Developing tapering protocols for psychotropic medications in adolescents with fetal alcohol spectrum disorder: incorporating relational environmental and cultural aspects of care

Psychotropic medications are commonly prescribed to adolescents with Fetal Alcohol Spectrum Disorder (FASD), despite limited disorder-specific evidence and the increased vulnerability of this group to adverse and paradoxical reactions. Inspired by presentations and debates at the International Conference on FASD, organized by the Santa Casa- Health Department of the Pontifical Delegation of Loreto-Italy (Dipartimento Sanitario “Santa Casa” della Delegazione Pontificia di Loreto), this article emphasizes the need for clearer, ethically grounded tapering strategies. Patterns of polypharmacy, inconsistent clinical responses, and iatrogenic effects underscore the urgency of creating structured tapering guidelines and protocols based on developmental, relational, and cultural factors. Drawing on clinical experience in Italy and the United States—including work within Native American communities where structural inequities amplify the consequences of pharmacological overreliance—the article presents a tapering model that integrates neurodevelopmental vulnerability, environmental stability, relational continuity, and cultural context. Tapering is reframed as a therapeutic process aimed at restoring autonomy, reducing exposure to unnecessary medications, and strengthening the individual’s relational and cultural resources. The discussion emphasizes the importance of understanding behavioral changes from a neurodevelopmental perspective, fostering collaboration among caregivers, educators, and community resources, and addressing systemic pressures that contribute to medication overuse. The article concludes by stressing the need for long-term pilot studies to evaluate the practicality and impact of this framework in different settings. Such research will be essential for refining tapering strategies that are aligned with current neurodevelopmental stages, ethical standards, and community-based psychosocial and recovery models.