Fetal Alcohol Spectrum Disorder Distinguished from Autism

Guidance for clinicians distinguishing FASD from ASD
Fetal alcohol spectrum disorders (FASDs) refer to 4 groupings of fetal alcohol-related birth defects characterized by varying degrees of growth deficiency, specific dysmorphic features, and central nervous system dysfunction and malformation.
Autism spectrum disorder (ASD) is a neurodevelopmental disorder with core deficits in social communication and interaction and restrictive, repetitive patterns of behavior. The diagnosis is based on behaviors that vary depending on the patient’s age, cognitive level, and language skills.
The cause of FASDs is alcohol exposure in utero, which has varying effects on the developing fetus, whereas the cause of ASD is multifactorial, including genetic and environmental factors. Both disorders share some common behavioral characteristics, but each disorder's overall symptom expression is unique.

Key Points

Dual diagnosis
A diagnosis of FASD does not preclude a diagnosis of ASD if the child meets the criteria for both disorders. A small minority of children with FASD are also diagnosed with ASD, and treatment can be more complex due to the need to address (sometimes overlapping) problems with behavior and social interactions associated with both disorders.

Common characteristics
ASD and FASDs may share characteristics, such as strong sensory interests and aversions, cognitive delays, and deficits in executive functioning and adaptive skills. [Bishop: 2007] The patterns of symptom expression, however, are unique to each disorder.

Differences in social interactions
Children with ASD and FASD both struggle in social interactions but in different ways. While children with ASD often appear aloof and uninterested in social interactions, children with FASD tend to be not only interested in social interactions but also indiscriminately friendly with poor boundaries and no sense of “stranger danger.” Furthermore, when children with FASD do approach others or engage socially, they often lack the interpersonal skills necessary to move the interaction forward in a positive way. Such behaviors might include

  • Inappropriate statements or questions
  • Difficulties with compromising, cooperating, or taking different roles with other children
  • Difficulty with sharing
  • Hyperactive or impulsive behavior that is difficult to manage from the standpoint of their interaction partner

Children with FASD struggle with social cues and often misunderstand or misinterpret facial expressions and eye gazes from other people. They also tend not to understand information conveyed by speech prosody. [Stevens: 2013]

Nonverbal gestures
Children with FASD can better use gestures and nonverbal communication to interact, demonstrate empathy, share enjoyment in social overtures, and use a greater range of facial expressions during social interactions than children with ASD. Thus, “shared affect behaviors” are relatively less impaired in children with ASD than in their counterparts with ASD.

Cognitive functioning
ASD and FASD also differ in their characteristic patterns of cognitive disability. One study comparing ASD with FASD in children found that 79% of ASD children had a higher nonverbal than verbal IQ. [Bishop: 2007] The opposite was true for children with FASDs, with the majority demonstrating a higher verbal than nonverbal IQ.

Roles of the primary care pediatrician
The medical home plays a central role in coordinating various aspects of care. This includes orchestrating referrals to subspecialists, overseeing therapeutic interventions, monitoring pain management strategies, aiding in accurate seizure diagnosis, and collaborating closely with specialists to ensure comprehensive and holistic care for the affected individuals.

Managing common problems
Research has shown that children with FASD and ASD share similarities in social and communicative functioning, so behavioral interventions that address those areas would be helpful. Additional problems that can occur both in children with FASD and children with ASD include sleep disturbances and psychiatric conditions like ADHD. Management of comorbid conditions can help improve functional capabilities and quality of life for children with FASD and ASD.

Diagnosis

Detailed diagnosis and management information can be found at:

Role of Primary Care

  • Ensure referral to appropriate specialists to assist in diagnosis, such as a developmental pediatrician, neurologist, or psychiatrist.
  • Recognize and address comorbidities, including sleep disorders, ADHD, mood disorders, inadequate nutrition or other growth concerns, learning disabilities, and the need for additional interventions like speech, occupational, or physical therapies.
  • Ensure the parent's know-how to access appropriate school services.
  • Ensure family-centered team collaboration.
  • Support the parents in advocating for needed services.
  • Prescribe medication or consult with a psychiatrist when indicated.

Incidence and Prevalence

FASDs
It is estimated that FASDs affect 2-5% of live births in the US and that FAS affects 2-7/1000. [May: 2009] The Centers for Disease Control and Prevention (CDC) estimates 0.2-1.5 cases of FAS per 1000 live births and that at least 3 times as many are affected by FASDs. [National: 2017] FASDs occur in all socioeconomic and cultural groups.

ASD
About 1:54 children have been identified with ASD. [Maenner: 2020] These estimates from the Autism and Developmental Disabilities Monitoring (ADDM) Network (CDC) are based on data collected from health and special education records of children living in 11 communities across the United States during 2014.

Co-occurrence of FASDs and ASD
Data on the association between FASD and ASD is limited. Prevalence data on both conditions are likely an underrepresentation given that both disorders are underdiagnosed. [Carpita: 2022] One systematic review found that the prevalence of ASD in children with FASD was 2.6%, which is almost twice the rate in the general population. [Lange: 2018]

Services and Referrals

Developmental - Behavioral Pediatrics (see NW providers [1])
IRefer for help with differential diagnoses, sorting out factors contributing to developmental delays, or for more challenging patients. Developmental-behavioral pediatricians can help differentiate between FASDs and ASD or help solidify co-occurrence of these diagnoses.

Psychiatry/Medication Management (see NW providers [0])
Because FASD and ASD can be accompanied by disruptive behavior and emotional problems, working with mental health providers to identify and treat these conditions is important. Referral to psychiatry may be particularly helpful in sorting out causation for attention problems, depression, and anxiety and guiding the approach to treatment.

Early Intervention for Children with Disabilities/Delays (see NW providers [3])
These low-cost programs involve in-home therapy and/or therapy within a playgroup. Each state provides early intervention services differently. In Utah, a diagnosis of FAS or ASD automatically qualifies the child for services. If a diagnosis cannot be established, documentation of developmental delay can help the child to qualify for the program.

Special Education/Schools (see NW providers [2])
Each school district will have an office responsible for ensuring appropriate services are provided to qualifying students. Contact the district officials if the school is unable or unwilling to offer needed services. Special education services can be provided for children over the age of 3 (qualification for Early Intervention services ends at age 3).

Resources

Information & Support

Related Portal Content
The Medical Home Portal provides related general diagnosis and management information, including:

Answers to questions that families may frequently ask can be found at: The Care Notebook may also be helpful for tracking medical history, test results, and records.

For Professionals

Differences Between FASD and Autism (ProofAlliance) (PDF Document 425 KB)
A table of the common “symptoms” of both FASD and ASD with bold indicating effects that are seen in both disorders.

Services for Patients & Families Nationwide (NW)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

Carpita B, Migli L, Chiarantini I, Battaglini S, Montalbano C, Carmassi C, Cremone IM, Dell'Osso L.
Autism Spectrum Disorder and Fetal Alcohol Spectrum Disorder: A Literature Review.
Brain Sci. 2022;12(6). PubMed abstract / Full Text

Benson AA, Mughal R, Dimitriou D, Halstead EJ.
Towards a Distinct Sleep and Behavioural Profile of Fetal Alcohol Spectrum Disorder (FASD): A Comparison between FASD, Autism and Typically Developing Children.
J Integr Neurosci. 2023;22(3):77. PubMed abstract

Shaffer RC, Reisinger DL, Schmitt LM, Lamy M, Dominick KC, Smith EG, Coffman MC, Esbensen AJ.
Systematic Review: Emotion Dysregulation in Syndromic Causes of Intellectual and Developmental Disabilities.
J Am Acad Child Adolesc Psychiatry. 2023;62(5):518-557. PubMed abstract

Authors & Reviewers

Initial publication: January 2017; last update/revision: June 2024
Current Authors and Reviewers:
Author: Maggie Bale, MD, MPH
Authoring history
2017: first version: Patrick Shea, MDSA; Deborah Bilder, MDR
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

Benson AA, Mughal R, Dimitriou D, Halstead EJ.
Towards a Distinct Sleep and Behavioural Profile of Fetal Alcohol Spectrum Disorder (FASD): A Comparison between FASD, Autism and Typically Developing Children.
J Integr Neurosci. 2023;22(3):77. PubMed abstract

Bishop S, Gahagan S, Lord C.
Re-examining the core features of autism: a comparison of autism spectrum disorder and fetal alcohol spectrum disorder.
J Child Psychol Psychiatry. 2007;48(11):1111-21. PubMed abstract

Carpita B, Migli L, Chiarantini I, Battaglini S, Montalbano C, Carmassi C, Cremone IM, Dell'Osso L.
Autism Spectrum Disorder and Fetal Alcohol Spectrum Disorder: A Literature Review.
Brain Sci. 2022;12(6). PubMed abstract / Full Text

Lange S, Rehm J, Anagnostou E, Popova S.
Prevalence of externalizing disorders and Autism Spectrum Disorders among children with Fetal Alcohol Spectrum Disorder: systematic review and meta-analysis.
Biochem Cell Biol. 2018;96(2):241-251. PubMed abstract

Maenner MJ, Shaw KA, Baio J, Washington A, Patrick M, DiRienzo M, Christensen DL, Wiggins LD, Pettygrove S, Andrews JG, Lopez M, Hudson A, Baroud T, Schwenk Y, White T, Rosenberg CR, Lee LC, Harrington RA, Huston M, Hewitt A, Esler A, Hall-Lande J, Poynter JN, Hallas-Muchow L, Constantino JN, Fitzgerald RT, Zahorodny W, Shenouda J, Daniels JL, Warren Z, Vehorn A, Salinas A, Durkin MS, Dietz PM.
Prevalence of Autism Spectrum Disorder Among Children Aged 8 Years - Autism and Developmental Disabilities Monitoring Network, 11 Sites, United States, 2016.
MMWR Surveill Summ. 2020;69(4):1-12. PubMed abstract

May PA, Gossage JP, Kalberg WO, Robinson LK, Buckley D, Manning M, Hoyme HE.
Prevalence and epidemiologic characteristics of FASD from various research methods with an emphasis on recent in-school studies.
Dev Disabil Res Rev. 2009;15(3):176-92. PubMed abstract

National Center on Birth Defects and Developmental Disabilities.
Data & Statistics: Fetal Alcohol Spectrum Disorders.
Centers for Disease Control and Prevention; (2017) http://www.cdc.gov/NCBDDD/fasd/data.html. Accessed on March 2017.

Shaffer RC, Reisinger DL, Schmitt LM, Lamy M, Dominick KC, Smith EG, Coffman MC, Esbensen AJ.
Systematic Review: Emotion Dysregulation in Syndromic Causes of Intellectual and Developmental Disabilities.
J Am Acad Child Adolesc Psychiatry. 2023;62(5):518-557. PubMed abstract

Stevens SA, Nash K, Koren G, Rovet J.
Autism characteristics in children with fetal alcohol spectrum disorders.
Child Neuropsychol. 2013;19(6):579-87. PubMed abstract