Fetal Alcohol Spectrum Difference: A Neurodivergent Perspective Beyond Misogyny and Socioeconomic Bias

I write this essay from the perspective of a GP working across both adult and adolescent correctional centres. Diagnosed autistic with ADHD, I have become a strong advocate for neurodivergent leadership, recognising the urgency of accelerating inclusion and diversity, and the many strengths and unique perspectives that neurodivergent people bring to governance and leadership.

In this work, I advocate for the recognition and inclusion of Fetal Alcohol Spectrum Difference (FASD) within the broader definition of neurodevelopmental conditions. While the medical literature continues to use the term disorder, I deliberately choose the framing of difference, aligning with a neurodiversity perspective that resists deficit-only language and instead acknowledges the adaptability, potential, and complexity that accompany FASD.

This essay is written from the perspective of a clinician who witnesses neurodivergence daily in practice. It is offered as a contribution to the growing recognition that difference is not deficit, and that the voices of people with FASD themselves must lead the way forward: nothing about us without us.

FASD as Neurodivergence: Equity, Stigma, and the Case for Needs-Based Approaches

Fetal Alcohol Spectrum Difference (FASD) should be understood not as a moral failing or purely maternal responsibility, but as another form of neurodivergence within the broad human spectrum of developmental differences. Like autism, ADHD, and other neurodevelopmental profiles, FASD is highly heterogeneous and often marked by the “spikiness” characteristic of neurodivergence — areas of difficulty coexisting with distinct strengths, such as creativity, adaptability, generosity, artistic ability, talkativeness, physical prowess, and strong people-centred skills. There are FASD accountants, engineers, academics, health workers, and almost certainly medical practitioners. Recognising FASD through a neuroaffirming lens shifts the discourse away from blame and deficit toward equity, inclusion, and support.

A critical inequity lies in how FASD has been conceptualised and diagnosed. Research and policy have historically focused almost exclusively on mothers, neglecting the well-documented role of paternal alcohol consumption. Since the mid-2000s, studies have highlighted paternal contributions — genetic, epigenetic, and lifestyle-related — in shaping fetal development. Animal studies have shown that paternal alcohol exposure alone, without maternal involvement, can produce grossly observable alcohol-related phenotypes in offspring, including changes in craniofacial features. A 2023 study found that preconception paternal ethanol exposure in rats induced craniofacial growth deficiencies mirroring FASD features. Human studies have also shown higher odds of microcephaly at birth linked to paternal, but not maternal, alcohol consumption before conception. Despite this evidence, the discourse around FASD remains overwhelmingly maternal-focused, reflecting entrenched gender bias that stigmatises women while limiting effective prevention and support strategies.

This bias is compounded by socioeconomic inequities in diagnosis. Children from lower socioeconomic backgrounds are disproportionately identified as having FASD, while children in higher socioeconomic groups are more likely to receive alternative diagnoses such as autism or ADHD. (It is also possible that a patient may fulfil multiple diagnoses, such as ADHD, autism, and FASD.) This reflects diagnostic bias rooted in social assumptions, not biology.

Evidence shows that alcohol consumption is higher in upper socioeconomic groups, including among parents planning families. Moreover, with an estimated 60% of pregnancies being unplanned, alcohol will remain an unavoidable teratogen in many cases. Yet children from wealthier families exhibiting FASD traits are more often given labels that carry less stigma and greater access to supports, while disadvantaged children are more likely to face exclusion and limited intervention. This entrenches inequality.

A universal, needs-based assessment model — focused on functional strengths and support needs rather than hierarchical labels — would mitigate such inequities.

Moreover, misdiagnosis is a significant issue. Approximately 80% of FASD cases are initially missed or misdiagnosed, usually labelled as ADHD instead. In one clinical sample of foster and adopted youth, 80.1% of those later confirmed to have FASD had never previously received that diagnosis, and many had been misdiagnosed under other labels.

Reframing FASD as one of many spiky neurodivergences reorients the focus toward equity and inclusion. Instead of isolating FASD as a maternal moral failing or limiting diagnosis by class-based assumptions, society must embrace a universal, needs-based approach. This means recognising both the challenges and the strengths of individuals — while dismantling outdated diagnostic criteria and harmful stigmas. Only then can FASD, alongside autism, ADHD, and other neurodevelopmental differences, be understood in neuroaffirming terms as part of the shared human spectrum.

FASD and the Justice System

Neurodivergent individuals are disproportionately represented in the justice system. Research indicates that juveniles diagnosed with FASD are 19 times more likely to be incarcerated than their non-affected peers. Despite this, neurodivergence often goes unrecognised or is misunderstood by both medical and legal professionals, resulting in misdiagnosis and inadequate support. This lack of recognition contributes to harsher penalties, insufficient accommodations, and limited access to appropriate rehabilitation programs.

In Western Australia, a study found that 36% of young people detained at the Banksia Hill Youth Detention Centre had FASD. Incorporating neuroaffirming assessments, followed by appropriate supports and interventions, could reduce recidivism, improve rehabilitation outcomes, and ensure fair treatment, while addressing systemic inequities related to socioeconomic class, gender, and diagnostic stigma.

Diagnostic practices also perpetuate stigma through the use of unnecessary physical markers such as facial stigmata. While historically central to the diagnosis of Fetal Alcohol Syndrome (FAS), research shows that characteristic facial features are present in only about 13% of individuals affected by prenatal alcohol exposure. Their continued inclusion in diagnostic systems reinforces a sense of “otherness,” creating exclusion without significant clinical benefit. Eliminating these criteria would align FASD diagnosis with neuroaffirming, needs-based models that prioritise lived experience and function over appearance.

Importantly, all forms of neurodivergence — including FASD — are evolutionarily situated. Human societies have coexisted with alcohol for at least 9,000 years. Across cultures, alcohol has been integral to social, spiritual, and communal life, while simultaneously posing risks as a teratogen. Many teratogens remain unknown, and alcohol should be understood in this broader context of human–environment interaction rather than in isolation. To pathologise FASD as exceptional is to ignore the deep evolutionary entwinement of alcohol with human history.

Conclusion

Narratives of blame, deficit, or disorder should no longer bind Fetal Alcohol Spectrum Difference. Reframing it within the neurodiversity paradigm enables a more accurate, compassionate, inclusive, and historically grounded understanding — one that resists misogyny, challenges class-based prejudice, and places lived experience at its core.

Dr Linda Mayer is a Senior Staff Specialist and VMO working in adult and juvenile correctional centres. Diagnosed at 62 as autistic with ADHD, she combines lived experience and clinical expertise to advocate for neuroaffirming practice and to challenge deficit-based frameworks in healthcare.

The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated. 

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