Alcohol is a known teratogen, with demonstrated impact on the development of the human fetus, but it continues to be poorly understood by many groups of clinicians having close contact with at-risk populations (1). The impact of alcohol is not easily explained, predicted, or defined, but fetal alcohol syndrome (FAS) is a severe disorder, affecting many domains of development throughout the lifetime. It is defined by four diagnostic criteria: 1) alcohol exposure; 2) growth retardation; 3) characteristic facial features; and 4) CNS impairment. A more broadly defined spectrum of disorders termed fetal alcohol spectrum disorders (FASDs) is estimated to occur in 1% of live births in the United States; it includes individuals without growth and/or facial features associated with FAS, but with equal degree of impairment in areas of neurocognitive and social functioning (2). These individuals have profound lifetime morbidity, including high risk for mental illness and substance abuse. A CDC study found that in individuals with FASDs, 16% meet criteria for mental retardation; 94% have mental illness; 23% have a history of suicide attempts; 40% of adults have a history of incarceration; and 80% of adults do not live independently (3). Despite a general awareness of the dangers of alcohol use during pregnancy, approximately 12% of pregnant women use alcohol, and 2% use heavily (4). Since FASDs are preventable, broader training, early identification, and counseling can be effective in limiting the impact of prenatal alcohol exposure on future pregnancies (5).

This study was designed to describe the education and experience in the area of FASDs of psychiatry trainees, including general-psychiatry residents, child-and-adolescent psychiatry fellows, and other fellows. It was hypothesized that trainees would have limited knowledge, training, and skills in this area. A demonstrated lack of adequate clinical training in understanding individuals with FASDs would demand an organized effort to address this major public health problem.

Data were collected between October 2008 and January 2009, by use of a web-based survey. Two requests for respondents were sent by e-mail to every residency and fellowship coordinator in the United States as listed in the AMA database of accredited training programs. The survey was designed to gather information about education and experience in the area of FASDs as well as knowledge and demographic characteristics of the respondents. The survey included approximately 30 multiple-choice and true/false questions. Percentages were calculated using the number of respondents entering a specific response, compared with the total number of respondents entering any response for each question independently. No data were collected to identify a specific training program, the computer being used to complete the survey, or an individual respondent. The university Institutional Review Board gave approval for the study under an Exempt status. Consent was implied by voluntary and confidential completion of the survey.

Approximately 300 residency and fellowship coordinators were identified. Requests were e-mailed to all of these coordinators, but the number of trainees who received e-mail requests forwarded from these coordinators is unknown. The survey was returned and at least partially completed by 308 trainees. Sixty-four percent of the respondents were women, and respondents varied in training position, with trainees at PGY1, PGY2, PGY3, PGY4, Child Fellow Year 1, and Child Fellow Year 2 comprising 16%, 18%, 21%, 16%, 10%, and 13%, respectively. Respondents were located throughout the U.S., with 74% training in large academic medical centers. Many racial groups were represented; White, Non-Hispanic: 59%; Black, non-Hispanic: 6%; Hispanic: 6%; and Asian, 21%.

The survey asked about trainees' education in the area of FASDs. Of all respondents, 60% and 31% reported having ≤2 hours of didactics or discussion-based education about FASDs during medical school and residency, respectively. Only 19% rated their education as "good" or "excellent," and 89% reported that they would like more education about FASDs.

Respondents were asked about their level of experience in general and their experience with individuals with FASDs in particular; 71% reported having seen more than 200 patients in psychiatric settings. During medical school or residency, a minority, around 40%, reported receiving supervision or consultation regarding a specific patient for whom an FASD was considered as a diagnosis. During fellowship training, this percentage increased to 53%. Seventy percent reported never having diagnosed a patient with FASD, and 51% reported never treating a patient with FASD. The overwhelming majority, 83%, did not report using any standardized diagnostic schema. Of the entire sample of trainees, only about 10% felt they were "very much" or well prepared to diagnose or treat an FASD.

When looking only at the most experienced respondents, those who reported seeing more than 400 patients in psychiatric settings, 66% reported never diagnosing an FASD, and 39% reported never treating a patient with an FASD. Those respondents who reported having supervision in the area of FASDs during residency or fellowship were much more likely to report having treated a patient with a FASD; 81% reported treating a patient with an FASD.

To assess actual knowledge about FASDs, the survey asked several factual questions. Most trainees (67%) correctly estimated the prevalence of FAS at 1—2 per 1,000, and they demonstrated some knowledge about the characteristic facial features associated with the full syndrome. The percentage of trainees reporting that they agree that "It is safe to drink some alcohol" during the first, second, and third trimesters was 6%, 15%, and 30% respectively. Only 31% correctly reported that individuals with a FASD are at equal risk for adverse outcomes as individuals with full FAS. The mean percentage of respondents correctly answering the 14 factual questions was 71%, and it varied very little with respect to training level.

This study was designed to describe the education of psychiatric trainees in the area of FASDs. Results reveal that training is inadequate. Trainees indicated a desire for more training. Although the validity of the survey questions in assessing knowledge of FASDs is not established, there is no change in these scores over years of training, suggesting that there is no related learning during psychiatry training. Studies have shown clear overrepresentation of people affected by FASDs in psychiatric settings, so trainees are treating these individuals without a fundamental understanding of the nature of their illness (6). Interestingly, trainees who reported receiving supervision specifically addressing FASDs also reported making the diagnosis much more frequently. This suggests that an effective way to increase skills and knowledge is supervision in clinical settings.

On the basis of the survey results, it is clear that profound underrecognition of FASDs in psychiatric training programs is a national problem. Although respondents reported seeing hundreds of patients in clinical settings, and the majority had knowledge of the defining characteristics of FAS, an overwhelming majority reported never having diagnosed an FASD. This underrecognition represents missed opportunities for intervention and prevention. Such failures to lessen the impact of this devastating disorder in high-risk groups such as psychiatric patients are tragic. Unfortunately, even among psychiatry trainees in the United States, the importance of alcohol abstinence during pregnancy is still poorly recognized, with 30% of respondents reporting that they agree it is safe to drink "some alcohol" during the third trimester, the period of fetal brain development considered to be most sensitive to the damaging effects of alcohol.

FASDs, like autism, should be recognized as a mental health condition with an underlying organic substrate, and guidelines should be established to provide basic training in diagnosis, treatment, and prevention to all psychiatry trainees. Ideally, FASDs would be recognized as a developmental disability, and funding provided to establish effective early intervention and prevention.

This study has some limitations. It was conducted without gathering identifiable information about the survey completers, thus limiting analysis of response rates. The recruitment e-mail contained the detail that the survey was about FASDs, possibly leading to recruitment bias. Also, retrospective surveys, such as the one used in this study, are limited by the accuracy of the respondents' memory and estimations.

At the time of submission, the authors reported no competing interests.