Nothing	works.	But	no	one’s	said	anything	

like	this	before.	And	when	you	sit	there	and	tell	me	that	

this	might	all	be	because	I	had	some	drinks	while	I	was	

pregnant...	[She sniffles some more.]

Master Clinician Note: It’s important at this point for the mental health professional to respond

to the fact that the client is feeling blamed and becoming agitated.

MENTAL	HEALTH	PROFESSIONAL:	 Then	I	have	to	apologize	to	you.	If	that’s	what	you’re	feeling,	

then	I’m	to	blame,	not	you.	I	haven’t	done	my	job	properly.	

It’s	incredibly	important	to	me	that	you	understand	that	my	

only	goal	is	to	work	with	you	to	identify	a	potential	root	

cause	for	the	problems	that	Jarrod	having,	because	it’s	clear	

that	his	situation	is	causing	you	distress.	That’s	all	I	want	to	

do.	There	are	many	cases	of	FASD.	Jarrod	would	not	be	the	

first	or	the	only	one.	No	mother	on	earth	does	anything	to	

intentionally	hurt	her	baby.	I	know	you	certainly	didn’t.	I	have	

a	child	of	my	own.	I	know	the	feeling	of	being	a	mother,	and	

it’s	very,	very	clear	to	me	how	much	you	love	your	son.	

DIXIE:	 I	just...	I	don’t	even	know	what	to	say.	I	feel	like	you’re	

pointing	a	finger	at	me.	[She is angry, beginning to cry.]

You’re	in	mental	health.	No	offense,	but	what	do	you	know	

about	medicine?	Or	about	my	son?	About	how	much	I	

love	him?	Or	about	what	we’ve	been	through?	I	can’t	even	

understand	that	you’re	sitting	there	saying	I	did	this	to	him.	
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Chapter 3: Clinical Vignettes

I	mean,	I	hear	your	“no	blame”	crap,	but	I’m	feelin’	real	

blamed	right	about	now!

MENTAL	HEALTH	PROFESSIONAL:	 Well,	like	I	said,	I	do	apologize	if	that	is	how	you	feel.	Maybe	

we	just	need	to	rule	out	FASD.	If	it	happened,	you	were	

going	on	the	advice	of	your	doctor.	Would	it	be	alright	if	we	

focused	on	what	you	want	to	do	next	for	Jarrod?	

DIXIE:	 [Waving her hand to stop the counselor.] What’s	it	called	

again?

MENTAL	HEALTH	PROFESSIONAL:	 Fetal	Alcohol	Spectrum	Disorders.	FASD.	I	can	give	you	a	

pamphlet	that	talks	about	the	basics	of	it.

Master Clinician Note: It is advisable to provide FASD information that does not include

pictures, particularly of children with prominent facial dysmorphology (e.g., thin upper lip,

smooth philtrum). These facial characteristics are present in only a small percentage of children

who have an FASD, and if the client’s child does not resemble the children in the pictures, this

may enable the client’s desire to believe that their child can’t possibly have an FASD.

DIXIE:	 [Taking the pamphlet.]	So	I	should	read	this?

MENTAL	HEALTH	PROFESSIONAL:	 Yes,	it	would	be	good	if	you	and	your	husband	both	read	

it	and	discussed	whether	you	think	it	describes	Jarrod’s	

situation.	

DIXIE:	 I	still	say	you’re	wrong.	But,	what	if	it	does?	What	happens	

then?

MENTAL	HEALTH	PROFESSIONAL:	 To	start,	I	think	you	could	begin	the	process	for	the	school	

to	start	testing	Jarrod	for	a	learning	disability.	There	are	

several	tests	that	could	help	them	understand	the	best	

way	to	teach	Jarrod	so	that	he	doesn’t	get	so	frustrated.	

There	are	a	few	pieces	of	the	testing	that	you	will	have	to	

complete,	like	his	developmental	history,	when	he	walked	

and	talked,	things	like	that.	I	think	you	should	also	look	at	

doing	another	test	for	ADHD.	In	the	meantime,	we	can	set	

up	another	appointment	to	talk	about	FASD,	possibly	with	

your	husband,	as	well.	And	if	the	two	of	you	are	okay	with	it,	

I	can	help	you	access	a	more	complete	evaluation.

DIXIE:	 Where	does	that	happen?

MENTAL	HEALTH	PROFESSIONAL:	 It	may	be	best	to	complete	the	assessment	with	a	

developmental	pediatrician	at	the	local	hospital.	I	am	sure	

that	doctor	will	want	to	see	the	test	results	from	school.	

If	you	like,	there	is	a	support	group	for	families	called	the	

Circle	of	Hope.	I	could	give	you	the	phone	number	or	e-mail	

address	for	them	if	you	need	someone	else	to	talk	to	who	

has	been	through	this.	How	would	that	be?	
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Master Clinician Note: Although the mental health professional makes repeated attempts to

assure Dixie that she does not need to feel blame about the possibility that Jarrod has an FASD,

Dixie has still become upset. This is a very natural response, and counselors should be prepared

for birth mothers to feel as though they are being ‘blamed’ for their child’s condition when FASD

is discussed. However, many pregnancies are unplanned, some doctors do still recommend a

glass of wine as a way for a pregnant woman to relax, and many women do not realize until well

into their first trimester that they are pregnant. The mental health professional utilizes these

realities as a way to reassure Dixie and disconnect her from a sense of guilt and consistently

reiterates their shared goal, to find the best way to help Jarrod. She also effectively coordinates

care by putting Dixie in touch with additional testing and offering a support group number.

7. REVIEWING AN FASD 

DIAGNOSTIC REPORT WITH THE 

FAMILY (FASD INTERVENTION)

Overview: The purpose of this vignette is 

to provide counselors with guidance on how 

to review a diagnostic report (or Medical 

Summary Report) with family members of a 

child who has been just diagnosed with FAS. 

Background: The client, Jenine, is the caregiver of her grandson, Brice. Jenine is meeting with a counselor from the Indian Health 

Service to review Brice’s Medical Summary 

Report for the first time. In a prior session, 

Jenine confided that she felt overwhelmed. 

Vignette Start

COUNSELOR:	 Welcome,	everyone.	It	is	so	good	for	Brice	that	you	could	be	here.	I	am	very	

happy	to	try	to	answer	all	of	your	questions	today.	We’ll	go	through	the	basics,	

so	that	we	can	work	on	what	is	best	for	Brice.	Does	that	sound	good?

JENINE:	 Yes.	

AUNT:	 Yes.

ELDER:	 Yes.

Knowing how detailed a Medical Summary 

Report can be, the counselor suggested that 

Jenine bring trusted family members and 

elders to this session. Together they arranged 

for Jenine’s sister, aunt, and an elder to attend.

Learning Objectives:

1. To recognize that clients will need support after an FASD-related diagnosis.

2. To identify how to help the client prioritize the child’s and the caregiver’s needs.

3. To recognize that the client will need to 

be educated to understand that the child’s 

behavior problems are due to damage to 

brain caused by prenatal alcohol exposure.

Master Clinician Note: The counselor is listening to everyone in order to validate the feelings

and concerns of all individuals attending the session.

COUNSELOR:	 As I mentioned when you arrived, I am so glad that each of you are here today

to support Jenine through this diagnostic process. Together, we can come

up with a plan and move forward from there. The plan will build on Brice’s

strengths, as well as the diagnosis. We’ll get started today, but it will take more

meetings and community support to understand this diagnosis. A lot of detailed

information can be overwhelming, but again, together, we will work through

this process.
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Chapter 3: Clinical Vignettes

JENINE:	 Okay.

COUNSELOR:	 Before	we	review	the	report,	let’s	talk	about	FAS.	What	kinds	of	things	have	you	

learned	about	FAS?

JENINE:	 I	have	been	reading	a	lot	on	the	internet.

Master Clinician Note: It is advisable for the counselor to caution the client and all attending

the session that the quality and reliability of online information about all forms of FASD varies.

She should provide the client with a reading list of up-to-date sources, but advise them to put it

down when they need a break to avoid feeling overwhelmed.

COUNSELOR:	 Okay, I like the internet as a source of information because there can be some

helpful sites. At the same time, not all internet information is up-to-date. Here

is a list of three Web sites that I recommend. They are updated all the time.

They’re really the best place to start. The first site publishes some basic facts

and I’d like to review that with you all for a few minutes.

Master Clinician Note: The counselor can now review the report with Jenine and her support

persons. The counselor can use the review to assess the knowledge level of the client and

her sister and elder, in order to determine how much education and support will be needed

throughout the process. It is also advisable to inquire about other family members (grandparents,

brothers, sisters, aunts and uncles, extended family) to assess how they will feel about the child’s

disability and to gain insight into cultural differences.

A sample Medical Summary Report can be viewed at the Web site of the Washington State FAS

Diagnostic & Prevention Network (FAS DPN): http://depts.washington.edu/fasdpn/pdfs/4-

digit-medsum-web-2006.pdf.

After completing the review, the counselor should focus on Brice’s priority problem area, as well

as the most significant need(s) of the caregiver.

COUNSELOR:	 Okay, now that we’ve worked our way through the report, we need to focus

on the number one area where Brice is having problems. Is that in school or at

home?

JENINE:	 Both, but I can handle home. School is getting out of control. I hope that this

diagnosis gets him the help he needs.

COUNSELOR:	 Well, I know that a diagnosis is not always the pathway to services that we

expect. But what I did see in the report was a clear description of Brice’s

speech and language difficulties, so I think that we can get him the speech

therapy services that will help in school.

JENINE:	 That would be wonderful. Brice stutters, and really has a hard time coming up

with the right word on the spot.

COUNSELOR:	 Okay, then let’s make the top priority for Brice to get services and therapy for

speech. Does that sound like the best place to start?

JENINE:	 Yes, let’s do that.

AUNT:	 I will help.

ELDER:	 We will help, too.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

COUNSELOR:	 Now let’s discuss a top priority for you, Jenine. I want to check in with your

stress level. If you are stressed, then it will be hard to be truly supportive for

Brice. And it is my experience that parents and caregivers of children who have

special needs do deal with burn-out.

JENINE:	 Yeah, that sounds like me.

COUNSELOR:	 Then since that’s the case, let’s use a couple of sessions to make a plan. If we

have any medical questions, I can consult with a pediatrician to try to get those

answered for you. Next, we’ll get the speech therapy going for Brice.

JENINE:	 Okay. How am I going to pay for all of this? All of these services?

COUNSELOR:	 I know some of that is being paid through your insurance company. I’m more or

less the case manager for Brice, so anything not covered, we’ll work together to

address how those things will get paid for.

JENINE:	 Okay. Now, what’s going to happen in school now, with this diagnosis?

Master Clinician Note: Even though answers to these questions cannot all be provided

immediately, the counselor assures the client that they will work together to establish plans to

address them.

COUNSELOR:	 I think that it will be a process, and that will be the focus of our time next week.

We’ll want to think about how you can best approach the school to get Brice’s

special needs met. We’ll also discuss how to talk to your family and friends as

well as his teachers about FAS.

JENINE:	 Okay.

COUNSELOR:	 One thing we can definitely do today is make a list of Brice’s strengths. It’s very

important that our plan for helping him focuses not just on his diagnosis but

also on his positive abilities. Can you all help me with that?

JENINE:	 Sure. He has a lot of wonderful qualities, he really does.

COUNSELOR:	 I know he does. We’re going to build on those. So, let’s recap. Our first priority

is to get the process started on Brice’s speech therapy. We also need a plan

to help you, Jenine, when you’re feeling burned out. We want to talk about

payment for services. And we want to address what this diagnosis means in

terms of special needs at school. Does that sound right?

JENINE:	 Yes.

AUNT:	 Yes.

ELDER:	 Yes, it does.

COUNSELOR:	 Good. I’m writing all this down, and I’ll give everyone a copy. And we’ll set up a

time for our next meeting. Let’s pick a time that works for everyone.
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Chapter 3: Clinical Vignettes

Master Clinician Note: A diagnosis of any form of FASD can be overwhelming for a family.

Although this vignette lacks specifics, the overarching theme of importance is that the counselor

is positive, is willing to work with the family to make a plan to address any areas of concern, and

is available to help them through the process. For families and caregivers of an individual with an

FASD, having this navigational assistance can be tremendously helpful and relieve much of the

stress that can go along with caring for such an individual. In addition to addressing the areas

identified by the family as priorities, it will be important in future sessions for the counselor to:

•	Consistently point out the child’s positive attributes;

•	Recommend a specific support group for the family, if available;

•	Emphasize the need for respite care; and

•	Ask the client about ways to involve the child in an area of interest, like music or sports or art.

This can provide a ‘break’ for both the child and the caregiver.

8. MAKING MODIFICATIONS 

TO TREATMENT FOR AN 

INDIVIDUAL WITH AN FASD 

(FASD INTERVENTION)

Overview: The purpose of this vignette is to 

demonstrate how to modify treatment plans 

for a client with an FASD. 

Background: The client, Yvonne, is an adolescent female with a history of truancy and 

fighting. She has been mandated to counseling 

for anger management, and has missed her 

last two appointments. When the counselor 

phoned her about the missed appointment, 

Yvonne’s mother suggested that Yvonne may 

not be taking her medication, and hinted that 

Yvonne may be depressed.

Learning Objectives: 

1. To adjust expectations regarding ageappropriate behavior, since individuals 

with an FASD may be adult-aged by 

calendar years, but are much younger 

developmentally and cognitively. 

2. To demonstrate the value of collateral 

information and how to ask an individual 

for consent.

3. To demonstrate the importance of 

seeking involvement from parents and 

caregivers.

4. To identify how concrete thinking plays a 

role in comprehension for clients with an 

FASD. 

5. To cite the value of time spent developing 

rapport and establishing trust.

Vignette Start

COUNSELOR:	 Hi, Yvonne. We’ve missed a couple sessions, so I haven’t talked to you in

awhile. How has everything been going? [Yvonne does not respond.] Are you

taking your medicine?

YVONNE:	 Yep.

COUNSELOR:	 I understand that you are not coming home at night. I’m concerned that on

those nights you’re not able to take your medicine.

YVONNE:	 I take my medicine! Can I go?
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

COUNSELOR:	 Well, we have more time today, so let’s keep talking. You know, I need a break.

Do you?

YVONNE:	 Yes, I want to leave.

COUNSELOR:	 Well, I don’t want you to leave yet, but we can go for a walk. Would you like to

walk around the courtyard, or go to the cafeteria?

YVONNE:	 Outside. I want to walk in the courtyard.

COUNSELOR:	 Yeah, let’s do that. It’ll get us out of this stuffy office.

They exit to the courtyard.

Master Clinician Note: Yvonne is clearly confrontational. The counselor is navigating around

the resistance by not repeating questions and insisting on answers, and changing the physical

environment to one that Yvonne chooses. The counselor then begins a rapport-building process

by holding off on treatment talk in favor of getting to know Yvonne personally.

COUNSELOR:	 So, tell me a little bit about things that you like to do. We’ve only seen each

other one time, and that was a few weeks ago. I’d like to know more about the

kinds of hobbies and things you like to do.

YVONNE:	 I love being outside. I love being with animals. My pets are the best.

COUNSELOR:	 Mine, too. I have three dogs, all Dalmatians. What kinds of pets do you have?

YVONNE:	 We have a dog named Scooter, he’s a chocolate lab, and we have a cat, Cory. I

don’t know what kind of cat he is. My brother also has a little lizard, but I think

it’s pretty gross.

This continues for several minutes. At an appropriate time, the counselor begins to shift the 

conversation back to treatment issues.

COUNSELOR:	 Let’s talk a little about your treatment plan, what is working and not working for

you.

YVONNE:	 Okay.

COUNSELOR:	 Sometimes clients do not like to take medication, or they don’t remember to

take their pills. Do you ever forget to take your medication?

YVONNE:	 Sometimes.

COUNSELOR:	 Okay. Well, that’s not surprising. Taking medication is hard to remember for a

lot of people. Sometimes there are bad side effects, or sometimes it’s just a

bother.

YVONNE:	 Yeah, it’s annoying.

COUNSELOR:	 What annoys you about your medication?

YVONNE:	 I don’t know.

Master Clinician Note: The counselor should not leave it at “I don’t know,” but probe further.

With a client who has an FASD, the probes should be very specific.
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Chapter 3: Clinical Vignettes

COUNSELOR:	 Does the medication make you feel bad?

YVONNE:	 No, not really.

COUNSELOR:	 Is it hard to remember to take it?

YVONNE:	 Yeah. I have a lot of stuff to do, ya know.

COUNSELOR:	 Yeah, I know what you mean. Ya know, I take a vitamin each day with my lunch.

That way, whenever I eat lunch, I know to take the vitamin. They go together.

Since I go home for lunch, I keep my vitamins at home on the counter, next

to the ‘frig. I also put a reminder in my phone so that at noon, my phone says

“Take vitamin.” I think we could work out a system like that for you, something

easy that reminds you to take your medication that won’t be annoying.

YVONNE:	 Okay.

COUNSELOR:	 Let’s start by writing this down.

The counselor works with Yvonne to develop a few simple, concrete steps to help her remember to 

take her medication. Once back in the office, the steps are written down and then reviewed with 

Yvonne to make sure she comprehends them.

COUNSELOR:	 Does that look okay?

YVONNE:	 Yeah.

COUNSELOR:	 When did we say you should start using that plan?

YVONNE:	 Right away.

COUNSELOR:	 That’s right.

Master Clinician Note: The counselor does not merely ask “Does that look okay?” but also

asks a follow-up question to make sure Yvonne understands. Since this is a client that has been

noncompliant with medication, the counselor also schedules another session at an early date to

reinforce the new plan, rather than waiting a week or longer.

COUNSELOR:	 Okay, let’s try this treatment plan for the next few days. I’d like to see you in

three days so that we can see how it worked.

YVONNE:	 Okay.

COUNSELOR:	 I’ll write all this down for you. Also, I’d like to ask that your mom help you with

taking the medication. Would it be okay if I talked to your mom after today’s

session? The three of us could spend a few minutes discussing how she can

help you remember to take your medication.

YVONNE:	 Yeah, that’d be okay.

COUNSELOR:	 I know she’s picking you up today, so let’s also ask if she can drop you off for

your next appointment.

YVONNE:	 Okay.

COUNSELOR:	 [Reinforcement of rapport-building]. Will you bring me a picture of Scooter and

Cory? I’d like to see what they look like.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

YVONNE:	 Sure. I’d like to see your Dalmatians.

COUNSELOR:	 I’ll bring a picture, too. Let’s program a reminder into our phones for our next

appointment, with a special note to bring pictures.

Master Clinician Note: The counselor has employed a number of steps to build rapport, avoid

confrontation, and simplify processes for a client that has an FASD:

•	Although clinicians are trained to ask open-ended questions, this counselor made the

questions quite specific. For example, when the question “How has everything been going?”

got no response (it’s a fairly abstract question to someone with an FASD), the counselor

avoided confrontation and switched to something specific: “Have you been taking your

medication?”

•	The counselor never used the word “why.” A person with an FASD will most likely struggle

with understanding or communicating their motivations.

•	The counselor limited choices to avoid overload; for example, instead of “What would you

like to do?” the counselor offered a specific choice: “Would you like to walk around the

courtyard, or go to the cafeteria?” This simplified the choice for Yvonne, and also changed the

environment to one she likes, allowing her to share a little more easily.

•	The counselor broke down the medication plan into small chunks, wrote them down, and

reviewed the steps one at a time with Yvonne. If Yvonne had not seemed to be grasping the

plan, the counselor could have considered reviewing it several more times, or even role-playing

to solidify each step.

•	The counselor scheduled a quick-turnaround follow-up visit so as not to lose valuable time if

the plan isn’t working, and is bringing the mother into the process as reinforcement.

•	Lastly, the counselor built rapport and found a common ground around something that Yvonne

really enjoys, her pets.

9. WORKING WITH AN 

ADOPTIVE PARENT TO CREATE 

A SAFETY PLAN FOR AN ADULT 

MALE WITH AN FASD WHO IS 

SEEKING LIVING INDEPENDENCE 

(FASD INTERVENTION)

Overview: The purpose of this vignette is to 

demonstrate how counselors can help develop 

a safety plan for clients with an FASD. This 

vignette focuses on creating a safety plan with 

a caregiver, as many individuals with FASD 

have someone in their life who provides advocacy and support. If there is no such person in 

the life of the client with FASD, an important 

treatment goal will be to identify persons who 

can fill that role.

Background: In this vignette, Mike’s son, 

Desmond, is 21 years old, and has been 

diagnosed with an FASD. Mike adopted 

Desmond when he was five years old. Since 

Desmond turned 16, and Mike’s wife left him 

(partly due to the difficulties of parenting 

Desmond), Mike has been Desmond’s sole 

caregiver. Lately, Mike has become increasingly distressed about his son and life in general, and has sought counseling from a mental 

health provider.

We are picking up this session after Mike has 

mentioned that Desmond is excitedly preparing to live on his own, with the move-in date 

just a month away. Mike is sure his son can’t 

handle all the responsibilities of independent 

living. He has tried to talk to Desmond about 

this, his son doesn’t seem to listen or agree. 

Mike is realizing that there is a lot he has not 

talked about with his son.
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Chapter 3: Clinical Vignettes

The counselor took time to gather a good deal 

of background information. Mike is here on 

his own in this visit, but the counselor has met 

Desmond. Desmond has intellectual abilities 

in what is called the borderline range (just 

below average). Like many individuals with an 

FASD, he acts like someone who is younger. 

In the first session, when the counselor asked 

Mike to estimate Desmond’s “acts-like” (i.e., 

functional) age, Mike said that Desmond 

still acts like someone who might be in 10th 

grade. As the counselor has gotten to know 

Desmond, this estimate seems accurate. 

The counselor has also carefully reviewed 

Desmond’s Medical Summary Report (from 

age 11) and his latest school testing (age 20, 

when he graduated from high school). She 

now better understands his unique learning 

profile.

Master Clinician Note: Clinical wisdom

in the field of FASD, and now some

scientifically validated treatments, hold that

knowing the unique cognitive/learning and

behavioral profile of the affected individual

is crucial to understanding the reasons

for their actions. This helps to reframe

caregiver understanding in light of the

individual’s brain-based disability.

Mike also told the counselor that Desmond 

was diagnosed with ADHD at age 8, which 

helped with an accommodations plan at 

school and a medication regimen. When 

Mike tried to transfer responsibility for taking the medication to Desmond 3 years ago, 

he couldn’t remember to take it on his own. 

When Mike and Desmond’s doctor realized 

Desmond showed no decline in function off 

the medications, they decided to stop the 

regimen. Without a clear benefit, and because 

Desmond could be pressured to give away his 

stimulants to peers, stopping the medication 

seemed wise.

Learning Objectives:

1. To show how to identify and validate 

caregiver concerns, and how to integrate 

common issues for individuals with 

FASD in safety planning.

2. To show that safety for a client with an 

FASD requires a plan that decreases risk, 

increases protective factors, and focuses 

on comprehensive life skills planning. 

3. To illustrate how to assist caregivers as 

they proactively develop strategies to 

ensure their child’s safety. 

4. To demonstrate that individuals with 

FASD need a plan that is practical, useful, 

developmentally appropriate, uses concrete language and visual aids, uses roleplay, and takes into account their unique 

cognitive/learning and behavioral profile. 

Vignette Start

[The dialogue starts with the counselor meeting with Mike in an individual counseling session. The 

counselor requested that Mike come in on his own for this session, but expects to meet with Mike 

and Desmond together in at least some future visits.]

COUNSELOR:	 What	are	your	greatest	concerns	about	Desmond	living	on	his	own?	

MIKE:	 Well,	I’ve	always	been	there	for	him,	and	I’m	really	concerned	that	he	could	

get	into	trouble	out	there	in	the	real	world.	He	has	a	lot	of	good	points,	and	I	

know	Desmond’s	tough.	We	got	through	it	when	his	mom	left	a	few	years	back.	

I	know	he	turned	21	and	he’s	feeling	independent,	but	I	know	that	he	can’t	be

totally	independent.	There’s	too	much	stuff	I	help	him	with,	all	the	time.	But	I	

do	need	some	time	of	my	own.	Some	days...well...there	are	those	days	that	
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

I’m zapped—done. The truth is: I’m at my wit’s end. I work my butt off. Besides

that, I don’t take vacations from being a parent. I’ve sacrificed. Don’t get me

wrong, I love him, but there are days.... Well, you know. I’m sorry, my head’s

somewhere else today.

COUNSELOR:	 I know how much stress parents of a young person with an FASD can be under,

and how much strength it takes to parent a child with a disability, especially

alone. Take all the time you need to explain what’s on your mind. Sounds like

there are many sides to this situation.

Master Clinician Note: Mike’s thoughts are somewhat discursive due to stress, and perhaps due

to grief about the challenges of his son’s upcoming life transition. Creating safety protection

for Desmond is an important way to help Mike, but the counselor should remain aware that

Mike also has his own needs. Research shows that caregivers have many unmet family needs,

often focusing on dealing with the emotional aspects of caregiving. The counselor is allowing

Mike to express all sides of the situation. This includes negative feelings, but the counselor is

also listening for signs of positive “expressed emotion,” deemed to be a protective factor. The

counselor is also thinking about how to promote caregiver self-care.

[Mike expresses his concerns for several more minutes. The counselor listens and normalizes, 

validates and reflects Mike’s emotions and thoughts, and also makes clarifying summary comments. 

Providing Mike with time to express his emotions and thoughts and to have his perspective heard 

allows the counselor to move ahead with more skills-based techniques. These include problemsolving, identifying social supports, identifying and clarifying treatment goals, and cognitive 

restructuring.]

COUNSELOR:	 Okay, thank you. I think I have a sense of your concerns, both for Desmond and

for your own situation.

MIKE:	 Yeah. I mean, this is one tough gig.

COUNSELOR:	 It is, and feeling “burned out” is natural. At the same time, if Desmond is going

to be on his own to some degree, as he moves into his life as a young adult,

that means a huge transition for both of you.

MIKE:	 That’s an understatement.

COUNSELOR:	 The good news is that I can provide you with some strategies to help you

cope, in the short-term and the long-term. The key here is that the definition

of independence and safety is different for a person with an FASD or other

developmental disabilities. I think it’s important that we start by identifying one

or more advocates or “champions” for Desmond. These can be professionals or

family members; people who are willing to help him—and help you—manage

various parts of his life. So, who can act as an advocate for Desmond? Who are

his supports?

MIKE: I can be an advocate, first and foremost. And so can my aunt. Desmond gets

along with her really well and sometimes she has him help at her law office

doing filing, that kind of stuff. Also, she is one of the few people he’ll talk to

when he gets upset or angry, and she’s good at calming him down. He also

helps out with the middle school football team, so Coach Gray looks out for

him, but they don’t see each other much in the off-season. But...I think he

would still be willing to help Des out. Yeah, I think they can help when I can’t.

And maybe Des can reconnect with his mom.
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Chapter 3: Clinical Vignettes

COUNSELOR:	 It sounds like Desmond has a number of advocates and supports, but that he

mayneed help with both identifying when he needs help and, then, how to best

communicate to get that help. I am so impressed and pleased that Desmond

is involved with your aunt and Coach Gray. That gives Desmond’s days and

weeks more structure and meaning and more opportunities to connect socially.

Everyone likes to feel useful! I bet there are more folks who can act as support

persons or advocates. We’ll try to figure out all those folks in our next session,

and what each support person can do. To help move us along, here is the first

page of a worksheet to do at home, to make a list of people you think of, their

contact info, and what kinds of things they can help with.

[Shows Mike the first part of the Crisis/Safety Plan Worksheet.]

Think about family friends, any providers that work with Desmond, people who

know him in his circles, like other people that help with the football team or

friends from the community, kids from his high school youth group, church,

anything like that. If possible, it is especially important to find someone in their

20’s—more Desmond’s age, who has good problem-solving skills, to be a kind

of “mentor.” Can you bring that back next time?

MIKE:	 [Nods, takes the first part of the Crisis/Safety Plan Worksheet.] I’ll try to get it

done. I don’t know about that mentor idea; can’t think of anyone right away.

But it does help to write things down. If I don’t have time for the worksheet...

well, you know.

COUNSELOR:	 Sounds good. This may be a chance to ask your aunt and Coach Gray for ideas,

too, as there may be someone that Desmond already knows that could be a

good mentor. In terms of the worksheet, I will leave that to you.

Master Clinician Note: Clinical wisdom, and now some new interventions for caregivers of

adolescents and young adults with FASD, such as the Partners for Success Program (information

available through the CDC-funded FASD Regional Training Centers), hold that mentors can

be very useful in intervention. Mentors can be community college students, aides who work

in developmental disabilities services, younger relatives or family friends, or students studying

to work in social services. A mentor is someone who can act as a very competent peer or

a caregiver closer in age to the affected individual. They can build an ongoing and positive

relationship, be available for check-ins to provide input and guidance on solving problems

with peer relationships and lifestyle problems, and work toward helping the affected individual

become more self-aware. They may also be able to connect the individual to pro-social and

competent peers, and help find appropriate, positive recreational activities for leisure time.

COUNSELOR:	 Okay, let me ask you: Have you worked much with developmental disability

services to help Desmond with life skills, how to live as independently?

MIKE:	 No, hardly at all. Desmond doesn’t qualify for those kinds of services because

of his FASD, and his ADHD diagnosis doesn’t help, either. He doesn’t have

really low scores on his IQ test. And, you know, even though he struggles

sometimes, he really tries to be friendly and sociable, and he talks a good

game. Sometimes I think his good points actually keep him from getting all the

help he needs.

COUNSELOR:	 It must be hard that others don’t always see that he struggles with a lot of

things. At that same time, it’s good to know that he has so many strengths.

Alright then, I think you and I will need to work together to identify the most
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

important things to think about as Desmond becomes as independent as he

can safely be.

MIKE:	 I think my biggest concern is that others will take advantage of Des. Especially

if he has a place of his own and people want to stay with him. He tends to do

things like steal to be someone’s friend, or fall in with wrong crowds, then it’s

always him that gets caught. I’m not going to be there to prevent that if he’s on

his own. I mean, Des is willing to accept help, and that’s good, but he may not

always realize he needs to ask, especially when he gets worked up.

COUNSELOR:	 I hear you. That sounds like a really big worry for you, so let’s talk about some

way to provide safety and structure for Des as he moves into having this new

freedom. This will be a safety plan, basically. We’ll have to find what works

and doesn’t work for him, and this will be an ongoing process. We can come

up with an initial plan, then when he gets into his own place, we can meet

together with Des a few times to modify the plan. We’ll kind of be testing it

out. Adjusting a plan is always a good idea.

MIKE:	 I’ve done a lot on my own, talking with Des about what is an appropriate

situation and what’s not. Appropriate money use. Appropriate touching. This

has been all from me. No doctor or therapist helped me out. I should write a

book on it. At least I got through to him about drinking, because he just tells

people he’s allergic, and so far, so good. But now...well, that’s another worry.

Master Clinician Note: For parents of individuals with developmental disabilities, it is very

helpful to be proactive. At the same time, “looking forward” is an emotional process. The

clinician will have to judge how far ahead the caregiver really wants (and needs) to plan. The

clinician also needs to use reflective listening and summary statements to help the caregiver

process their own emotional reactions as they do future planning. Beyond this, the clinician

can help caregivers plan ahead in a practical way. Because Desmond is a young adult (though

functionally an adolescent), and is starting to build an independent life, the clinician can coach

Mike on how to help Desmond self-advocate and self-monitor.

One important direction is to coach Mike in creating concrete, behavioral “benchmarks” for his

son, so Desmond can show daily or weekly progress and also show his father that he is ready

for this life transition. This could include practicing things such as buying groceries as if he were

already living on his own, and/or troubleshooting, such as thinking out loud about what to do

in real-life situations—e.g., if he gets sick, the toilet starts overflowing, etc. If Desmond resists

doing this (which would not be unlikely given his functional age), the counselor can work with

father and son to integrate rewards for Desmond after he shows certain behaviors or masters

specified tasks. An age-appropriate reward for someone functioning at an adolescent level

could be more ‘space,’ i.e., increased time between check-ins from his father after Desmond

demonstrates mastery.

Mike has educated his son carefully about drinking, which is good, but he should think

about other areas he needs to talk about with Desmond, as well, including 1) safe sex; 2)

communicating clearly with partners about consensual activity; 3) use of cigarettes; 4) use of illicit

substances, such as marijuana and other drugs; 5) the consequences of criminal activity; and 6)

ideas on what to safely do when Desmond has times of feeling irritable and negative (calming

strategies).

COUNSELOR:	 I’m glad you already laid the groundwork! For now, let’s write down some of

the ideas you already figured out. We’ll make cards. Two kinds, actually. First,
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Chapter 3: Clinical Vignettes

when Des comes in we can make an identity card that says “I have an FASD”

for Desmond to give to caregivers, police, co-workers, etc. Then we can make

Safety Cards that he can use as reminders in his new routine. The Safety Cards

can be one thing to talk to Desmond about when he comes with you to see

me. We will also plan to talk about specific behavior benchmarks or things

you want to see him doing before he moves out. We can talk to Des about

how having him do this will let you be more comfortable giving him space and

independence. [The counselor and Mike work together to identify areas of 

safety concern for Desmond.]

Master Clinician Note: Choice and level of language used on Safety Cards will differ depending

on the intellectual level of the individual with an FASD. Areas of safety concern may include:

•	Household reminders (buying groceries, paying bills, cleaning the apartment, taking out the

trash, maintaining personal cleanliness, etc.)

•	Useful phone numbers (advocates, police, hospital, primary providers, etc.)

•	Transportation (routes, times, and costs)

•	Work and school schedules

•	Personal and household safety reminders (turning off appliances, locking doors and windows,

etc.)

•	High-risk behavior warnings (e.g., unsafe sex, alcohol or drug use, getting really irritable and

upset)

There are programs for caregivers raising affected youth that have other useful ideas for ways to

plan ahead (e.g., the Families Moving Forward Program and Partners for Success Program).

COUNSELOR:	 What else could help you with keeping Desmond safe?

MIKE:	 Well, I think, as long as he applies these things we’re writing down for him and

I check in on him regularly, things may go okay. For awhile, anyway. Then I just

need to get organized with my aunt and Coach, so they’re helping to keep an

eye on him. Like I said, he’s pretty good about accepting help and listening to

us when we give him advice. That’s one of the most important things I taught

him—accepting help. But he really has trouble asking for help, or watching for

signals that he’s getting into trouble.

Master Clinician Note: Research on FASD and, more generally, on developmental disabilities

has uncovered important protective factors. Many of these are well-known, such as positive

family and peer relationships, appropriate social services and freedom from substance abuse by

the individual, peers, or family members. Other protective factors may be less obvious but are

no less important. For the caregiver, these include decreased stress and depression, a sense of

parenting efficacy, positive expressed emotion and a viewpoint on the affected individual, and

adequate caregiver support and self-care. For the affected individual, these include a willingness

to ask for (and value) help from others, positive, time-filling extracurricular activities, adequate

and refreshing sleep, connections to pro-social and competent peers, a positive self-perception,

a sense of meaningfulness through activities such as a job, talents that others recognize and

value, spirituality, and more.

COUNSELOR:	 Will Des be working?

MIKE:	 He’s going to continue as an assistant with the football team as a volunteer.

And he can keep helping my aunt. When he gets done with his training, we

think he’ll be able to do inventory and stocking at the grocery store.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

COUNSELOR:	 Okay. Let’s start figuring out how all this is going to work. So, I think it may

make sense for you to manage Des’s budget, at first anyway, by doing his

shopping and grocery list-making until new routines are established.

MIKE:	 Yeah, I expected that. I’m gonna be checking in on him every day for as long as

I need to, then less often if I’m sure he’s doing okay. I made sure the apartment

isn’t far away, even though we have to pay a bit more. He isn’t showing a real

interest or understanding of all the little things required to live on your own;

budgeting, or don’t buy all your groceries at the gas station just because that’s

where you get gas, stuff like that. He can use my car if he asks permission, and

tells me where he’s going and when he’ll be back. Mostly, he’s going to be

taking the bus. I can’t imagine him knowing how to take care of his own car,

even though he’s a pretty good driver.

COUNSELOR:	 Clearly, you’ve already thought a lot of things through! Okay, so, why don’t you

bring Des next time? That will give me a chance to see if I think he needs the

support of his own mental health counselor. With his ADHD, and times he gets

irritated, that might be a good idea down the road. He has lots of supports, but

we should think about this angle, too.

MIKE:	 That sounds like a plan. I appreciate your help, Doc. I feel like the load is a little

lighter.

COUNSELOR:	 I’m glad. Remember—if you bring that worksheet back next time we can move

forward more quickly with our plan.

Master Clinician Note: This session shows what it is like to work with the caregiver of someone

with FASD. A possible future session could include Desmond’s aunt and the coach, to create

advocacy or “look-out” tasks they could all divide up to help Desmond stay organized while

Desmond first starts living on his own. In sessions that include Desmond, the clinician will need

to change pace and style. Specific ideas that would help Desmond, and can be used with most

other affected individuals:

•	Work with the affected individual to identify his or her goals, including how to generate an

effective goal, “mini-steps” to achieve the goal, and needed supports.

•	Discuss warning signs that they need help.

•	Discuss and practice through role-play how to ask for help.

•	Create a written Crisis/Safety Plan.

This vignette would play out differently depending on the culture and ethnicity of the caregiver

and youth. Research shows there are different expectations for independence and type of family

relationships in different cultures. This interacts with the impact of developmental disabilities.

In some cultures, for instance, adult children are not expected to move out of the family home,

though they will still increasingly assume more leadership and adult responsibilities within the

family. In cultures where the extended family tends to be closer, affected individuals may have

more resources and support from relatives, or a greater likelihood of available peer models to

serve as caregivers or mentors. Research also shows that some protective factors may differ by

culture: Attachment to and identification with the values of one’s culture of origin is a protective

factor for immigrant youth. Yet this can also be a risk: Data suggest that these youths may also

be at higher risk for marginalization and discrimination. Recommending involvement in culturally

relevant and pro-social leisure time activities can be a productive way for an individual with an

FASD to learn about their own culture.
89

Chapter 3: Clinical Vignettes

10. WORKING WITH 

A BIRTH MOTHER TO 

DEVELOP STRATEGIES FOR 

COMMUNICATING WITH 

A SCHOOL ABOUT AN 

INDIVIDUALIZED EDUCATION 

PLAN FOR HER DAUGHTER 

WHO HAS AN FASD (FASD 

INTERVENTION)

Overview: This vignette illustrates how a 

social worker can make useful suggestions for 

a parent or caregiver’s first meeting with educators at the beginning a new school year.

Background: The start of the school year is 

2 weeks away. Denise is a birth mother who 

is meeting with a social worker to get some 

advice on how to educate the school staff 

about working with her daughter, Elise, who is 

11. Elise has recently been identified as having an FASD, although she has been tested as 

having a “normal” IQ and is in a mainstream 

learning setting. This social worker was part 

of the diagnostic team that assessed Elise 

for FASD, but this is her first time helping 

with Elise’s school issues. Denise is hoping to 

develop learning strategies that she can discuss with the school staff in an Individualized 

Education Plan (IEP) meeting.

Learning Objectives:

1. To describe typical challenges that children with an FASD may face in the 

classroom.

2. To demonstrate how collaboration and 

creativity can lead to accommodations 

that result in improved outcomes for a 

child with an FASD.

Vignette Start

DENISE: Now that we’re gearing up for a new school year, with a new teacher who

is also new to the school, I need some tips on talking to her. I want to

avoid last year’s fiasco with the parent aide who complained that Elise was

disrespectful and “the worst.”

SOCIAL WORKER:	 This will be 6th grade for Elise this year, correct?

DENISE:	 Correct.

SOCIAL WORKER:	 And what happened last year?

DENISE:	 The parent aide was a nightmare from the get-go. I had heard it all before:

“Your kid won’t listen” or “Your kid isn’t motivated” or “Your kid never does

her homework.” I knew this aide was gonna be a problem, but I couldn’t be

in the classroom because I was working full-time. Poor Elise got in trouble

day after day for the same stuff; homework not completed, late to class,

missing class, getting in fights. Honestly, I think the parent aide did not get

any insight into FASD from the teacher at all.

SOCIAL WORKER:	 That’s unfortunate, but not uncommon, as you know. Educators will

sometimes relate differently to a birth mother than they do to adoptive or

foster parents. We’ve talked about those issues before, and it is something

that may come up again.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Master Clinician Note: Whether intentional or not, the birth mother of a child with an FASD can

be perceived negatively by others, including educators, for having “caused” her child’s disorder.

The social worker is gently preparing Denise for this possibility and reinforcing the positive

nature of how she advocates for her child.

DENISE:	 I know. I’ve been there.

SOCIAL WORKER:	 Well, it’s important to remember that you’re a fantastic mom, dealing with

issues that not many people would have the courage to handle. You’re open

and willing to learn, to educate yourself about what will work best for Elise,

and she is successful because of all the love and support you give her.

DENISE:	 Thank you, I appreciate that. When I set up the meeting, do you think you

can attend with me?

Master Clinician Note: If the social worker cannot attend an IEP meeting with the client, they

should still encourage them to have a support person with them, if at all possible; someone else

who is familiar with the caregiving situation.

SOCIAL WORKER:	 I won’t be able to attend with you, unfortunately, but I absolutely suggest

that you bring someone with you to all meetings. I recall that your sister-inlaw has helped out a lot. Is she available, or a good friend?

DENISE:	 My sister-in-law is the best, yeah. She’d be a great support. She knows the

questions to ask.

SOCIAL WORKER:	 Great. We’ll come up with the suggestions and strategies, and you and Elise

and your sister-in-law can talk and jot down any additional key issues that

you think of. Definitely include Elise. It’s her education, after all. Will she be

part of the meeting with the school?

DENISE:	 We weren’t planning to include her in the actual meeting, no. She wasn’t in

it last year. We do talk to her about the issues, though.

SOCIAL WORKER:	 Well, she’s at an age now where it might be worthwhile to consider including

her. She’s in middle school now, and at this age it might be beneficial to

her to see how caring people are planning her supports. Plus, it teaches

her to self-advocate, and she can offer specific information and suggestions

about problems she’s having, or environmental issue that are bothering her;

lighting, noise, etc.

DENISE:	 Okay, we’ll talk to her about joining us.

SOCIAL WORKER:	 Great. And you’re meeting with her teacher only? Are there any volunteers

in the class this year?

DENISE:	 I’m not sure.

SOCIAL WORKER:	 You might wanna ask. If there are volunteers, it would be great if they can

attend, as well.

DENISE:	 Okay.
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Chapter 3: Clinical Vignettes

SOCIAL WORKER:	 And be sure to allow enough time in the meeting to discuss concrete

solutions. Accommodations can take a lot of time to work out. It shouldn’t

be left to the end of the session.

DENISE:	 I’ll try to address them right up front. What suggestions do you have?

SOCIAL WORKER:	 I have a couple suggestions for the meeting itself, and then some examples

of free, simple accommodations that can improve Elise’s school experience.

These go beyond the stuff on a standard IEP form. You did a plan last year,

correct?

DENISE:	 Yes, we did.

SOCIAL WORKER:	 And she’ll be in the same school?

DENISE:	 Yes.

SOCIAL WORKER:	 Okay, good. So there’s already a record with the school of an

accommodation history.

DENISE:	 Right. And it really is just frustrating to have to do this every year. I’m always

surprised that one teacher can be great and the next is like a blank slate.

SOCIAL WORKER:	 I find that, as well. Many families have to start over every year with

the school, transferring information, as school personnel changes each

September. At the same time, the child is growing and changing, too.

Elise is growing older, and what worked for her last year might need to be

revised this year. Also, the accommodations in last year’s plan might not

have been implemented, at least not fully. Elise can speak to that if she’s in

the meeting. So, let’s go through a few simple things that I’ve found have

worked for other clients and their children.

Master Clinician Note: Denise is clearly frustrated with the educational process, and this is

understandable. At the same time, the social worker is tempering this frustration and laying the

groundwork for a more successful IEP meeting by helping Denise remember the reasons why

annual meetings are worthwhile even if difficult. For the meeting itself, the counselor makes the

following suggestions:

•	To spotlight the child’s aptitudes and hobbies, bring pictures of the child enjoying these

activities and/or examples of things they’ve done or created (e.g., artwork, crafts).

•	Parent should be encouraged to “catch more flies with honey than with vinegar.” The parent’s

frustration with the system as a whole should not be targeted at the individuals on the other

side of the table.

•	Parent should approach the meeting with a mindset of using statements such as “My child

needs...” rather than “I want my child to...” The federal law is for educators to meet the child’s

needs, not the parent’s wishes.

DENISE:	 I like those ideas, thanks. What accommodations were you thinking of?

Master Clinician Note:

•	Example 1: Federal law limits schools in terms of sanctioning children who act out as a result of

a disabling condition, such as an FASD. If the child is acting out, a Behavioral Modification Plan

should be considered instead.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

SOCIAL WORKER:	 This first example is really important because I see so many kids with FASD

who get into trouble when they’re revved up. As a parent, you probably

see this often with Elise, and you know her triggers, but educators won’t. I

worked with a middle-school-aged child, a boy, and his caregiver. The boy

was acting out, hitting the bus driver. The school threatened to get the

police involved, and the boy was kicked off the bus. I suggested that he be

given time at end of each day to relax. It turned out that one of his favorite

places was the library, because he could listen to music, so he ended up

being able to use last period to go there and sit with headphones on, and

we arranged with the librarian to keep an eye on him and monitor the time

for him. We called it his “chill zone.” After that, he was always cool for the

bus ride home.

DENISE:	 I like that. Elise gets antsy very easily, especially with headphones on, but

she’ll sit still to read and draw. The library might work.

Master Clinician Note:

•	Example 2: Watch for cases when bad behavior is a result of modeling other children with

behavioral issues.

SOCIAL WORKER:	 Another student I worked with, a girl, was getting out of control during

the day. She sat in the front row of her classroom, but the teachers and

classroom volunteers still reported that even on a good day she was fidgety,

and on bad ones she was practically climbing the walls. I explained that

sitting in the front row typically helps children focus, but a child with an

FASD can also get distracted by kids nearby. In the girl’s class, the rest of the

kids in the front row were working on behavioral issues, including ADHD. In

this case, the girl was modeling the behavior of these classmates in an effort

to make friends. I suggested we move the girl next to a model student who

could maybe be her buddy or mentor, and that worked well.

DENISE:	 That could prove useful, as well. Elise does tend to model other children’s

behavior.

Master Clinician Note:

•	Example 3: Work with the educational staff to think “outside the box” when it comes to

accommodations.

SOCIAL WORKER:	 Educators are generally working from a menu of options when it comes to

accommodations; such-and-such is suggested based on what the child’s

condition is. Now, this menu is fairly long, as you know, but it’s still an

Individualized Education Plan. It should still be geared to Elise’s specific

needs. Don’t be afraid to suggest ideas that you’ve found work for her, even

if they aren’t “on the form.” Think about what you’ve done with her in other

environments, like at church or in other social activities.

DENISE:	 Okay. Thanks for your suggestions.

SOCIAL WORKER:	 You’re welcome. Please call me after the meeting and let me know how it

goes.

DENISE:	 I will, thank you.

Refer to Part 1, Chapter 2 for additional guidance on educational accommodations for 

individuals with an FASD who are still in school.
93

Part 2: Administrator’s Guide to 

Implementing FASD Prevention 

and Intervention

Introduction

This Treatment Improvement Protocol (TIP) 

is designed to assist not only substance abuse 

treatment and mental health counselors in 

providing FASD-informed services, but also 

the clinical supervisors and administrators 

who support the work of these professionals. The need for a TIP that addresses FASD 

prevention and intervention for these settings 

is clear:

•	 Individuals with an FASD experience 

higher rates of substance abuse and mental health issues than the general population (Streissguth et al., 1996; Streissguth 

& O’Malley, 2000; Astley, 2010). In 

addition, individuals with an FASD 

exhibit higher rates of life problems commonly encountered in substance abuse 

and mental health treatment populations, 

including higher risk of suicide (Huggins 

et al., 2008), exposure to multiple traumas 

throughout the lifespan (Henry, Sloane, 

& Black-Pond, 2007; Greenbaum et al., 

2009), homelessness (Fryer, McGee, Matt, 

Riley, & Mattson, 2007), and increased 

interaction with the criminal justice system (Streissguth et al., 1996).

•	 According to the 2009 National Survey 

on Drug Use and Health (NSDUH), 17.1 

percent of women age 18 or over in the 

U.S. received mental health treatment 

or counseling in 2009, compared to 

only 9.2 of men in the same age group 

(Center for Behavioral Health Statistics 

and Quality [CBHSQ], 2010), while 

the Treatment Episode Data Set (TEDS) 

indicates that 33.0 percent of admissions 

to substance abuse treatment facilities 

in 2011 were female, more than half of 

whom (50.5 percent) indicated alcohol as 

a primary, secondary, or tertiary substance 

of abuse (CBHSQ, 2013). In addition, 

an in-depth study of 80 birth mothers 

of children with FAS revealed that 97 

percent had from 1 to 9 mental disorders, 

and the subset that successfully achieved 

abstinence was significantly more likely to 

have received treatment for their mental 

disorders than the subset who did not 

achieve abstinence (Astley et al., 2000b).

Thus, these settings are 1) likely to see a high 

prevalence of individuals with an FASD (and/

or their parents/caregivers), and 2) provide an 

ideal environment for conducting interventions with women of childbearing age to prevent additional incidences of FASD.

The methods and techniques presented in this 

TIP are appropriate for clients in all stages 

of recovery and treatment. However, this TIP 

is not meant to create a ‘one-stop shop’ for 

FASD-informed services. An FASD is not a 

simple category that can be addressed with 

a simple, categorical response; the disorders 

in this spectrum cannot be cured, and clients 
94

Addressing Fetal Alcohol Spectrum Disorders (FASD)

with an FASD need specialized treatment 

from a variety of healthcare professionals to 

function at their maximum potential. At the 

same time, when treating a substance abuse or 

mental health issue with a client, the counselors’ role is to:

1. Be able to recognize when a client is 

exhibiting a co-occurring issue (such as 

an FASD) that can impede treatment 

success;

2. Address how the physical, cognitive, and 

behavioral manifestations of that issue 

interact with treatment; and

3. Develop a collaborative treatment relationship with the other healthcare and 

social service professionals who do—or 

potentially can—provide assistance to the 

client to maximize that person’s potential 

for success, both in and outside treatment.

Like any other co-occurring issue in treatment—trauma, homelessness, etc.—addressing 

FASD is a fundamental step toward helping 

the whole person and ensuring that he or she 

does not encounter treatment barriers.

Note: This Implementation Guide follows two 

tracks; FASD prevention, and FASD intervention. This is because this TIP promotes 

1) the screening of all women of childbearing 

age (whether pregnant or not) in all behavioral health settings for alcohol consumption, 

to help prevent future incidences of FASD 

[FASD prevention], and 2) the development of staff skills in recognizing individuals 

who have or may have an FASD, to be able 

to more effectively tailor treatment to their 

needs [FASD intervention]. In Part 1 of this 

TIP, these topics are treated separately. In the 

Implementation Guide, they are discussed 

together, since they each represent organizational change and the core processes involved 

in making such changes within a program 

overlap significantly.
95

1 The Administrative 

Response to FASD 

in Behavioral Health 

IN THIS CHAPTER Settings 

•	Why SAMHSA Created 

an Implementation 

Guide as Part of This TIP 

• Why Address FASD 

Prevention and 

Intervention?

•	Thinking About 

Organizational Change

•	The Role of the 

Administrator in 

Introducing and 

Supporting New Clinical 

Practices

Why SAMHSA Created an Implementation 

Guide as Part of This TIP 

Part 1 of Addressing Fetal Alcohol Spectrum Disorders (FASD)

provides the tools your clinicians need to begin addressing 

FASD prevention and intervention with clients. However, an 

extensive literature review suggests that without specific attention to implementation issues, these tools are likely to go unused 

or to be used ineffectively (Fixsen, Naoom, Blase, Friedman, & 

Wallace, 2005). This Implementation Guide will help you ensure 

that the ideas in Part 1 are put into practice in your program or 

agency in a way that creates value, both for your agency and your 

clients. Implementation will require the active support of executive administration and the expertise of clinical supervisors.

Much of the guidance provided in this Implementation Guide 

will be familiar to readers of TIP 48, Managing Depressive 

Symptoms in Substance Abuse Clients During Early Recovery

(Center for Substance Abuse Treatment [CSAT], 2008). TIP 

48 provides a useful framework for approaching organizational 

change, and a significant portion of that framework is reiterated 

here, but with some important modifications and “tweaks” that 

are essential to providing FASD-informed services. Another 

useful resource is SAMHSA’s Technical Assistance Publication 

(TAP) 31, Implementing Change in Substance Abuse Treatment 

Programs (CSAT, 2009).

Why Address FASD Prevention and 

Intervention? 

The value of screening women of childbearing age in behavioral health settings is clear-cut. For any woman who is or may 
96

Addressing Fetal Alcohol Spectrum Disorders (FASD)

become pregnant, protecting the health of that 

pregnancy (or potential pregnancy) is a fundamental health issue for the woman herself. 

Added to this, alcohol consumption questions 

are built into most forms of health screening, 

making exploration of this issue a professional 

commitment. If pregnant women are part of 

your client base, ignoring this issue means not 

fully serving the client.

The case for providing services tailored to 

individuals who have or may have an FASD 

may not be as simple, but is equally compelling. The historical perception that an FASD 

represents permanent brain damage, and thus 

these people cannot be helped in a mental 

health or substance abuse treatment setting 

is only half true: Yes, an FASD does represent 

permanent brain damage; no, it does not mean 

that these people cannot be helped, any more 

than being homeless or involved with the 

criminal justice system means an individual 

cannot be helped in these settings. 

An FASD is a co-occurring disorder, and 

needs to be approached from that perspective. 

Families are seeking this expertise, even if they 

don’t yet know to call it ‘FASD,’ and clients in 

need of FASD-informed services will continue 

to appear in your settings. There is an active 

movement in the mental health field toward 

a recovery focus and a strengths-based focus, 

toward meeting clients “where they are.” This 

movement is growing in the substance abuse 

treatment field, as well, as are the traumainformed and family-centered care movements. An individual who has or may have an 

FASD fits perfectly into any of these paradigms. Individuals with an FASD do want to 

recover, whether in substance abuse or mental 

health treatment; they do have strengths; they 

do experience trauma (at higher rates than the 

general population); they do have families; and, 

as with any other client, they are capable of 

responding positively when treatment is tailored to their unique needs.

The Effects of FASD on Recovery 

At the same time, it cannot be ignored that 

clients with an FASD are likely to experience 

challenges to successful treatment above and 

beyond those experienced by clients who do 

not have one of these disorders. The client 

with an FASD may have difficulty in any or 

all of the following areas: 

•	 Remembering program rules or following 

multiple instructions. 

•	 Remembering and keeping appointments. 

•	 Making appropriate decisions by themselves about treatment needs and goals. 

•	 Appropriately interpreting social cues 

from treatment professionals or other 

clients. 

•	 Attending (and not disrupting) group 

activities. 

•	 For those accessing substance abuse 

treatment, staying substance-free after 

treatment.

•	 Interpreting or understanding complex 

meanings of language or information.

The combination of some or all of these factors may lead a counselor to assume that an 

individual with an FASD is resistant to treatment (and this assumption is often made). It 

is essential that staff be able to discriminate 

between a symptom of an FASD and actual 

treatment resistance. Clients with an FASD 

may fully intend to be compliant with treatment and want to do well in recovery, but lack 

the skills and understanding from the provider 

to help them meet their unique challenges 

while participating in a recovery program.

The Benefits to Your Program of Addressing 

FASD Prevention and Intervention

A growing body of evidence is demonstrating that interventions with individuals with 

an FASD can be effective, that this population can and does succeed in treatment when 

approaches are properly modified, and that 
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Chapter 1: The Administrative Response to FASD in Behavioral Health Settings 

these modifications can lead to reduced 

stress on family/caregivers as well as providers (Bertrand, 2009). Moreover, in a study of 

1,400 patients with prenatal alcohol exposure, 

Astley (2010) found that 9.3 percent presented with no central nervous system (CNS) 

dysfunction, despite alcohol exposure levels 

as high as the 10 percent that did receive a 

diagnosis of FAS. The one factor that significantly differentiated the children with no 

CNS dysfunction (no evidence of learning or 

behavior problems) from those with full FAS 

was a stable, nurturing home environment 

with intervention services.

Addressing FASD also has the potential to 

enhance the treatment experience for both 

the individual with an FASD and those 

around him or her, increase retention, lead to 

improved outcomes, reduce the probability of 

relapse, increase engagement rates in aftercare 

services (alternately referred to as recovery 

support services), and reduce overall societal 

costs. In addition to the benefits for the client, 

addressing FASD as part of your program can 

potentially lead to increased clinical competence of your staff, an increase in appropriate 

referrals, increased staff retention, higher levels 

of staff satisfaction, reduced risk of burnout, 

and reduced turnover.

Addressing co-occurring disorders is also a 

key priority for the federal government, state 

governments, insurance companies, credentialing boards, and accrediting organizations. 

By starting now to address FASD, you will 

be better positioned to compete in the future 

treatment marketplace. Ideally, your agency 

can become part of the larger community 

of research practitioners who seek the best 

ways to help clients more quickly experience 

a higher quality of recovery. By joining with 

other agencies in your network, you can coordinate treatment practices and perhaps collaboratively obtain research grants. Many effective treatment practices in both the substance 

abuse and mental health fields, as in the field 

of approaches to FASD, are not yet validated 

through research because agencies do not fully 

realize the value to the greater treatment community of their unique approaches. However, 

the body of research around FASD is growing 

rapidly, and addressing FASD now positions 

your agency at the front end of an emerging 

skill area.

Most importantly, addressing FASD provides 

another possible route to success with a client. 

Individuals with an FASD are a largely hidden 

population, yet one that is at an increased risk 

of presenting in your treatment setting. For 

every client that did not return for additional 

appointments, or seemed noncompliant or 

resistant with no clear explanation of why, 

or just didn’t seem to ‘get it,’ a knowledge of 

FASD on the part of your staff can be the 

one additional clue that solves that puzzle 

and enables success for both the client and 

the program.

Thinking About Organizational 

Change 

If you have decided to implement some or 

all of the recommendations in Addressing 

Fetal Alcohol Spectrum Disorders (FASD), Part 

1, you, your staff, your clients, and the other 

agencies and organizations with which you 

interact may require the development of new 

treatment protocols and policies, as well as 

new clinical knowledge, attitudes, and skills. 

These changes can be rewarding and/or frustrating. Any change in services or approaches 

to clients will call for a significant change in 

organizational culture, but will be beneficial to 

client well-being in the long run.

The box “Key Elements of Assessment and 

Planning” summarizes the key elements of 

organizational assessment and planning for 

change, topics that are discussed in greater 

detail in Chapter 2 of this Guide.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Key Elements of Assessment and Planning

The following five areas are critical to organizational assessment and change planning.

•	

•	

•	

•	

•	

An excellent resource for organizational assessment for change is the Program Change Model discussed by Lehman, Greener, 

& Simpson (2002; http://forces4quality.org/sites/default/files/Tool2.1Lehman_Assessing_Agency_Readiness_for_change.

pdf), and its accompanying survey, Organizational Readiness for Change (http://www.ibr.tcu.edu/pubs/datacoll/Forms/orc-s.

pdf). Their model addresses strategies and tools for assessing institutional and personal readiness and outlines the stages of 

the transfer process.
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Chapter 1: The Administrative Response to FASD in Behavioral Health Settings 

Ultimately, the application of these elements may suggest that the best decision 

is to delay attempting a change and focus 

instead on organizational climate and readiness. Introducing organizational change before 

the groundwork has been laid—much like 

introducing change to a client when they are 

not at the right stage of readiness—can hinder 

later change opportunities. However, if you 

decide to move forward with a change plan, 

the box “Key Principles of Implementation” 

provides information on implementation.

Key Principles of Implementation

Principles for implementing the change plan are directly analogous to principles of treatment 

and recovery in that both are achieved in steps, making it a process rather than an outcome. The 

following principles of managing change are directly adapted from principles of care that are 

relevant to providing effective FASD-informed services.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

The Challenges of Implementation 

Any approach to organizational change should 

assume that resistance may challenge the 

process. Specific to FASD, some of the usual 

forms of staff resistance you may encounter 

are included below, along with suggested 

responses that may help staff members to see 

the change process in a more positive light.

It is also useful to remember that resistance 

can be valuable to a change effort, as it often 

springs from legitimate needs and/or concerns. 

By rolling with resistance, you can identify 

aspects of your change plan that warrant revisiting or revising.

At the same time, failure to implement new 

clinical practices often has little to do with 

resistance to change on the part of staff. 

Addressing resistance directly will 

lessen the likelihood that opposition 

will spread and influence others.

- ATTC Change Book, 2nd Edition, 

 p. 27

Failure to implement can be a result of issues 

such as inadequate modeling from administration, lack of follow-through, inadequate 

training, and many others. Even the best 
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Chapter 1: The Administrative Response to FASD in Behavioral Health Settings 

counselors and administrators are highly constrained by the contexts in which they work. 

Accordingly, implementation success requires 

administrators to 1) be proactive in making 

the new practice fit the context, and 2) create 

an organizational climate that encourages and 

supports implementation. 

These two tasks are intertwining: Fitting new 

practices to your context requires a thorough 

review of your agency’s current operations. 

Such self-examination, in turn, helps create 

an organizational climate of openness to new 

ideas and experimentation. Before implementation begins, it is important to create positive 

expectations among staff. Investing the time to 

educate staff, express support for the specific 

implementations, and explore potential barriers and concerns with staff can go a long way 

toward creating an environment of operational 

transparency and ensuring staff acceptance of 

change, especially in the early stages. 

Often, the executive staff faces more immediate resistance or ambivalence because the 

initial groundwork was not done. Moreover, 

administrators have likely considered the 

change ideas for some time and expect staff to 

be at a similar level of enthusiasm and commitment to the proposal. Change is easier to 

make when those involved: 

•	 Understand why the change is needed 

and the benefits they will realize;

•	 See how the new ways will integrate into 

and honor what has been done previously; 

and 

•	 Are given motivation strategies for 

providing ideas and offers of assistance in 

implementation. 

Maximizing the Fit 

For a clinical innovation to take hold, it must 

fit with: 

(1) Key characteristics of your target 

population and community (e.g., values, 

expectations);

(2) The skills, licensures, certifications, and 

team structures of your staff;

(3) Your program or agency’s facilities and 

resources;

(4) Your policies and practices;

(5) Local, state, and federal regulations;

(6) Available interagency networks (e.g., 

needed outside resources, memoranda of 

understanding); and

(7) Your reimbursement procedures.

Certain kinds of mismatches will impede 

change. For example, no one would expect 

successful implementation of an innovation when staff lacks the skills to perform it. 

However, something as seemingly trivial as a 

lack of appropriate space or needed audiovisual equipment can also stall an innovation. As 

with many endeavors, the details are critical. 

It is likely that adjustments will be needed 

both in your agency or program’s context 

and in the ways that the recommendations 

presented in Part 1 are implemented. Part 2, 

Chapter 2 of this TIP provides procedures, 

checklists, and other tools for assessing the 

fit between the recommendations provided in 

Part 1 and your program or agency’s current 

context, procedures, and so on. Useful though 

these materials are, your ultimate success in 

“maximizing the fit” will depend on creativity, 

problem-solving skills, and determination and 

patience in applying them. 

The Stages of Organizational Change

Change in a program, just like change for a 

client, occurs in stages. In the early stages of 

implementing the recommendations in Part 1, 

organizations will profit from a climate that 

promotes: 

•	 A willingness to take risks and try unconventional approaches;

•	 A willingness to tolerate some ambiguity as the fit between new practices and 

context evolves;
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

•	 An	ability	to	recognize	false	starts	and	to	

abandon	approaches	that	are	not	working;

•	 Transparency	and	inclusion	when	pursuing	change;	and

•	 Appreciation	and	reward	for	ideas	and	

implementation.

As	noted	earlier,	the	later	stages	of	implementation	will	be	facilitated	by:	

•	 A	commitment	to	continuous	quality	

improvement;	

• The	development	of	structures	that	

support	and	reinforce	the	change	(e.g.,	

standardized	training	for	new	staff,	and	

continuing	education	and	supervision	for	

all	staff );	

• Expressions	of	organizational	pride	in	

accomplishment;	and	

•	 Institutionalization (in which new practices become everyday practices).

The Role of the Administrator in 

Introducing and Supporting New 

Clinical Practices 

Chapter 2 of this Implementation Guide

presents the tasks you will need to accomplish

to implement the changes elaborated in Part

1. Important as these tasks are, successful

implementation will ultimately depend on

the leadership you provide as they are carried

out. The box,“Key Elements of Leadership,”

provides a summary and leads directly into the

more detailed discussions of Chapter 2 of this

Implementation Guide.

Key Elements of Leadership
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Chapter 1: The Administrative Response to FASD in Behavioral Health Settings 

105

2 Building an FASD 

Prevention- and 

Intervention-Capable 

IN THIS CHAPTER Agency • Introduction

•	Assessment and 

Planning Before 

Implementation

• Addressing Policies and 

Procedures

• Addressing Relevant 

Regulations

• Addressing Staff 

Competence

•	Staff Qualifications and 

Competencies

•	Addressing Gaps in 

Staff Capacity to Deliver 

Services

• Approaches to Staff 

Training

• Addressing Community 

Relationships

• Addressing Financial 

Considerations

• Addressing Continuity 

and Fidelity

Introduction 

The resources presented in this chapter have been organized 

into those related to organizational assessment and those related 

to planning and implementing organizational change. The 

change process in your agency or program will require creative 

and thoughtful adaptation and application of these resources to 

your specific circumstances. They should be viewed as points of 

departure only. You should revise or otherwise modify the materials as needed for your organization. 

You may also wish to consult with colleagues who have managed organizational change in organizations similar to yours. At 

this point in the development of implementation strategies for 

human services, many excellent ideas are still to be found outside 

the published literature. Your colleagues may have insights or 

ideas that are equal to or more applicable than those presented in 

this Implementation Guide.

The Change Book, produced by the Addiction Technology

Transfer Center (ATTC) Network, provides the basis for the

organizational change process presented in TIP 48 and in this TIP.

The page numbers referenced in this chapter refer to the Second

Edition, 2010, which can be downloaded for free from the ATTC

Network (www.attcnetwork.org) in English or Spanish (http://

www.attcnetwork.org/explore/priorityareas/techtrans/tools/

changebook.asp).

Additionally, you may wish to consult Implementation Research: 

A Synthesis of the Literature (Fixsen et al., 2005; http://cfs.cbcs.

usf.edu/_docs/publications/NIRN_Monograph_Full.pdf). This

monograph provides a valuable summary of the scientific basis

for various implementation practices.

Another resource is SAMHSA’s TAP 31, Implementing Change in 

Substance Abuse Treatment Programs (CSAT, 2009). 
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Assessment and Planning Before 

Implementation 

How Do You Decide Whether to Implement a 

Policy for Addressing FASD? 

To determine whether it makes sense for your 

agency to implement the recommendations 

made in Part 1 of this TIP, refer to Figure 2.1.

How Do You Identify the Issue or Need? 

The How-To components on the following 

pages provide ways to operationalize the steps 

presented in Figure 2.1. 

Figure 2.1: Decision Tree

How to Decide Whether to Implement a Policy for Addressing FASD

 

 

 

 

 

 

Each of the steps in this figure tie to the How-To’s throughout this chapter. (For instance, Steps A and B tie to How-To 2.1, 

below.)
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

How-To 2.1: How to Identify the Issue or Need (Figure 2.1, Steps A and B) 

Research suggests that the following issues or problems may be relevant to your agency’s

treatment outcomes. Think about the three levels where change can occur (i.e., program/

organizational, practitioner/counselor, and client/patient) when considering the following steps.

Also, begin thinking about the part of the agency where you may want to implement changes

first (for more information, see also the section How Do You Decide Where To Start? later in this

chapter).

1.	 Individuals with an FASD are at higher risk for substance abuse and mental health issues.

Determine whether clients who have or may have an FASD are being identified and effectively

treated in your agency (see How-To 2.2).

2.	 People who present with FASD symptoms may take longer and/or require different guidelines

and rules to benefit from treatment. Determine whether this is an issue for your agency. Does

your program offer the option of longer treatment stays to clients who may have an FASD?

Does it offer alternatives to standard policies (e.g., zero tolerance rules) for such clients? If not,

how is this need addressed? What practices may need to be changed?

3.	 Unrecognized symptoms of an FASD result in poorer substance abuse treatment outcomes.

Determine whether a goal for your agency is to improve retention rates of clients with an FASD.

Determine whether a goal for your agency is to more effectively reduce the number of barriers

experienced by these clients.

One aspect of the identification process is to assess the organizational capability of the agency to

implement or augment a program for services to clients with an FASD.

How Do You Assess the Capacity of the 

Agency to Provide FASD Prevention and 

Intervention? 

Individuals with an FASD may see themselves 

as not fitting in, may be hostile or act out, 

and may struggle with multiple directions 

and tasks. Is this addressed in your treatment 

program? For example, are people failing to 

make appointments with no clear explanation 

of why? Speaking at the wrong time during 

group sessions? Or consistently completing 

only a portion of the treatment tasks they’re 

given? In terms of prevention, is your program 

serving pregnant women and/or women of 

childbearing age? Are these women being 

asked about their alcohol consumption? Are 

they being made aware of the risk of FASD? 

Assess the current capacity of your agency 

How-To 2.2: How To Assess Current Capacity to Address FASD (Figure 2.1, 

Step C) 

For	each	program	setting	consider	the	following	questions:	

1.	 Has	a	needs	assessment	been	done	to	determine	the	needs	of	both	the	clients	and	the	agency?

2.	 If	FASD	prevention	and	intervention	have	been	identified	as	areas	of	need,	are	they	adequately	

addressed	in	treatment	plans?	

3.	 Have	key	personnel	looked	into	the	literature	on	FASD	intervention	methods?	Are	appropriate	

interventions	planned	to	treat	signs	of	an	FASD?	

4.	 Are	the	FASD	prevention	and	intervention	methods	already	in	use	(if	any)	effective	with	the	

program’s	clientele?	
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

5.	 Are	the	treatment	teams	interdisciplinary	(e.g.,	psychiatrist,	nurse,	licensed	master’s	level	

clinicians,	certified	counselors,	clinicians,	and	counselors	in	training)?	If	not,	your	agency	can	still	

address	FASD	through	interagency	collaboration.

6.	 Does	the	supervisory	staff	have	the	knowledge,	skills,	and	attitudes	necessary	to	supervise	or	

coach	the	line	staff	in	addressing	FASD?	

7.	 Does	the	program	have	referral	or	consultation	relationships	with	the	necessary	agencies	and	

professionals	(e.g.,	trained	and	licensed	physicians,	physical	therapists,	occupational	therapists,	

neuropsychologists	and	speech	language	pathologists,	prenatal	care,	FASD	evaluation/diagnosis	

teams	or	agencies)?

Note:	For	more	information	on	assessing	capacity	and	capabilities,	see	Sample	Policies	1–6	and	

Checklists	1–4.	

or program to deliver FASD prevention and 

intervention (see How-To 2.2). 

How Do You Organize a Team to Address the 

Problem?

Once you have identified an issue or problem, 

you need to create a workgroup to address the 

problem (see How-To 2.3).

How Do You Identify a Specific Outcome to 

Target for Change? 

Once you’ve organized a workgroup to address 

the problem, you need to identify a specific 

outcome to be targeted for change (see HowTo 2.4).

How Do You Decide Where to Start? 

Once you’ve identified a specific outcome or 

outcomes to target for change, you will want 

the workgroup to assess the agency and the 

staff (both frontline and supervisory) to be 

targeted by the implementation. You will have 

How-To 2.3: How to Organize a Team to Address the Problem (Figure 2.1, 

Steps D and E) 

1.	 Identify	one	person	to	lead	the	effort.	Many	programs	that	have	successfully	implemented	

programming	for	individuals	with	an	FASD	were	able	to	do	so	because	there	was	one	

committed,	passionate	person	willing	to	lead	the	effort,	a	‘champion.’	This	person	must	have	

the	backing	of	senior	administration	and	the	respect	of	direct	treatment	staff.	

2. Obtain	the	commitment	of	the	Chief	Executive	Officer	of	the	agency	to	articulate	the	vision	for	

implementation	throughout	the	agency	and	with	all	stakeholders	(including	clients).	

3. Convene	an	implementation	workgroup	consisting	of	key	leaders	from	different	stakeholder	

groups;	client	leaders,	family	leaders,	team	leaders,	clinical	leaders,	and	program	and	

administrative	leaders.	Some	stakeholders	will	serve	as	ongoing	members	of	the	workgroup,	

while	information	from	others	may	be	solicited	through	focus	groups.	If	your	program	has	a	

residential	or	inpatient	component,	be	sure	to	include	an	individual	from	the	night	staff	(i.e.,	

aide,	tech,	night	nurse).	This	staff	will	actually	have	more	conversations	with	patients	than	

most	clinical	staff	and	are	in	a	position	to	support	this	program	through	their	observations	and	

understanding.	

4.	 Identify	the	program	oversight	committee	to	which	the	work	group	will	report.	For	example,	

if	your	agency	has	a	quality	improvement	committee,	the	work	group	may	report	its	findings,	

recommendations,	strategic	plans,	and	modifications	to	that	committee.	This	is	one	way	to	

initiate	and	sustain	implementation.	
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

How-To 2.4: How to Identify a Specific Outcome to Target for Change (Figure 

2.1, Step F) 

1.	 Begin with the issue or problem identified in Step A of Figure 2.1, and determine a specific

variable that can be measured that is directly related to improving the management of FASD.

For example, in terms of prevention, the variable may be to “Add FASD awareness as an

element of client education with all female clients of childbearing age, whether pregnant or

not.” In terms of intervention, the variable may be to “Increase staff ability to identify signs of a

client who may have an FASD.”

	 -	 Identify a way to measure “identify signs of a client who may have an FASD.” For

example, there is a list of common physical and behavioral manifestations of FASD

in Part 1, Chapter 2 of this TIP, and repeated later this chapter, that can be used as a

checklist.

-	 Identify a way to measure “client education with all female clients of childbearing age,

whether pregnant or not.” For example, tracking instances of client education on the

topic of alcohol-exposed pregnancies, and/or rates of abstention among pregnant

clients.

2.	 Measure a baseline prior to implementing FASD prevention or intervention. For example,

determine how many women of childbearing age you see at your agency in a given month. In

terms of intervention, review cases of client noncompliance, particularly where no specific cause

of the noncompliance is known. Did these clients forget appointments? Not follow directions?

Act out? Exhibit family instability and/or have a history of multiple foster care placements?

These can become cues for identifying case of possible FASD in the future.

3.	 Identify which outcome you are most interested in measuring to determine whether

implementing FASD prevention or intervention is working. For example:

	 • Intervention

•	 Number of staff trained in FASD intervention methods

•	 Rates of identifying potential cases of an FASD

•	 Rates of conducting FASD evaluations/assessments

•	 Rates of finding/filling FASD assessment slots

•	 Diagnoses achieved

•	 Follow-up/Aftercare: Family stability over time

•	 Multiple foster placements reduced

	 •	 Prevention

•	 Number of staff trained in FASD prevention

•	 Implementation of alcohol screening with all women of childbearing age, whether

pregnant or not

•	 Treatment planning adaptation based on this screening

•	 Achieving abstinence/reduction of at-risk drinking

•	 Use of effective contraception by the client

an easier time implementing your plan if you 

start with a small program where staff members already work well with one another and 

believe in the new techniques. Staff members 

on closely knit teams work with one another’s 

strengths and will have an easier time assigning responsibilities when it comes time to 

implement the practice. Alternatively, you may 

choose a small, core group of staff members 

who are ready to try new techniques and are 
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

prepared to be part of an implementation 

process (i.e., target early adopters across programs). These will be the first staff members 

trained and coached in using these techniques. 

Other advantages to starting small include the 

following: 

1. It is easier to track the success of the 

implementation. 

2. It is easier to identify and make any 

modifications to the techniques that 

may be necessary to accommodate the 

agency’s clientele. 

3. The core group members will talk about 

the success they are having with the techniques and get other staff interested in 

learning and using the techniques. 

For more information on assessing your agency’s readiness for implementation, see How-To 

2.5. 

How-To 2.5: How to Assess the Agency’s Organizational Readiness for 

Implementation (Figure 2.1, Step G) 

1.	 The committee assesses the agency’s organizational readiness by first determining whether

implementing practices to improve the management of FASD in the agency’s clientele are

consistent with the agency’s mission statement. (See also the section Modifying Existing 

Policies, this chapter).

2.	 The committee determines the obstacles to implementation:

a.		 Rate of staff turnover in the agency, including average longevity of clinical and support

	 	 staff.

b.		 Inadequate funding for training, technical assistance, and outcome measurement.

	 c.		 Policies and procedures that would have to be changed (see Sample Policies 1–6, this

chapter).

d.		 Agency facilities and resources.

e.		 Federal, state, and local regulations that affect the decision to implement FASD prevention

	 and intervention (see Addressing Relevant Regulations, this chapter).

3.	 The committee determines the opportunities created by implementing FASD prevention or

intervention:

a.		 Increased funding.

b.		 Increased collaboration with other agencies.

c.		 Improved community relations and marketing opportunities.

4.	 The committee determines the organization’s stage of change (see also the ATTC’s Change

Book, p. 29).

5.	 The committee determines where the resources will come from to provide support for the

change initiative (Change Book, p. 29).

6.	 The committee determines what adoption of this change will mean at all levels of the

organization and what the benefits are for administrators, supervisors, and counselors (Change

Book, p. 29).

7.	 The committee determines what is already happening that might lay the foundation for the

desired change (Change Book, p. 29). For example, you may already have an FASD ‘champion’

on your staff.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Addressing Policies and 

Procedures 

Although varying in format and structure 

as a result of regulatory and organizational 

diversity, policies and procedures serve as 

the foundation of organizational practice. 

Planning and implementing a new program 

component almost always impacts existing 

policies and procedures, but those same policies and procedures constitute one of the most 

common and effective mechanisms for institutionalizing organizational practices. As such, 

they will need to be reviewed and adapted to 

be sure they are in conformance with the new 

program.

Modifying Existing Policies 

In addition to adopting policies on addressing 

FASD, provider agencies might consider modifying other policies and program descriptions 

to provide continuity of care for (1) women 

who are or may become pregnant who screen 

positive for at-risk drinking, and (2) individuals who have or may have an FASD.

For example, each program will develop its 

own approach to screening and monitoring 

for FASD based on (a) the characteristics 

of its clientele; (b) its resources, especially 

its staff training and background; (c) legal 

and reimbursement considerations; and (d) 

other factors unique to your agency (e.g., 

specific arrangements worked out with referral resources or consultants, participation in 

clinical trials, or other external influences). 

Your professional input into developing the 

necessary policies and procedures is essential, 

and at a minimum there should be a protocol 

that stipulates: 

•	 What standard questions a client is asked, 

when they are asked (by interview and/

or self-report mechanisms), and when 

they should be repeated (especially what 

observations or events might trigger a 

fuller evaluation for an FASD)—These 

elements of the protocol should use 

published, reliable tools as discussed in 

Part 1 and the Literature Review for this 

TIP (Appendix C, Public and Professional 

Resources on FASD, contains useful links 

to sites where tools can be accessed);

•	 Who can ask these questions and what 

training is provided or needed regarding 

the questions and the overall process, 

procedures, and policies; 

•	 Exactly how scoring or assessment of the 

clients’ responses will be done, including 

exact guidelines for the follow-up triggered by various responses; 

•	 Where these policies and procedures fit 

within the agency’s policies and procedures and what chain of command and 

communication exist; 

•	 How long AEP screening and prevention 

and/or treatment modification for FASD 

intervention will typically take, which will 

help you calculate how many interventions one staff member can realistically 

accomplish per day, anticipate staffing 

requirements for the project, and project 

potential income (consult with your 

administration and billing department—

billing for both Medicaid and private 

insurance may require an intervention of 

at least 15 minutes’ duration);

•	 How personnel will obtain necessary 

training, forms, or materials;

•	 How FASD-informed prevention and/

or intervention will be introduced to 

the client (it might be helpful to have 

introductory statements worked out and 

written down in advance, and available to 

all staff ); and

• How FASD prevention and/or intervention will be documented, whether as 

written or electronic medical record 

documentation.
112

Addressing Fetal Alcohol Spectrum Disorders (FASD)

This section provides six samples of critical 

policies and procedures related to addressing 

FASD prevention and intervention within 

substance abuse treatment and mental health 

agencies. In each topic area, a policy statement and set of procedures related to the topic 

are presented. These sample policies can be 

used as presented, combined into one or more 

comprehensive policies, or integrated into the 

organization’s existing policies. Each policy 

is divided into an example of a policy statement and a set of procedures, as the language 

will differ depending on whether an agency is 

revising policies to incorporate FASD intervention or FASD prevention.

Sample Policy 1a

Topic: Clinical staff training and competency [FASD intervention].

Policy Statement: All clinical staff will demonstrate basic competency in identifying signs of an

FASD.

Procedures:

1.	 All clinical and support staff will participate in a 3–5 hour training session covering FASD, the

impact of these disorders on treatment, retention, and outcomes, and criteria and procedures

for referring individuals to services aimed at formally diagnosing and addressing FASD. (See

Appendix C, Public and Professional Resources on FASD, for training resources.)

2.	 The clinical supervisor of new employees will provide site-specific information on the

procedures for screening and referring individuals who exhibit signs of a possible FASD.

3.	 Clinical competency checklists completed at hire and annually thereafter will ensure that all

clinical staff members have a basic knowledge of FASD, an understanding of strategies for

assessing the significance of FASD, and an awareness of appropriate referral procedures.

Sample Policy 1b

Topic: Clinical staff training and competency [FASD prevention].

Policy Statement: All clinical staff will demonstrate basic competency in screening women of

childbearing age (whether pregnant or not) for alcohol consumption.

Procedures:

1.	 All clinical and support staff will participate in a 3–5 hour training session covering FASD, the

impact of alcohol on a fetus, and (if necessary) criteria and procedures for referring women

who screen positive for at-risk drinking to appropriate services. (See Appendix C, Public and 

Professional Resources on FASD, for training resources.)

2.	 The clinical supervisor of new employees will provide site-specific information on the

procedures for screening and referring women who screen positive for at-risk drinking.

3.	 Clinical competency checklists completed at hire and annually thereafter will ensure that

all clinical staff members have a basic knowledge of FASD, an understanding of strategies

for assessing the dangers of alcohol consumption for women of childbearing age, and an

awareness of appropriate referral procedures.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Sample Policy 2a

Topic: Recruitment, training, and supervision of FASD-capable clinical staff [FASD 

intervention].

Policy Statement: Counselors interested in providing FASD-informed care and who possess

the relevant basic counseling skills, knowledge, and attitudes (see Checklist 2, Characteristics 

and Competencies of All Clinical Staff, this chapter) will be recruited, trained, and supervised to

deliver these interventions.

Procedures:

1.	 At least one clinical position in each program or modality of care will be designated to

provide FASD-informed care.

2.	 Individuals exhibiting the attitudes, knowledge, skills, and job performance required to

provide FASD-informed care will be identified by their clinical supervisor and designated to

provide these services.

3.	 The counselors identified to provide FASD-informed care will receive an initial training and

additional “update” training each year in some or all of the following areas (see Appendix C,

Public and Professional Resources on FASD, for training resources):

•	 Fundamentals of FASD, including the effect of alcohol on the developing fetus and

typical cognitive and behavioral impact across the lifespan.

•	 Summary of current literature on FASD intervention, and on scientifically validated

FASD intervention approaches.

•	 Adapting treatment approaches for individuals with an FASD.

•	 Talking with individuals with an FASD about their diagnosis.

•	 Planning for client safety.

•	 Principles of trauma-informed care.

•	 Providing a “hands-on hand-off” approach to outside services (i.e., not simply making

a referral and assuming that the client takes the appropriate action).

•	 Addressing FASD in the context of cultural competency.

•	 Building client self-efficacy and self-advocacy

•	 Client-centered care.

•	 Motivational interviewing.

•	 Targeted provider and school consultation.

•	 Personal boundaries and professional ethics.

•	 Termination, referral, and discharge planning.

•	 Appropriate community linkages.

•	 Anticipatory guidance and planning for the future.

4.	 Counselors providing FASD-informed care will receive clinical supervision twice monthly that

includes direct observation or review of tapes of individual sessions with clients who have or

may have an FASD.

5.	 Counselors providing FASD-informed care will meet quarterly to provide peer support,

supervision, and share resources related to the management of clients who have or may have

an FASD.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Sample Policy 2b

Topic: Recruitment, training, and supervision of clinical staff capable of screening 

women of childbearing age (whether pregnant or not) for alcohol consumption 

[FASD prevention].

Policy Statement: Counselors interested in providing alcohol screening and referral and

who possess the relevant basic counseling skills, knowledge, and attitudes (see Checklist 2,

Characteristics and Competencies of All Clinical Staff, this chapter) will be recruited, trained, and

supervised to deliver these interventions.

Procedures:

1.	 At least one clinical position in each program or modality of care will be designated to

provide alcohol screening to women of childbearing age.

2.	 Individuals exhibiting the attitudes, knowledge, skills, and job performance required to

provide alcohol screening will be identified by their clinical supervisor and designated to

provide these services.

3.	 The counselors identified to provide alcohol screening will receive an initial training and an

additional update training each year in some or all of the following areas (see Appendix C,

Public and Professional Resources on FASD, for training resources):

•	 Fundamentals of FASD, including the effect of alcohol on the developing fetus and

typical cognitive and behavioral impact across the lifespan.

•	 Summary of current literature on FASD intervention, and on scientifically validated

FASD intervention approaches.

•	 Planning for client safety.

•	 Principles of trauma-informed care.

•	 Providing a ‘hands-on hand-off’ approach to outside services (i.e., not simply making a

referral and assuming that the client takes the appropriate action).

•	 Addressing FASD in the context of cultural competency.

•	 Building client self-efficacy and self-advocacy

•	 Client-centered care.

•	 Motivational interviewing.

•	 Targeted provider consultation.

•	 Personal boundaries and professional ethics.

•	 Termination, referral, and discharge planning.

•	 Appropriate community linkages.

•	 Anticipatory guidance and planning for the future.

4.	 Counselors providing alcohol screening will receive clinical supervision twice monthly that

includes direct observation or review of tapes of individual sessions with female clients of

childbearing age.

5.	 Counselors providing FASD-informed care will meet quarterly to provide peer support,

supervision, and share resources related to providing alcohol screening to female clients of

childbearing age.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Sample Policy 3a

Topic: Observation and referral of clients exhibiting signs of an FASD [FASD 

intervention].

Policy Statement: The possible presence of an FASD will be considered with all noncompliant

or resistant or ‘problem’ clients, and possible indicators will be noted through a process of

observation and interviewing. Clients exhibiting signs of a potential FASD will be referred as

needed.

Procedures:

1.	 During intake and throughout the early stages of treatment (i.e., first month), all clients

exhibiting persistent (and otherwise unexplained) noncompliance with treatment will be

observed, and the individual’s case history reviewed, for FASD ”indicators” based on a

checklist (see the FASD 4-Digit Code Caregiver Interview Checklist in Part 1, Chapter 2 of this

TIP).

2.	 Individuals exhibiting signs of an FASD will either be assessed by an identified in-house team

with FASD expertise or be referred to an accepted FASD evaluation agency.

3.	 With or without a formal diagnosis of FASD, a client exhibiting signs of an FASD will

be referred to a counselor competent in providing FASD-informed care and capable of

modifying treatment to account for the observed behavioral/cognitive deficits (see Sample

Policy 2).

4.	 All screening results, consultation sessions with the clinical supervisor, and referrals (and

ongoing communications) to an FASD evaluation agency will be documented in the client’s

record.

5.	 The counselor providing FASD-informed care will provide the client with an emergency

contact list that includes agency personnel and emergency care providers. The client can

refer to this list if he or she has treatment or safety issues outside business hours or when a

counselor is not available. (See Appendix F for a Sample Crisis/Safety Plan that can be filled

out with clients.)

Sample Policy 3b

Topic: Screening and referral of female clients of childbearing age exhibiting signs of 

an alcohol use/abuse [FASD prevention].

Policy Statement: All women of childbearing age (whether pregnant or not) will be screened for

alcohol consumption and referred as needed.

Procedures:

1.	 During the intake process, all women of childbearing age will be screened for alcohol

consumption.

2.	 Staff will be trained in using specific alcohol screening tools that are validated for use with

women, such as the T-ACE or TWEAK (for pregnant women), the AUDIT-C Questionnaire (nonpregnant women), or the CRAFFT Interview or FRAMES (with adolescent and young adult

clients).
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

3.	 Individuals screening positive for at-risk alcohol consumption will receive an appropriate

assessment or be referred for one, to be conducted by a qualified substance abuse treatment

professional.

4.	 Clients who are determined by a qualified substance abuse treatment professional to have an

alcohol-related disorder will receive or be referred for substance abuse treatment, also to be

delivered by that professional. Collaborative relationships with appropriate providers will be

developed.

5.	 All women of childbearing age will receive FASD-related education (pamphlet, suitable

Web site, etc.), whether pregnant or not and whether screening positive for at-risk alcohol

consumption or not.

6.	 All screening results, consultation sessions with the clinical supervisor, and referrals (and

ongoing communications) to a qualified substance abuse treatment professional will be

documented in the client’s record.

7.	 The counselor providing substance abuse treatment will provide the client with an emergency

contact list that includes agency personnel and emergency care providers. The client can

refer to this list if she has treatment issues outside business hours or when a counselor is not

available. (See Appendix F for a Sample Crisis/Safety Plan that can be filled out with clients.)

Sample Policy 4a

Topic: Treatment planning, service recording, discharge planning, and continuity of 

care [FASD intervention].

Policy Statement: Management of FASD will be integrated with substance abuse/mental health

services, be properly documented, and include appropriate discharge and transfer planning.

Procedures:

1.	 Screening and observation for signs of an FASD and—when indicators are present—strategies

for addressing FASD will be included in the client’s treatment plan.

2.	 Treatment plans incorporating FASD management will be jointly developed by the

interdisciplinary team and the client within and/or across programs.

3.	 To minimize client confusion, the client will be provided with information about the roles and

responsibilities of those delivering care.

4.	 Treatment plans will include referral to other community resources and peer support activities

that may increase the client’s self-efficacy and reduce FASD-related treatment barriers.

5.	 Interdisciplinary treatment update sessions including all professionals involved with the client’s

care should occur regularly. (The frequency of treatment plan updates should be consistent

with state and organizational standards and will vary by modality of care and regulatory

agency.) Ideally these would be held weekly for short-term residential treatment and monthly

for long-term residential treatment and outpatient settings.

6.	 Services delivered by the primary counselor will be recorded in the client’s record at each

contact and will be available to other members of the treatment team.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

7.	 Major changes in the client’s condition or treatment compliance/success will be

communicated between the primary counselor and the interdisciplinary team.

8.	 The checklist of FASD “indicators” (see Sample Policy 3) will be completed at the last session

before termination to assist in developing the discharge plan and to be used by the quality

assurance department for outcome monitoring.

9.	 Discharge and transfer planning will include recommendations for the client about self-care,

self-advocacy, and other available FASD-informed services that are available to them.

Sample Policy 4b

Topic: Treatment planning, service recording, discharge planning, and continuity of 

care [FASD prevention].

Policy Statement: Treatment for at-risk alcohol consumption among all women of childbearing

age (whether pregnant or not) will be integrated with substance abuse/mental health services, be

properly documented, and include appropriate discharge and transfer planning.

Procedures:

1.	 Screening for alcohol consumption among all women of childbearing age (whether pregnant

or not) and strategies for addressing the client’s alcohol use will be included in the client’s

treatment plan.

2.	 Treatment plans incorporating alcohol use management will be jointly developed by the

interdisciplinary team and the client within and/or across programs.

3.	 To minimize client confusion, the client will be provided with information about the roles and

responsibilities of those delivering care.

4.	 Treatment plans will include referral to other community resources and peer support activities

that may increase the client’s self-efficacy and reduce alcohol consumption.

5.	 Interdisciplinary treatment update sessions including all professionals involved with the client’s

care should occur regularly. (The frequency of treatment plan updates should be consistent

with state and organizational standards and will vary by modality of care and regulatory

agency.) Ideally these would be held weekly for short-term residential treatment and monthly

for long-term residential treatment and outpatient settings.

6.	 Services delivered by the primary counselor will be recorded in the client’s record at each

contact and will be available to other members of the treatment team.

7.	 Major changes in the client’s condition or pattern of alcohol use (or simply changes in alcohol

use, if this is the primary objective of treatment) will be communicated between the primary

counselor and the interdisciplinary team.

8.	 An appropriate alcohol screening tool agreed upon by the interdisciplinary team will be

completed at the last session before termination to assist in developing the discharge plan

and to be used by the quality assurance department for outcome monitoring.

9.	 Discharge and transfer planning will include recommendations for the client about self-care,

self-advocacy, and other alcohol use support services that are available to them.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Sample Policy 5a

Topic: Counselor performance appraisal [FASD intervention].

Policy Statement: Counselors capable of providing FASD-informed services will have job

descriptions that include a high level of specific performance expectations related to provision of

services for these clients.

Procedures:

1.	 Job descriptions for counselors agreeing/qualified to provide FASD intervention services may

include reduced caseload and productivity expectations, particularly during an agreed-upon

early stage of implementation.

2.	 Performance appraisal of counselors providing FASD intervention services will include

demonstration of relevant core competencies (e.g., as observed directly and/or through

videotaping).

3.	 Annual training requirements will be outlined in the job descriptions of counselors identified

to provide FASD-informed services.

4.	 Client satisfaction surveys and outcome reports will be discussed in performance evaluations

with counselors providing FASD intervention services. Such evaluations may need to occur

more regularly than annually when implementing new practice.

Note: The following sample policy is potentially more relevant in mental health treatment settings than 

in substance abuse treatment settings, as alcohol use management services are a core competency in substance abuse treatment and presumably would not be separated out in a policy statement in this fashion.

Sample Policy 5b

Topic: Counselor performance appraisal [FASD prevention].

Policy Statement: Counselors capable of providing alcohol consumption screening for women

of childbearing age (whether pregnant or not) and appropriate services/referral will have job

descriptions that include a high level of specific performance expectations related to provision of

services for these clients.

Procedures:

1.	 Job descriptions for counselors agreeing/qualified to provide FASD prevention services may

include reduced caseload and productivity expectations, particularly during an agreed-upon

early stage of implementation.

2.	 Performance appraisal of counselors providing FASD prevention services will include

demonstration of relevant core competencies (e.g., as observed directly and/or through

videotaping).

3.	 Annual training requirements will be outlined in the job descriptions of counselors identified

to provide alcohol use management services.

4.	 Client satisfaction surveys and outcome reports will be discussed in performance evaluations

with counselors providing FASD prevention services. Such evaluations may need to occur

more regularly than annually when implementing new practice.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Sample Policy 6a

Topic: Evaluation of service effectiveness and quality assurance [FASD intervention].

Policy Statement: Services for addressing FASD will be reported annually through the agency’s

quality assurance system along with indicators of effectiveness based on client outcomes.

Procedures:

1.	 The agency’s quality assurance program will include monitoring the implementation of policies

related to FASD screening and treatment modifications, FASD evaluation referral procedures,

documentation and treatment planning, and supervision of counselors providing FASDinformed services.

2.	 Data from admission and discharge screening of clients exhibiting FASD “indicators” (see

Sample Policy 3) will be aggregated by the quality assurance coordinator for annual reporting

to the agency.

3.	 The following overall agency performance outcomes will be reviewed annually by the

management team:

a.	 The proportion of clients dropping out of treatment before the third session after

implementation of FASD-informed services, or appropriate length of time based on your

agency’s treatment schedule (it will be important to have information on the dropout rate

after implementation to assess the impact of these services on treatment engagement

and retention).

b.	 The number of clients receiving FASD-informed services, as a percentage of overall client

population.

c.	 The number of clients referred to an FASD evaluation agency, as a percentage of overall

client population.

d.	 A comparison of (1) the proportion of all clients experiencing a relapse during treatment,

and (2) the proportion of all clients receiving FASD-informed care that experience a

relapse during treatment.

Note: As with sample policy 5b, the following sample policy is potentially more relevant in mental 

health treatment settings than in substance abuse treatment settings, as alcohol use management services 

are already a core competency in substance abuse treatment.

Sample Policy 6b

Topic: Evaluation of service effectiveness and quality assurance [FASD prevention].

Policy Statement: Services for managing alcohol use consumption among women of

childbearing age (whether pregnant or not) will be reported annually through the agency’s quality

assurance system along with indicators of effectiveness based on client outcomes.

Procedures:

1.	 The agency’s quality assurance program will include monitoring the implementation of policies

related to alcohol use management among women of childbearing age (whether pregnant or

not), substance abuse treatment referral procedures, documentation and treatment planning,

and supervision of counselors providing alcohol use management services.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

2.	 Data	from	admission	and	discharge	screening	of	clients	who	are	women	of	childbearing	age	

and	have	received	alcohol	use	management	services	(see	Sample	Policy	3)	will	be	aggregated	

by	the	quality	assurance	coordinator	for	annual	reporting	to	the	agency.

3.	 The	following	overall	agency	performance	outcomes	will	be	reviewed	annually	by	the	

management	team:	

a.	The	proportion	of	clients	who	receive	screening	for	at-risk	alcohol	use	who	subsequently	

drop	out	of	treatment,	as	a	comparison	with	clients	who	do	not	receive	this	screening	

and	subsequently	drop	out	of	treatment.	

b.	The	proportion	of	these	clients	evidencing	at-risk	alcohol	consumption	at	both	admission	

and	discharge.	

c.	 The	number	of	clients	who	are	women	of	childbearing	age	who	receive	screening	for	

at-risk	alcohol	use,	as	a	percentage	of	overall	client	population.	

d.	The	number	of	clients	who	are	women	of	childbearing	age	who	receive	services	

for	alcohol	use	management	or	a	referral	to	a	qualified	substance	abuse	treatment	

professional,	as	a	percentage	of	overall	client	population.

e.	A	comparison	of	(1)	the	proportion	of	all	clients	experiencing	a	relapse	during	treatment,	

and	(2)	the	proportion	of	all	clients	who	are	women	of	childbearing	age	and	receiving	

alcohol-use	management	services	that	experience	a	relapse	during	treatment.

Addressing Relevant Regulations

Another aspect of assessing your agency is to 

determine whether implementing FASD prevention and/or intervention will conflict with 

the existing local and governmental regulations and standards that apply to your agency’s 

operation.

For example, both the federal government 

and individual states have developed their 

own laws regarding the reporting of cases of 

known or suspected substance-exposed infants. 

These laws vary widely in their requirements, 

but are nonetheless of critical importance to 

any healthcare setting serving the needs of 

pregnant women. In addition, providing services to individuals who have or may have an 

FASD—a recognized disability—carries its 

own legal and ethical responsibilities.

The following sections discuss relevant regulatory issues related to (1) women who drink 

during pregnancy, and (2) individuals who 

have or may have an FASD.

Legal Issues Related to Women Who Drink 

During Pregnancy

Federal laws related to alcohol use during 

pregnancy tend focus on prevention and treatment of FASD rather than being punitive. 

State and local laws vary. Some states, such as 

Hawaii and Montana, have laws authorizing 

FASD prevention and treatment programs. 

Others, such as New Hampshire and Rhode 

Island, require that information on FASD be 

available to couples seeking marriage licenses. 

At least one state, Missouri, requires physicians to counsel pregnant patients about the 

dangers of alcohol use. It is important for 

counselors to stay abreast of state laws related 

to alcohol use during pregnancy and their 

effect on treatment and recovery.

The Administration for Children & Families, 

an agency within HHS, provides a searchable guide to state-level statutes regarding 

the reporting of substance-exposed infants 

(http://www.childwelfare.gov/systemwide/

laws_policies/state/).
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Custody Issues

Several states (e.g., Florida, South Carolina) 

do take punitive measures toward alcohol use 

during pregnancy, such as including prenatal 

alcohol exposure in their definitions of abuse 

or neglect. Such measures can be used to 

remove the child from the parent’s custody. 

Texas allows involuntary termination of 

parental rights if a woman causes her child to 

be born addicted to alcohol (other than via a 

controlled substance legally obtained by the 

mother by prescription; Section 161.001[1-

R]). Generally, a mother who abuses substances may be charged with child neglect or 

abuse. As a result, her children may be taken 

from her.

In Virginia, physicians, nurses, teachers, and 

other professionals are required to report certain injuries to children. For purposes of the 

law, “reason to suspect that a child is abused or 

neglected” includes a diagnosis by an attending 

physician within 7 days of a child’s birth that 

the child has fetal alcohol syndrome attributable to in utero exposure to alcohol (Section 

63.2-1509). One state, South Dakota, permits 

involuntary commitment of a pregnant woman 

who is drinking.

A number of experts fear that such punitive 

measures may discourage pregnant women 

with alcohol problems from seeking treatment. 

Many states take a more supportive approach:

•	 Arizona (http://www.azleg.state.az.us/

ars/36/00141.htm)

•	 California (http://law.justia.

com/codes/california/2005/

hsc/11998-11998.3.html) 

•	 Washington state (http://apps.

leg.wa.gov/RCW/default.

aspx?cite=70.83C.005) 

These three states give pregnant women priority for alcohol treatment slots or otherwise 

provide access to treatment. Others (e.g., 

California) provide outreach or case management to pregnant women with substance abuse 

problems. California also may cover residential 

treatment for pregnant women under MediCal. In addition, Iowa prohibits discrimination against pregnant women seeking alcohol 

treatment (http://www.legis.state.ia.us/

IACODE/2001SUPPLEMENT/125/32A.

html). 

State and federal governments have established various policies in response to the risks 

associated with drinking during pregnancy. 

Among these are various arrangements to 

increase access to substance abuse treatment 

by pregnant and postpartum women. Such 

arrangements include state-run treatment 

services, funding for private providers, and 

mandates that such women receive a priority 

for available treatment. The Alcohol Policy 

Information System (APIS) addresses statutes 

and regulations mandating priority access to 

substance abuse treatment for pregnant and 

postpartum women who abuse alcohol. In 

addition, the SAMHSA FASD Center for 

Excellence Web site provides an FASD legislation report that is updated twice a year.

State statutes that remove custody from 

birth mothers of children with an FASD are 

designed to protect the children. However, 

the threat of losing custody can interfere with 

the woman’s recovery, or cause her to leave 

prenatal care and/or treatment. The goal is 

to remain alcohol-free long-term and acquire 

parenting skills needed to retain child custody and have a healthy, intact family. When 

screening or referring pregnant women for 

substance abuse treatment, counselors will 

need to be familiar with the laws in his or 

her state and their impact on efforts at family 

reunification and client recovery.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Child Abuse Prevention and Treatment Act 

(CAPTA)

One of the most significant pieces of legislation impacting the provision of services to pregnant women is the Child Abuse 

Prevention and Treatment Act, or CAPTA 

(P.L. 93-247). Most recently reauthorized 

on December 20, 2010 (S 3817), CAPTA is 

designed to protect rather than punish women 

who give birth to substance-exposed infants. 

The intent of these reporting laws is that “The 

newborn and their families will be brought to 

the attention of the child protective agency in 

the community, and they will ideally receive 

needed services within their community” 

(Burke, 2007).

A new CAPTA state grant eligibility requirement modifies earlier CAPTA language that 

mandates identifying and making appropriate referrals by healthcare providers to child 

protective services—and developing service 

‘plans for safe care’ of the child—of newborns 

affected by prenatal drug exposure. Added 

as a new category of ‘referral’ and ‘safe care 

plan’ requirement are newborns diagnosed 

with an FASD. This CAPTA amendment 

was not meant to cover all situations where a 

newborn’s mother drinks alcohol during her 

pregnancy, but rather those where a newborn 

has facial characteristics, growth restriction, or 

other abnormalities (birth defects) caused by 

prenatal alcohol use.

This new CAPTA provision (and the earlier 

requirement regarding drug-exposed newborns) is not intended to have states make 

prenatal alcohol or drug exposure a category 

of child abuse or neglect or to make those 

children subjects of mandatory reporting laws. 

Congress carefully chose the word “referral” 

to avoid that. Rather, the goal is to address 

the safety and well-being of these children. 

Intervening early through safety plans that 

promote the health and well-being of these 

children will be key.

The U.S. Department of Health and Human 

Services (HHS) provides a comprehensive 

guide to the CAPTA legislation and its 

impact on service provision, as well as its 

implications for community-based family 

resource and supports grants (http://www.

childwelfare.gov/systemwide/laws_policies/

federal/index.cfm?event=federalLegislation.

viewLegis&id=142). CAPTA is also discussed 

in Part 3 of this TIP, the online literature 

review. 

Territorial and Tribal Laws

At this time, no U.S. Territories have laws 

related to alcohol use during pregnancy. Tribal 

laws vary, but the Indian Child Welfare Act 

(http://www.nicwa.org/policy/law/icwa/

ICWA.pdf) requires the Indian Health 

Service (IHS) to make residential treatment 

available for pregnant women with alcohol 

problems. In addition, the definition of ‘health 

promotion’ in the Act includes FASD prevention. The Act also allows the IHS to make 

grants to tribes and tribal organizations for 

various FASD prevention efforts, including 

alcohol treatment for high-risk women. It 

also has provisions related to educating Native 

women about FASD.

Counselors working with Tribal populations will also want to consider the implications of the Tribal Law and Order Act 

(TLOA) of 2010 and the Indian Health Care 

Improvement Act (IHCIA), which was made 

permanent in 2010. Both seek to strengthen 

access to care and protection of personal rights 

among Tribal populations, particularly women.

Information about the TLOA can be accessed 

at 

http://www.narf.org/nill/resources/tloa.html.

Information about the IHCIA can be accessed 

at http://www.ihs.gov/ihcia/. 
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Confidentiality Issues

Laws such as the Health Insurance Portability 

and Accountability Act (HIPAA) may affect 

activities such as reporting of alcohol use during pregnancy. HIPAA has certain requirements regarding privacy and sharing of client 

information and records. Confidentiality laws 

vary by state and may affect the addiction 

professional’s ability to share information with 

various social, health, and legal systems, such 

as child welfare agencies.

It is essential to be familiar with confidentiality laws in one’s state and to consult with an 

attorney if necessary. Inappropriate reporting 

of current or previous alcohol use during pregnancy can jeopardize long-term recovery and 

can harm a counselor’s career.

Legal Issues Related to Individuals with an 

FASD

The most prominent regulatory issue related 

to individuals who have or may have an FASD 

is to recognize their rights as individuals with 

(or potentially having) a recognized disability.

Americans with Disabilities Act Compliance 

in Treatment Plans

The Americans with Disabilities Act (ADA) 

of 1990 is a federal law that prohibits discrimination on the basis of disability in 

employment, state and local government, 

public accommodations, commercial facilities, transportation, and telecommunications. 

An individual with a disability is defined by 

the ADA as a person who has a physical or 

mental impairment that substantially limits 

one or more major life activities, a person who 

has a history or record of such an impairment, or a person who is perceived by others 

as having such an impairment. Treatment 

facilities cannot discriminate on the basis of 

a disability. Many individuals with an FASD 

will have cognitive disabilities that meet the 

definitions set forth by the ADA; in any case, 

such individuals should receive treatment that 

recognizes their condition as a disability that 

should not be discriminated against.

Counselors will need to incorporate accommodations for persons with an FASD into 

any treatment plans. For example, lighting at 

meetings may need to be dimmed to keep the 

person with an FASD from becoming overstimulated. Reading materials may need to 

be adapted to a lower literacy level to accommodate cognitive deficits. More information 

on accommodating disabilities can be found 

in Appendix D of TIP 29, Substance Use 

Disorder Treatment for People With Physical and 

Cognitive Disabilities (CSAT, 1998; http://

www.ncbi.nlm.nih.gov/books/NBK64881/). 

Part 1, Chapter 2 of this TIP discusses accommodations specific to individuals who have or 

may have an FASD.

More information on the ADA can be found 

at http://www.ada.gov/. For technical assistance related to ADA requirements, visit 

http://www.ada.gov/taprog.htm or contact 

SAMHSA’s FASD Center for Excellence tollfree at 1-866-STOPFAS or by visiting 

www.fasdcenter.samhsa.gov.

Addressing Staff Competence 

Where Is the Clinical Expertise in Your Agency? 

Change in clinical practice is best facilitated 

by assessing the skills of well-trained and 

experienced clinicians and targeting them 

for training and/or enlisting them in helping 

less skilled counselors facilitate change. Two 

clinical management structures are described 

here—interdisciplinary teams and traditional 

clinical supervisors. 

Interdisciplinary teams are one effective way to 

ensure that the expertise for providing FASDinformed treatment is available in your agency 

(Clarren & Astley, 1997; Clarren et al., 2000). 

If you have interdisciplinary teams in your 

program, the teams assume the responsibility 
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

of tailoring interventions to an individual 

client’s needs in a way that addresses FASD 

seamlessly. Such teams provide ongoing 

support, education, and treatment planning 

assistance for all staff. Teamwork creates an 

enriched environment for implementing 

FASD-informed techniques.

If your agency has an interdisciplinary team 

format for responding to other issues, this 

may be adapted to FASD. With an interdisciplinary team, you have an advanced level of 

capability for addressing FASD prevention 

or intervention in clients with substance use 

or mental disorders. This assumes that the 

more experienced and skilled members of the 

team have the knowledge, skills, and attitudes 

required to apply FASD-informed interventions and to supervise and coach application of 

an intervention for other counselors. 

Many treatment agencies do not have interdisciplinary teams and instead rely on the 

expertise of clinical supervisors to evaluate 

and support the work of line staff. Clinical 

supervisors must have the knowledge, skills, 

and abilities required to apply an intervention 

and be able to demonstrate the intervention 

before they can coach others to perform it. 

The supervisors must also have the time to 

supervise and coach the staff. If this describes 

the supervisors in the setting where you 

work, you have an intermediate capability to 

provide FASD-informed care. If the supervisors have not yet reached this level, then you 

have a beginning capability for implementing 

FASD-informed care and must develop a plan 

to build the resources necessary to increase 

capacity. 

The Frontline Staff and Clinical Supervisors 

Once you’ve assessed the agency, you may 

want to assess the staff who will actually 

implement the change (see How-To 2.6). 

Staff Qualifications and Competencies 

As a part of implementing FASD-informed 

services, a number of process-oriented tasks 

How-To 2.6: How to Assess the Frontline Staff and Clinical Supervisors for 

Change (Figure 2.1, Step H) 

The committee determines the specific program and staff members who will be the first to

implement change.

1.	 Are there incentives/organizational supports for change (ATTC Change Book, p. 29)?

2.	 What are the barriers to change (ATTC Change Book, p. 28)?

3.	 At what stage of change is the program staff (ATTC Change Book, p. 29)?

4.	 How will staff practice be affected (ATTC Change Book, p. 29)?

5.	 What additional support will staff need (ATTC Change Book, p. 29)?

6.	 Does staff have the prerequisite knowledge, attitudes, and skills?

7.	 What training and continuing resources are necessary to provide the core intervention com	

	 ponents?

See also Sample Policies 1–6 and Checklists 1–4 in this chapter for additional information to be

used in assessing staff readiness. See Appendix C, Public and Professional Resources on FASD, for

links to training resources.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

should be completed, including an assessment 

of initial staff competence, education and 

training, development of skills and resources, 

and supervision. These considerations are 

relevant not only to the counselors’ ability to 

deliver the services but also to clinical supervisors, other clinical staff, and support staff 

responsible for recording and billing services.

Compared with those providing support services, however, the required level of knowledge 

and skill is significantly different for those 

directly involved in clinical care. For this 

reason, the attitudes, knowledge, and skills 

required to provide FASD-informed services 

are separated into four categories:

1. Administrative and support staff

2. All clinical staff

3. Counselors designated to provide FASDinformed services

4. Clinical supervisors overseeing the counselors who provide these services

The four checklists that follow serve two 

purposes. First, they can be used to assess staff 

and organizational readiness to implement or 

sustain FASD-informed services. Second, they 

can be used to identify gaps in training and 

supervision to be addressed with individuals or 

groups. 

Addressing Gaps in Staff Capacity to Deliver 

Services 

Not all clinical staff are ready, willing, or able 

to address co-occurring issues such as FASD. 

The clinical supervisor is charged with helping 

staff and administration differentiate the level 

Checklist 1: Characteristics and Competencies of Administrative and Support 

Staff 

Attitudes

Integrating FASD-informed care is important for promotion of the agency mission.

FASD prevention and intervention constitute valid and important experiences for our clients

and deserve and require specialized attention.

Knowledge

Recognizes the relationship between FASD-informed care and treatment effectiveness.

Recognizes how provision of FASD-informed services fits in the mission and goals of the

organization.

Is familiar with the policies and procedures related to recording and billing services for

FASD-informed services.

Recognizes the distinction between a person formally diagnosed with FAS/pFAS/ARND and

the general signs of an FASD in an individual.

Knows the agency’s policies and procedures on providing FASD-informed services as they

relate to the specific position (e.g., administrative staff in clinical records are familiar with

documentation requirements for these services, and the finance staff are knowledgeable

about how services are defined for billing purposes).

Understands the role of self-help and support groups in recovery and how those groups can

support the goals of the program in providing FASD-informed care.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Skills

Communicates to the public the role of specialized services related to FASD prevention/

intervention.

Identifies the ‘indicators’ of an FASD listed in the screening policy and procedure (see

Sample Policy 3).

Administers FASD screening and observation properly.

Conducts basic client education session on the relationship between substance abuse/mental health issues and FASD.

Conducts basic client education sessions with all female clients of childbearing age (whether pregnant or not) on the relationship between alcohol use during pregnancy and the risk

of an FASD.

Collaborates with other team members on treatment and discharge planning.

Conducts a suicide risk screening.

Checklist 2: Characteristics and Competencies of All Clinical Staff

Attitudes

Integrating FASD-informed care is important for promotion of the agency mission.

FASD prevention and intervention constitute valid and important experiences for our clients

and deserve and require specialized attention.

Clients have a central role in creating and shaping their treatment goals.

Substance abuse/mental health issues and FASD can be both interrelated and independent;

resolving one set of concerns may not lead to resolution of the other set of concerns without specialized treatment.

There is no one “right” approach to addressing FASD in our clients.

Individual sessions can be particularly valuable for clients who have or may have an FASD

and can provide an effective adjunct to group treatment.

Knowledge

Recognizes the relationship between FASD-informed care and treatment effectiveness.

Recognizes how provision of FASD-informed services fits in the mission and goals of the

organization.

Recognizes the distinction between a person formally diagnosed with FAS/pFAS/ARND and

the general signs of an FASD in an individual.

Knows the agency’s policies and procedures on addressing FASD prevention/intervention.

Recognizes the interrelationship between substance abuse/mental health issues and FASD.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Skills

Communicates to the public the role of specialized services related to FASD prevention/

intervention.

Identifies the ‘indicators’ of an FASD listed in the screening policy and procedure (see

Sample Policy 3).

Administers FASD screening and observation properly.

Conducts basic client education session on the relationship between substance abuse/mental health issues and FASD.

Conducts basic client education sessions with all female clients of childbearing age (whether pregnant or not) on the relationship between alcohol use during pregnancy and the risk

of an FASD.

Collaborates with other team members on treatment and discharge planning.

Conducts a suicide risk screening.

Checklist 3: Characteristics and Competencies of All Clinical Staff

Attitudes

Integrating FASD-informed care is important for promotion of the agency mission.

FASD prevention and intervention constitute valid and important experiences for our clients

and deserve and require specialized attention.

Clients have a central role in creating and shaping their treatment goals.

Substance use/mental health issues and FASD can be both interrelated and independent;

resolving one set of concerns may not lead to resolution of the other set of concerns without specialized treatment.

There is no one ‘right’ approach to addressing FASD in our clients.

Individual sessions can be particularly valuable for clients who have or may have an FASD

and can provide an effective adjunct to group treatment.

Resistance to change from clients is surmountable within the influence of the counseling

relationship.

The client is an integrated whole rather than one or more diagnoses or sets of symptoms.

A desire exists to deliver services to clients who have or may have an FASD along with a

substance abuse/mental health issue.

A desire exists to deliver FASD-informed care to female clients of childbearing age (whether pregnant or not).
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Checklist 3: Characteristics and Competencies of All Clinical Staff

Knowledge

Recognizes the relationship between FASD-informed care and treatment effectiveness.

Recognizes how provision of FASD-informed services fits in the mission and goals of the

organization.

Recognizes the distinction between a person formally diagnosed with FAS/pFAS/ARND and

the general signs of an FASD in an individual.

Demonstrates a nuanced understanding of the relationship between substance use/mental

health issues and FASD.

Recognizes the distinctions among screening, assessment, and diagnosis of an FASD.

Knows the common approaches to addressing FASD in substance abuse/mental health

treatment settings including motivational interviewing, accommodations, parent/personal

navigator, and the importance of coordinated care.

Recognizes how FASD presents in ethnic and other cultural groups encountered in the

agency.

Knows community resources (particularly substance abuse/mental health, primary care,

FASD service providers, school contacts when applicable, family/caregiver navigators).

Understands how 12-Step and other mutual-help support programs can support someone

with an FASD.

Is aware of the role of transference and countertransference in the counseling relationship.

Recognizes the role of religion and spirituality in promoting recovery for some clients.

Knows how to learn more about FASD intervention methods.

Skills

Communicates to the public the role of specialized services related to FASD prevention/

intervention.

Identifies the “indicators” of an FASD listed in the screening policy and procedure (see

Sample Policy 3).

Administers FASD screening and observation properly.

Conducts basic client education session on the relationship between substance abuse/mental health issues and FASD.

Conducts basic client education sessions with all female clients of childbearing age (whether pregnant or not) on the relationship between alcohol use during pregnancy and the risk

of an FASD.

Collaborates with other team members on treatment and discharge planning.

Conducts a suicide risk screening.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Checklist 4: Characteristics and Competencies of Clinical Supervisors

Attitudes

Substance abuse counselors have the basic characteristics needed to provide FASD prevention/intervention.

Clinical supervision extends beyond talking about treatment to observing and coaching

counselors directly.

Knowledge

Possesses all of the knowledge areas listed on Checklist 3.

Is knowledgeable of the role of clinical supervision.

Recognizes the limits and opportunities related to the role of counselors with specialized

training in FASD-informed services and supports training for counselors as needed.

Can determine when a client who has or may have an FASD needs additional skills and services beyond the qualifications of currently-staffed counselors.

Is trained to screen and observe for “indicators” of an FASD.

Exhibits evidence-based thinking (tailoring approach to service based on clinical experience, client characteristics, knowledge of field, consultation with supervisor, constraints, and

resources available).

Uses clinical supervision effectively.

Demonstrates empathic listening skills and reflection.

Demonstrates competency in common approaches to addressing FASD (e.g., motivational

interviewing, accommodations, parent/personal navigator, coordinated care).

Displays confidence in ability to provide FASD-informed services.

Acts as a role model for a balanced, healthy lifestyle.

Exhibits advanced skills in dealing with resistance to change through non-confrontational

approaches.

Identifies and responds to variations in learning styles among clients.

Demonstrates the ability to quickly establish a therapeutic alliance with the client: treating

the client with respect, communicating a nonjudgmental attitude, listening reflectively, setting appropriate limits, being sensitive to culture and value contexts, and acting as a role

model.

Is comfortable with and able to resolve conflict.

Is able to prepare clients for discharge.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

of new knowledge, attitudes, and skills needed 

to help counselors and support staff address 

co-occurring substance use/mental health 

disorders and FASD prevention and intervention. The characteristics and competencies 

checklists presented above outline the qualifications needed at various levels or in agencies 

wishing to provide FASD-informed services 

in clients with substance use or mental disorders. However, gaps may exist; staff may be 

lacking in various areas and require additional 

training and support. In this instance, the 

implementation workgroup described in earlier sections may be commissioned to identify 

these gaps and to develop plans to provide 

specific training and support to individual staff 

members on an as-needed basis. 

In addition to developing individualized plans 

to develop attitudes, skills, and knowledge, a 

number of organizational approaches can be 

used both to reinforce the change and to overcome resistance to change. The Change Book

(ATTC, Second Edition 2010) offers valuable 

Is aware of the role of transference and countertransference in the counseling and supervisory relationship.

Recognizes resistance to change among clinical staff and is knowledgeable of strategies to

address resistance.

Is aware of change processes, process steps and strategies for supporting them.

Possesses knowledge of the FASD intervention literature and scientifically-validated intervention techniques.

Counseling Skills

Possesses all of the skills listed on Checklist 3.

Supervisory Skills

Articulates his or her approach and philosophy to clinical supervision as it relates to clinical

supervision approaches described in the literature.

Identifies and responds to variations in learning styles among counselors.

Is comfortable with and able to resolve conflict among team members.

Models advanced counseling skills including development of therapeutic alliance, preparing

clients for discharge, and dealing with client resistance.

Uses direct observation or taping to conduct supervisory sessions.

Is able to teach and model skills for providing FASD-informed services.

Is able to determine when referral for a formal FASD assessment is required, and facilitate

such a referral.

Provides incentives through encouragement and support for counselors to enhance skills in

providing FASD-informed services.

Conducts competency assessment of counselors’ skills in providing FASD-informed services.

Shows how to learn more about FASD intervention methods.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

suggestions on addressing resistance to change 

(particularly pp. 27–28). These include such 

strategies as openly discussing staff feelings 

related to the change, celebrating victories, 

promoting feedback about the change as a 

vehicle to improve the process, being realistic 

about goals, identifying and using the change 

leaders in promoting the change, and providing training related to the change.

Approaches to Staff Training 

It is recommended that training aimed at 

developing the basic attitudes, knowledge, and 

skills for delivering FASD-informed care be 

provided to all agency staff as part of implementation. It is important for clinical staff to 

see the link between the change and organizational leadership. Thus, administrators need 

to attend these sessions to personally provide 

the vision of the organization. In addition 

to training current staff, it is important to 

consider the ways in which the organization 

can communicate the vision to new staff. This 

may be most efficiently accomplished by using 

existing vehicles, such as new staff orientation 

and training sessions and worksite orientation 

procedures. 

Training of all clinical staff members on attitudes, knowledge, and skills specific to their 

positions can be conducted by administrative 

or clinical supervisors. Again, it is important 

to communicate the commitment of leadership to integrating FASD-informed services. 

In addition, it is recommended that training 

sessions provide practice in the skill areas outlined in Checklist 3. To reinforce the importance of the need to provide FASD-informed 

services, clinical and administrative supervisors 

are advised to incorporate didactic education, 

identification of incompatible attitudes, and 

coaching on the skills needed to implement 

the policies within existing supervision sessions and team meetings. In short, the agency’s 

vision and commitment to addressing FASD 

must inform all clinical interactions between 

supervisors and counselors.

Figure 2.2 provides a list of recommended credentials for trainers; Appendix C, Public and 

Professional Resources on FASD, lists resources 

for FASD prevention and intervention training. How-To’s 2.7 and 2.8 discuss the process 

of selecting a trainer, and how to continue the 

learning after the initial training is completed. 

Figure 2.2

Recommended Credentials for Individuals Providing Training in FASD 

•	Advanced education in counseling, social work, or psychology.

•	Minimum of 5 years’ experience delivering substance abuse and/or mental health treatment.

•	Being a qualified/experienced FASD Trainer.

•	Understanding of commitment to preparing counselors to provide FASD-informed services.

•	Possessing skills and experience in motivational interviewing, care coordination, and

accommodations to address FASD.

•	Meeting all certification or licensure qualifications and competencies for clinical supervisors.

•	Knowledge of the FASD intervention literature and scientifically-validated intervention

techniques.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

How-To 2.7: How to Select a Trainer 

Qualifications to look for in a trainer include the following:

1.	 Experience working with the clientele being served.

2.	 Ability to demonstrate the techniques as needed in role-play with staff or in-vivo (if possible).

3.	 Ability to address the types of challenging cases frontline staff encounter and how to work

with challenging clients.

4.	 Understanding of the obstacles and challenges with which the frontline staff and the clinical

supervisors are dealing.

5.	 Respectful attitude toward the clinical staff.

6.	 Models the principles and strategies of the intervention with the participants.

7.	 Ability to maintain and modify the technique for the treatment setting, willingness to review

transcripts or tapes of actual sessions, and willingness to consult on the phone.

8.	 Willingness to accept specific training objectives to target specific staff skill sets in a case

review format.

9.	 Knowledge of tested methods of FASD intervention and intervention literature.

See Appendix C, Public and Professional Resources on FASD, for links to organizations that

can provide training and/or trainers. The SAMHSA FASD Center for Excellence, the National

Organization on FAS (NOFAS), the Minnesota Organization on FAS (MOFAS), and the CDC’s

Regional Training Centers (RTCs) are good starting points.

How-To 2.8: How to Continue the Learning After the Initial Training is 

Completed 

1.	 Assess the staff’s knowledge, abilities, and skills with the core components of the techniques.

2.	 Check to see that staff continue to reframe the issues of individuals with FASD as being due

(in part) to underlying neurological impairment.

3.	 Emphasize mastery of the underlying principles of the interventions. Always give feedback on

how well staff members are doing with interventions and provide advice on simple ways to

improve practice.

4.	 Emphasize mastery of the common techniques across approaches (e.g., motivational interviewing, case coordination, accommodations, establishing boundaries, strengths-based

approaches).

5.	 When staff members have the basics, let them choose the approach they want to focus on

next (e.g., behavioral, cognitive, beliefs, affective, family-systems, solution-focused).

6.	 Explore with staff members their interest in learning specific validated FASD intervention

methods.
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

Addressing Community 

Relationships 

How Do You Develop Referral Relationships? 

Access to a range of other health and social 

resources is essential to quality care in substance abuse and mental health treatment 

settings, particularly for clients who have or 

may have an FASD. Agencies to which staff 

might refer can be screened using the following variables: 

•	 Willing to accept referral of clients who 

have or may have an FASD.

•	 Sensitive to substance use or mental 

health issues. 

•	 Able and willing to work with agencies 

such as ours, including regular review/

discussion of any collaborative issues.

•	 No or low funding impediments to working collaboratively. 

•	 Good professional reputation in the 

community. 

•	 Sufficient funding to address the needs of 

clients we are referring. 

•	 Willing to cross-train with our staff.

•	 Existing personal relationship with the 

referral agency.

Also, it is preferable if certain FASD capabilities are present in any agency to which you 

refer:

•	 Individualized service planning.

•	 Acceptance of disability.

•	 Recognition of strengths.

•	 Incorporating individual behaviors.

•	 More active involvement (transportation, 

personally ensuring client ‘hand-off,’ follow up, etc.).

•	 Services available to child and Mom 

(when the FASD is intergenerational).

•	 Flexibility in programming (modifications 

will be necessary; are they willing to make 

them?).

How Do You Develop Relationships With the 

12-Step Community? 

It is useful to have the program’s policy and 

procedures manual reflect an understanding 

of the essential role that 12-Step programs 

play in the treatment of clients with substance 

abuse complicated by FASD. Mental health 

personnel need to be sensitive and competent 

in integrating the principles and practices of 

self-help programs into the clinical process. 

This requires knowledge of the underlying 

philosophy of the 12-Step model, and an 

understanding of how the programs function 

and are structured. In like manner, counselors 

practicing from a 12-Step facilitation model 

need to appreciate how principles and practices are linked to sound counseling. 

For example, the use of slogans as a form of 

cognitive restructuring and debate is helpful 

to most clients. The use of structured practices 

like daily meetings, sponsor contact, and reading self-help group literature can help create 

alternate forms of reward, relief, and life-management. The policy should recognize barriers 

to individuals with an FASD accessing and 

using 12-Step programs, including:

•	 Whether the individual being referred 

requires a navigator to help them find 

meetings, attend them regularly and ontime, and participate appropriately;

•	 Insufficient social communication and 

social awareness skills on the part of the 

individual being referred; and

•	 Potential exploitation of the individual by 

other members of the group.

How Do You Find and Use Behavioral Health 

Resources in the Community? 

Most substance abuse and mental health 

programs can benefit from consulting relationships with physicians, psychologists, social 

workers, and other community medical, rehabilitation, social service, and mental health 

providers who have specialized knowledge and 
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

resources in addressing the needs of clients 

who have or may have an FASD. As indicated in Part 1, Chapter 2 in the table titled 

In-House FASD Assessment: An Ideal Core Team, 

important professional areas to focus on in 

building relationships include neuropsychology and speech language pathology, occupational therapy, physical therapy, and a primary 

care physician.

These professionals can provide adjunct 

resources for such issues as difficult assessments and differential diagnosis, placement 

in appropriate treatment programs and/or 

support groups, medical management of cooccurring chronic medical conditions, specialized psychopharmacological services for clients 

with an FASD, discharge planning, and family 

services.

Finding and using these resources may be 

different from finding and using referral 

resources. Understanding the services that can 

be provided, fees for service, whether the service can be provided in the treatment program 

or whether the client must travel to a remote 

site, and the processes for reporting results of 

evaluations are some of the issues that need to 

be considered in using community resources. 

Generally, unlike referral resources, community 

resources will not have a formalized contract 

or agreement with the treatment program. 

Therefore, issues of confidentiality and information reporting will need to be explored. 

Addressing Financial 

Considerations 

Billing 

Integration of FASD-informed services is 

intended to enhance treatment outcomes 

and, because these services are delivered by 

licensed and/or certified counselors who are 

modifying or offering tailored treatment, rather 

than changing the focus of treatment, such 

services are likely to be reimbursable under 

the client’s primary treatment diagnosis. In 

this case, individual sessions that incorporate 

accommodations for FASD may be billed as 

individual counseling, psychotherapy (interactive or regular), or family therapy associated 

with the primary diagnosis. Organizations 

are advised to clarify this with state, county, 

federal, and private funding sources and to 

identify the specific procedures required to 

facilitate billing. Financial considerations also 

reinforce the need for support staff responsible 

for billing to understand how these services 

are delivered and their relationship to the primary diagnosis.

For organizations reimbursed based on case 

or capitated rates, reimbursement is not likely 

to change. Services that incorporate FASD 

are likely to be viewed by managed care organizations or funding agencies as value-added 

or optional services and thus included in 

established rates of reimbursement. Although 

incorporating FASD-informed services is 

not likely to increase reimbursement rates, it 

may improve performance on contractually 

mandated outcomes such as treatment engagement, retention, and effectiveness.

In their document Operational Standards for 

Mental Health, Intellectual/Developmental 

Disabilities, and Substance Abuse Community 

Services Providers (2011), the state of 

Mississippi has developed operational standards that can help define and inform a state 

reimbursement system. They are reprinted 

in full in Appendix H, Operational Standards 

for Fetal Alcohol Spectrum Disorders (FASD): 

A Model. In addition, Part 3 of this TIP, the 

online literature review (http://store.samhsa.

gov/home), contains a discussion of reimbursement codes related to FASD, as well as 

the implications of the Patient Protection and 

Affordable Care Act.

Sources of Funding 

Most of the costs of implementing FASDinformed services occur early in the process 
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Chapter 2: Building an FASD Prevention- and Intervention-Capable Agency

of implementation, so local foundations are 

potential sources of funding. A one-time cost 

of training and knowledge dissemination to 

staff offers a discrete, relatively low-cost, and 

an attractive opportunity for local foundations to contribute to improving treatment 

outcomes. Applying collaboratively with other 

agencies demonstrates established partnerships, and should be pursued where possible. 

The Council on Foundations (www.cof.org) 

is an excellent starting point for identifying 

foundations near you and researching their 

missions. Other potential sources of funding 

include traditional state and federal grants 

and contracts, direct charges for services from 

third-party payors, and client fees for service.

Additionally, if the services provided are innovative (addressing FASD is an emerging area 

of care), agencies should consider partnering 

with social and psychological researchers at 

a local university to obtain research funds to 

support clinical efforts. Such research efforts 

can have many beneficial secondary effects 

for agency status in the community, such as 

developing alternative sources of funding, 

partnering with new groups interested in 

substance abuse or mental health issues in the 

community and/or creating learning communities, as well as providing funds for the 

identified project. 

Addressing Continuity and 

Fidelity 

For FASD-informed services to be fully 

adopted, the importance of these services 

will need to be consistently communicated. 

Policies, mission statements, program descriptions, clinical and administrative training, 

team meetings, and clinical supervision sessions are all useful avenues for communicating 

the organization’s commitment to delivering 

FASD-informed care (see Figure 2.3). If 

not formally revised, these policies should 

at least be reviewed to ensure that they are 

broad enough to encompass FASD-informed 

services.

Implementing the Intervention With Fidelity 

When implementing any intervention, it is 

important to identify the active elements 

that characterize that specific intervention. 

Ensuring that a new intervention is being 

implemented with fidelity, as distinguished 

from standard practice, allows administrators 

Figure 2.3 Avenues for Communicating Organizational Commitment to 

Delivering Services to Address FASD 

•	Mission and vision statements

•	Strategic plans

•	Annual goals

•	Program descriptions

•	Treatment philosophy statements

•	Policies and procedures

•	Training sessions

•	Team meetings

•	Clinical supervision

•	Management meetings

•	Quality assurance plans

•	Employee newsletters

•	Electronic communication vehicles including e-mail and Intranet
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

to more easily determine whether the new 

intervention is responsible for changes in 

expected outcomes. 

For FASD-informed care, fidelity can present challenges. Behavioral health fields are 

encouraged by federal agencies and funding organizations to use evidence-based 

approaches that have not been developed for, 

or accommodated to, FASD. Evidence-based 

approaches specifically tailored for FASD are, 

for now, limited, though some that have been 

developed and tested do have built-in fidelity 

monitoring mechanisms. 

Fortunately, the FASD evidence base is growing rapidly. There are several scientifically 

validated interventions now available. There is 

also expert clinical consensus and publications 

using systematic research review and synthesis 

that provide support for the interventions 

recommended in this TIP (e.g., Adubato & 

Cohen, 2011).

There is also precedent for tailoring interventions. For example, the past decade has 

brought methods for inclusion of trauma and 

other co-occurring disorders into treatment 

provision and planning into mental health 

and substance abuse treatment. This could be 

considered ‘trauma-informed’ care. Established 

practice (e.g., cognitive behavioral therapy, 

or CBT) has been altered and improved by 

informing standard care with methods to 

respond to these issues (e.g., trauma-focused 

CBT). The strategies that have been used to 

modify or transform practice with these issues 

in mind can be used by agencies to create 

FASD-informed care while still maintaining 

fidelity of existing practices.

To create FASD-informed care and demonstrate fidelity, agencies are encouraged to:

•	 Access reliable FASD prevention and 

intervention training (training resources 

provided in Appendix C).

•	 Use this TIP and/or other manualized 

approaches for FASD-informed care. 

Suggested resources for other manualized 

approaches include:

− The SAMHSA FASD Center 

for Excellence (primarily FASD 

intervention)

− The CDC (FASD prevention and 

intervention approaches)

− (http://www.cdc.gov/ncbddd/fasd/

training.html) 

•	 Use checklists provided in this 

Implementation Guide to conduct process and outcome measurement.

− If available, use fidelity checklists 

for other manualized approaches for 

FASD-informed care (be sure that 

fidelity checklists describe the active 

elements of an intervention and 

define them in behavioral terms).

•	 Where possible, and if not cost-prohibitive, bolster use of checklist(s) with direct 

observation of new clinical activities.

Some issues to be solved when implementing 

intervention fidelity monitoring:

•	 Which staff members measure specific 

parts of the checklist(s)?

•	 How are results conveyed to staff?

•	 How does a program define an acceptable 

fidelity score?

•	 How are positive results of the efforts 

measured by the checklist rewarded?

•	 What actions need to be taken if there 

is poor fidelity to program elements and 

goals?

•	 How are elements of checklist(s) updated 

over time, and when program changes 

occur?
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challenges. Disability & Society, 24(1), 103-115.

Zlotnick, C., Johnson, D. M., Stout, R. L., Zywiak, W. H., Johnson, J. E., & Schneider, R. J. 

(2006). Childhood abuse and intake severity in alcohol disorder patients. Journal of Traumatic 

Stress, 19(6), 949-959.
157

Appendix B—Selected 

Screening Instruments for 

Identifying Alcohol Use 

Among Women

[NOTE: Part 3 of this TIP, the online Literature Review, contains a full discussion of these and other alcohol screening instruments for use with women.]

T-ACE

The T-ACE is a 4-item instrument appropriate for detecting heavy alcohol use

in pregnant women (Sokol, Martier, & Ager, 1989). T-ACE uses the A, C, and E

questions from the CAGE screening tool and adds one on Tolerance for alcohol.

The first question assesses tolerance by asking if it takes more than it used to, to

get “high” (i.e., intoxicated). T-ACE has sensitivity equal to the longer Michigan

Alcohol Screening Test (MAST) and greater than the CAGE (Bradley, Bush,

McDonell, Malone, & Fihn, 1998). It has been validated only for screening pregnant

women with risky drinking (Russell, 1994).

1.	 How many drinks does it take for you to feel high? (Tolerance)

2.	 Have people Annoyed you by criticizing your drinking?

	 A) Yes	 B) No

3.	 Have you ever felt you ought to Cut down on your drinking?

	 A) Yes	 B) No

4.	 Have you ever had a drink first thing in the morning to steady your nerves or

get rid of a hangover? (Eye-opener)

	 A) Yes	 B) No

Scores

Any woman who answers more than two drinks on question 1 is scored 2 points.

Each “yes’” to the additional 3 questions scores 1. Scoring 2 or more is considered a positive screen (Chang, Wilkins-Haug, Berman, & Goetz, 1999), and the

woman should receive—or be referred to a specialist for—further assessment. At

the same time, a woman could drink 2 drinks per day during pregnancy and not

get a positive screen using this tool. She may not be at risk for alcoholism, but

because of her pregnancy she’s drinking at an unsafe level.

Sources:

•	 Bradley, K. A., Bush, K. R., McDonell, M. B., Malone, T., & Fihn, S. D. (1998). Screening for problem drinking: Comparison of CAGE and AUDIT. Ambulatory Care Quality Improvement Project

(ACQUIP). Alcohol Use Disorders Identification Test. Journal of General Internal Medicine, 13(6),

379–388.

•	 Chang, G., Wilkins-Haug, L., Berman, S., & Goetz, M. A. (1999). The TWEAK: Application in a prenatal setting. Journal of Studies on Alcohol, 60(3), 306–309.

•	 Russell, M. (1994). New assessment tools for risk drinking during pregnancy: T-ACE, TWEAK, and

others. Alcohol Health and Research World, 18(1), 55–61.

•	 Sokol, R. J., Martier, S. S., & Ager, J. W. (1989). The T-ACE questions: Practical prenatal detection of

risk drinking. American Journal of Obstetrics and Gynecology, 160(4), 863-870.
158

Addressing Fetal Alcohol Spectrum Disorders (FASD)

TWEAK

TWEAK (Russell, Czarnecki, Cowan, McPherson, & Mudar, 1991) identifies pregnant women who

are at risk for alcohol use. It consists of five items and uses a 7-point scoring system. In a study of

more than 3,000 women at a prenatal clinic, the TWEAK was found to be more sensitive than the

CAGE and Michigan Alcohol Screening Test (MAST), and more specific than the T-ACE (Russell et

al., 1996). The tolerance question scores 2 points for an answer of three or more drinks. However,

if the criterion for the tolerance question is reduced to two drinks for women, the sensitivity of

TWEAK increases, and the specificity and predictive ability decrease somewhat (Chang et al., 1999).

1.	 (T – Tolerance) How many drinks does it take for you to feel high?

2.	 (W – Worried) Does your partner (or do your parents) ever worry or complain about your

drinking? 

	 A) Yes	 B) No

3.	 (E – Eye-Opener) Have you ever had a drink first thing in the morning to steady your nerves

or get rid of a hangover? (Eye-opener)

	 A) Yes	 B) No

4.	 (A – Amnesia) Have you ever awakened the morning after some drinking the night before and

found that you could not remember part of the evening before?

	 A) Yes	 B) No

5.	 (K – K/Cut down) Have you ever felt that you ought to cut down on your drinking?

	 A) Yes	 B) No

Scores

A woman receives 2 points on question 1 if she reports that she can hold more than 5 drinks

without falling asleep or passing out. A positive response to question 2 scores 2 points, and a

positive response to each of the last 3 questions scores 1 point each. A total score of 2 or more

indicates that the woman is a risky drinker and requires further assessment. At the same time,

drinking at any level during pregnancy is unsafe, even if the woman scores negative with this tool.

Sources:

•	 Chang, G., Wilkins-Haug, L., Berman, S., & Goetz, M. A. (1999). The TWEAK: Application in a prenatal setting. Journal 

of Studies on Alcohol, 60(3), 306–309.

•	 Russell, M., Czarnecki, D. M., Cowan, R., McPherson, E., & Mudar, P.J. (1991). Measures of maternal alcohol use as predictors of development in early childhood. Alcoholism: Clinical & Experimental Research, 15(6), 991–1000.

•	 Russell, M., Martier, S. S., Sokol, R. J., Mudar, P., Jacobson, S., & Jacobson, J. (1996). Detecting risk drinking during

pregnancy: A comparison of four screening questionnaires. American Journal of Public Health, 86(10), 1435– 1439.

The CRAFFT Screening Interview

The CRAFFT is a behavioral health screening tool for use with children under the age of 21 and

is recommended by the American Academy of Pediatrics’ Committee on Substance Abuse for

use with adolescents. It consists of a series of six questions developed to screen adolescents for

high-risk alcohol and other drug use disorders simultaneously. It is a short, effective screening tool

meant to assess whether a longer conversation about the context of use, frequency, and other

risks and consequences of alcohol and other drug use is warranted. The questions should be asked

exactly as written.

Begin: “I’m going to ask you a few questions that I ask all my patients. Please be 

honest. I will keep your answers confidential.” 

Part A
159

Appendix B—Selected Screening Instruments for Identifying Alcohol Use Among Women

Sources:

•	 American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, fourth edition, text revision. Washington DC: American Psychiatric Association.

•	 Knight, J. R., Sherritt, L., Shrier, L. A., Harris, S. K., & Chang, G. (2002). Validity of the CRAFFT substance abuse screening test among adolescent clinic patients. Archives of Pediatrics & Adolescent Medicine, 156(6), 607-614.

•	 Knight, J. R., Shrier, L. A., Bravender, T. D., Farrell, M., Vander Bilt. J., & Shaffer, H. J. (1999). A new brief screen for adolescent substance abuse. Archives of Pediatrics & Adolescent Medicine, 153(6), 591-596.
160

Addressing Fetal Alcohol Spectrum Disorders (FASD)

AUDIT-C

The AUDIT-C comprises the first three questions of the World Health Organization (WHO) AUDIT. 

The AUDIT-C was first described in VA patients (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998; 

Bradley et al., 2003), but has now been validated in other U.S. clinical populations (Bradley et al., 

2007; Frank et al., 2008; Seale et al., 2006; Williams & Vinson, 2001).

 

Sources:

•	 Bradley, K. A., Bush, K. R., Epler, A. J., Dobie, D. J., Davis, T. M., Sporleder, J. L., Maynard, C., Burman, M. L., &

Kivlahan, D. R. (2003). Two brief alcohol-screening tests From the Alcohol Use Disorders Identification Test (AUDIT):

Validation in a female Veterans Affairs patient population. Archives of Internal Medicine, 163(7), 821-829.

•	 Bradley, K. A., DeBenedetti. A. F., Volk, R. J., Williams, E. C., Frank, D., & Kivlahan, D. R. (2007). AUDIT-C as a brief

screen for alcohol misuse in primary care. Alcoholism: Clinical and Experimental Research, 31(7), 1-10.

•	 Bush, K., Kivlahan, D. R., McDonell, M. B., Fihn, S. D., & Bradley, K. A. (1998). The AUDIT alcohol consumption questions

(AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789-195.

•	 Frank, D., Debenedetti, A. F., Volk, R. J., Williams, E. C., Kivlahan, D. R., & Bradley, K. A. (2008). Effectiveness of the

AUDIT-C as a screening test for alcohol misuse in three racial/ethnic groups. Journal of General Internal Medicine, 23(6), 

781-787.

•	 Seale, J. P., Boltri, J. M., Shellenberger, S., Velasquez, M. M., Cornelius, M., Guyinn, M., Okosun, I., & Sumner, H. (2006).

Primary care validation of a single screening question for drinkers. Journal of Studies on Alcohol and Drugs, 67(5), 

778-784.

•	 Williams, R., & Vinson, D. C. (2001). Validation of a single screening question for problem drinking. The Journal of Family 

Practice, 50(4), 307-312.
161

Appendix C—Public and 

Professional Resources on 

FASD

The SAMHSA FASD Center for Excellence

SAMHSA FASD Center for Excellence

www.fasdcenter.samhsa.gov

The official site of the SAMHSA FASD Center for Excellence provides information

and resources about FASD, as well as awareness materials, a fully searchable

database, and access to training, technical assistance, and conference/event

speakers.

National Association of FASD State Coordinators

http://fasdcenter.samhsa.gov/statesystemsofcare/nafsc.aspx

The SAMHSA FASD Center for Excellence helped to establish the National

Association of FASD State Coordinators (NAFSC) in 2003 to support state-based

efforts to increase the system of care available to individuals with an FASD and

their families. NAFSC’s mission is to promote prevention, treatment, and care

systems for FASD, nationwide, through collaboration with systems within their

respective states and among member states. The site provides updates on current

activities, a roster of current members, and full contact information.

Assessment and Diagnosis

National Organization on FAS (NOFAS)

www.nofas.org

NOFAS is a leading voice and resource for the FASD community, and was one

of the first. Founded in 1990, NOFAS is still the only international non-profit

organization committed solely to FASD primary prevention, advocacy, and

support. NOFAS has 30 affiliate programs around the country, and provides a

Resource Directory to help locate FASD-related services. Also see Information and 

Training, below.
162

Addressing Fetal Alcohol Spectrum Disorders (FASD)

University of Washington: FAS Diagnostic & Prevention Network

http://depts.washington.edu/fasdpn/

The Washington State FAS Diagnostic & Prevention Network (FAS/DPN) is a network of four

WA State community-based interdisciplinary FASD diagnostic clinics linked by the core clinical/

research/training clinic at the Center on Human Development and Disability at the University of

Washington in Seattle. The network was established in 1993. Each clinic in the network uses the

same interdisciplinary approach to diagnosis and the same systematic diagnostic method; the

4-Digit Diagnostic Code. The mission of the FAS DPN is primary and secondary prevention of

FAS through screening, diagnosis, intervention, training, education, and research. The FAS DPN

began diagnosing patients in 1993, and has diagnosed over 2,000 patients to date. See also

Information and Training, below.

Grant Opportunities

SAMHSA Grant Opportunities

http://www.samhsa.gov/grants/

SAMHSA’s grant management site allows applicants and prospective applicants to review

Requests for Application (RFA’s) from each of SAMHSA’s sub-agencies, submit applications

online, track application status, review reporting requirements, and manage the activity of

awarded grants.

Grants.gov

www.grants.gov

Grants.gov was established as a governmental resource named the E-Grants Initiative, part of the

President’s 2002 Fiscal Year Management Agenda to improve government services to the public.

Today, Grants.gov is a central storehouse for information on over 1,000 grant programs and

provides access to approximately $500 billion in annual awards. The site is searchable by agency,

keyword, and a variety of other variables.

Information and Training

Families Moving Forward

http://depts.washington.edu/fmffasd/

The Families Moving Forward Program intervention is a scientifically validated behavioral

consultation program tailored for families raising preschool and school-aged individuals with

FASD or confirmed prenatal alcohol exposure. The intervention includes methods and materials

that appropriately trained counselors can use when working with families of a client who has an

FASD. Training on FASD intervention, and on the Families Moving Forward Program, is regularly

available through the East Coast (Florida) or West Coast (Seattle) training centers, or on-site at

an agency location in the United States, Canada, or elsewhere. Once training is completed, all

materials are freely available on a Web site to be downloaded.

The FASD Information Page of the Centers for Disease Control and Prevention (CDC)

http://www.cdc.gov/ncbddd/fasd/

The CDC’s FASD page offers extensive information on the background of FASD, diagnosis and

treatment, and training and educational materials, as well as access to articles, print materials,

and multimedia tools for raising awareness.
163

Appendix C—Public and Professional Resources on FASD

FASD Regional Training Centers

http://www.cdc.gov/ncbddd/fasd/index.html

The CDC’s FASD Regional Training Centers (RTCs) develop, implement, and evaluate educational

curricula regarding FASD prevention, identification, and care, and incorporate the curricula into

training programs at each grantee’s university or college, into other schools throughout their

regions, and into the credentialing requirements of professional boards. Check the site for links

to specific, currently-active regional sites. Currently funded regional sites include the following:

•	Southeastern FASD Regional Training Center

•	Arctic FASD Regional Training Center

•	Frontier FASD Regional Training Center

The National Institute on Alcohol Abuse and Alcoholism

http://www.niaaa.nih.gov

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) is one of the 27 Institutes and

Centers that comprise the National Institutes of Health (NIH), a component of HHS. NIAAA is

the primary U.S. agency for conducting and supporting research on the causes, consequences,

prevention, and treatment of alcohol abuse, alcoholism, and alcohol problems, including health

effects such as FASD. NIAAA disseminates research findings to general, professional, and

academic audiences. The Web site has links to relevant NIAAA publications. The FASD-specific

Web link at NIAAA is http://www.niaaa.nih.gov/research/major-initiatives/fetal-alcoholspectrum-disorders. This page also links to overviews of the activities of NIAAA’s Interagency

Coordinating Committee on FASD (ICCFASD).

National Organization on FAS (NOFAS)

www.nofas.org

NOFAS is a leading voice and resource for the FASD community, and was one of the first.

Founded in 1990, NOFAS is still the only international non-profit organization committed solely

to FASD primary prevention, advocacy, and support. The official site provides access to materials

for educators, healthcare professionals, expectant mothers, and individuals and families living

with an FASD. Also see Assessment and Diagnosis, above.

University of Washington FAS/DPN Training

http://depts.washington.edu/fasdpn/htmls/training.htm

In addition to assessment and diagnostic services, the University of Washington’s FAS/DPN offers

1-day trainings on screening, diagnosis, treatment planning, and primary prevention of FASD,

and also 2-day and online trainings for interdisciplinary clinical teams (or individual clinical team

members) seeking to establish a FASD Diagnostic Clinic in their community.
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Addressing Fetal Alcohol Spectrum Disorders (FASD)

Research and Journal Articles

Appendix A of this TIP contains an extensive bibliography for further reading on FASD, and Part

3 of this TIP, the online Literature Review (http://store.samhsa.gov/home), contains its own

bibliography. In addition, the following Web sites and journals are excellent resources for further

literature on FASD and related issues.

Alcohol

http://www.sciencedirect.com/science/journal/07418329/44/7-8

In 2010, the journal Alcohol published two issues devoted entirely to FASD diagnosis and

intervention (Volume 44, issues 7-8). Together, these issues contain 16 articles, all of which can be

accessed via the link above. Note: There is a cost for each article.

The Collaborative Initiative on FASD (CIFASD)

http://cifasd.org/

The Collaborative Initiative on FASD (CIFASD) is a consortium dedicated to informing and

developing effective interventions and treatment approaches for FASD through multidisciplinary

research involving basic, behavioral, and clinical investigators and projects. The Web site contains

an extensive bibliography of recent FASD-related literature (2004 to the present). Many of the

bibliographic items link to full abstracts through PubMed, but full articles must be purchased.

The Journal of Psychiatry & Law

http://www.federallegalpublications.com/journal-of-psychiatry-law/ 

The Winter 2010 (Volume 38, issue 4) and Spring 2011 (Volume 39, issue 1) issues of

The Journal of Psychiatry & Law are devoted entirely to FASD-related issues, ranging from

intervention approaches, to addressing FASD in the criminal justice system, to FASD as an

adoption disclosure issue. A full listing of the articles is contained at the Volume links above.

Note: There is a cost for each full issue.

Research Search Engines

Both the SAMHSA FASD Center for Excellence and NOFAS offer free online search engines that

can be used to access FASD-related literature by author, title, keywords, or topic area.

Support Networks for Individuals with an FASD and Their Families

Birth Mothers Network

http://www.nofas.org/join-the-circle-of-hope/

The Birth Mothers Network, also known as the Circle of Hope, was founded through NOFAS in

2004. It is a network of women who have consumed alcohol during pregnancy and may have a

child or children with an FASD. Members are lovingly referred to as “Warrior Moms” because of

their incredible strengths. Many of the women are in recovery from alcoholism, or alcohol and

drug addiction. However, the network also includes women without the disease of addiction, but

who drank alcohol during pregnancy. The women of the Birth Mothers Network serve as mentors

to one another, help each other cope with the challenges of parenting a child with an FASD, and

provide caring, non-judgmental support to members who are in recovery.
165

Living With FASD

http://www.nofas.org/living

The Living With FASD page is provided by NOFAS, and contains links to financial assistance

programs such as Supplemental Security Income (SSI) and Social Security Disability Insurance

(SSDI) (both can be contacted at 1-800-772-1213), and Medicaid, as well as family and mother

support programs such as Women, Infants and Children (WIC).

Additional Support Sites

In addition to research and general information, each of the following sites provides access to

other members of the FASD community, as well as parenting guidance, personal stories from

others who are coping with FASD, and guides to services.

•	The FAS Community Resource Center

http://www.come-over.to/FASCRC/

•	FASlink

http://www.faslink.org/

•	One-Stop Centers

http://www.careeronestop.org/

One-Stop Centers are Internet job sites that can provide links to your state Department of Labor

and Workforce Development, the local division for vocational rehabilitation services, and/or

specific state initiatives for development of customized employment for people with disabilities.

Appendix C—Public and Professional Resources on FASD
166

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Appendix D—The FASD 

4-Digit Code Caregiver 

Interview Checklist: Profiles 

of FASD

The form below was developed by the Washington State FAS Diagnostic and 

Prevention Network (FAS DPN), and is part of the 4-Digit Diagnostic Code

(Astley, 2004). The caregivers of all patients receiving an FASD diagnostic evaluation in the Washington State FAS DPN clinics participate in a 2-hour interview 

with the pediatrician and psychologist. The purpose of the interview is to identify 

areas of significant delay/impairment across a wide array of functional domains. 

The article Profile of the First 1,400 Patients Receiving Diagnostic Evaluations 

for Fetal Alcohol Spectrum Disorder at the Washington State Fetal Alcohol Syndrome 

Diagnostic & Prevention Network, by Dr. Susan Astley (2010), provides a graphical summary of the first 1,400 caregiver interviews conducted by the FAS DPN 

clinics. Presented is the proportion of patients classified by the pediatrician as 

“significantly delayed/impaired” in behaviors addressed in a 2-hour, structured 

caregiver interview administered jointly by the pediatrician and psychologist during the FASD diagnostic evaluation. This graphical presenta-tion illustrates the 

cumulative increase in impairment as one advances across the FASD diagnostic 

groups. The illustration is color-dependent and too complex to present in this 

TIP. However, readers are encouraged to access the article at the following link: 

http://depts.washington.edu/fasdpn/pdfs/astley-profile-2010.pdf

The FASD 4-Digit Code Caregiver Interview Checklist

Severity Score: Severity of Delay/Impairment (Displayed along left margin) 

Circle: 0 = Unknown, Not Assessed, Too Young 1 = Within Normal Limits 2 = Mild 

to Moderate 3 = Significant 

 

 

 

 

 
167

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source: Astley, S. J. (2004). Diagnostic guide for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code, Third Edition. 

Seattle, WA: University of Washington. Accessed June 1, 2012 at http://depts.washington.edu/fasdpn/pdfs/FASD-2004-

Diag-Form-08-06-04.pdf. Used with permission from the author. 

Appendix D—The FASD 4-Digit Code Caregiver Interview Checklist: Profiles of FASD
168

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Appendix E—Comparison 

of Current FASD Diagnostic 

Systems

Fetal Alcohol Syndrome (FAS) is a permanent birth defect syndrome caused by 

maternal consumption of alcohol during pregnancy. Almost four decades have 

passed since the term FAS was first coined. The condition is now recognized as 

a spectrum of disorders: Fetal Alcohol Spectrum Disorders (FASD). Substantial 

progress has been made in developing specific criteria for delineating diagnoses 

under the umbrella of FASD. In the 14 years since the publication of the seminal report on FAS by the Institute of Medicine in 1996, clear consensus has 

been reached on two fundamental issues: 1) an FASD diagnostic evaluation is 

best conducted by a team of professionals from multiple disciplines (medicine, 

psychology, speech-language, occupational therapy) and 2) the team should use 

rigorously case-defined and validated FASD diagnostic guidelines.

In 2011, Dr. Susan Astley wrote a chapter on Diagnosing FASD in a book entitled Prenatal Alcohol Use and Fetal Alcohol Spectrum Disorders: Diagnosis, Assessment 

and New Directions in Research and Multimodal Treatment (Astley, 2011). This 

chapter provided a brief overview of the discovery of FASD, diagnostic challenges, how diagnostic guidelines and clinical models have evolved over time to 

address these challenges, and how new technology may influence the future of 

FASD diagnosis. The tables below come from that chapter, and provide a sideby-side comparison of the five most commonly used diagnostic guidelines for 

forms of FASD; the 4-Digit Diagnostic Code (Astley, 2004b), the guidelines 

developed by the Centers for Disease Control and Prevention (Bertrand et al., 

2004), the Canadian guidelines (Chudley et al., 2005), the revised guidelines of 

the Institute of Medicine (IOM) (Hoyme et al., 2005), and the original IOM 

guidelines (Stratton et al., 1996). Table 1 compares diagnostic criteria for FAS; 

Table 2, pFAS; Table 3, ARND; and Table 4, ARBD. These tables are reprinted 

here with the permission of the author.

It is important to note that, for the purposes of this Appendix, the 4-Digit 

Diagnostic Code has been translated, as best as possible, into a text (rather than 

numeric) format. This was done to facilitate comparison to the other guidelines 

that publish their diagnostic criteria in text format. Diagnostic teams should not 

use the textual translations of the 4-Digit Code presented in Tables 1-4 to derive 

a 4-Digit Code, but rather the numeric format presented in the Diagnostic Guide 

for Fetal Alcohol Spectrum Disorders: The 4-Digit Diagnostic Code, Third Edition 

(Astley, 2004a).
169

Table 1. FAS Diagnostic Criteria: Comparison Across the Five Most Current 

FASD Diagnostic Guidelines

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Appendix E— Comparison of Current FASD Diagnostic Systems
170

Addressing Fetal Alcohol Spectrum Disorders (FASD)

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a. 4-Digit Code: Domains may include, but are not limited to: executive function, memory, 

cognition, social/adaptive skills, academic achievement, language, motor, attention, or activity 

level.

b. CDC: Performance substantially below that expected for an individual’s age, schooling, 

or circumstances, as evidenced by: 1) Global cognitive or intellectual deficits representing 

multiple domains of deficit (or significant developmental delay in younger children) with 

performance below the 3rd percentile (2 standard deviations below the mean for standardized testing) or 2) Functional deficits below the 16th percentile (1 standard deviation below 

the mean for standardized testing) in at least three of the following domains: a) cognitive or 

developmental deficits or discrepancies b) executive functioning deficits c) motor functioning 

delays d) problems with attention or hyperactivity e) social skills f ) other, such as sensory 

problems, pragmatic language problems, memory deficits, etc.

c. Canadian: Impairment indicates scores > 2 SDs below the mean, discrepancies of 1.5-2 SDs 

among subtests, or > 1 SD discrepancy between subdomains.

Table 2: Partial FAS Diagnostic Criteria: Comparison Across the Five Most 

Current FASD Diagnostic Guidelines

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Appendix E— Comparison of Current FASD Diagnostic Systems

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Addressing Fetal Alcohol Spectrum Disorders (FASD)

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a. The CDC Guidelines only address FAS.

b. 4-Digit Code: Domains may include, but are not limited to: executive function, memory, 

cognition, social/adaptive skills, academic achievement, language, motor, attention, or activity 

level. 

c. Canadian: Impairment indicates scores > 2 SDs below the mean, discrepancies of 1.5 to 2 

SDs among subtests, or > 1 SD discrepancy between subdomains.

d. Hoyme: Marked impairment in the performance of complex tasks (complex problem solving, 

planning, judgment, abstraction, metacognition, and arithmetic tasks); higher-level receptive and expressive language deficits; and disordered behavior (difficulties in personal manner, emotional lability, motor dysfunction, poor academic performance, and deficient social 

interaction).

e. IOM: Complex pattern of behavior or cognitive abnormalities that are inconsistent with 

developmental level and cannot be explained by familial background or environment alone: 

e.g., learning difficulties; deficits in school performance; poor impulse control; problems in 

social perception; deficits in higher level receptive and expressive language; poor capacity for 

abstraction or metacognition; specific deficits in mathematical skills; or problems in memory, 

attention or judgment.

Table 3. ARND (or its equivalent: Static Encephalopathy/Alcohol Exposed or 

Neurobehavioral Disorder/Alcohol Exposed) Diagnostic Criteria: Comparison 

Across the Five Most Current FASD Diagnostic Guidelines

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Appendix E— Comparison of Current FASD Diagnostic Systems

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Addressing Fetal Alcohol Spectrum Disorders (FASD)

a. The CDC Guidelines only address FAS.

b. 4-Digit Code: Domains may include, but are not limited to: executive function, memory, 

cognition, social/adaptive skills, academic achievement, language, motor, attention, or activity 

level. MRI research confirms Neurobehavioral Disorder/Alcohol Exposed is a distinct, clinically meaningful subclassification under the umbrella of FASD [6]. 

c. Canadian: Impairment indicates scores > 2 SDs below the mean, discrepancies of 1.5-2 SDs 

among subtests, or > 1 SD discrepancy between subdomains. 

d. Hoyme: Marked impairment in the performance of complex tasks (complex problem solving, 

planning, judgment, abstraction, metacognition, and arithmetic tasks); higher-level receptive and expressive language deficits; and disordered behavior (difficulties in personal manner, emotional lability, motor dysfunction, poor academic performance, and deficient social 

interaction). 

e. IOM: Complex pattern of behavior or cognitive abnormalities that are inconsistent with 

developmental level and cannot be explained by familial background or environment alone: 

e.g., learning difficulties; deficits in school performance; poor impulse control; problems in 

social perception; deficits in higher level receptive and expressive language; poor capacity for 

abstraction or metacognition; specific deficits in mathematical skills; or problems in memory, 

attention or judgment.

Table 4. ARBD Diagnostic Criteria: Comparison Across the Five Most Current 

FASD Diagnostic Guidelines

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175

Appendix E— Comparison of Current FASD Diagnostic Systems

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•	

•	
176

Addressing Fetal Alcohol Spectrum Disorders (FASD)

a. The 4-Digit Code and Canadian Guidelines do not recognize ARBD as a FASD diagnostic 

classification.

b. The CDC Guidelines only address FAS.
177

Appendix F—Sample Crisis/

Safety Plan 

The following is a suggested Crisis/Safety Plan that can be used with a client 

who has or may have an FASD, or with a family member or caregiver of the client. The plan is designed to help identify safety concerns for the client, actions 

that can be taken to prevent or address those concerns, and support persons that 

can assist.

If you have access to an electronic version of this TIP, consider printing this and 

the following page back-to-back as a way to reproduce the form for your use. 

This form has been adapted from materials in the Families Moving Forward 

Program (http://depts.washington.edu/fmffasd/). Check their Web site for 

additional resources.

Client Crisis/Safety Plan

Client’s Name: 																																																																		 

Caregiver(s): 

Legal Guardian(s): 

Provider/Counselor: 

1.	 List the crisis or safety concerns for the client and other family members/

caregivers.

 No crisis or safety concerns were identified. Clients were given appropriate 

resources. Item #2 below was filled out.

2.	 List formal and informal supports. These can be family, friends, respite

providers, social workers, community supports such as faith-based

organizations (and so on). These are people available to help with crisis/

safety concerns. (Fill out even if there are no current concerns.)
178

Addressing Fetal Alcohol Spectrum Disorders (FASD)

3.	 How can these support people help during a crisis?

Name: 																																																																																		 

	 Action: 

Name: 																																																																																		 

	 Action: 

Name: Phone: 

	 Action: 

Name: Phone: 

	 Action: 

4.	 Steps for the crisis plan. (Use if safety concerns are immediate or the situation could get out 

of hand. Describe what might happen and what you’d do. Include phone numbers of people 

you would call.) 

IF THERE IS A MEDICAL EMERGENCY, CALL 911.

5.	 Local Crisis Line number: 

This is only a suggested action plan. Input from other service providers should be taken into

account. This can include therapists, doctors, and emergency services.

This sample Crisis/Safety Plan was developed as part of the Families Moving Forward Program and adapted for this TIP with

permission of the authors.
179

Appendix G—Services and 

Supports Checklist

Counselors can provide invaluable assistance to the family/caregivers of an individual who has or may have an FASD, or to their client with FASD, by helping 

them access appropriate services and supports. Below is a comprehensive checklist that can help a counselor and client identify what supports are needed, and 

choose what community resources are realistic as linkages. 

If you have access to an electronic version of the TIP, consider printing this and 

the following page back-to-back to use with clients as an efficient worksheet. 

This form has been adapted from materials in the Families Moving Forward 

Program (http://depts.washington.edu/fmffasd). Check their Web site for more 

resources.

Services and Supports Checklist

Client’s Name: Date: 

Which of the following would you like to look into?

Material and Financial Assistance and Resources

_____Government/financial assistance (SSI, WIC, etc.)

_____Low-cost housing

_____Adoption funding

_____Developmental disabilities funding

Information and Advocacy Resources

_____Advocacy services

_____Case management services

_____Diagnostic and evaluation services (FASD/non-FASD)

_____Guardian/future planning services

_____Information and referral services

_____Parent/family training, parenting classes

_____Legal services/assistance

Health and Mental Health Resources

Health/mental health care financial support

Medication evaluation
180

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Mental health services

Alcohol and drug treatment/recovery programs

Family planning/contraceptive resources

Substance abuse education for children

Childcare and Respite Resources

In-home respite/sitter services

Out-of-home respite services

Daycare

Crisis Lines and Response Teams

Crisis lines/response teams

Crisis response teams

Child protective services

Other crisis resources

Mentor and Support Groups and Resources

FASD caregiver/family support groups

FASD self-advocacy resources

Birth mother network

Other types of support groups

Sibling support groups

Parent-to-parent support (formal and informal)

Mentor programs

Recreational activities

Recovery supports

Other support resources

Educational Services and Job Resources

Special education and other accommodation programs

School-based treatment/therapeutic services

Behavior management assistance

Tutoring

Educational advocacy services

Vocational rehabilitation

Vocational or job counseling/coaching

Internet and Educational Resources

Information on FASD and FASD supports

E-mail lists (for? )

Internet sites (about? )

Other brochures, books (about? )

OTHER

Juvenile justice services

Representative (or protective) payee services

This checklist was developed as part of the Families Moving Forward Program, and is adapted for this TIP with permission

of the authors.
181

Appendix H—Operational 

Standards for Fetal Alcohol 

Spectrum Disorders (FASD): 

A Model

The state of Mississippi has developed operational standards addressing FASD 

that can potentially help define and inform other state reimbursement systems. 

The following selected standards are taken from the Mississippi Department 

of Mental Health’s Operational Standards for Mental Health, Intellectual/

Developmental Disabilities, and Substance Abuse Community Service Providers, published January 2011.

•	 XVI.D.1. Fetal alcohol spectrum disorders (FASD) is an umbrella term 

describing the range of effects that can occur in an individual whose mother 

drank alcohol during pregnancy. These effects may include physical, mental, 

behavioral, and/or learning disabilities with possible lifelong implications. 

Behavioral or cognitive problems may include intellectual disability, learning 

disabilities, attention deficits, hyperactivity, poor impulse control, and social, 

language, and memory deficits. FASD occurs in about 1% of all live births, 

or about 450 to 500 new cases in Mississippi per year. The damage caused 

by prenatal alcohol exposure is permanent. The effects cannot be reversed, 

but many of them can be treated with the appropriate combination of 

interventions and support. Secondary disabilities of FASD include mental 

health issues (90%), school problems (60%), trouble with the law (60%) and 

attempted suicide (23%). Early identification and diagnosis of children with 

an FASD can help ensure appropriate treatment which in turn will help 

reduce the occurrence and impact of these secondary disabilities. 

•	 XVI.D.2. Children ages birth to age 18 must be screened within six 

(6) months of Intake to determine if there is a need for a Fetal Alcohol 

Spectrum Disorders (FASD) diagnostic evaluation. Youth ages 18 to 24 may 

be screened for an FASD if the provider has reason to believe that there was 

prenatal alcohol exposure.

•	 XVI.D.3. The FASD screening tool1 will be provided by the Division of 

Children and Youth Services (see the DMH Record Guide). The screening 

may be conducted by a case manager, a therapist, or other children’s mental 

health professional. 

•	 XVI.D.5. Results of the FASD screening and FASD diagnostic evaluations, 

if indicated, must be reflected in the child’s Individual Service Plan and/or 
182

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Case Management Service 185 Plan. If a child receives a fetal alcohol-related diagnosis, it 

should be recorded on the appropriate Axis. 

•	 XVI.D.6. If a child’s initial FASD screening result is negative and if additional information 

regarding maternal alcohol history is obtained that might change the results of the initial 

FASD screen from negative to positive for possible prenatal alcohol exposure, the result of 

the initial screening must be revised on the FASD Screening Form to reflect this change 

and a diagnostic evaluation must be sought.

•	 XVI.D.7. With consent obtained from the parent/legal guardian, children who receive a 

positive FASD screen should be referred to the Child Development Clinic at the University 

of Mississippi Medical Center or other multi-disciplinary children’s clinic qualified to 

diagnose FASD for a diagnostic evaluation. With consent obtained from the parent/legal 

guardian, best practice requires a provider staff person to accompany the child and parent/

guardian to the diagnostic appointment in order to participate in the child’s history interview and the informational interview. If this best practice is not followed, the child’s record 

must be documented to show the effort put forth by the staff person to attend the diagnostic appointment and the reason this did not occur. A copy of the full diagnostic report must 

be placed in the child’s record. 

•	 XVI.D.8. Treatments and interventions recommended by the FASD multi-disciplinary 

diagnostic team must be either provided or facilitated by the CMHC. Referral to the local 

MAP Team should be made when appropriate. 

•	 XVI.D.9. Because children with an FASD often are not able to respond to traditional 

mental health services and/or treatments, children’s mental health services may need to 

be modified in order to be more effective for children with an FASD. FASD services and 

service modifications must be documented in the child’s record.

1 The FASD screening tool referred to in operational standard XVI.D.3 is available on pp. 129-131 of the Department of 

Mental Health Record Guide for Mental Health, Intellectual and Developmental Disabilities, and Substance Abuse Community 

Providers, 2012 Revision (http://www.dmh.state.ms.us/pdf/DMH%20Record%20Guide%202012%20Revision.pdf), published by the Mississippi Department of Mental Health. The tool is less extensive than the FASD 4-Digit Code Caregiver 

Interview Checklist included in Part 1, Chapter 2 of this TIP, and is intended primarily for use with children (although it is suggested for limited use with individuals ages 18-24).
183

Appendix I—Stakeholders 

Meeting Participants

Sally Anderson, Ph.D.

Special Assistant to Deputy Director, 

National Institute on Alcohol 

Abuse and Alcoholism

Jacquelyn Bertrand, Ph.D.

Behavioral Scientist, Centers for 

Disease Control and Prevention

Sterling K. Clarren, M.D., FAAP

Chief Executive Officer and Scientific 

Director, Canada NW FASD 

Research Network; Clinical 

Professor of Pediatrics, University 

of British Columbia; Clinical 

Professor of Pediatrics, University 

of Washington; TIP Co-Chair

Carolyn Hartness

FASD Project Specialist, Northwest 

Portland Area Indian Health Board

Lynne Haverkos, M.D., M.P.H.

Medical Officer, National Institute 

of Child Health and Human 

Development

John H. McGovern, M.G.A.

Senior Public Health Analyst, 

Health Resources and Services 

Administration

Sara Messelt 

Executive Director, Minnesota 

Organization on Fetal Alcohol 

Syndrome

Kathleen Mitchell, M.H.S., LCADC 

Vice President and National 

Spokesperson, National 

Organization on Fetal Alcohol 

Syndrome

Melinda M. Ohlemiller, M.A.

Chief Executive Officer, Nurses 

for Newborns Foundation; TIP 

Co-Chair

Feng Zhou, Ph.D. 

Past President, FASD Study Group; 

Professor, Indiana University 

School Medicine

Center for Substance 

Abuse Treatment

Sharon Amatetti, M.P.H. 

Public Health Analyst, Division of 

Services Improvement, Center for 

Substance Abuse Treatment

Christina Currier 

Project Officer, CSAT Knowledge 

Application Program, Division of 

Services Improvement, Center for 

Substance Abuse Treatment
184

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Richard T. Kopanda, M.A.

CSAT Deputy Director, Center for Substance 

Abuse Treatment

Linda White-Young, M.S.W., LC SW 

Public Health Advisor, Division of Services 

Improvement, Center for Substance Abuse 

Treatment

Center for Substance Abuse 

Prevention

Jon Dunbar-Cooper, M.A., CPP

Task Order Officer, SAMHSA FASD Center 

for Excellence, Division of Systems 

Development, Center for Substance Abuse 

Prevention

Patricia Getty, Ph.D. 

Deputy Task Order Officer, SAMHSA FASD 

Center for Excellence, Division of Systems 

Development, Center for Substance Abuse 

Prevention

CDR Josefine Haynes-Battle, R.N., B.S.N., 

M.S.N.

Past Deputy Task Order Officer, SAMHSA 

FASD Center for Excellence, Division 

of Systems Development, Center for 

Substance Abuse Prevention 

Mike Lowther, M.A.

Acting Deputy Director, Center for Substance 

Abuse Prevention

Virginia Mackay-Smith, M.P.H.

Director, Division of Systems Development, 

Center for Substance Abuse Prevention

Center for Mental Health 

Services

Anna Marsh, Ph.D.

Deputy Director, Center for Mental Health 

Services

Deborah Stone, Ph.D.

Social Science Analyst, Center for Mental 

Health Services (Retired)
185

Appendix J—Field Reviewers

Susan Adubato, Ph.D.

Director, Northern New Jersey FAS 

Diagnostic Center

Director, New Jersey/North East 

FASD Education and Research 

Center, University of Medicine 

and Dentistry of New Jersey, New 

Jersey Medical School

Newark, NJ

Sally Anderson, Ph.D.

Special Assistant to Deputy Director

National Institute on Alcohol Abuse 

and Alcoholism

Rockville, MD

Susan Astley, Ph.D.

Professor of Epidemiology/Pediatrics, 

University of Washington

Director, WA State FAS Diagnostic & 

Prevention Network

Seattle, WA

Michael Baldwin, M.N.S.

Alaska Mental Health Trust Authority

Anchorage, AK 

Jacqueline Bertrand, Ph.D.

Psychologist

Centers for Disease Control and 

Prevention

Atlanta, GA

Eileen B. Bisgard, J.D.

Project Director

Seventeenth Judicial FASD Project

Brighton, CO

Anthony Bullock

Hattiesburg, MS

Janet S. Burtt, M.A.

Southern California Alcohol & Drug 

Programs, Inc.

Downey, CA

Melissa Clarke

Lissie’s Luv Yums

Great Falls, MT

Deborah E. Cohen, Ph.D.

Director, Office for Prevention 

of Mental Retardation and 

Developmental Disabilities, State 

of New Jersey (Retired)

Longboat Key, FL

Randolph Crawford

Norman, OK

Leah Davies

TOPDD

Austin, TX
186

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Mary DeJoseph, D.O.

Doctor 

New Jersey FASD Education and Research 

Center

Palmyra, NJ

Thomas Ebert, M.S.S.W., Ph.D.

ARC Community Services, Inc.

Madison, WI

Louise Floyd, R.N., D.S.N.

Team Leader/Behavioral Scientist

Fetal Alcohol Syndrome Prevention Team

National Center for Birth Defects and 

Developmental Disabilities

Centers for Disease Control and Prevention

Atlanta, GA

Sid Gardner, M.P.A.

President

Children and Family Futures

Irvine, CA

Julie Gelo

Trainer/Consultant/Advocate/Parent

Executive Director, NOFAS Washington

Support Person, Self Advocates with FASD in 

Action

Bothell, WA

Linda Grant

Evergreen Manor

Everett, WA

Therese Grant, Ph.D.

Ann Streissguth Endowed Professor in Fetal 

Alcohol Spectrum Disorders Director, 

Fetal Alcohol and Drug Unit

University of Washington School of Medicine 

Seattle, WA

Cecily Hardin, M.S.W.

FASD Project Coordinator 

Child Guidance Center

Jacksonville, FL

Patricia A. Harrison, Ph.D.

Research Director

Minneapolis, MN

Trisha Hinson, M.Ed., CMHT

FASD State Coordinator/Project Director

Mississippi Department of Mental Health

Brandon, MS

Sr. Johnelle Howanach

Lissie’s Luv Yums

Great Falls, MT

Catherine Hutsell, M.P.H.

Health Education Specialist

FAS Prevention Team

National Center on Birth Defects and 

Development Disorders

Centers for Disease Control and Prevention

Atlanta, GA

Wendy O. Kalberg, M.A., CED

Senior Program Manager

UNM CASAA

Albuquerque, NM

Judith King, M.S.W., LCSW, LCADC, 

CPAS

Coordinator, Perinatal Addictions Prevention 

Project

Hudson Perinatal Consortium, Inc.

Jersey City, NJ

Suzie Kuerschner, M.Ed.

FASD Consultant and Trainer

Northwest Portland Area Indian Health 

Board

Rhododendron, OR

John H. McGovern, M.G.A.

Senior Public Health Analyst

Health Resources and Services Administration 

Rockville, MD
187

Sara Messelt

Executive Director

Minnesota Organization on FAS (MOFAS)

St. Paul, MN

Violet Mitchell-Enos, M.S.W.

Scottsdale, AZ

Patricia Moran

Program Manager

White Earth Substance Abuse Program

Ponsford, MN

Jeri Museth

Wellness Coordinator, Tribal Family and 

Youth Services

Central Council of the Tlingit and Haida 

Indian Tribes of Alaska

Juneau, AK

Raquelle Myers

Santa Rosa, CA

Diane O’Connor

FASD Prevention Initiative, Research 

Foundation of Mental Hygiene

Support Person, Self Advocates with FASD in 

Action (SAFA)

Albany, NY

Heather Carmichael Olson, Ph.D.

Department of Psychiatry and Behavioral 

Sciences

University of Washington School of Medicine 

and Seattle Children’s Research Institute

Seattle, WA

Carol Rangel

FASD Project Director

Division of Health and Human Services

Arkansas Division of Child and Family 

Services

Little Rock, AR

Jamie Reinebold, M.S.W.

Supervisor, FACES 

Memorial Health System

South Bend, IN

Julia Robbins

Institute for Health and Recovery

Cambridge, MA

Paulette Romashko, M.S.W., LCSW

Director of Program Development and 

Evaluation

FASD Project Director

ARC Community Services, Inc.

Madison, WI

Iris Smith, Ph.D., M.P.H.

Clinical Associate Professor

Department of Behavioral Sciences and 

Health Education

Rollins School of Public Health

Atlanta, GA

Brenda Stoneburner, M.A., LPC

Communicable Disease Specialist

Michigan Department of Health

Bureau of Substance Abuse and Addiction

Lansing, MI

Sue Taylor, M.S.

Manager Early Childhood Services

Memorial Health System

South Ben, IN

Tracey Waller, M.B.A., RD, LD

Bellbrook, OH

Mary Kate Weber, M.P.H.

Behavioral Scientist 

Fetal Alcohol Syndrome Prevention Team 

National Center on Birth Defects and 

Developmental Disabilities 

Centers for Disease Control and Prevention

Atlanta, GA

Appendix J—Field Reviewers
188

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Nancy Whitney, M.S., LMHC

Clinical Director, King County Parent Child 

Assistant Program

University of Washington

Seattle, WA

Georgiana Wilton, Ph.D.

Associate Scientist, Family Medicine

University of Wisconsin

Madison, WI

Barbara Wybrecht, R.N.

FASD Clinical Nurse Specialist

Advocate/Trainer

Support Person, Self Advocates with FASD in 

Action

Grand Rapids, MI

Rob Wybrecht

Lifelong Expert on FASD

Arc of Kent County

Network Coordinator, Self Advocates with 

FASD in Action (SAFA)

Grand Rapids, MI
189

Appendix K—

Acknowledgments

Numerous people contributed to the development of this TIP, including the TIP 

Consensus Panelists (see pp. ix-x), Stakeholder meeting attendees (see Appendix 

I) and field reviewers (see Appendix J).

This publication was produced under the Fetal Alcohol Spectrum Disorders 

(FASD) Center for Excellence contract with the Northrop Grumman 

Corporation, for the Substance Abuse and Mental Health Services 

Administration, Center for Substance Abuse Prevention.

Callie B. Gass served as the FASD Center for Excellence Project Director, and 

Sharon James Ackah, J.D., M.P.H., served as the Deputy Project Director. Other 

Northrop Grumman-FASD Center for Excellence personnel included Dan 

Dubovsky, M.S.W., LCSW, Senior FASD Specialist; Vinitha Meyyur, Ph.D., 

Senior Evaluator and TIP Task Manager; Susan Kimner, Manager for Product 

Development; Jason P. Merritt, M.A., Senior Writer; Barbara Kosogof, M.P.A., 

and Katie Chan, Health Research Analysts and Literature Review Authors; 

Sharon J. Lytle, Quality Assurance Editor; and Jennifer Aggelis, Graphic 

Designer.
190

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Index

12-Step self-help groups, 13, 47, 98, 

103, 128, 133

A

abuse, 3, 9, 27, 33, 34, 35, 38, 42, 121, 

122

accommodations, xxi, 17, 25, 27, 36, 

83, 89, 91-92, 123, 128, 129, 131, 

132, 134, 180

achievement levels (reading, spelling, 

math), 27

adolescents, xxiv, 5, 20, 26, 27, 29, 37, 

38-43, 79-92, 115, 158-159

aftercare, 17, 31, 33, 41, 97, 109

Alcohol (journal), 164

Alcohol-Exposed Pregnancy (AEP), xx, 

xxiv-xxvi

•	 prevention of, 1-15, 49-64

•	 risk factors for, 3

Alcohol-Related Birth Defects 

(ARBD), xix, 168, 174, 176

Alcohol-Related Neurodevelopmental 

Disorder (ARND), xix-xxi, 20, 

22, 125, 126, 128, 168, 172-173

Alcohol Screening and Brief 

Intervention (SBI), 8, 9, 13

American College of Obstetricians and 

Gynecologists (ACOG), 3

Americans with Disabilities Act 

(ADA) of 1990, 123

assessment, 11, 18, 19, 20, 22-26, 30, 

36, 37, 40, 46, 75, 108, 116, 128, 

130, 134, 158, 159, 161-163

•	 Risk Assessment

Questions, 22

Attention Deficit Disorder (ADD), 20, 

24, 28

Attention Deficit/Hyperactivity 

Disorder (ADHD), 20, 22, 32, 38, 

72, 75, 85, 88, 92

AUDIT-C, 5, 115, 160

B

balance, 22, 23, 168

billing, 111, 125, 134

bipolar disorder, 20

birth mother, 20, 22, 25, 32, 35, 43, 51, 

68-76, 89-92, 93, 121, 180

•	 Birth Mothers

Network, 45, 164

boundaries, 19, 30, 33, 36, 113, 114, 

132

brain-based disorder, 18, 43, 83

brain function, 23, 28

brief interventions, 1, 2, 6, 7, 8

British Columbia, 30, 39

buddy system, 30

C

caregiver interview, 20, 21, 26, 115, 166

Case Coordinator, 23

Centers for Disease Control and 

Prevention (CDC), xxi, xxiii, 3, 

4, 7, 12, 23, 24, 85, 132, 136, 162, 

163, 169-176

•	 FASD Regional Training

Centers (RTCs), 24, 85,

132, 163

central nervous system (CNS), 97, 

169-174 
191

Index

Change Book: A Blueprint for Technology 

Transfer, 100, 105, 106, 110, 125, 130

Chavez Memorial Fund, 24

Child Abuse Prevention and Treatment Act 

(CAPTA), 122

client strengths, xxv, 18, 26, 33, 36, 38, 77, 78, 

85, 96, 98, 109, 132, 133, 164

clinical intake, 25

clinical supervision, 98, 113, 114, 129, 130, 135

Cognitive–Behavioral Therapy (CBT), xxv, 

9, 13

cognitive deficits, xxvi, 40, 42, 115, 123

Collaborative Initiative on FASD 

(CIFASD), 164

communication, 15, 25, 26, 27, 29, 31, 32, 33, 

34, 38, 40, 46, 103, 111, 115, 116, 133, 

135, 169-173

•	 expressive, 27, 172, 174

•	 receptive, xxii, xxv, 27, 172, 174

•	 written, 27, 30, 32, 34, 36, 40, 42, 81,

88, 103, 111

community supports, 13, 19, 27, 31, 33, 45, 

46, 177

comprehension, xxvi, 33, 36, 40, 79, 81

confidentiality, 123, 134

•	 Health Insurance Portability and

Accountability Act (HIPAA), 123

consent issues (permission), 11, 43, 79, 182

continuity of care, 111, 116, 117

contraception, 3, 10, 11, 12, 37, 53, 109

co-occurring disorders, xvii, 3, 10, 18, 27, 

31-32, 43, 47, 56, 94, 97, 125, 130, 136

coping skills, 27

Council on Foundations, 135

counselor self-assessment, 42

CRAFFT Screening Interview, 5, 115, 

158-159

criminal justice involvement, xi, xiv, xv, 11, 29, 

64, 93, 96, 164

cultural competence, 14, 49, 113, 114

•	 Attitudes and Behaviors of 

Culturally Competent Counselors, 50

populations, 14

•	 services for Hispanic/Latin

•	

custody

services for Native populations, 14

	 •	 training in cultural competence, 14

, 121

D

daily living skills, 27, 31

denial, 33, 35

depression, 20, 28, 29, 34, 50, 51-53, 56, 59, 87

diagnosis, xv, xix, xx-xxi, xxiii, xxiv, 18, 20, 

23-27, 29, 30, 41, 45, 46, 64, 76-79, 85, 

97, 108, 113, 115, 121, 128, 134, 161, 

162, 163, 164, 168-176, 181, 182

diagnostic summary, 26

diagnostic summary report, 26

diffuse brain damage, xx, xxvi, 18

Disease Model, xxvi, 34

dissociative disorder, 28

Double Trouble meetings, 47

Drinking and Reproductive Health: A Fetal 

Alcohol Spectrum Disorders Prevention

Tool Kit, 10

drinking rates among pregnant women, 

xxv, 3, 4

dysmorphology, xx, xxii, 24, 26, 75

dysplasia, xix, 175

E

educational support, 41

Enhancing Motivation for Change in Substance 

Abuse Treatment (TIP 35), 10

F

Families Moving Forward Program, 28, 45, 87, 

162, 177-180

•	 Sample Crisis/Safety Plan, 177-178

	 •	 Services and Supports Checklist,

179-180

family-centered care, 43, 96

family support, 10, 12, 180

FAS Community Resource Center, 22, 46, 165

FASD 4-Digit Diagnostic Code, xx, 20, 21, 

24, 115, 166-167, 182

•	 FASD 4-Digit Code Caregiver

Interview Checklist, 20, 21, 115, 

166-167, 182

•	 New Patient Information Form,

24, 25
192

Addressing Fetal Alcohol Spectrum Disorders (FASD)

Fetal Alcohol Effects (FAE), xx

Fetal Alcohol Spectrum Disorders (FASD)

•	 causal factors, xix-xxi, 7

•	 cost factors, xxii

•	 developments in the field, xxvi

	 •	 historical background, xxiii

•	 lack of success with typical

treatment approaches, xxv-xxvi

•	 misdiagnosis of, xxiii, xxv, 20

•	 presentation of, xxii

	 •	 prevalence, xxi

•	 secondary disabilities related to, xxiii,

xxv, 17, 18, 181

	 •	 treatment barriers, xxv, xxvi, 11, 18,

19, 26, 27, 37, 38, 94, 99, 101, 107, 

116, 133

Fetal Alcohol Spectrum Disorder: Canadian 

Guidelines for Diagnosis, xxi, 24

Fetal Alcohol Syndrome (FAS), xix-xxi, xxiii, 

121, 166, 168

Fetal Alcohol Syndrome: Diagnosis, Epidemiology, 

Prevention, and Treatment, xix, xxi, xxiii

Fetal Alcohol Syndrome: Guidelines for Referral 

and Diagnosis, xxi

fidelity, 98, 135-136

FLO (Feedback, Listen, Options), 8, 51, 53

follow-up debriefing, 26

foster care, xxi, 28, 38, 67, 109

FRAMES (Feedback, Responsibility, Advice, 

Menu, Empathy, Self-efficacy), 8, 9, 115

Free and Appropriate Public Education 

(FAPE), 41

funding, 13, 110, 121, 133, 134-135, 136, 179

G

gait, 23

Grants.gov, 162

guardianship, 10, 30, 177, 179, 182

H

harm reduction, 12

health literacy, 4, 6, 14

hearing, 26, 27, 175

Helping Patients Who Drink Too Much, 6, 8

Hispanic/Latino populations, 10, 14

homelessness, xvii, xxiv, 32, 93, 94, 96

I

Implementation Research: A Synthesis of the 

Literature, 105

implementation workgroups, 108, 130

Implementing Change in Substance Abuse 

Treatment Programs (TAP 31), 95, 105

impulsivity, 21, 27, 29, 30, 38, 47, 167

independent living, 43, 82-88

Indian Health Care Improvement Act, 122

individual vs. group counseling, xvii, 19, 33, 

35-36, 96, 107, 126, 127, 133

Individualized Education Plan (IEP), 41, 51, 

89-92

Individuals With Disabilities Education Act 

(IDEA), 41

Institute of Medicine (IOM), xv, xx-xxi, xxiii, 

xxiv, 1, 2, 168-176

•	 IOM continuum of care model, 1, 2

o indicated prevention, 1, 2, 5, 

 9, 10

o selective prevention 1, 2, 5, 6, 

 8-10, 51, 53

o universal prevention, 1, 2, 5, 

 6, 7-9

interagency collaboration, 101, 108, 133-134

Interagency Coordinating Committee on 

FASD, xxiii, 23, 163

interdisciplinary team, 22, 23, 24, 25, 26, 38, 

108, 116, 117, 123, 124, 162, 163

interpersonal relationships, 27, 46

J

job coaching, 37-38

Journal of Psychiatry & Law (journal), 164

judgment, xvii, xx, xxvi, 9, 19, 21, 28, 29, 30, 

34, 38, 42, 50, 58, 61, 68, 129, 164, 167, 

172, 174

K

L

leadership, 88, 102-103, 106, 131

life skills, 41, 83, 85

Living With FASD (Web site), 46, 165

loss and grieving, xxv, 33, 34, 35, 39, 43, 84
193

Index

M

Managing Depressive Symptoms in Substance 

Abuse Clients During Early Recovery

(TIP 48), 50, 95, 105

March of Dimes, 24

Maternity Support Services, 13

Medicaid, xxii, 13, 46, 111, 165

Medicare, 13

medication, 7, 26, 27, 37, 39, 41, 56, 79, 80, 81, 

82, 83, 179

memory impairment, xx, xxii, 19, 21, 27, 30, 

33, 37, 42, 60, 65, 167, 169-174, 181

mentor, 32, 33, 36, 37, 40, 41, 44, 45, 46, 85, 

88, 92, 98, 164, 180

Motivational Enhancement Therapy, 13

motivational interviewing, 9, 10, 113, 114, 128, 

129, 131, 132

motor function, 27, 170

N

National Association of FASD State 

Coordinators (NAFSC), 13, 161

National Center on Child Abuse and 

Neglect, 28

National Organization on FAS (NOFAS), 25, 

46, 132, 161, 163, 164, 165

National Institute on Alcohol Abuse and 

Alcoholism (NIAAA), xxiii, 4, 8, 163

National Survey on Drug Use and Health

(NSDUH), xxiv, 3, 4, 93

National Task Force on FAS and FAE, xxiii

Native populations, 10, 14, 122

	 •	 Indian Health Care Improvement

Act (IHCIA), 122

	 •	 Territorial and Tribal Laws, 122

	 •	 Tribal Law and Order Act (TLOA)

of 2010, 122

navigator, 24, 32, 128, 129, 133

needs assessment, 107

Neurobehavioral Disorder/Alcohol Exposed 

(ND/AE), xix, xx, 172-174

Neurodevelopmental Disorder/AlcoholExposed (ND/AE), xix, xx

neuropsychological testing, 24

O

Occupational Therapist, 23, 26, 102, 108

One-Stop Centers, 47, 165

Operational Standards for Mental Health, 

Intellectual/Developmental Disabilities, 

and Substance Abuse Community Services 

Providers, 134, 181-182

Oppositional Defiant Disorder (ODD), 20

organizational assessment, 97, 98, 105

organizational change, 94, 95, 97, 98, 99, 100, 

101, 105

outcomes (treatment), xvii, xix, xx, xxiii, 11, 

17, 18, 43, 44, 89, 97, 107, 112, 119, 120, 

134, 135, 136

oversight committees, 108

P

Parent-Child Assistance Program (PCAP), 

12, 13

Partial FAS (pFAS), xix, xx, xxi, 20, 125, 126, 

128, 168, 171

Patient Protection and Affordable Care Act 

(ACA), 134

peer pressure, 27, 29, 40

phenotype, xx

philtrum, 75, 169, 171, 172, 174

physical examination, 26

Physical Therapist, 23, 38, 108

physician, 22, 26, 38, 45, 102, 108, 120, 121, 

133, 134

Post-Traumatic Stress Disorder, 28

Practical and Clinical Approach to the Diagnosis 

of Fetal Alcohol Spectrum Disorders: 

Clarification of the Institute of Medicine 

Criteria, 21

Project CHOICES, 7, 12, 13

psychologist, 23-24, 25-26, 38, 41, 102, 133, 

166

psychometric screening/evaluation, 26

psychosexual development, 41

Q

R

Reactive Attachment Disorder, 28

record review, 25

Recovery Centers (‘drop-in’ centers), 47

referral, xxi, 1, 2, 4, 5, 7, 11-15, 20, 23, 25, 42, 

45, 46, 64, 97, 108, 111-120, 122, 130, 

133, 134, 179, 182
194

Addressing Fetal Alcohol Spectrum Disorders (FASD)

reframing, 11, 43, 44

regulations, 101, 110, 120, 121

Relational Theory, 12

resistance, 11, 33, 35, 80, 96, 99, 101, 127, 129, 

130, 131

respite, 43, 44, 79, 177, 180

role-play, 30, 31, 32, 33, 36, 40, 41, 82, 88, 132

S

safety, 27, 30, 31, 38, 45, 46, 51, 82-88, 113, 

114, 115, 116, 122, 177-178

SAMHSA Treatment Locator, 11

Screening Decision Tree for AEP Prevention, 4, 

5, 7

screening instruments - See Appendix B

secondary disabilities, xxiii, xxv, 17, 18, 181

Self-Advocates with FASD in Action (SAFA) 

Network, 46-47

self perception, xxvi, 33, 34, 87

self-esteem 32, 33, 35, 38

sensory-motor integration/skills, 33, 36

sexual abstinence, xxvi, 8, 9, 10, 12, 37, 58, 63, 

93, 109

Social Security Disability Insurance (SSDI), 

46, 165

social skills, xx, xxii, xxv, 3, 19, 22, 27, 28, 29, 

30, 31, 33, 34, 35, 36, 37, 38, 39, 40, 41, 

45, 46, 68, 72, 85, 96, 133, 167, 170-174, 

177, 181

Speech Language Pathologist, 23, 26, 102, 108

speech, 26, 77, 78, 168

staff competency, 97, 98, 102, 112, 113, 114, 

115, 118, 119, 123-130

staff training, 23, 24, 99, 102, 110, 111, 112, 

113, 114, 118, 124, 125, 130-132, 161, 

162, 163

Stages of Change, 12

Stakeholders, 98, 99, 103, 108

standard drink, 6, 55

Static Encephalopathy/Alcohol-Exposed 

(SE/AE), xix, xx, xxi, 172, 173

Substance Use Disorder Treatment for People 

With Physical and Cognitive Disabilities

(TIP 29), 123

suicide, xxiv, 28, 29, 93, 126, 127, 128, 181

Supplemental Security Income (SSI), 46, 165

support groups, 33, 44, 64, 75, 76, 79, 125, 

134, 180

T

T-ACE, 5, 115, 157, 158

talk therapy, 34, 36, 39

teratogen, xxi, xxiii, xxv, 176

transitional services, 19, 25, 27, 31, 33, 41, 42, 

45-47, 84, 86

trauma, xx, xxi, xxiv, 7, 10, 93, 94, 96, 113, 114, 

136

Treatment Episode Data Set (TEDS), xxiv, 4, 93

treatment modification, xix, xxi, xxvi, 10, 15, 

17, 18, 20, 25, 26, 27, 31-33, 38, 39-40, 

49, 51, 68, 79-82, 96-97, 100, 115, 119

treatment planning, xvii, xxi, 32, 39, 43, 109, 

116, 117, 119, 124, 163

trimester, 3, 4, 7, 59, 61, 62, 76 

TWEAK, 5, 115, 158

U

United States Department of Justice, 28

University of Washington, xxiii, 24, 29, 162, 

163

V

violence, 27, 28

vocational rehabilitation, 23, 38, 47, 165, 180

vocational skills, 27

W

Washington State Department of Social and 

Health Services, 24

Washington State FAS Diagnostic and 

Prevention Network (FAS DPN), xxi, 

20, 23, 24, 25, 26, 41, 77, 162, 163, 166

Washington State Senate Bill 5688, 24

What You Need to Know fact sheets, 8

Women, Infants and Children (WIC) 

programs, 9, 46, 165, 179

X

Y

Z

zero tolerance, 39, 107
195

TIP 1 State Methadone Treatment Guidelines—

Replaced by TIP 43

TIP 2* Pregnant, Substance-Using Women—

BKD107

TIP 3 Screening and Assessment of Alcohol- and 

Other Drug-Abusing Adolescents—Replaced 

by TIP 31

TIP 4 Guidelines for the Treatment of Alcoholand Other Drug-Abusing Adolescents—

Replaced by TIP 32

TIP 5 Improving Treatment for Drug-Exposed 

Infants—BKD110

TIP 6* Screening for Infectious Diseases Among 

Substance Abusers—BKD131

Quick Guide for Clinicians QGCT06

KAP Keys for Clinicians KAPT06

TIP 7 Screening and Assessment for Alcohol and 

Other Drug Abuse Among Adults in the 

Criminal Justice System—Replaced by TIP 44

TIP 8 Intensive Outpatient Treatment for Alcohol 

and Other Drug Abuse—Replaced by TIPs 46 

and 47

TIP 9 Assessment and Treatment of Patients With 

Coexisting Mental Illness and Alcohol and 

Other Drug Abuse—Replaced by TIP 42

TIP 10 Assessment and Treatment of CocaineAbusing Methadone-Maintained Patients—

Replaced by TIP 43 

TIP 11* Simple Screening Instruments for Outreach 

for Alcohol and Other Drug Abuse and 

Infectious Diseases—BKD143 

Quick Guide for Clinicians QGCT11

KAP Keys for Clinicians KAPT11

TIP 12 Combining Substance Abuse Treatment 

With Intermediate Sanctions for Adults in 

the Criminal Justice System—Replaced by TIP 

44 

TIP 13 Role and Current Status of Patient 

Placement Criteria in the Treatment of 

Substance Use Disorders—BKD161

Quick Guide for Clinicians QGCT13 

Quick Guide for Administrators QGAT13

KAP Keys for Clinicians KAPT13 

CSAT TIPs and Publications Based on TIPs

What Is a TIP?

Treatment Improvement Protocols (TIPs) are the product of a systematic and innovative process that 

brings together clinicians, researchers, program managers, policymakers, and other Federal and non-Federal experts to reach consensus on state-of-the-art treatment practices. TIPs are developed by SAMHSA 

to improve the treatment capabilities of the nation’s behavioral health service system.

What Is a Quick Guide?

A Quick Guide clearly and concisely presents the primary information from a TIP in a pocket-sized 

booklet. Each Quick Guide is divided into sections to help readers quickly locate relevant material. Some 

contain glossaries of terms or lists of resources. Page numbers from the original TIP are referenced so 

providers can refer back to the source document for more information.

What Are KAP Keys?

Also based on TIPs, KAP Keys are handy, durable tools. Keys may include assessment or screening 

instruments, checklists, and summaries of treatment phases. Printed on coated paper, each KAP Keys set 

is fastened together with a key ring and can be kept within a treatment provider’s reach and consulted 

frequently. The Keys allow you, the busy clinician or program administrator, to locate information easily 

and to use this information to enhance treatment services.

Ordering Information

Publications may be ordered or downloaded for free at http://store.samhsa.gov/. To order by phone, 

please call 1-877-SAMHSA-7 (1-877-726-4727) (English and Español).

*Under revision
196

Addressing Fetal Alcohol Spectrum Disorders (FASD)

TIP 14 Developing State Outcomes Monitoring 

Systems for Alcohol and Other Drug Abuse 

Treatment—BKD162 

TIP 15 Treatment for HIV-Infected Alcohol and 

Other Drug Abusers—Replaced by TIP 37 

TIP 16 Alcohol and Other Drug Screening of 

Hospitalized Trauma Patients—BKD164 

Quick Guide for Clinicians QGCT16

KAP Keys for Clinicians KAPT16 

TIP 17 Planning for Alcohol and Other Drug Abuse 

Treatment for Adults in the Criminal Justice 

System—Replaced by TIP 44

TIP 18 The Tuberculosis Epidemic: Legal and 

Ethical Issues for Alcohol and Other Drug 

Abuse Treatment Providers—BKD173

Quick Guide for Clinicians QGCT18

KAP Keys for Clinicians KAPT18

TIP 19 Detoxification From Alcohol and Other 

Drugs—Replaced by TIP 45

TIP 20 Matching Treatment to Patient Needs in 

Opioid Substitution Therapy—Replaced by 

TIP 43

TIP 21 Combining Alcohol and Other Drug Abuse 

Treatment With Diversion for Juveniles in 

the Justice System—(SMA) 08-4073

Quick Guide for Clinicians and 

Administrators QGCA21

TIP 22 LAAM in the Treatment of Opiate 

Addiction—Replaced by TIP 43

TIP 23 Treatment Drug Courts: Integrating 

Substance Abuse Treatment With Legal 

Case Processing—(SMA) 08-3917

Quick Guide for Administrators QGAT23 

TIP 24 A Guide to Substance Abuse Services for 

Primary Care Clinicians—(SMA) 08-4075

Concise Desk Reference Guide BKD123

Quick Guide for Clinicians QGCT24

KAP Keys for Clinicians KAPT24

TIP 25 Substance Abuse Treatment and Domestic 

Violence—(SMA) 08-4076

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Treatment Providers MS668 

Linking Substance Abuse Treatment and 

Domestic Violence Services: A Guide for 

Administrators MS667 

Quick Guide for Clinicians QGCT25 

KAP Keys for Clinicians KAPT25 

TIP 26 Substance Abuse Among Older Adults—

(SMA) 08-3918

Substance Abuse Among Older Adults: A 

Guide for Treatment Providers MS669 

Substance Abuse Among Older Adults: A 

Guide for Social Service Providers MS670 

Substance Abuse Among Older Adults: 

Physician’s Guide MS671 

Quick Guide for Clinicians QGCT26

KAP Keys for Clinicians KAPT26 

TIP 27 Comprehensive Case Management for 

Substance Abuse Treatment—(SMA) 

08-4215

Case Management for Substance Abuse 

Treatment: A Guide for Treatment Providers 

MS673

Case Management for Substance Abuse 

Treatment: A Guide for Administrators 

MS672

Quick Guide for Clinicians QGCT27

Quick Guide for Administrators QGAT27

TIP 28* Naltrexone and Alcoholism Treatment—

Replaced by TIP 49

TIP 29 Substance Use Disorder Treatment for 

People With Physical and Cognitive 

Disabilities—(SMA) 08-4078 

Quick Guide for Clinicians QGCT29 

Quick Guide for Administrators (SMA) 

08-3592 

KAP Keys for Clinicians KAPT29 

TIP 30 Continuity of Offender Treatment for 

Substance Use Disorders From Institution to 

Community—(SMA) 08-3920

Quick Guide for Clinicians QGCT30 

KAP Keys for Clinicians KAPT30 

TIP 31 Screening and Assessing Adolescents for 

Substance Use Disorders—(SMA) 08-4079

See companion products for TIP 32. 

TIP 32 Treatment of Adolescents With Substance 

Use Disorders—(SMA) 08-4080

Quick Guide for Clinicians QGC312 

KAP Keys for Clinicians KAP312 

TIP 33 Treatment for Stimulant Use Disorders—

(SMA) 06-4209

Quick Guide for Clinicians QGCT33 

KAP Keys for Clinicians KAPT33 

*Under revision
197

TIP 34 Brief Interventions and Brief Therapies for 

Substance Abuse—(SMA) 07-3952 

Quick Guide for Clinicians QGCT34 

KAP Keys for Clinicians KAPT34

TIP 35 Enhancing Motivation for Change in 

Substance Abuse Treatment—(SMA) 

08-4212 

Quick Guide for Clinicians QGCT35 

KAP Keys for Clinicians KAPT35 

TIP 36 Substance Abuse Treatment for Persons 

With Child Abuse and Neglect Issues—

(SMA) 08-3923 

Quick Guide for Clinicians QGCT36 

KAP Keys for Clinicians KAPT36 

Helping Yourself Heal: A Recovering Woman’s 

Guide to Coping With Childhood Abuse 

Issues—(SMA) 08-4132

Available in Spanish: PHD981S 

Helping Yourself Heal: A Recovering Man’s 

Guide to Coping With the Effects of 

Childhood Abuse—(SMA) 08-4134

Available in Spanish: PHD1059S 

TIP 37 Substance Abuse Treatment for Persons 

With HIV/AIDS—(SMA) 08-4137 

Quick Guide for Clinicians MS678 

KAP Keys for Clinicians KAPT37 

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide—(SMA) 08-4127 

Drugs, Alcohol, and HIV/AIDS: A Consumer 

Guide for African Americans—(SMA) 

07-4248

TIP 38 Integrating Substance Abuse Treatment and 

Vocational Services—(SMA) 06-4216 

Quick Guide for Clinicians QGCT38

Quick Guide for Administrators QGAT38 

KAP Keys for Clinicians KAPT38

TIP 39 Substance Abuse Treatment and Family 

Therapy—(SMA) 08-4219 

Quick Guide for Clinicians QGCT39

Quick Guide for Administrators QGAT39

TIP 40 Clinical Guidelines for the Use of 

Buprenorphine in the Treatment of Opioid 

Addiction—(SMA) 07-3939

Quick Guide for Physicians QGPT40

KAP Keys for Physicians KAPT40

TIP 41 Substance Abuse Treatment: Group 

Therapy—(SMA) 05-3991

Quick Guide for Clinicians QGCT41

TIP 42 Substance Abuse Treatment for Persons 

With Co-Occurring Disorders—(SMA) 

08-3992

Quick Guide for Clinicians (SMA) 07-4034

Quick Guide for Administrators QGAT42

KAP Keys for Clinicians (SMA) 08-4036 

TIP 43 Medication-Assisted Treatment for Opioid 

Addiction in Opioid Treatment Programs—

(SMA) 08-4214

Quick Guide for Clinicians QGCT43 

KAP Keys for Clinicians (SMA) 07-4108 

TIP 44 Substance Abuse Treatment for Adults in the 

Criminal Justice System—(SMA) 05-4056 

Quick Guide for Clinicians QGCT44

KAP Keys for Clinicians (SMA) 07-4150 

TIP 45 Detoxification and Substance Abuse 

Treatment—(SMA) 08-4131 

Quick Guide for Clinicians (SMA) 06-4225

KAP Keys for Clinicians (SMA) 06-4224 

Quick Guide for Administrators (SMA) 

06-4226 

TIP 46 Substance Abuse: Administrative Issues in 

Outpatient Treatment—(SMA) 06-4157 

Quick Guide for Administrators—(SMA) 

07-4232 

TIP 47 Substance Abuse: Clinical Issues in 

Outpatient Treatment—(SMA) 06-4182

Quick Guide for Clinicians—(SMA) 07-4233

KAP Keys for Clinicians—(SMA) 07-4251

TIP 48 Managing Depressive Symptoms in 

Substance Abuse Clients During Early 

Recovery—(SMA) 08-4353 

TIP 49 Incorporating Alcohol Pharmacotherapies 

Into Medical Practice—(SMA) 09-4380

Quick Guide for Counselors (SMA) 10-4542

KAP Keys for Clinicians (SMA) 10-4544

Quick Guide for Physicians (SMA) 10-4543

TIP 50 Addressing Suicidal Thoughts and Behaviors 

in Substance Abuse Treatment—(SMA) 

09-4381

TIP 51 Substance Abuse Treatment: Addressing the 

Specific Needs of Women—(SMA) 09-4426

*Under revision
TIP 52 Clinical Supervision and Professional 

Development of the Substance Abuse 

Counselor—(SMA) 09-4435

TIP 53 Addressing Viral Hepatitis in People With 

Substance Use Disorders—(SMA) 11-4656

TIP 54 Managing Chronic Pain in Adults With or in 

Recovery From Substance Use Disorders—

(SMA) 11-4661

TIP 55 Behavioral Health Services for People Who

Are Homeless—(SMA) 13-4734

TIP 56 Addressing the Specific Behavioral Health

Needs of Men—(SMA) 13-4736
HHS Publication No. (SMA) 13-4803 

Printed 2014

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Prevention