Preventing exclusionary discipline and adverse life experiences in FASD: Teachers’ ability to recognize students with FASD in the classroom and develop and implement preventative strategies to support learning and behavior

Abstract

Background:

People with fetal alcohol spectrum disorders (FASD) experience significant behavioral and academic challenges and high rates of exclusionary discipline practices (EDP). The current study investigated teachers’ perspectives on barriers and facilitators to recognizing students with FASD in the classroom, and how teachers develop and use preventative strategies to support students with FASD.

Methods:

Qualitative interviews were conducted with 23 teachers with experience educating students with FASD. Data analysis used a phenomenological approach and content analysis.

Results:

Teachers identified barriers to recognition of students with FASD including lack of diagnosis, stigma and discrimination, variability and inconsistency in skills, and compensatory strategies. Experienced teachers could recognize students with FASD and effectively supported students by tailoring existing strategies to the student’s profile, building a positive relationship with the student, reframing their understanding of the student’s behavior, and collaborating with others.

Conclusions:

Results indicate experienced teachers’ potential to reduce adverse outcomes and EDP for students with FASD.

Graphical Abstract

We interviewed 23 teachers to understand their perspectives on barriers and facilitators to recognizing students with fetal alcohol spectrum disorders (FASD) in the classroom, and how they support students with FASD. Barriers to recognition of students with FASD were lack of diagnosis, stigma and discrimination, variability and inconsistency in skills, and compensatory strategies. Teachers reported tailoring existing strategies to the student’s profile, building a positive relationship with the student, reframing their understanding of the student’s behavior, and collaborating with others.

Introduction

Fetal alcohol spectrum disorders (FASD) represent a range of neurodevelopmental differences associated with prenatal alcohol exposure (PAE). People with FASD have strengths in social motivation, positive personality characteristics, and individual talents (Flannigan et al., 2021; Kautz-Turnbull et al., 2022). They also experience challenges in many areas of functioning including executive functioning, sensory processing, and social communication (Mattson et al., 2019). This pattern of challenges leads to significant difficulty in school, as the classroom environment places high demand on task-based skills in addition to being a place of high sensory input and high social demand, and individuals with FASD may have heterogenous learning styles not supported in traditional learning environments (Burnside & Fuchs, 2013).

Systemic barriers like lack of diagnostic centers and few medical and mental health providers who are aware of FASD mean many people with FASD will never be diagnosed. In one study, FASD was found to affect 1.1-5% of U.S. school-aged children, but less than 0.01% of children qualifying for a diagnosis had already been diagnosed (May et al., 2018). FASD is often not readily apparent physically, making it a hidden disability, and even when present, physical features tend to diminish over time (Moore & Riley, 2015). High levels of stigma and discrimination mean parents and caregivers may be uncomfortable discussing an FASD diagnosis or PAE with others, including providers, educators, and even family and friends (Roozen et al., 2020).

Students with FASD experience high rates of academic disruption, likely due in part to lack of recognition and appropriate support in the classroom. McLachlan and colleagues (2020) found that of a clinical sample of over 700 adolescents and young adults with diagnosed FASD, almost 20% were currently experiencing exclusionary school discipline (i.e., suspension and expulsion). Lifetime rates of school suspension in adolescents with diagnosed FASD in a clinical sample have been estimated at 53% and lifetime rates of expulsion at 29%. Moreover, 14% of young children in a clinical sample (aged 6-12) had experienced school disruption (Streissguth et al., 2004). Exclusionary discipline practices (EDP) have been robustly implicated in adverse life experiences including the school to prison pipeline (Chaitoo, 2022; Mallett, 2016; Skiba et al., 2014) and are linked to poor academic performance and increased rates of dropout (Chaitoo, 2022). Even exclusionary discipline occurring in early grades (i.e., fifth grade or earlier) has a long-term impact on academic performance, predicting school dropout and the likelihood of high school graduation (Andrew & Blake, 2023), as well as later criminal justice involvement (Jackson et al., 2021).

People with FASD are also disproportionately affected by factors that increase the risk of EDP and later legal trouble, including marginalized racial group status, disability status, poverty and low socioeconomic status (SES), and trauma (May & Gossage, 2001; Rockhold et al., 2025; Russo et al., 2004). Black and Latine individuals are significantly more likely than White individuals to experience EDP (Morris & Perry, 2017; Skiba et al., 2014; Pierce et al., 2022; Welch et al., 2022). Importantly, differential support and treatment for Black students compared to White students accounts for 46% of the gap in EDP, while differences in behavior accounted for only 9% (Owens & McLanahan, 2020). Students with disabilities are roughly twice as likely to be suspended and expelled compared to students without disabilities (Losen & Gillespie 2012; Sullivan et al., 2013), especially those with attention-deficit/hyperactivity disorder, impulsivity, and neuropsychological deficits (Novak, 2022; Pierce et al., 2022). Students experiencing poverty and those from families of lower SES are more likely to experience EDP (Pierce et al., 2022; Sullivan et al., 2013). Finally, rates of behavioral problems and EDP in school are related to a number of adverse childhood experiences (ACEs), and students with 4 or more ACEs were 4 times more likely to be suspended or expelled (Pierce et al., 2022).

Unsupported learning and behavioral challenges compounded by factors increasing higher risk for EDP mean it is imperative teachers are equipped to support students with FASD in the classroom. Preventative strategies and positive behavioral intervention support (PBIS) have been suggested to prevent EDP and improve outcomes (DiClemente, 2021; Horner & Sugai, 2015; Mallett, 2016; McIntosh et al., 2021a; McIntosh et al., 2021b; McNeill et al., 2016; Nese & McIntosh, 2016). PBIS has roots in applied behavior analysis and behavior theory and emphasizes the recognition of environmental antecedents and implementation of proactive strategies to prevent unwanted behaviors (Horner & Sugai, 2015). Federal and state-level government bodies have implemented regulations requiring schools to reform current discipline practices to focus on prevention-level strategies such as those in PBIS rather than suspension and expulsion (Fenning & Johnson, 2016). Relationship building has also been described as a method of preventing EDP, with one study finding that teachers deliberately used positive relationship building to reduce overall EDP and racial disparities in suspension (Anyon et al., 2018).

Study Purpose

To prevent adverse outcomes and EDP in the context of underdiagnosis of FASD and barriers to school-based services, teachers must first recognize students with FASD at risk of learning and behavioral problems, then must develop and implement behavioral strategies to support them. Our research questions were (1) what are teachers’ perspectives on barriers and facilitators of recognition of students with FASD in the classroom, and (2) how do teachers use preventative strategies to support those students.

Methods

Participant Recruitment

Convenience and criterion sampling was used (Marshall et al., 2022), in which teachers who responded to national recruitment advertisements and notices were included if they met eligibility criteria. First, parent participants involved in previous FASD research, all of whom have children with confirmed PAE or FASD, received an email informing them about the study and encouraging them to share recruitment materials with their child’s teacher. Parents and teachers were encouraged to forward study information to others who may be interested and eligible. We also directly targeted teachers and school staff through national email newsletters and social media forums.

Participant Demographics

Participants were 23 teachers who had experience educating students with FASD. Demographics are presented in Table 1. The majority of participants in the current study were special education teachers and identified as white and female. They represented diverse school settings (rural, suburban, urban), a range of experience, and resided across several U.S. states and Canada, with over half from Colorado. Most had both current and past experience with students with FASD.

Table 1.

Participant Demographics

	N	%
Job title
Special education teacher	17	73.91%
General education teacher	5	21.74%
Othera	1	4.35%
Years of experience as a P-12 educator
0-4 years	3	13.04%
5-10 years	8	34.78%
11-15 years	1	4.35%
16-20 years	4	17.39%
21-25 years	5	21.74%
25 years or more	2	8.70%
Education
Bachelor's degree	5	21.74%
Master's degree	4	17.39%
Education or credits beyond Master’s degree	14	60.87%
Grades currently taught
Preschool	2	8.70%
Elementary	12	52.17%
Middle	4	17.39%
High school	2	8.70%
Transition	2	8.70%
Geographical location
Rural	8	34.78%
Suburban	9	39.13%
Urban	6	26.09%
State/Province
Alaska	1	4.35%
Colorado	12	52.17%
Florida	1	4.35%
Maryland	1	4.35%
Michigan	1	4.35%
New York	2	8.70%
Ontario	1	4.35%
Washington	2	8.70%
Did not provide	2	8.70%
Approximate number of students in school
100 or less	1	4.35%
101-250	5	21.74%
251-400	5	21.74%
400 or more	12	52.17%
Gender
Female	21	91.30%
Male	2	8.70%
Race/ethnic group
White	19	82.61%
Asian	0	0.00%
Black or African American	1	4.35%
Native American/Pacific Islander	0	0.00%
Other	1	4.35%
Do not wish to respond	1	4.35%
Ethnicity
Not Hispanic/Latine	19	82.61%
Hispanic/Latine	2	8.70%
Do not wish to respond	1	4.35%

Note. P-12=Preschool through grade 12. ^aOne teacher was employed as a coach at the time of the interview but was a certified teacher with experience teaching children with FASD, so met eligibility criteria and was included.

Study Procedure

Interested participants were directed to the study REDCap (Harris et al., 2009; 2019) site where they gave informed consent and completed questions related to eligibility. Inclusion criteria were: 1) age 18 or older; 2) current employment in a preschool–12th grade school setting; and 3) experience teaching a student with FASD. Participants were not required to be in the US, although recruitment strategies targeted US educators. All school settings were eligible. If eligible, participants were directed to demographic surveys and were contacted via email to schedule an interview. Sixty participants consented, 38 of whom were eligible and contacted for an interview, and 23 completed an interview. Scheduling difficulty was the primary reason eligible teachers did not complete interviews. No participants withdrew during the interview.

The current study took place entirely online. Participants were interviewed via secure Zoom videoconferencing; both audio and video were recorded. Participants were free to join from wherever they were most comfortable, most often from their home, classroom, or office. Observation of and interaction with participants was limited to the interview. Only the interviewer and the participant were present for interviews unless the participant was in a space with others present (e.g., in their classroom). When this was the case, interviewers noted the presence of others and participants were encouraged to find a private space if possible, but were allowed to continue with the interview if they chose.

Study Design

This secondary data analysis used data originally collected for a needs assessment informing development of an educational intervention for teachers (Kautz-Turnbull et al., 2023). In-depth, semi-structured interviews were conducted using a qualitative approach informed by phenomenological principles consistent with the goal to “explore, describe, and analyze the meaning of individual lived experience” (Marshall et al., 2022, pg. 22). For this secondary data analysis a constructionist lens was employed, using inductive content analysis to identify patterns of meaning across participants (Schreier, 2012). Data analysis focused on understanding thematic commonalities and variation, rather than seeking a unified essence of experience.

Interviews took place from April-June 2021. Each participant was interviewed only once, by one interviewer. Interviews were conducted by a team of four interviewers, including the first and third authors and two research assistants. Three interviewers identified as female and one identified as non-binary; all had obtained at least a Bachelor’s level degree, with two interviewers holding a Master’s degree. All interviewers underwent training in interviewing administered by the lab principal investigator (fifth author). Prior to the interview, no interviewers had relationships with participants, and interactions with participants were limited to emails and the interview itself. Participants were told the reason for the research. The interview questions were developed prior to interviews and were not pilot tested. The interview guide was designed for the initial needs assessment (Kautz-Turnbull et al., 2023) and included questions about experiences with students with FASD broadly (e.g., “Tell me about your experience having a student with FASD in your classroom”, “What were some positives/challenges of having a student with FASD in your classroom?”) as well as specific questions about teachers’ needs for an FASD-informed resource. The interview questions were revised once during the interview process. Specifically, two key changes were made: 1) questions about teachers' relationships with parents and administrations were added, as these topics consistently emerged in early interviews; 2) follow-up questions were clarified. Interviews lasted for an average of 53 minutes, 23 seconds (range: 29 minutes, 22 seconds to 81 minutes, 57 seconds). Participants did not review transcriptions or findings and data saturation was not discussed.

Field Notes and Interview Memos

Minimal field notes were taken during interviews to flag follow-up topics. Interviewers’ impressions and notes were recorded in methodological memos completed after the interviews. Methodological memos served several purposes, consistent with Marshall et al. (2022). First, they were used to document interviewer observations during interviews. These observations were not used during coding or theme development but were intended to understand the interview process, the interview context, and the participant’s experience of the interview, consistent with a phenomenological influence. Another purpose was to understand themes and patterns as they were generated in the data. Researchers recorded and discussed preliminary themes of interviews and their own initial understanding of the data.

Ethical Considerations

All study procedures were approved by the University of Rochester Institutional Review Board. Participants were informed they could withdraw from the study at any time and their data would be deleted. They were also informed they could skip any question in the interview and it would not affect their participation in the study. Any identifying information in interview transcripts was redacted.

Data Analysis and Analytic Framework

Given the aims of the present secondary data analysis, we used an approach informed by phenomenology to understand the essence of participants’ experiences from their perspectives (Marshall et al., 2022). An inductive, latent content analysis approach was used to select and focus on key aspects of the data and to interpret meaning from the content of these data (Hseih & Shannon, 2005; Schreier, 2012). Consistent with a phenomenological approach, interviews were analyzed individually and then compared across participants to understand shared experiences.

The steps of content analysis were used as recommended by Schreier (2012). Subcategories were initially developed inductively from the data during a pilot coding phase. These subcategories were then organized into broader categories through discussion among three coders (first, second, and third authors). These categories and subcategories were refined through discussion among three coders (first, second, and third authors), then all interviews were coded (interviews coded in the pilot phase were re-coded). All interviews were coded by the full coding team, and any discrepancies or questions related to coding were discussed and resolved collaboratively. During this process, a codebook was compiled with agreed-upon codes.

For this secondary analysis, these codes were used to explore educators' experiences supporting students with FASD. To do this, inductive latent content analysis was used for existing codes to interpret underlying meanings around how educators made sense of their experiences. Themes were inductively and collaboratively derived from the data, with discussion focused on coders’ own understandings, reflections, and impressions of the data. After the interpretative phase of data analysis, participant matrices and code co-occurrence tables were used to understand how themes manifested across participant demographics to deepen understanding of meaning within context.

Researcher Role and Positionality

All researchers in the study, including the interviewers and data coders, have a background in research and clinical work with caregivers of children with FASD, and all have significant experience with children with FASD. Given frequently reported tension between caregivers and schools (e.g., Petrenko et al., 2020), researchers purposefully and frequently discussed biases and expectations around the teachers’ perceptions and experiences during interviewing and data analysis. The research team also had significant experience with research around stigmatizing language and discrimination against children and adults with FASD, as well as reasons for PAE, and were sensitive to their own reactions and emotions when these issues occurred during interviews and analysis.

One researcher on the team was previously a teacher and had related insight into educational practices. The majority of the research team identified as white and non-Hispanic, with one interviewer identifying as Asian; all researchers were aged 24-27 and were assigned female at birth. Four of the five researchers identified as female, with one identifying as non-binary. These demographic characteristics may have introduced biases related to gender, racial/ethnic, and generational differences. Researchers made an effort to understand and vocalize these biases, and results should be interpreted with these in mind.

Transparency and Openness

We report determination of sample size and all measures in the study. The study follows JARS (Applebaum, et al., 2018) and adheres to the consolidated criteria for reporting qualitative research (COREQ; Tong et al., 2007). Data, codes, and all code co-occurrence and demographic analyses were managed using Dedoose Version 9.0.62 (SocioCultural Research Consultants, 2022). Coding schema and coding book are available upon request to the corresponding (first) author. Data are unavailable due to the potentially identifying nature of qualitative data. This study was not pre-registered.

Results

Question 1. Teachers’ perspectives on barriers and facilitators of recognition of students with FASD

Teachers agreed many students with FASD went unrecognized, and are at-risk for learning and behavioral problems due to factors such as lack of diagnosis, stigma and discrimination preventing caregiver disclosure of PAE, variable and inconsistent learning profiles, and student compensation and coping strategies. Teachers also discussed consequences for students with FASD associated with these barriers.

Lack of diagnosis

The most common reason teachers reported for lack of recognition was lack of diagnosis. Teachers reported few students with FASD had a confirmed diagnosis, and even fewer had their diagnosis documented at the school (e.g., on an Individualized Education Program (IEP)). Teachers sometimes had PAE disclosed to them by a parent or caregiver. One teacher reported her school’s enrollment process included documentation of prenatal exposure to alcohol and other drugs, often without a formal diagnosis.

Regardless of formal identification or diagnosis, some teachers could recognize signs of FASD in students. These teachers were identified as “experienced” teachers based on their description of educating themselves by seeking out resources independently, learning from parents, and adapting their behavioral and classroom supports over time, rather than by years of teaching experience. These experienced teachers overwhelmingly reported recognizing FASD in students who were not diagnosed once they had had a student with FASD or PAE. They described paying special attention to signs of FASD in students who were in foster care, who had other labels such as emotional/behavioral disorders, or who had a parent with a substance use disorder. After learning about FASD, teachers also recalled many students who they believed had FASD but were not diagnosed at the time: “In retrospect, now that I have learned so much more about FASDs, I can see kids who probably did…I'm like, ‘Yeah, I probably had a lot of kids that could have been impacted by this’” (P4).

Stigma and discrimination

Many teachers attributed lack of recognition to stigmatization around the disorder and parents’ discomfort in sharing either a formal diagnosis or a history of PAE. Teachers also noted they would not broach the subject of prenatal exposure with parents due to stigma and perceived shame associated with it. “I don't bring [PAE] up, I would never say that kind of thing unless [parents] offer it” (P48). Other teachers described biological parents disclosing PAE to them, which helped their students get more appropriate supports:

“So, he was on our radar and we were trying things, but in a general education setting. And when I finally got him in eighth grade, the mother…came to me and she came in person and she said, 'Well, you know, I just want you to know that I've been sober now two years and I think me drinking during pregnancy affected him.' And so that made everything all clear…we finally put him on an IEP for the first time in eighth grade”

(P11).

Variable and inconsistent learning profiles

Another common reason students went unrecognized was an often variable learning profile, with significant strengths in some areas and significant weaknesses in others, and inconsistency from day to day: “We find that because, especially with my students that appear more neurotypical because they do have some high skills in some areas, they've made it through life without grasping some of the more basic skills” (P30). Teachers noted students with FASD at times lacked fundamental adaptive academic skills such as reading, telling time, and working with money, even into middle and high school. Heterogeneity of FASD presentation also complicated teachers’ understanding of their students, including the inconsistent presence of physical features. Some students were able to receive formal supports regardless of an FASD diagnosis, most commonly due to co-occurring diagnoses such as an intellectual or learning disability. But until they had specific knowledge of FASD, teachers felt they were missing an important piece of the student’s profile: “Once I figured out how the thought process of my student with FASD worked, we clicked and he was able to process and learn. He was very, very receptive to the different strategies that I used with him” (P32).

Compensation and coping strategies

Teachers described students with FASD as aware of their challenges and differences from other children but hesitant to ask for help, instead developing strategies to compensate for challenges: “They're really good at coping. …When I look at the kids that are doing their work, I don't see [my student with FASD] struggling because she’s doing something and she’s gotten really good at kind of coping and not turning stuff in” (P25). Children with FASD were described as highly socially motivated and hesitant to ask for help lest they appear unintelligent or were bullied by other students. Additionally, students with FASD were described as feeling embarrassed and different, which may have further contributed to their hesitance to ask for help: “It's difficult because he is intelligent and so he understands that he is different, but then doesn't really understand how to fit in better. And so, there were many times where he said that he, you know, felt bad and he feels different” (P14).

Consequences associated with lack of recognition and support of students with FASD

Students were described as facing additional challenges later in life, including trouble with the law, suspension/expulsion, mental health challenges, and bad reputation and stigmatization. Students with FASD were often removed from the classroom, whether for the day or for a suspension, or even asked to move schools or districts. Teachers expressed concern for the future of their students with FASD both in regard to disruptive behaviors and aggression and to students’ difficulty learning. “As a teacher, it's really scary [because] you see how sweet they are and you know that at this size, [their behavior is] not a big deal, but when they're bigger, it's absolutely going to be much worse for them” (P7).

Teachers also described negative impressions of students with FASD. “Then that kid starts to get labeled as the scary kid or then the classroom has to get evacuated because so-and-so threw a chair again” (P48). This reputation may follow them at school: “Last year we could hear this one student always screaming at the end of the day, always like screaming. And so, like when I had that student on my list, I was nervous” (P15).

Question 2. Teachers’ use of preventative strategies to support students with FASD

Teachers developed and put in place preventative academic and behavioral strategies for their students with FASD, despite limited formal training around FASD and classroom presentation. This was accomplished in four main ways: individualizing existing strategies to the student’s learning profile, developing a positive relationship with the student, reframing their interpretation of the student’s behavior, and working with other teachers and parents. Teachers described challenges which went along with these preventative strategies, but also discussed successes for their students with FASD.

Individualization of existing strategies to fit the student’s learning profile

Teachers selected accommodations based on specific challenges, focusing on executive functioning, social skills, attention, and communication needs. They described spending a significant amount of time understanding their student’s unique profile, including impairments and strengths across almost every area of functioning. See Figure 1 for teachers’ descriptions of strengths and challenges across heterogenous areas of functioning. Teachers also emphasized the level of challenge varies considerably for people with FASD. They described inconsistency and variability in their students with FASD, which could be impacted by fatigue, mental health, self-esteem, and social difficulties.

Figure 1:

Strengths and challenges described by teachers for students with FASD.

Note: Red boxes indicate challenges and green boxes indicate strengths.

Teachers rarely described using strategies unique to FASD; instead, they described using traditional environmental accommodations such as visual supports, extra time, and scheduled breaks, but personalized these strategies to each student: “A lot of kids maybe just needed movement breaks. And so, I had systems set up where they could ask for those in specific ways, ways that they were comfortable. Some kids didn't want to raise their hand [to] ask for something, so they'd have a little sign with the B on it for break” (P17). They also adjusted their teaching to address gaps and adapted activities to suit students' learning styles.

Many teachers cited coursework and formal training they had completed in autism or other disabilities as informing the way they support their students with FASD: “I started comparing what I saw in the classroom to the autism kids, started to see a ton of similarities, and figured, ‘Okay, it's worth a shot. Let's see if this works both ways.’...[The strategies] seem to work pretty well across the board” (P20). Others felt simply borrowing strategies from other disabilities was not enough: “I think a lot of the things we borrow are from things for students with autism. …I think that's where the most of my time is spent, trying to adapt the curriculum. Which is fine, but I know I borrow a lot of stuff from like the autism resource websites and then modify it” (P39).

Building a positive relationship with the student

Building trust and respect was emphasized as an integral first step. “I think before even having any accommodations, you have to make a connection with the student” (P32). Teachers noted their students wanted to be known, understood, cared for, comfortable, and wanted. They emphasized using a strengths-based approach and establishing themselves as someone students can go to for support. “And as the school year went on, we noticed his condition was better because he was building that bond and that trust with us” (P45). Teachers also described being a positive support for students in an environment in which many of them have encountered significant negativity.

Teachers’ flexibility and adaptability were key skills in supporting and building trust with students with FASD: “I think the other thing is just being calm and in the moment; like, this is happening, it doesn't matter what I had planned, I'm going to sit here for the next hour while she cries because she doesn't want to walk into the classroom. I think it was just moving my agenda to the side because there's no way around it” (P7).

Reframing understanding of behavior

Teachers reported understanding behavior as a result of a disability, rather than as purposeful misbehavior, helped them to better proactively support the student. FASD is a hidden disability, and many may struggle to recognize it: “Teachers, when they aren't seeing a physical difference, then they have a hard time understanding that a lot of it, it's their brain that's been affected” (P29). Without knowledge or physical evidence of the disability, behaviors like eloping, task refusal, meltdowns, inattention, and attention seeking seem willful or defiant: “You have your students who are heavily impacted, that physically have the characteristics of a child who has had significant exposure to alcohol, and then you have your students that don't necessarily have those physical characteristics. It comes across as oppositional defiant. They are unkind. They are mean” (P30).

When teachers were aware of challenges underlying the behaviors, they felt better able to understand the functions of the behavior and, most importantly, better able to support the students. “You have to tell yourself she's just not doing this, you know, to be defiant. She's doing this because something is upsetting her or something. She's overwhelmed or she's tired. You just got to tell yourself that and it's not to be defiant or whatever…because then you view the child a little bit differently.” (P15). This improved understanding of behavior helped teachers feel more effective and regulated in their teaching.

Collaboration with other teachers and parents

Teachers worked to ensure consistent support for students with FASD in the school across multiple people, settings, and contexts. They felt this was especially important for students with FASD as their need for predictability and consistency was high. Some worked to educate other teachers and school staff about FASD, especially in seeing how behaviors were rooted in brain-based challenges. For example, one teacher worked with her staff on understanding confabulation, a memory disorder in which gaps in memory are unconsciously filled with fabricated or distorted information: “One thing that has been really challenging for my staff this year is the confabulation…the difference between a student who is flat out lying and the prevalence of confabulation with FASD” (P30).

Teachers emphasized the importance of communication with parents in supporting students with FASD. Positive parent-teacher relationships aided mutual understanding, consistent strategies, prompt issue resolution, and validation. Teachers noted challenges in the home-school relationship, including past negative experiences with parents, feeling underappreciated, increased conflict during the COVID-19 pandemic, and differing expectations: “A lot of times caregivers will come in thinking they know the solutions, and they don't because every solution is based on resources, it's based on environment, and it's based on the student” (P56). To build positive relationships with parents, teachers increased communication about the child's experiences and their investment in the child. They felt recognizing families’ strengths was crucial, especially considering the challenges faced by parents of children with FASD such as stigmatization, constant need for advocacy, and barriers to accessing services.

Challenges in using preventative strategies

Teachers reported exhaustion and burnout related to the substantial time and effort they invested in developing and using preventative strategies: “I remember going home and just being completely drained because I gave my all to him and not as much my other students” (P10). FASD symptoms presented other challenges like inhibitory difficulties, memory issues, and impulsivity. Unsupported, these could lead to safety issues such as elopement, risk-taking, and aggression. Certain symptoms, like rapid escalation, presented particular difficulties for teachers: “If it's a slow buildup, that's fine. What's scary, and what wigs teachers out, is when there's a quick explosion and a chair's going across the room” (P48). Despite teachers' effort, students still experienced school disruption and other adverse experiences. This came with a variety of complex emotions for teachers, including frustration, anger, grief, and helplessness.

Classroom and school limitations, especially in general education settings, posed challenges in meeting academic standards while accommodating students' needs. “Even though my students have disabilities, we still have to take the same accountability measures as all the other students. …That's where it gets frustrating because I know what they're capable of, but [they’re] still held to the same standards of [they] have to produce it in a certain way” (P39). Teachers also noted they could only provide time-limited support, and without broader awareness, students may be less well supported in later grades.

Success for students with FASD

Many teachers described successes for their students with FASD and tied these successes into the hard work on both the student’s and teacher’s part. They described success in emotion regulation and coping: “It did take a lot of work and a lot of one-to-one assistance…Now, a lot of the times if he's upset… he can use his coping strategies to like squeeze something or like just take a deep breath or just like look over and just kind of zone out of it for a little bit until he’s ready…We gave him a lot of replacement behaviors and strategies for that” (P57). Others described success in self-advocacy, saying once they helped students with FASD understand their learning styles, the students were able to advocate for their needs. Teachers emphasized it was important for the student’s own preferences and goals to be incorporated into how success was defined, and essential that small steps and achievements were recognized along the way.

Discussion

The current study investigated teachers’ perspectives on barriers and facilitators to recognizing students with FASD, and teachers’ abilities and strategies to proactively support them. Experienced teachers (i.e., those who had worked with a student with FASD and, crucially, described seeking out resources on FASD or learning through experience) were generally able to recognize FASD, identify strengths and challenges in students, and use effective preventative behavior strategies, often without formal training.

These findings expand on Ryan & Ferguson (2006) who found experienced teachers could differentiate instruction for students with FASD, while early-career teachers experienced frustration and did not know how to adapt instruction. The current results suggest experienced teachers can and do develop in-depth profiles of students with FASD and implement effective strategies to support them, often without formal training. While this demonstrates the dedication and resourcefulness of teachers, it underscores the great need for accessible FASD-informed training and institutional support, especially for early-career teachers. Peer collaboration, already common and beneficial in schools (Nguyen & Ng, 2022), may help bridge this gap and should be encouraged by administration.

In a crucial second step in avoiding adverse outcomes and EDPs, teachers used their recognition of FASD and knowledge of FASD to select more effective, individualized, and proactive behavioral strategies to support them. Knowledge and beliefs around individual students are some of the most important influences on decision making around behavioral strategies in the classroom, including for students with disabilities (Lawson & Jones, 2018; Stough & Palmer, 2001). Recognition of FASD also helped teachers understand challenging behavior not as willful misbehavior but challenges related to a brain-based disability. This aligns with attribution theory (Weiner, 1972), which suggests beliefs about behavior influence responses. Similar processes have been observed among caregivers of children with FASD (Petrenko et al., 2016). Interestingly, teachers discussed adapting or borrowing strategies used for students with other disabilities; while this further demonstrates the skill possessed by these teachers, it emphasizes the need for teachers to more easily access FASD-specific resources (Kautz-Turnbull et al., 2023).

Experienced teachers’ ability to recognize and support students with FASD in the classroom provides a much-needed avenue to reducing adverse outcomes. This is crucial as significant barriers prevent widespread screening and identification of FASD across settings. Barriers to diagnosis and awareness of FASD identified by teachers mirror those faced by caregivers, including limited trained providers, low awareness of FASD, and stigma (Olson et al., 2023; Petrenko et al., 2014). Teachers, who are not equipped to diagnose, can engage other school staff (e.g., social workers, school psychologists) in obtaining an evaluation or diagnosis. However, low awareness and limited training, combined with pervasive stigma, often prevent these conversations.

Stigma and discrimination was a common theme, with teachers describing parents’ discomfort in sharing information about PAE and students’ hesitance to ask for help. Stigma contributes to discrimination and feelings of shame and guilt for biological and adoptive caregivers (Roozen et al., 2020). Bad reputations in the school resulting from lack of early recognition and support contribute to self-stigma, or feelings of shame directed toward oneself, and may make students with FASD less likely to ask for help, creating a cycle of lack of support and exacerbated challenges. Self-stigma is especially important to note given its association with mental health challenges and other adverse experiences later in life (Roozen et al., 2020).

Teachers felt building trust and creating a positive relationship with students was an important strategy for students with FASD. People with FASD frequently report strong relationships as an critical protective factor (Burnside & Fuchs, 2013) and have notable strengths in social motivation (Flannigan et al., 2021; Kautz-Turnbull et al., 2022). Not only is this a vital consideration for the health and wellbeing of people with FASD, positive student-teacher relationships are often a factor in preventing EDP. One study found that for youth in foster care, higher perceived quality of relationships with non-parental adults, especially teachers and school staff, was associated with fewer school absences and less EDP (Lamb et al., 2022).

Teachers expressed significant concern for their students’ futures, especially in regard to lack of early support. Many described positive outcomes when they were able to implement supports that carried over to future grades or coordinated across systems. This again illustrates the potential of teachers to help prevent adverse outcomes, but must be considered in the context of the significant challenges teachers faced in doing so. They described feeling frustrated, angry, and sad in response to the barriers they saw their students face, which contributed to burnout, rates of which are already extremely high in teachers, especially special education teachers (Capone & Petrillo, 2020; McGrew et al., 2023).

Limitations

The current study includes a number of limitations. The sample was homogenous in race, ethnicity, and gender, limiting generalizability to people of color and those who identify as male or non-binary. Some areas were not represented, and one location (Colorado) was overrepresented, which may affect the generalizability of results, especially given differing availability of FASD supports by region. Additionally, teachers must have had experience teaching a student with FASD and self-selected into the study, potentially creating bias in terms of more positive or successful experiences. Because of the lack of inclusion of inexperienced teachers, conclusions cannot be drawn as to the effect of experience with FASD on teachers’ ability to recognize and support students with FASD. Bias may also have been introduced by the interviewers, researchers, and data analysis, particularly lack of formal evaluation of data saturation. Finally, results are reflective of the 2021 post-pandemic sociopolitical context, yet offer insights that may extend beyond that period.

Implications and Future Directions

The current study is one of the only studies to investigate experienced teachers’ abilities to recognize and support children with FASD in the classroom. It demonstrates the potential of teachers to first recognize FASD in the classroom, regardless of a diagnosis, and then design and implement better strategies which may prevent exclusionary discipline and adverse life outcomes. Future research should extend the current work to more diverse populations and should incorporate longitudinal designs to understand how FASD knowledge and experience develop and change over time. Intervention work should emphasize increasing teacher awareness of FASD, develop and test FASD-informed professional development interventions, and create scalable solutions to capitalize on the potential of the school system to provide access to FASD-informed care and prevent adverse outcomes.