FASD and Sexually Inappropriate Behaviors: A Guide For Criminal Justice and Forensic Mental Health Professionals

Fetal Alcohol Spectrum Disorder (FASD) Today 2018, Volume 1, Issue 1, 1-35
LITERATURE REVIEW ARTICLE
Fetal Alcohol Spectrum Disorder (FASD) and Sexually

Inappropriate Behaviors: A Guide for Criminal Justice and
Forensic Mental Health Professionals
Jerrod Brown,1,2,3 Rae Mitten4, Megan N. Carter5,6i, Jeffrey Haun7,8ii, Amanda

Fenrich9iii, Diane Neal10, Brenda Frye2, Judge Anthony Wartnik2, Stefanie Varga11,
Trisha M. Kivisalu12ix, Charlotte Gerth Haanen13x, Hal Pickett14, Diane Harr2,
Elizabeth (Anne) Russell15, & Ryan Van Gundy16
1
Pathways Counseling Center, Inc., St. Paul, MN, USA;
2
Concordia University, St. Paul, MN, USA;
3
American Institute for the Advancement of Forensic Studies, St. Paul, MN, USA;
4
Mitten Law, Redvers, SK, Canada;
5
University of Washington, Seattle, WA, USA;
6
Department of Social and Health Services, Special Commitment Center, Steilacoom, WA;
7
University of Minnesota, Minneapolis, MN, USA;
8
Direct Care & Treatment - Forensic Services, St. Peter, MN, USA;
9
Washington State Department of Corrections, Monroe, WA, USA;
10
Project Pathfinders, St. Paul, MN, USA;
11
Treehouse Psychology, PLLC, Hugo, MN, USA;
12
UT Health, San Antonio, TX, USA;
13
Minnesota Department of Corrections, MN, USA:
14
Headway Emotional Health Services, MN, USA:
15
Russell Family Fetal Alcohol Disorders Association (rffada), Australia;
16
Dakota County Sheriff's Office, Hastings, MN, USA
Corresponding Author: Jerrod Brown, Ph.D., 1919 University Avenue West Suite 6 St. Paul,
Minnesota, 55104. Email: [email protected]
i
This article and included views and findings are the author’s own and are in no way affiliated with the
Department of Social and Health Services, Special Commitment Center.
ii
This article and included views and findings are the author’s own and are in no way affiliated with
Minnesota Department of Human Services, Direct Care and Treatment – Forensic Services.
iii
Washington State Department of Corrections
ix
This article and included views and findings are the author’s own and are in no way affiliated with UT
Health San Antonio.
x
Minnesota Department of Corrections.
Page 1 of 35
An Official Membership Publication of the American Institute for the Advancement of Forensic Studies (AIAFS)
ABSTRACT
Affecting millions of individuals in North America, Fetal Alcohol Spectrum Disorder

(FASD) is characterized by impairments in cognitive, social, and adaptive functioning.
The presence and severity of these symptoms vary widely by individual, as such typical
mental health screening, assessment, and diagnostic processes often fail to accurately
identify FASD. A consequence of these diagnostic difficulties is that individuals with
FASD often go untreated or receive ineffective treatment services. It is common for
some individuals with FASD to struggle to comprehend interpersonal cues and non-
verbal behaviors of others, understand normative social boundaries, control one’s
impulses, and find socially appropriate ways to express sexual desires. When adequate
treatment services are not provided, individuals with FASD may become inadvertently
involved in the legal system for crimes including sexual misconduct. Individuals with
FASD who become involved in the criminal justice system often have more difficulty
obtaining benefit from services provided compared to those without FASD and maybe
at greater risk for recidivism. This is especially the case when interventions, services,
and supports fail to take into account the short and long-term deficits caused by prenatal
alcohol exposure. To serve as a guide for criminal justice and forensic mental health
professionals, this article provides background information on FASD, explores the role
of FASD symptoms in sexually inappropriate behaviors, discusses screening and
assessment considerations, identifies potential treatment and intervention options, and
makes recommendations for future research. Finally, example cases are provided to
assist the reader in understanding how FASD influences the individual who engages in
inappropriate sexual behaviors. These examples provide detailed descriptions of the
various areas of functioning affected by FASD and how this can result in different kinds
of inappropriate sexual behaviors resulting in involvement in both the mental health and
criminal justice systems.
Keywords: fetal alcohol spectrum disorder, forensic mental health, screening, sexual
behaviors, sex offender treatment
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OVERVIEW
Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder

caused by prenatal exposure to alcohol and besets millions of individuals in North
America. More recently, May and colleagues (2018) estimate that 3% to 5% of the
population is afflicted with FASD. This is an increase from earlier reported birth rates
that estimate FASD in 3 of every 1000 births (Dehaene et al., 1991; Sampson et al.,
1997). FASD is an umbrella term that is used to describe the various conditions that can
result from more than minimal prenatal alcohol exposure. The most severe of these
conditions, Fetal Alcohol Syndrome (FAS), is consistent with individuals who have
experienced growth deficiencies, facial abnormalities, and brain damage resulting in
central nervous system (CNS) problems (e.g., memory difficulties, impulsivity,
impaired executive functioning, etc.). Those with FAS may also experience some
physical problems, such as abnormal development in hearing, vision or skeletal
structure. Those with FAS may also experience intellectual disabilities. Those with
Alcohol-Related Birth Defects (ARBD) may experience problems with internal organs
such as the heart, kidney, or skeletal structure due to prenatal alcohol exposure.
Alcohol-Related Neurodevelopmental Disorder (ARND) is a condition in which those
with prenatal alcohol exposure may not have the physical symptoms associated with
alcohol exposure (e.g., growth deficiencies, facial abnormalities) but they experience
the brain damage resulting in CNS problems and may experience intellectual disabilities
(Doyle & Mattson, 2015; Manning & Hoyme, 2007; Murawski, Moore, Thomas, &
Riley, 2015). Beginning in 2013 with the release of the fifth edition of the Diagnostic
and Statistical Manual (DSM-5), Neurobehavioral Disorder – Prenatal Alcohol
Exposure (ND-PAE) was included as a recognized diagnosis by the American
Psychiatric Association (American Psychiatric Association, 2013). ND-PAE provides
the ability for clinicians to provide a diagnosis for those exposed prenatally to alcohol
and experiencing significant problems associated with various areas of functioning but
do not necessarily qualify for a diagnosis of FAS.
Typically, FASD is characterized by impairments in cognitive (e.g., information

processing, attention, and memory), social (e.g., verbal and non-verbal communication),
and adaptive (e.g., decision making and problem solving) capacities (Brown, Connor, &
Adler, 2012; McGee, Bjorkquist, Price, Mattson, & Riley, 2009). In a minority of cases,
physical symptoms such as facial dysmorphia and other skeletal and muscular
conditions may be present (Spohr et al., 1993, 1994; Steinhausen, Willms, & Spohr,
1993). The presence and severity of these symptoms varies widely by individual and is
impacted by the variations in dose and frequency of prenatal alcohol exposure.
Additionally, other environmental influences (e.g., early interventions, childhood
environment, head injuries, exposure to violence, etc.) may also affect the
manifestations of FASD symptoms, which can cause wide variability in symptoms
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between individuals (Fast & Conry, 2009). As such, one individual with FASD can
present with completely different symptoms than another individual with FASD. For
example, while one person with FASD may present with a well below average
intellectual ability, others may have average or higher IQ’s. Such varied presentations
make it difficult to screen, assesses, and diagnose FASD. A direct consequence of the
difficulty in identifying this disorder is that many individuals with FASD are either
misidentified or undiagnosed, particularly if they have not received mental health
services or intervention early in life. In addition, while not required for a diagnosis, a
more accurate diagnosis would include admission of alcohol use during pregnancy by
the mother or collateral information indicating alcohol use by the mother during
pregnancy. This can often be very difficult given the stigma associated with alcohol use
during pregnancy and possibly the lack of involvement of the biological mother at the
time of assessment (Legge, Roberts, & Butler, 2000; Westrup, 2013).
The accurate identification of FASD is further hindered by the fact that FASD
typically co-occurs with other conditions and forms of psychopathology (i.e., mental
disorders or maladaptive behaviors; Burd et al., 2003; Popova et al., 2016). In some
instances, the presence of FASD may even predispose an individual to other types of
psychopathology. Disorders that are commonly co-morbid with features of FASD
include anxiety, mood (i.e., depression and mania), behavioral (e.g., autism and conduct
disorder), substance use, and other neurological disorders (e.g., attention
deficit/hyperactivity disorder; Burd et al., 2003; Popova et al., 2016). Additionally,
those with FASD often experience significant sleep disturbance problems resulting in
further deficits in many areas of functioning (e.g., attention and concentration; Burd et
al., 2003; Ipsiroglu, McKellin, Carey, & Loock, 2013). Although it may necessitate
consultation with or a referral to an FASD specialist, differential diagnosis with
nuanced psychological and neurological screening is imperative in the effort to
accurately diagnose a client suspected of having FASD. Without a strong understanding
of the client’s individual needs, the development of plans for treatment and services are
likely to have less than optimal effectiveness.
When untreated, individuals with FASD may be prone to various adverse life
experiences, including involvement in the legal system. Streissguth, Barr, Kogan, and
Bookstein (1996) estimate that as many as 60% of those with FASD become involved
in the criminal justice system during their life. The reason for this high likelihood of
involvement is that many of the deficits of FASD are risk factors for antisocial behavior
in the absence of FASD (Byrne, 2002). For example, cognitive deficits like impaired
information processing and disinhibition may make it difficult for an individual to
control one’s impulses. Social impairments like immaturity and ineptness could lead to
awkward social interactions and engagement in illegal activities to gain favor with
antisocial peers. Furthermore, these impairments may lead one to lack understanding of
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the social nuances of situations and they may act out of context without recognizing
they are doing so. Finally, adaptive functioning deficits like difficulty contextualizing
consequences and comprehending cause and effect could contribute to the individual
taking actions without realizing the severity of their behavior. Together, this
combination of impairments has the potential to contribute to antisocial behavior (Byrne
2002; Malbin 2004; Page, 2001; Schonfeld et al., 2005).
One type of crime that individuals with FASD may be prone to is sexual
misconduct (Graham, 2014; Novick, 1997; Streissguth et al., 2004). These behaviors
may include inappropriate sexual touching, exposure, voyeuristic behavior, or sexual
aggression. Research indicates that about half of adolescents and adults with FASD
engage in inappropriate sexual behavior, and about 18% of those with FASD and
criminal involvement engage in sexual aggression (Streissguth et al., 2004). This same
research also has found that inappropriate sexual behaviors was the second most
common adverse life outcome for those with FASD following co-morbid mental health
problems. This risk of engaging in inappropriate sexual behaviors is conferred by the
same cognitive, social, and adaptive impairments often characteristic of those living
with FASD, which can increase the likelihood of committing a crime (Brown, Connor,
& Adler, 2012). In particular, these impairments likely make it difficult for an
individual living with FASD to learn the difference between appropriate and
inappropriate sexual behavior, comprehend appropriate versus inappropriate
interpersonal cues through non-verbal behavior, control their impulses, and find socially
appropriate ways to express sexual desires (Boland, Chudley, & Grant, 2002; Clark,
Lutke, Minnes, & Ouellette-Kuntz, 2017; Kodituwakku, Kalberg, & May, 2001). After
becoming entangled in the criminal justice system, individuals with FASD are unlikely
to benefit from much of the programming typically provided to sexual offenders
(Baumbach, 2002). Standard treatment programming for sex offenders is ineffective for
those with FASD and their associated variability in social, cognitive and interpersonal
functioning given the emphasis on cognitive and social skills goals as well as the pace
with which these programs often run. More tailored interventions are necessary to treat
and reduce recidivism among those with FASD. Unfortunately, individuals with FASD
and a history of sexual offending may be more likely to have difficulty complying with
the conditions of their supervision in custodial or community settings, resulting in an
elevated risk to reoffend and increased adverse outcomes for the person with FASD
(e.g., additional incarceration, inability to be released from sex offender registry, etc.).
Although the legal consequences of inappropriate sexual behavior among

individuals with FASD are clear, the topic is understudied in the empirical literature. To
this point, most information has been drawn from case law, popular media news stories,
and accounts provided by caregivers and professionals. In fact, accounts of caregivers
and professionals are integral in helping establish the links between FASD and
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inappropriate sexual behaviors (Brown, Wartnik, Connor, & Adler, 2010; McMurtrie,
2011; Streissguth et al., 1996). Behaviors highlighted by these accounts include asking
questions about sex, non-consensual sexual touching or groping, public autoeroticism,
stalking, and rape. Going forward, sophisticated and nuanced empirical research on this
topic is of paramount importance. Any information garnered will be fruitful in the
development of FASD-targeted treatment programs and improved legal process
techniques.
In addition to this need for research, there is a strong demand for FASD
awareness among forensic mental health professionals. Currently, there is a significant
lack of knowledge and a wealth of misunderstanding about FASD among professionals
working in criminal justice settings (McLachlan, Roesch, Viljoen, & Douglas, 2014).
The lack of training on FASD and the difficulties in assessing FASD are likely large
contributors to this misunderstanding (Brown & Singh, 2016). This is due not only to
the complicated symptomatology of these clients, but also the fact that it is exceedingly
difficult, in a number of cases, to obtain confirmation of prenatal alcohol exposure.
Providing advanced education and training opportunities on FASD to criminal justice
professionals is of the utmost importance. As prior pilot study research by Brown and
Singh (2016) noted, there is a lack of knowledge of FASD in sexually violent predator
civil commitment professionals. Moreover, the outcomes of the pilot study found many
civil commitment professionals either had no or limited training in FASD and varied in
their ability to precisely identify the characteristics of FASD (Brown & Singh, 2016).
Once FASD is better recognized in criminal justice settings, the appropriate treatment
and services can be provided to the client. To this end, the present article serves as a
guide for forensic mental health professionals by providing background information on
FASD, exploring the role of FASD in sexually inappropriate behaviors, discussing
screening and assessment concerns, as well as identifying potential treatment and
intervention options.
The Role of FASD in Inappropriate Sexual Behaviors
The relationship between FASD and inappropriate sexual behaviors is

complicated due to the diverse and varied symptomatology characteristic of FASD. As
discussed above, there are a host of cognitive, social, and adaptive functioning deficits
that can be present in individuals with FASD making it difficult to accurately identify
the etiology of the inappropriate sexual behaviors. This section explores, in further
detail, how different aspects of FASD may contribute to inappropriate sexual behaviors.
Executive Function Deficits
Executive functioning deficits are perhaps the most deleterious of FASD

impairments (Kodituwakku, 2009). Executive functioning can be defined as the
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capacity to consciously execute goal-directed behavior including planning and adapting

to arising issues while maintaining focus and attention (Kodituwakko, Kalberg, & May,
2001). In other words, executive functioning is an individual’s aptitude to collect and
process relevant information in an effort to reach a goal (Rasmussen et al., 2008).
Deficits in executive functioning are often caused by the frontal lobe damage that
results from prenatal alcohol exposure (PAE) (Rasmussen et al., 2008), and can be
debilitating even in the presence of average to good scores on intelligence tests (Green
et al.,2009; Rasmussen & Bisanz, 2009; Rasmussen, 2005). As noted previously,
executive function deficits can vary widely between individuals with FASD although
those with FASD typically have some level of difficulties with executive functioning.
Several different FASD-related deficits can interfere with an individual’s

capacity for executive function. First, inattention, affective dysregulation, impulsivity,
and the inability to delay gratification can result in an individual not succeeding,
discontinuing, or falling short, on an attempt to accomplish a goal (Fast & Conry,
2009). Second, memory and learning difficulties can impair, or challenge, individuals’
ability to learn from experience and associate actions with consequences (Fast & Conry,
2009). Third, individual’s with FASD may also exhibit poor planning and organization
skills, which complicate an individual’s ability to reflect and make sound decisions
(Mattson et al., 2011; Petrenko, Tahir, Mahoney, & Chin, 2014; Rasmussen, 2005).
Because many of these deficits are often present in an individual with FASD,
suboptimal outcomes, such as low educational attainment and antisocial behavior, often
result from poor executive functioning (Brown et al., 2012; Olson, Feldman,
Streissguth, Sampson, & Bookstein, 1998; Streissguth et al., 1996).
One type of antisocial behavior that could result from the executive functioning
impairments of individuals living with FASD is inappropriate sexual behaviors. In fact,
research has found that sexual offenders more generally are characterized by low levels
of executive functioning abilities (Rasmussen & Wyper, 2007). Deficits in executive
functioning could impact the manner by which individuals living with FASD manage
urges of a sexual nature, particularly in situations characterized as stressful or unusual
(Brown, Wartnik, Connor, & Adler, 2010). If this is the case, such inappropriate sexual
behavior may be the result of the effects of FASD on the brain rather than the
maliciousness of the individual with FASD (Brown et al. 2010). Nonetheless, there has
been an absence of research on the prevalence of FASD related to executive function
deficits among those who have sexually offended and in particular among individuals
classified as “sexually violent predators.”
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Adaptive/Social Functioning Deficits
Adaptive functioning is an individual’s ability to successfully resolve the tasks

and problems of everyday living (Mariasine, Pei, Poth, Henneveld, & Rasmussen,
2014). In other words, these are the skills necessary to successfully function across
different settings such as adjusting to and from home to work. There are several
problems that can interfere with an individual’s capacity for adaptive functioning that
include: poor coping skills, deficits in abstract thinking, generalized learning
impairments, trouble identifying risky situations, difficulty recognizing and
comprehending social cues, emotion regulation, boundary problems, and immaturity. It
is important to note that deficits in adaptive functioning can persist independently of
intelligence (Streissguth et al., 1991; Streissguth et al., 1996). As such, adaptive
functioning deficits could be pervasive and persistent even in individuals who score
well on intelligence tests.
Often present among individuals with FASD (Ladue, Streissguth, & Randles,
1992; Thomas, Kelly, Mattson, & Riley, 1998), are problems with adaptive functioning,
which become more apparent, and worse, as the individual with FASD ages into
adulthood (Crocker, Vaurio, Riley, & Mattson, 2009; Mattson & Riley, 2000; O'Connor
et al., 2006; Quattlebaum & O'Connor, 2013). This challenge in maturity of adaptive
functioning has been linked to the limited development of the frontal lobe and other
regions of the brain beginning during the childhoods of those with FASD (Fagerlund et
al., 2012; O'Connor, Kogan, & Findlay, 2002; Treit et al., 2013). The consequences of
adaptive functioning deficits can be devastating for individuals with FASD. For
example, they may contribute to problems with learning and developing skills, solving
novel problems across different situations (e.g., school, work, and home), in addition to
difficulty establishing and maintaining interpersonal relationships (Coriale et al., 2013;
Jirikowic, Kartin, & Olson, 2008; Mitten, 2011).
In light of the pervasive consequences, adaptive functioning deficits may very

well contribute to inappropriate sexual behaviors among individuals with FASD.
Specifically, issues with establishing relationships and trouble understanding social cues
and boundaries may, at least in part, precipitate sexual offending. Consequently, an
individual with FASD may experience sexual urges, fail to detect social cues
discouraging acting on these urges, and then act on these urges without realizing it is
not consensual. Further, the individual may not recognize that their behavior is illegal or
has severe consequences due to the issues with learning and understanding
consequences that are characteristic of moderate and severe forms of the effects of
FASD in individuals. In addition, because of adaptive functioning deficits, those with
FASD may be more prone to engage in social relationships with others who are much
younger resulting in the development of emotional identification with children
(Edwards & Greenspan, 2010; LaDue & Dunne, 1996). Feelings of connection and
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acceptance with children may lead some adolescents and adults to engage in sexual
behaviors with children rather than learning to develop the skills to engage in social and
sexual relationships with similar age peers.
To begin to address inappropriate sexual behavior in individuals with FASD,

social nuances and legal behaviors must be the focal points. This should include clear
and concrete examples of both appropriate and inappropriate behaviors (Novick, 1997).
In treatment if the goals are directed toward only inappropriate behaviors and what they
are not allowed to do, this will result in confusion because the individual will not have
options and a plan for what they can do (Baumbach, 2002). Difficulties with
generalizing information may lead an individual with FASD to lack the ability to act
appropriately in even somewhat different circumstances. Explaining and teaching
appropriate behaviors is of paramount concern as individuals with FASD have, like all
other individuals, normative sexual urges that need healthy and appropriate outlets
(Mitten, 2011). Providing information about appropriate behaviors allows for the
replacement of maladaptive functioning and an increased sense of well-being. It would
be most beneficial for examples to incorporate when, where, and with whom sexual
behaviors are appropriate. Teaching clients this information and these skills will likely
require modeling appropriate social behaviors across several situations with consistent
and substantial repetition (Mitten, 2011). Employing variation and repetition are
essential because individuals with FASD have difficulty learning new information and
then generalizing this knowledge to different situations (Boland, Chudley, & Grant,
2002).
Theory of Mind Deficits
One specific type of social skills deficit that needs to be considered when
someone with FASD engages in inappropriate sexual behaviors is a deficit in Theory of
Mind (ToM). Theory of Mind (ToM) is generally referred to as the ability to recognize
and understand others’ mental states and predict their behaviors as well as the
recognition that others can have different thoughts, beliefs, or desires than one’s own
(Rasmussen et al., 2009). This is typically assessed using a story, for example, of an
object being placed in one location by the main character and then the object is later
moved to a new location by another character without the main character’s knowledge.
The examinee is then asked to predict where the main character will say the object is.
This requires the person being tested to understand the perspective of the main character
rather than simply identifying where the object is based on their own knowledge. At
times, this also requires the person to make inferences in various areas of social
communication including the other person’s emotions and knowledge. For example,
identifying another person’s emotions about that person’s experience. ToM is strongly
related to executive functioning, particularly working memory and inhibition
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(Rasmussen et al., 2009), areas of functioning often impaired by prenatal alcohol

exposure.
Only a few research studies have been completed on those with FASD and their
skills in ToM, and consistently those with FASD have been found to have significant
deficits in this area of functioning compared to peers who were not alcohol exposed
(Greenbaum et al., 2009; Lindinger, et al., 2016; Rasmussen et al., 2009). Even when
compared to other children with executive functioning difficulties (e.g., those with
ADHD), the children with FASD performed more poorly (Greenbaum et al., 2009). For
those with FASD and associated deficits in ToM, there may be instances when the
impacted individual engages in inappropriate sexual behavior because of their difficulty
taking the other person’s perspective, understanding the other person’s emotional
reactions and appropriately interpreting the other person’s behaviors or social
communication. For example, if an older adolescent or adult with FASD approaches
and engages a young child in sexual contact, the young child may become quiet and
shrink away from the older person out of fear but without explicitly saying no or
verbally indicating their fear. The older person may misinterpret this reaction as
compliance as the child did not protest although others would likely be able to
accurately interpret the non-verbal communication of fear. A similar scenario could
occur with an adult victim of a sexual assault as well, with a person with FASD
initiating the sexual contact not recognizing the expressions of fear and non-consent on
the person’s face and in their body language and not being able to understand that
person’s experience.
As previously noted, those with Theory of Mind deficits have particular

difficulty with specific executive functioning skills such as inhibition. Those with ToM
deficits may be less likely to be able to redirect their urges and behaviors based on the
behaviors of others and therefore discontinue inappropriate behavior, including sexual
behavior. Unfortunately, intellectual abilities have little influence on the person’s ability
to engage in ToM skills (Lindinger et al., 2017) so even those with higher IQ’s who
have been exposed to alcohol prenatally may be more likely to engage in sexually
inappropriate behavior. However, research specific to this phenomenon (ToM deficits in
those with FASD and engagement in sexually inappropriate behavior) has not been
completed so further investigation is warranted. Specifically, those who have offended
sexually are generally likely to have Theory of Mind deficits (Massau et al., 2017), but
no research has been completed to specifically determine if those with FASD
significantly differ from typically functioning sexual offenders to determine if
specialized interventions to improve ToM skills would be beneficial for those who have
FASD and have engaged in inappropriate sexual behaviors.
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Diminished Ability to Appropriately Express and Exhibit Empathy
The impairments due to the effects of FASD may also manifest in individuals as
difficulties with exhibiting empathy (Page, 2002). Although, this could also be related
to an inability to identify the consequences of their behavior (Rogers, McLachlan, &
Roesch, 2013) as individuals with FASD often have atypical affect characterized by
trouble displaying emotions in an appropriate manner. For example, affective
dysregulation can result in individuals with FASD showing no affective response, flat
affect, a lack of remorse, laughing, crying, or acting erratically (e.g., child behaviors
like temper tantrums) at inappropriate times across different settings (Brown et al.,
2010; Page, 2002; Rogers, McLachlan, & Roesch, 2013; Thiel et al., 2011).
Furthermore, it is also important to note that inappropriate reactions could be magnified
in stressful situations.
Appropriate emotional expression and exhibiting empathy are of paramount

concern in criminal justice settings. FASD related deficits may limit an individual’s
capacity to demonstrate that they understand the seriousness of an offense along with
the offense’s impact on the victim(s). If the impression of remorselessness or a lack of
empathy is left on the jury or judge, the type and severity of legal consequences may be
exacerbated (Nash et al., 2006; Page, 2002; Rogers et al., 2013; Stevens et al., 2015).
Mental health professionals in criminal justice settings must caution other stakeholders
to not make such assumptions. In many instances, it is plausible that both the offense
and the failure to demonstrate remorse and empathy are the result of prenatal alcohol
exposure rather than the inherent maliciousness or deviousness of the individual with
FASD (Aragon et al., 2008; Boland, Burrill, Duwyn, & Karp, 1998; Nash et al., 2006;
Streissguth, Moon-Jordan & Clarren, 1995).
Judgment Issues
Individuals with FASD often struggle with abstract thinking and rational
judgments (Kodituwakku, 2007; Streissguth, 2007). Limitations in these areas are
contributed to by brain damage-related deficits in the ability to delay gratification,
control impulses, resist manipulation, create and execute plans as well as anticipated
consequences of behaviors (Brown, Gudjonsson, & Connor, 2011; Greenspan &
Woods, 2014). Further, the thought patterns of individuals with FASD, in many cases,
can tend to be concrete and inflexible in nature. As a result, individuals with FASD are
prone to making poor or rash decisions and they may not adequately consider the moral
consequences of their decisions. For example, someone with FASD and over the age of
majority may meet a group of adolescents at a park and be invited to join them. The
person with FASD may be dared to kiss/ fondle a young female adolescent and then
engage in this behavior to seek acceptance from the group without understanding the
behavior is illegal and may result in significant consequences. The person was simply
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seeking approval and acceptance from a group of potentially socially and

developmentally more advanced individuals but used poor judgment and concrete
problem-solving (i.e., following the directions of the group of adolescents to gain
acceptance).
Deficits in making effective judgments can serve to complicate the performance

of an individual’s daily life tasks. For example, individuals with FASD and challenges
in judgment will likely struggle in the area of social relationships, including how to
express and reciprocate appropriately their sexuality with others. Symptoms like
impulsivity and poor decision-making likely contribute to risky sexual behaviors in
addition to issues recognizing the verbal and social cues of consent. More generally,
individuals with FASD may struggle with understanding social cues (Martyniuk &
Melrose, 2018; Wilhoit, Scott, & Smecka, 2017). Research shows that sexual offenders,
specifically those with intellectual disabilities, and individuals with Autism Spectrum
Disorder (ASD) can have deficits in social functioning which may contribute to these
individuals misinterpreting social and sexual cues (Grant, Furlano, Hall, & Kelley,
2018; Marotta, 2017). In many instances, individuals with FASD may tend to focus on
their immediate gratification and not the short- or long-term consequences of their
behavior. These issues are often magnified during adolescence as puberty and sexual
development to maturation occur. It is not uncommon for this to continue into
adulthood for those affected by FASD. As such, individuals with FASD could find
themselves entangled in the legal system due to inappropriate sexual behavior in the
absence of adequate ongoing support and services.
Immaturity
Emotional, intellectual, and behavioral immaturity are often present among

individuals with FASD. This can be operationalized as a person functioning at a level
that is lower than average for their biological age. Linked to frontal lobe damage,
symptoms can often include poor cognitive control, affective regulation, and behavioral
control (Greenspan & Driscoll, 2015; Verbrugge, 2003). This constellation of
symptoms can result in naiveté, poor judgment, a disregard for personal safety, and
thoughtless and impulsive actions. For example, individuals with FASD may quickly
act without considering how their actions impact others or the repercussions of their
behaviors (Fast & Conry, 2009; Rasmussen, 2005). Moreover, these issues may become
more apparent as a child ages into adolescence and adulthood with the physiological,
neurochemical and hormonal changes occurring in the body. In the presence of learning
difficulties that limit the capacity to comprehend cause and effect, such actions may
become dangerous and repeated across situations, particularly when reinforced by peers
or media content (Henry, Sloane, & Black-Pond, 2007; Weinberg, Sliwowska, Lan, &
Hellemans, 2008).
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Immaturity has been linked to inappropriate sexual behaviors, especially among

adolescents with cognitive deficits. It stands to reason that individuals with FASD who
struggle with maturity issues would also be susceptible to inappropriate sexual
behaviors (Malbin, 2004). For example, an 18-year-old with the cognitive and social
functioning of a 13-year-old may believe it is appropriate to engage in sexual activity
with a 13-year-old. Although the 18-year-old has the same cognitive and social
functioning levels as the 13-year-old, this would legally constitute a crime.
Complicating matters, the impulsivity that could characterize such inappropriate sexual
behaviors may be misperceived as intentional and malicious, resulting in more severe
punishments (Brown et al., 2010). The first line of defense in efforts to effectively
address such inappropriate sexual behaviors among individuals with FASD is sexual
education that emphasizes both appropriate and inappropriate sexual behaviors. Social
skills training can assist with FASD in better social relationships with those similar to
their own age making age-appropriate social and sexual relationships more likely. It is
imperative that social skills training around the area of sexually appropriate behaviors
and the nuances of dating be taught kinesthetically and with a lot of repetition.
Interpersonal boundaries
Individuals with FASD may exhibit difficulty complying with the norms of
interpersonal boundaries. This includes struggling to recognize inappropriate incursions
into the personal space of other individuals. The origins of these issues with
interpersonal boundaries may be related to the social deficits of FASD such as verbal
and non-verbal communication issues, which become more apparent with age. As a
result, individuals with FASD often have unintentional conflicts with other people due
to violations of interpersonal boundaries (Malbin, 2004; Thiel et al., 2011).
Unfortunately, this can result in awkwardness in some situations, and in other contexts,
be viewed as dangerous or antisocial.
Inappropriate sexual behaviors are one area where the violation of interpersonal
boundaries have particularly severe consequences for individuals with FASD (Chudley
et al., 2005; Conry, Fast, & Loock, 1997; Graham, 2014). For example, individuals with
FASD could have difficulty comprehending the inappropriateness of sexual encounters
with minors (Streissguth et al., 2004). Alternatively, individuals with FASD may not
recognize, either verbally or non-verbally, that the other person is not willingly
consenting to their sexual advances (Streissguth et al., 2004). Regardless, individuals
with FASD may cross interpersonal boundaries with inappropriate sexual behaviors that
harm someone else. If the role of FASD in these behaviors is not recognized, the
individual with FASD will likely face serious and long-term consequences rather than
receive specialized interventions (Brown et al., 2010).
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Sexual education is essential in preventing such legal outcomes for individuals

with FASD. Foremost, clients need to learn about both appropriate and inappropriate
relationships along with how to address their sexual desires in a socially acceptable
manner (Novick, 1997). Such education should include information about both in-
person interactions as well as online sexual behaviors including the use of pornography
and the generation/distribution of sexual material they create. Any intervention must
include information about how to recognize and respect interpersonal boundaries in
daily conversations as well as in intimate or social contexts. Addressing the role of
culture in this process is integral. Along these lines, building and maintaining a strong
social support system for the client can help create safe environments for the client to
comfortably learn about this nuanced topic inside and outside of therapy sessions. In
most instances, guidance on social norms and how to comply with them in an
acceptable manner will be necessary for the rest of the client’s life (Graham, 2014).
Perseveration
A common symptom of FASD, perseveration is the inability to alter one’s

attention or behavior once engaged on a path. This behavior then persists even in the
presence of negative consequences (Brown et al., 2010). Perseveration has been linked
to cognitive impairments including the capacity to monitor one’s self, receive and
respond to feedback, consider and anticipate outcomes of the behavior as well as other
aspects of executive control (Edwards & Greenspan, 2011; Streissguth et al., 2004;
Thiel et al., 2011). In cases of individuals with FASD, where perseveration is present,
inappropriate sexual behaviors could result in situations without clear and apparent
social boundaries (Brown et al.,2010). For example, an individual with FASD may
perseverate on fulfilling a sexual desire and fail to recognize verbal and non-verbal cues
that indicate another individual does not wish to participate in such sexual activities. In
the aftermath of criminal justice involvement, the client could seem resistant to
treatment or other instructions. However, professionals must keep in mind that this
could be due to symptoms of the disorder rather than the purposeful actions, or intent,
of the client. As previously described, a strong and proactive support group as well as
positive sexual education to attain healthy sexual behaviors are key to managing
sexually inappropriate behavior, including perseverative sexual behavior in those with
FASD.
Vulnerability and Risk of Victimization
Individuals with FASD are prone to victimization by a range of devastating acts

(Conry, Fast, & Loock, 1997; Conry & Lane, 2009). This is directly related to the
cognitive, social, and adaptive impairments of the disorder. In fact, the symptoms
characteristic of FASD may make those who live with the disorder compelling targets
for sexual abuse by others. Conry and colleagues (1997, 2009) have reported that well
Page 14 of 35
over half of those with FASD have reported experiencing significant abuse including
sexual abuse. Their difficulties with understanding social interactions, particularly
subtle or manipulative behavior of others, may make them more vulnerable to being
taken advantage of sexually. Because individuals with FASD may be very
impressionable, they may, in turn, engage in similar inappropriate sexual behaviors later
in life. This likelihood is only exacerbated by pre-existing symptoms such as
impulsivity and affective dysregulation, which make it difficult for individuals with
FASD to control themselves. In such instances, individuals with FASD may not
recognize that the inappropriate sexual behavior was problematic or realize there are
consequences for these acts. Forensic and mental health professionals must turn to
interventions that address impulsivity and affective dysregulation along with efforts to
distinguish between appropriate and inappropriate sexual behaviors. Interventions for
those who have experienced trauma, including sexual trauma earlier in life, may benefit
from trauma-focused interventions or trauma-informed care.
Diminished Ability to Understand Consequences of their Actions
Individuals with FASD often struggle to understand how their actions are related
to consequences. This can manifest itself in different ways. On one hand, individuals
with FASD may not be able to foresee the consequences and punishments that could
result from a given behavior. One the other hand, individuals with FASD may have
trouble associating the punishment that they received with the action that precipitated
the punishment. Consequently, individuals with FASD may be likely to have trouble
learning from previous experiences and adjusting their behavior accordingly (Brown et
al., 2010). These issues are often compounded by other FASD-related deficits including
impulsivity, inattentiveness, and compromised communication skills (Kelly et al., 2000;
Kully-Martens et al., 2012; Timler et al., 2005). Failure to adequately treat individuals
with FASD often results in prolonged behavioral issues and involvement in the criminal
justice system.
Criminal justice-involvement can take several forms. In some cases,

involvement in the criminal justice system may be due to the actions of other
individuals. Specifically, individuals with FASD could be vulnerable to serving as
pawns for the perpetrator of a crime. This vulnerability is related to the social deficits
characteristic of FASD, which often includes an eagerness to please others. In turn, an
individual with FASD may be willing to say that they committed a crime to protect
someone that they consider as a friend. In other cases, individuals with FASD could
commit inappropriate sexual behaviors due to other social deficits as described above
(McMurtrie, 2011). Whether the act was unintentional or not, individuals with FASD
may fail to comprehend why the act was problematic in many instances. In both types
of cases, the individual with FASD may have a limited understanding of the severity of
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any consequences for taking the blame or engaging in the behavior (Malbin, 2004; Thiel
et al., 2011).
Suggestibility
Individuals with FASD may be predisposed to suggestibility (Brown,

Gudjonsson, & Connor, 2011). This can be defined as the propensity to adopt another
individual’s point of view or beliefs, even if this is not accurate (Clare & Gudjonsson,
1993). The potential of suggestibility and manipulation by others in turn places
individuals with FASD in peril of a few different suboptimal criminal justice outcomes.
First, individuals with FASD may be convinced by peers, or others, to participate in a
crime that they would never have committed on their own. In some cases, individuals
with FASD may not even recognize that the act is a crime or that it has consequences.
For example, peers could encourage the individual with FASD to act out sexually as a
joke such as streaking or masturbating in a public space. Alternatively, individuals with
FASD may go along with the crime in an effort to gain friends or impress peers. For
example, other adolescents (or adults) may convince a young adolescent with FASD to
send naked pictures of him/her self in order to gain friendship or in hopes of developing
a romantic relationship without realizing this behavior is a crime. Second, individuals
with FASD may take the blame for actions committed by someone else. Such blame
taking could be done purposefully in an effort to please peers or unconsciously via
confabulation as a result of police interview and interrogation techniques (Brown et al.,
2011; Douglas, 2010; Greenspan & Driscoll, 2015; Roach & Bailey, 2009). The
consequences of this in the criminal justice system could include false confessions and
wrongful convictions.
Confabulation
As mentioned above, the presence of confabulation can be troublesome among

individuals with FASD (Rasmussen, Talwar, Loomes, & Andrew, 2008). Confabulation
is the non-purposeful alteration of existing memories or creation of new memories to
fill memory gaps. These confabulated memories may range from a slight adjustment to
a memory of a real event or extend to the full creation of a memory of an event that
never took place. Inspiration for confabulation can come from personal experiences,
popular media, or imagination. Furthermore, an individual struggling with
confabulation may believe that their memory of an event happened last week, but the
event may have actually taken place decades ago. A key aspect of confabulation is that
the individual does not realize that these memories are inaccurate or untrue (Smith &
Gudjonsson, 1995). The causes of confabulation may include frontal lobe damage,
cognitive impairments (e.g., executive functioning and memory), social deficits, and an
effort to compensate for gaps in memory (Baddeley, 1990; Gudjonsson & Clare, 1995).
It may also occur as a way to please law enforcement officials when they are being
Page 16 of 35
interviewed about an alleged crime. Confabulation can have devastating consequences

in the criminal justice system, including false confessions and wrongful convictions of
inappropriate sexual behavior that never took place (Baumbach, 2002; Fast & Conry,
2009; Fast & Conry, 2004).
Private vs. Public Behaviors
Similar to those with autism, the tendency to engage in private behaviors in

public spaces is common among individuals with FASD (Kalyva, 2010; Ruble &
Dalrymple, 1993; Van Bourgondien et al., 1997). This tendency could be attributed to
several different FASD symptoms. For example, the social deficits often characteristic
of FASD, include difficulty understanding social cues and conventions. Alternatively,
FASD may also manifest itself in obsessional behaviors where the individual has
difficulty controlling their compulsive actions. In turn, deficits related to frontal lobe
dysfunction, including impulsivity and failure to consider the consequences of their
actions may contribute to private behaviors being manifested in public situations. In all
of these instances, individuals with FASD may inadvertently commit inappropriate
sexual behaviors without comprehending the severity of their actions or their
consequences. Compounding problems, individuals with FASD may, unfortunately,
have limited exposure to how to express their sexual desires in a socially acceptable
manner, which could result in engaging in inappropriate sexual behaviors out of
frustration (Brown & Singh, 2016; Streissguth et al., 1996).
Intended Benefits of Routine Screening for Fetal Alcohol Spectrum Disorder

(FASD) Within Sex Offender Treatment Programs
FASD often goes undiagnosed into adulthood. In fact, the symptoms of FASD
are typically misdiagnosed as another disorder, or are not diagnosed at all, when they
are not initially recognized in childhood. This is due, in part, to the presence of
comorbid disorders such as anxiety, depression, and behavioral issues among
individuals with FASD. This makes the differential diagnosis process difficult at best.
In the absence of accurate diagnosis, individuals with FASD often do not receive
adequate support, treatment, and services. This exacerbates the risk of negative
outcomes such as low educational attainment, under-employment or unemployment,
and involvement in the criminal justice system. Improved recognition and knowledge of
FASD by professionals is essential to prevent these adverse outcomes.
This need of advanced education and training is salient among criminal justice
and forensic mental health professionals that work with sex offenders (Brown & Singh,
2016). As highlighted by Baumbach (2002), the amalgam of the poor identification of
FASD and the perceived risk of inappropriate sexual behaviors among individuals with
FASD suggests that individuals with a history of inappropriate sexual behaviors could
Page 17 of 35
possibly be living with the effects of FASD. If this is the case, the presence of FASD
should be routinely screened for in an effort to inform any allocation of treatment or
support services for sex offenders. Such diagnostic information could also be utilized by
judges and correctional staff when setting placement decisions and requirements.
Further, improved identification of FASD in sex offending treatment programs could
help facilitate research on the most effective treatment and interventions for this group.
Ultimately, the effectiveness of interventions and successful re-entry to the community
for individuals with FASD and exhibiting inappropriate sexual behaviors could be
improved by routine screening.
Intervention and Treatment Recommendations
As shown in previous sections, FASD is characterized by a diverse and varying

set of symptoms that must be methodically considered during treatment planning.
Unfortunately, the deficits of FASD are not typically considered and accounted for in
traditional sexual offender treatment programs, particularly with the heavy emphasis on
cognitive abilities in treatment programs. This is problematic because brain damage
often limits an individual’s capacity to benefit from a range of treatment options. As
such, individuals with FASD often struggle in such sexual offender treatment programs
(Rutman, 2011). The primary consequences of this have been not only ineffective
programming, but also a waste of resources, a disservice to the individual with FASD,
increased risk to the community and, in some cases, even iatrogenic effects. This
includes an exacerbation of symptoms, persistent inappropriate sexual behaviors, and
continued involvement in the criminal justice system (Novick, 1997).
Although there are limited research-based recommendations for sexual offenders

with FASD at this point, a developmentally-informed individualized approach holds the
most promise. Specifically, treatment providers should carefully assess the individual’s
risks and needs. To do this successfully, professionals require substantial training and
expertise to be able to recognize and assess these needs in clients with FASD. Needs
that should be considered include the consideration of the individual’s cognitive, social,
and adaptive functioning. Once identified, consideration of needs should be a central
component of developing a treatment plan. Maintaining flexibility to address these
needs when appropriate during the treatment process through specialized case
management is paramount. This is consistent with the Risk, Needs, and Responsivity
(RNR) model that is commonly used in corrections settings, and has a demonstrated
impact on the desistance of sexual and other criminal behavior (Hanson, Bourgon,
Helmus, & Hodgson, 2009). However, when the client’s personal needs are not
considered, treatment tends to be less effective and the potential for harm to the client
and others persists.
Page 18 of 35
There are several broad tips that professionals treating sexual offenders with
FASD should consider and adopt. First, the professional should confer with the client in
the identification of treatment goals. In this process, the professional must ensure that
these goals remain practical, obtainable, and mutually beneficial (Roberts & Nanson,
2000). This will help the client better understand how they can benefit from the
therapeutic process. Throughout this process, professionals must engage the client. This
could take the form of praising the successes of the client as they progress through
treatment.
Second, treatment and any treatment-related discussions should be held at the

cognitive and developmental level of the client. Due to the deficits associated with
prenatal alcohol exposure, individuals living with FASD often process information at a
rate that is much slower than expected for their chronological age. To account for this,
professionals should use a deliberate pace with frequent breaks. Information should be
disbursed in manageable chunks, as well as periodic checks to ensure the individual
understands the information, is warranted. More importantly, those with FASD are
often able to verbally present as more sophisticated than they actually function so it is
important that professionals working with those who have FASD check to make sure
the person is actually understanding information and not simply parroting back phrases.
The pace and organization of sessions should be consistently organized and predictable.
Professionals need to make an effort to keep the therapeutic environment calm and free
from distractions such as noise or bright lights (Graham, 2014). Temporal supports like
visual timers or procedural supports like a step-by-step outline plan could be helpful.
These steps should maximize the client’s chance to absorb, process and retain the
information and to be consistent with the approaches often used in clients with special
needs (Baumbach, 2002; Graham, 2014; Novick, 1997).
Third, professionals should keep in mind the best ways to verbally, and non-
verbally, communicate with the client. This includes the use of clear, concise, and
specific language that is concrete rather than abstract in nature. For example, jargon that
could be potentially confusing should be avoided. In other words, professionals would
benefit from using plain language and simple terms. When useful, professionals should
also explore the use of non-verbal communication modalities like drawing,
photography, or journaling. Throughout these interactions, it is wise for the professional
to check in and verify if the client has comprehended a statement or concept. The best
approach for verification is asking the client to explain recent content in their own
words. If the client is unable to do this, it is wise to cover this information again. It will
also be important to repeat and review content multiple times over longer periods of
time to ensure retention.
In addition to these broad tips, there are several techniques that hold promise for
these clients. The use of a multi-disciplinary treatment team is the foremost among
Page 19 of 35
these approaches. This should include a combination of psychological, medical, and

social workers that coordinate regularly in service of the client. Topics that this team
should address include medical and behavioral care, case management, living situation,
finances, life skills, and criminal justice issues. Addressing this broad range of care and
needs assists in providing the structure and support those with FASD need to develop
adaptive skills for successful life functioning. The use of role-plays and rehearsals are
particularly effective in addressing many of the difficulties and deficits in individuals
with FASD (Roberts & Nanson, 2000). Modeling should be used in a supportive
environment throughout the treatment interaction. For example, this can help ensure
that clients master tangible life skills and problem-solving abilities (e.g., stress and
anger management and communication skills) that they can apply in other settings (Fast
& Conry, 2004; Novick, 1997). Additionally, it may be beneficial to utilize a trauma-
informed approach in addressing these wide-ranging issues, as many individuals with
FASD have been victimized from an early age (Conry, Fast, & Loock, 1997; Streissguth
et al., 2004).
Another essential topic to cover with individuals who have FASD and who have
engaged in inappropriate sexual behaviors is the topic of appropriate sexual behavior.
This should begin with basic sexual socialization and information about sexuality
(Novick-Brown, 2007). There should be clear discussions of what constitutes sexual
consent and the identification of appropriate and inappropriate sexual behaviors. This
includes distinguishing the differences between inappropriate and illegal sexual
behaviors based on societal norms and laws. The client must understand that all sexual
encounters must be consensual and be equipped to navigate the consent process. An
important part of this process is ensuring that the client understands how such
inappropriate sexual behaviors impact others while providing them with the knowledge
and skill to replace inappropriate sexual behaviors with appropriate behaviors. One
promising technique for assisting those with developmental delays/ deficits, including
those with FASD, is the use of social narratives or stories to assist in learning and
understanding social behaviors such as sexual interactions. The use of short stories to
teach social skills was originally developed by Carol Gray (1995) to teach children on
the autism spectrum improved communication skills. The use of social narratives has
been found to be effective in modifying social behavior and understanding as it
provides information to teach appropriate responses as opposed to admonishing
inappropriate responses. Therapists, teachers, or caregivers can develop individualized
stories for unique individuals and situations depending on the need. These stories
typically involve very brief descriptions along with pictures to assist in understanding,
followed by discussion with the trainer (e.g., teacher, therapist, caregiver). The stories
are simple and do not require high levels of literacy such that individuals with difficulty
reading can understand them and they can be implemented with caregivers who may not
have high levels of education but understand social interactions well. Over time, the use
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of this technique has expanded to other special needs populations beyond the autism
spectrum disorders (e.g., children with hearing impairments, those with other
developmental disabilities). This technique uses specially developed stories/ narratives
with particular characteristics to teach social skills and behaviors, focusing on the
positive perspective (e.g., teaching what to do rather than focusing on what not to do).
This can be particularly useful with sexual behaviors as the interactions can be subtle
and the consequences for inappropriate interactions can be severe. Those with FASD
tend to do best with overt, concrete instruction so using social narratives to teach sexual
socialization can provide this type of communication in a non-threatening manner and
provide for the incorporation of other means of learning, such as role-playing, following
the story to practice and develop skills before they are needed in real life experiences.
Additionally, because the stories use various forms of communication including
pictures, written story, and verbal discussion, the format for learning is easily accessible
for those who require more than one type of educational system.
While specific research has not been completed with the use of this technique
for those with FASD, the similarities between the social and communication deficits of
those with FASD and other developmental disorders like autism indicate this may be a
useful technique for assisting in education and intervention for inappropriate sexual
behaviors for those with FASD. In particular, research more generally on social skills
deficits in those with FASD indicate that the deficits appear more pronounced as the
person gets older. Research specifically with adolescents and adults using social
narratives to teach sexual socialization may be particularly useful in developing an
effective program to assist those who have FASD and engage in inappropriate sexual
behavior. Throughout all the intervention processes, professionals must consistently
verify that the client understands and retains the information covered during sessions.
This can be done through repetition and inquiry as to the individual’s understanding and
retention of the information.
All of these services including an accurate assessment of the client’s potential

and abilities need to be available to the client on an ongoing basis (Novick, 1997).
Because FASD cannot simply be cured, the symptoms will need to be managed for the
rest of the client’s life (Douglas, 2010). Continued external support, organization and
structure (often referred to as the ‘external brain’) for those with FASD provides the
most likely outcome for success in the community. Failure to address these symptoms
will contribute to the client’s deterioration and the potential emergence of new
exacerbating symptoms. As a result, a lack of treatment and services increases the risk
of recidivism and other negative life outcomes in the client (e.g., the development of
secondary disabilities such as additional mental health problems, drug and alcohol
addition, etc.). Early and effective interventions offer the best path forward for the client
and the community (McLachlan, 2012).
Page 21 of 35
Future Directions
Inappropriate sexual behaviors among individuals with FASD are an under-

researched area that offers several opportunities for growth (Brown & Singh, 2016).
First, epidemiological works such as surveys are imperative to better understand the
prevalence of FASD and inappropriate sexual behaviors among this group. Second,
research that explores the causal relationship between FASD symptoms and
inappropriate sexual behaviors could be promising. This should account for the
moderating influences of comorbid psychopathology along with developmental, gender,
and cultural differences. Third, the development and validation of assessment tools for
use in this population is necessary. Such instruments should focus on the identification
of FASD-related deficits through official diagnostic criteria for Neurodevelopmental
Disorder-Prenatal Alcohol Exposure (ND-PAE); the diagnosis provided in the DSM-5
as well as the risks and needs of this population in criminal justice settings.
Improvements in these areas of assessment have the potential to guide treatment and
supervision going forward resulting in a more successful outcome for the individual and
society more broadly. Fourth, research has a strong role to play in the development,
evaluation, and refinement of sex offender treatment programs for individuals with
FASD. These studies may explore the suitability of attachment-based or trauma-
informed approaches with this population. Fifth, there is a strong need for
developmentally sensitive research on how to best educate and support individuals with
FASD about sexuality and sexual expression. For example, promising techniques, such
as social narratives, found helpful in other populations with similar deficits have not
been systematically explored with those with FASDs. Further research to determine
effective interventions that target the various types of inappropriate sexual behaviors
should be further explored. Sixth, research that elucidates how characteristics of FASD
may contribute to challenges in individual’s participation and functioning in the
criminal justice system is needed. This could include the process of making legal
decisions, competency to stand trial, and the ability to meet the conditions of
supervision in confined settings and community supervision like probation. Last but not
least, research must work to develop education and training programs on FASD and
inappropriate sexual behaviors for criminal justice and forensic mental health
professionals. In combination, research in these areas has the potential to improve
outcomes for clients and improve public safety.
Case Example
The following case example is a combination of FASD features that may be

observed in someone who engaged in inappropriate sexual behaviors. This is a case
example composed of features of various individuals and is not a description of any one
person. The features highlighted in this case example illustrate how an individual with
an average level of intellectual functioning within FASD may result in involvement in
Page 22 of 35
both mental health services and the criminal justice system given that those who have
significant intellectual and other deficits may be found to not be competent to stand trial
(and therefore not managed in the criminal justice system) or will be provided services
through other agencies (e.g., developmental disabilities services, state hospitals, etc.).
Mr. Jones is a 61-year-old Caucasian male who is currently civilly committed

under the mental health system. He was born to an intact family to a father who worked
in a professional position while his mother worked part-time in an office setting. His
mother is known to have consumed significant amounts of alcohol while pregnant with
him but otherwise experienced a normal pregnancy. Records indicate that Mr. Jones
was a hyper child who demonstrated difficult behaviors including intrusiveness,
inattention, poor school performance, and difficulty with social relationships. He was
physically abused at times when his parents’ attempts at discipline were ineffective.
Generally, he remained somewhat isolated from peers throughout his childhood but
when he did interact with others, he tended to play with much younger children. This
resulted in inappropriate sexual behavior at a young age as he sexually acted out with
the younger children. Interventions to prevent continued sexual behaviors with younger
children were ineffective, and Mr. Jones continued to engage in sexually inappropriate
behavior with young children off and on throughout his life. He also engaged in other
behaviors indicative of sexual preoccupation including seeking out pictures of partially
clothed or unclothed children in medical books or store flyers and eventually on the
Internet.
While intellectual testing has indicated he intellectually functions in the lower

range of average, his adaptive functioning and communication skills are generally much
lower. He was never able to live independently as he could not manage money, reliably
track and pay bills, and often could not tell time. He was unable to track appointments
or follow a schedule without external support. As Mr. Jones got older, he continued to
demonstrate difficulties with impulsivity and poor social skills as well as emotional
dysregulation.
As a young adult, Mr. Jones was convicted of molesting several male children
(ages 8-10 years old) after meeting them near his job where he worked in a somewhat
supported environment in custodial services. He explained that he felt accepted by the
children and that they did not judge him as he felt adult peers would do. Following his
conviction, he was provided a brief period of counseling and moved to a new area.
Shortly after moving, new allegations of sexual contact with young boys were made;
however, no charges were filed. He was often found to engage in other problematic
behavior including telephone harassment (i.e., threats made when he had difficulty with
emotion regulation) and ‘pranks’ on neighbors (i.e., impulsive behaviors like moving
their belongings or writing obscene messages in the dirt on their car windows). Mr.
Jones was also the target of harassment with neighborhood kids/ adolescents
Page 23 of 35
vandalizing his home on numerous occasions or calling and harassing him over the
phone.
Another feature of Mr. Jones’ inappropriate behavior included attempts to

engage others in sexual behavior in a socially inappropriate manner such as asking a
taxi driver if he could masturbate while the taxi driver transported him to appointments.
At one point, while attending an appointment, he asked a young woman in the lobby for
a hug and when she acquiesced, Mr. Jones fondled her breast. Mr. Jones has reported
that he engaged in such behaviors in an attempt to initiate sexual contact. While in
institutional settings, he would approach others with offers of sexual contact or he
would attempt to watch them shower. There were frequent complaints of his unwanted
sexual advances, often resulting in further social isolation.
Despite various interventions and consequences, Mr. Jones continued to engage

in these sexually inappropriate behaviors and eventually agreed to civil commitment to
seek help and due to his risk to others and inability to reside independently in the
community. His interpersonal interactions are abrasive at times, although he tries to
connect with others in an inept manner, and he is unable to function within a group for
treatment. He tends to be very rigid in his problem solving and will often refuse to
participate in particular types of treatment (medical and mental health) until he feels a
sufficient reason has been provided. He does not tell others when he does not
understand, rather he pretends to understand until he gets in trouble for not following
rules. Unfortunately, this rigidity and lack of understanding what is expected of him
often results in the conclusion by direct caregivers that he is ‘lazy’ or unmotivated to
comply with rules or treatment plans. Previously, this has resulted in the erroneous
diagnosis of a personality disorder and the misattribution of his difficulties. With the
appropriate diagnosis established by a multi-disciplinary evaluation team through
extensive research of his records, interviews with family members, and psychological/
neuropsychological testing, Mr. Jones was properly identified as experiencing FASD
and treatment planning was modified to appropriately address his complex needs
through individualized interventions and supports.
Case Example 2
This case example incorporates descriptions of several male sex offenders who
have FASD and engage in sexually inappropriate behaviors. All identifying information
has been changed to protect the anonymity of the person(s) included. Mr. Davis is a 28-
year-old Caucasian male who is currently incarcerated for a sexual offense. He reported
that his mother consumed alcohol while pregnant with him, but otherwise reports a
fairly normal pregnancy, with few complications. Mr. Davis reports that his mother died
when he was 5 years old and that child protective services removed him from his
father’s care. He would spend the remainder of his childhood living with a family
Page 24 of 35
member. Prior to his mother’s death, there was a history of domestic violence and
excessive alcohol use in the home. Upon reviewing his records, Mr. Davis lacked
prosocial relationships, has been unable to maintain healthy romantic relationships,
isolates, and struggled in school.
Intellectual testing has been conducted confirming that he has deficits in

intellectual functioning such as problem solving, abstract thinking, judgment, and
adaptive functioning. He has an additional diagnosis of depression and post-traumatic
stress disorder. He has refused mental health services in the community and during
incarceration.
As an adult, Mr. Davis was convicted of child molestation after he was found by
a family member engaging in sexual role-plays with a six-year-old child for the purpose
of sexual gratification. During the investigation, thousands of images of child
pornography were found on his computer. Detectives also found that Mr. Davis had
been corresponding with several minor females through social media sites. During the
conversations, Mr. Davis would ask these victims to send nude photos to him and then
attempt to engage them in sexually explicit conversations. In addition, other victims
came forward and reported that Mr. Davis had engaged in similar inappropriate sexual
behaviors with other minors, including voyeurism. His offending towards minors spans
over 10 years and includes victims ages 3-11 years-of-age.
While in incarcerated, Mr. Davis continues to engage in sexually inappropriate

behaviors as he was found watching television shows containing minor children,
therefore, reinforcing his deviant arousal towards children. During a cell search, officers
found drawings of minor children engaging in sexual acts. Mr. Davis struggles to admit
to his offending behaviors and continually fails to take responsibility for his actions. He
does not want to talk about his emotions and only wants to admit to behaviors found in
official documentation (e.g., police reports, pre-sentence investigation). Despite a
continued pattern of deviant arousal to minor children and numerous attempts to gain
access to minor victims, he denies having a problem.
After a thorough assessment and many case staffing sessions, Mr. Davis was
diagnosed with FASD. Treatment approaches have been modified to help Mr. Davis
learn and apply appropriate and healthy interventions.
CONCLUSION
The cognitive, social, and adaptive functioning symptoms of FASD may

contribute to some individuals with this disorder to engage in inappropriate sexual
behaviors. In the absence of accurate diagnosis and appropriate treatment services,
inappropriate sexual behaviors and criminal justice-involvement may persist across an
extended period of time. This is troublesome because individuals with FASD are not
Page 25 of 35
well equipped to function in the criminal justice system and make legal decisions.
Furthermore, well trained professionals on the aspects and treatment needs related to
FASD within the criminal justice system are lacking.
The effects of FASD pose a challenge to forensic contexts which require

cognitive competency of charges and court proceedings. Prior research indicates
ensuring adequate knowledge about FASD as well as having resources to refer
individuals for assessment are a first step towards effective intervention to ensure due
process for each person in the criminal justice system (Brown & Singh, 2016).
Diagnosed or not, FASD can place individuals at a disadvantage in their legal cases.
Having a thorough understanding and diagnosis can promote effective counsel and
guidance in criminal justice settings and forensic contexts; thereby ensuring fairness for
those living with the effects of FASD. To effect changes, criminal justice and forensic
mental health professionals must not only become aware of the link between FASD and
inappropriate sexual behaviors, but also need to take proactive measures.
Actions can include the expanded use of FASD screening and assessment
measures among individuals with a history of inappropriate sexual behaviors resulting
in more individualized and specialized interventions. When both FASD and
inappropriate sexual behaviors are present, professionals should form a multi-
disciplinary team including legal professionals, treatment providers, social workers, and
family members to address the diverse treatment needs of the client. These efforts
would be greatly enhanced by systematic research on the etiology, assessment, and
treatment of individuals living with FASD and sexually inappropriate behaviors. In
combination, advances in these areas have the potential to improve outcomes for clients
and enhance the safety of the community.
Page 26 of 35
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What is Fetal Alcohol Spectrum Disorder and how does it impact individuals?

What is Fetal Alcohol Spectrum Disorder and how does it impact individuals?

What challenges do individuals with FASD face in understanding social cues and boundaries?

What challenges do individuals with FASD face in understanding social cues and boundaries?

Fetal Alcohol Spectrum Disorder (FASD) Today 2018, Volume 1, Issue 1, 1-35

LITERATURE REVIEW ARTICLE

Fetal Alcohol Spectrum Disorder (FASD) and Sexually

Jerrod Brown,1,2,3 Rae Mitten4, Megan N. Carter5,6i, Jeffrey Haun7,8ii, Amanda

Affecting millions of individuals in North America, Fetal Alcohol Spectrum Disorder

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder

Typically, FASD is characterized by impairments in cognitive (e.g., information

Although the legal consequences of inappropriate sexual behavior among

The Role of FASD in Inappropriate Sexual Behaviors

The relationship between FASD and inappropriate sexual behaviors is

Executive Function Deficits

Executive functioning deficits are perhaps the most deleterious of FASD

capacity to consciously execute goal-directed behavior including planning and adapting

Several different FASD-related deficits can interfere with an individual’s

Adaptive/Social Functioning Deficits

Adaptive functioning is an individual’s ability to successfully resolve the tasks

In light of the pervasive consequences, adaptive functioning deficits may very

To begin to address inappropriate sexual behavior in individuals with FASD,

Theory of Mind Deficits

(Rasmussen et al., 2009), areas of functioning often impaired by prenatal alcohol

As previously noted, those with Theory of Mind deficits have particular

Diminished Ability to Appropriately Express and Exhibit Empathy

Appropriate emotional expression and exhibiting empathy are of paramount

seeking approval and acceptance from a group of potentially socially and

Deficits in making effective judgments can serve to complicate the performance

Emotional, intellectual, and behavioral immaturity are often present among

Immaturity has been linked to inappropriate sexual behaviors, especially among

Sexual education is essential in preventing such legal outcomes for individuals

A common symptom of FASD, perseveration is the inability to alter one’s

Vulnerability and Risk of Victimization

Individuals with FASD are prone to victimization by a range of devastating acts

Diminished Ability to Understand Consequences of their Actions

Criminal justice-involvement can take several forms. In some cases,

Individuals with FASD may be predisposed to suggestibility (Brown,

As mentioned above, the presence of confabulation can be troublesome among

interviewed about an alleged crime. Confabulation can have devastating consequences

Private vs. Public Behaviors

Similar to those with autism, the tendency to engage in private behaviors in

Intended Benefits of Routine Screening for Fetal Alcohol Spectrum Disorder

Intervention and Treatment Recommendations

As shown in previous sections, FASD is characterized by a diverse and varying

Although there are limited research-based recommendations for sexual offenders

Second, treatment and any treatment-related discussions should be held at the

these approaches. This should include a combination of psychological, medical, and

All of these services including an accurate assessment of the client’s potential

Inappropriate sexual behaviors among individuals with FASD are an under-

The following case example is a combination of FASD features that may be

Mr. Jones is a 61-year-old Caucasian male who is currently civilly committed

While intellectual testing has indicated he intellectually functions in the lower

Another feature of Mr. Jones’ inappropriate behavior included attempts to

Despite various interventions and consequences, Mr. Jones continued to engage

Intellectual testing has been conducted confirming that he has deficits in

While in incarcerated, Mr. Davis continues to engage in sexually inappropriate

The cognitive, social, and adaptive functioning symptoms of FASD may

The effects of FASD pose a challenge to forensic contexts which require