Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan

The publication of new guidelines for Fetal Alcohol Spectrum Disorder (FASD) raises concerns about the ongoing push for FASD specific assessment and support programs. Legion children present with "evidence of pervasive brain dysfunction" who do not have FASD. Current developmental practice emphasizes interaction of "function" and "environment", not etiologic labels.1

-FASD is clinically indistinguishable from other causes of neurobehavioural disorders (e.g. antenatal alcohol or other teratogens, complex trauma, genetic, etc.).2

-Treatment for neurobehavioural disorders is non-specific (e.g. environmental supports), and based on function (i.e. cognitive, memory, executive, self-regulation, etc.).

-Emphasizing an etiologic label with no specific treatment is misleading to the public and unethical.

-"Function-based", non-medical diagnosis specific services are compatible with a vigourous public health program in prevention of antenatal alcohol exposure.

-Basing resources on an etiologic label marginalizes individuals with neurobehavioural disabilities without a unifying diagnostic label.

-FASD specific programs will create an increase in wasteful diagnosis -seeking behaviour (i.e. as seen in Autism Spectrum Disorder).

- A universal FASD specific diagnostic program based on current guidelines is not tenable3 and emphasizes the question of qualification for an FASD diagnosis, which is of low practical clinical relevance.

- The label of FASD carries potential harm to many through stigmatization and prejudice, particularly the "at risk FASD" category.4

-Ironically, FASD-specific programs will exclude many affected by antenatal alcohol who do not meet criteria.

-There is no good quality evidence indicating a need to diagnose children early with FASD (as opposed to diagnosing function-based problems).

We need equitable, non-etiologic diagnosis based services for all individuals with neurobehavioural disorders. Prioritization for assessment and intervention programs should be based on severity of functional disability, not etiology. Diagnosticians need to focus on functional impairment rather than often futile (and sometimes damaging) attempts to attribute causality.

References

1. Rosenbaum P, Gorter JW. The 'F-words' in childhood disability: I swear this is how we should think! Child Care Health Dev. Jul 2012;38(4):457-463.

2. Malone M, Koren G. Alcohol-induced behavioural problems in fetal alcohol spectrum disorders versus confounding behavioural problems. Journal of population therapeutics and clinical pharmacology = Journal de la therapeutique des populations et de la pharamcologie clinique. 2012;19(1):e32-40.

3. Goulden KJ. Are FASD guidelines practical and sustainable? CMAJ. Oct 25 2005;173(9):1070; author reply 1070-1071.

4. McLennan JD. Encounters: Alcohol-exposed? Next. CMAJ. 2015;187:682-683.

Conflict of Interest:

None declared