Children with Prenatal Alcohol Exposure

This article was originally printed for ‘Court in the Act’ by Andi Crawford PhD and is republished with permission. Court in the Act is a publication coordinated by the Office of the Principal Youth Court Judge.


Prenatal Alcohol Exposure damages the developing brain. For some children and youth this results in severe neurodevelopmental impairments that meet criteria for a Fetal Alcohol Spectrum Disorder. Children and youth with FASD often experience significant problems with inattention, impulsivity, communication, memory, social skills and emotional dysregulation (Mattson et al., 2011). During their lifetime many people with FASD experience disrupted school, trouble with the law and alcohol and drug issues (Streissguth et al., 2004).

Doctoral research in the Hawke’s Bay was undertaken to understand what factors were important for independent functioning at home and at school. The study included 39 children aged (8-12) who were referred to the FASD assessment pathway in the Child Development Service at Hawke’s Bay DHB. Many of the children referred were male (77%), Māori (82%), resided in high deprivation areas (Dep 9-10, 59%) and whose mothers had not completed any high school qualifications (72%).

A comparison group (N= 29) was also included which was matched on age, gender, ethnicity, maternal education and deprivation index. It is important to recognise that the higher incidence of Māori in this study must be considered as a direct effect of colonisation, historical trauma and social disadvantage rather than due to ethnicity itself. Importantly, the research project was supported by a strong partnership with Te Wāhanga Hauora Māori (Māori Health Service) and findings were considered with regard to both the psychological literature, colonised history of Aotearoa New Zealand and Te Ao Māori worldview. 

Research findings showed that children in the FASD group experienced severe learning and behaviour difficulties, often in the context of psychosocial complexity. Interestingly, impairments in social thinking (taking someone’s perspective, recognising emotions) was the only important predictor of functioning at school even after accounting for IQ, higher reasoning skills and adverse childhood experiences the ability to understand social interactions. In particular, those children who could recognise emotions on adult’s faces were more able to adaptive and function independently at school. Recognising emotions is important because it is the first stage of a social interaction relationships. Difficulties in social and emotional thinking is important as it can affect relationships and connections between children and their teachers thus resulting in a less effective learning environment.

Social thinking is especially important in Te Ao Māori as many communities are organised by social connectedness via whakapapa. Connectedness is also vital for passing down values and beliefs, for example the passing down of whakatukii occurs in a social dialogue rather than learning from books. Tikanga requires high levels of social and emotional competence as decisions are made by consensus rather than a more authoritarian or patriarchal approach. Consensus requires an ability to understand the emotions, intents and beliefs of others, reflect on others position, compare with their own and then find solutions that made sense to all. Whakawhanaungatanga (the process of building relationships) is essential in creating a secure identity. Difficulties in connecting with others may therefore threaten identity, belonging and participation in the community.

Children in this study also faced a number of other challenges. Many had experienced multiple placements, although most had been in a stable placement for the last three years. A high number of birth parents also experienced learning difficulties and 56% of children had experienced more than 4 Adverse life Experiences, which has been found to be associated with increased health risks such as alcohol and drug issues, depression, suicide, sexually transmitted diseases and suicide (Dube et al., 2003; Felitti et al., 1998). Using Durie’s (1997) Māori model of health ‘Te Whare Tapa Whā’ many children with FASD were experiencing difficulties in all of the pillars; impairments in thinking (Taha hinengaro), poor physical health and housing issues, (Taha tinana), whānau separation or issues such as family violence (Taha whānau), and loss of connection to their whānau, land and where they belong (Taha wairua).

Despite challenges in all of the pillars, many children did not meet criteria for tertiary health and education services. Only 39% met criteria for Disability Services as acceptance criteria is based on a co-morbid diagnosis of Intellectual Disability, only 5-8% met criteria for Mental Health Services and only 46% had received specialist service from the Ministry of Education.

Within Te Whare Tapa Whā we can see that current services (health and education) are only brokered around one of the four components. Difficulties in taha hinengaro may broker service to the individual child in health (Disability, Mental Health) or education services, however many of the children with FASD in this study did not meet the criterion thresholds required to access these services. Our system creates barriers to complex presentations when we only offer service based on diagnosis or specific impairments. When services are brokered on separate components we can lose the cumulative effect when a number of risks/issues are present.

The present study has found a large proportion of the children referred for an FASD assessment are Māori and the way services are contracted for these children are fragmented with many children denied access to tertiary health service despite presenting with significant need. This gives an example of how western/Pākehā models of health, especially when they are formed around diagnoses, do not acknowledge strengths nor recognise the level of need that is present. It is true that these Pākehā, or western models of health may not also satisfy the needs of either Pākehā or any other cultural group who experience FASD. However Pākehā are not experiencing the corresponding, historical trauma due to colonisation, level of inequality and social disadvantage that is present within Māori communities (Hawke’s Bay District Health Board, 2014; Ministry of Health, 2015). Māori have specific cultural needs that must be viewed in a holistic way to in order to address the increasing risk factors that threaten a positive life experience for a child with FASD.

If eligibility for service is based on each issue considered separately then the system will inevitably fall well short of supporting these children and their whānau in a culturally appropriate way and therefore is an example of institutional racism. The way services are contracted must replicate what we are expected to do in clinical and cultural practice. Māori Models of health provide a holistic basis to review need within a culturally safe and appropriate context. Moving forward we must focus not just on the child but the whole whānau. Initiatives need to focus on building connectedness, belonging and identity. And for the courts? Moving forward it will be important to:

  • Recognise and advocate for a holistic view of children and youth.
  • Advocate for youth to have someone they trust, and are connected to, in the court process.
  • Focus on the connection and attachments when youth are transitioning: back to school, between residences.
  • Focus on plans which aim to support youth to create social connections, establish identity, and involve whānau (including the siblings).


Durie, M. H. (1997). Māori cultural identity and its implications for mental health services. International Journal of Mental Health, 26(3), 23-25. https://doi.org/10.1080/00207411.1997.11449407 

Hawke’s Bay District Health Board. (2014). Health equity in Hawke’s Bay technical report. Hawke’s Bay, New Zealand: Hawke’s Bay District Health Board. Retrieved from http://www.hawkesbay.health.nz/page/pageid/2145884299/Health_inEquity_in_Hawkes_Bay 

Mattson, S. N., Crocker, N., & Nguyen, T. T. (2011). Fetal alcohol spectrum disorders: Neuropsychological and behavioral features. Neuropsychology Review, 21(2), 81-101. https://doi.org/10.1007/s11065-011-9167-9

Ministry of Health. (2015). Tatau kaukura: Māori health chart book 2015 (3rd edition). (No. 978-0-478-44863-4). Wellington, New Zealand: Ministry of Health. Retrieved From https://www.health.govt.nz/system/files/documents/publications/tatau-kahukura-maori-health-chart-book-3rd-edition-oct15.pdf

Streissguth, A. P., Bookstein, F. L., Barr, H. M., Sampson, P. D., O’Malley, K., & Young, J. K. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Journal of Developmental & Behavioral Pediatrics, 25(4), 228-238. https://doi.org/10.1097/00004703-200408000-00002


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