Fetal Alcohol Spectrum Disorders: Update & Expert Q&A

Prenatal alcohol exposure is the most common preventable cause of developmental disabilities and birth defects.¹ The fetal alcohol spectrum disorders (FASD) represent the range of cognitive, physical, emotional, and behavioral abnormalities that can result from in utero exposure to alcohol. These disorders include fetal alcohol syndrome (FAS), partial FAS, alcohol-related birth defects, and alcohol-related neurodevelopmental disorder. Additionally, neurobehavioral disorder associated with prenatal alcohol exposure was introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders in 2013 as a “condition in need of further study.”²

The Centers for Disease Control and Prevention and expert collaborators previously developed diagnostic guidelines for FAS, and experts from numerous US universities, in conjunction with the National Institutes of Health National Institute on Alcohol Abuse and Alcoholism, published guidelines for all FASD in 2016.^3,4 Prevalence estimates of FASD in the United States and some western European countries have been placed as high as 5%, although rates have varied widely across studies because of the divergent methodologies used.⁵

The authors of a new systematic review and meta-analysis published in JAMA Pediatrics noted the importance of establishing updated prevalence rates to inform awareness, prevention, and treatment efforts.⁶ In their analysis of data from 24 studies involving a total of 1416 children and youth with FASD (ages 0-16.4 years), they found the following prevalence rates:

• The estimated global prevalence of FASD was 7.7 per 1000 population (95% CI, 4.9-11.7 per 1000 population).
• The World Health Organization region with the highest prevalence of FASD was the European Region (19.8 per 1000 population; 95% CI, 14.1-28.0 per 1000 population)
• The Eastern Mediterranean Region had the lowest prevalence of FASD (0.1 per 1000 population; 95% CI, 0.1-0.5 per 1000 population).
• The 5 countries with the highest FASD prevalence were: South Africa (111.1 per 1000 population; 95% CI, 71.1-158.4 per 1000 population); Croatia (53.3 per 1000 population; 95% CI, 30.9-81.2 per 1000 population); Ireland (47.5 per 1000 population; 95% CI, 28.0-73.6 per 1000 population); Italy (45.0 per 1000 population; 95% CI, 35.1-56.1 per 1000 population); and Belarus (36.6 per 1000 population; 95%CI, 23.7-53.2 per 1000 population).
• Of 187 countries for which estimates were available, 76 had a prevalence of >1.0%.

In addition, it was estimated that 1 in every 13 women who consumed alcohol while pregnant delivered a child with FASD, which translates to more than 630,000 infants born with FASD each year globally. It was further determined that youth in the following special populations had substantially higher prevalence rates than those in the general global population: aboriginal (15.6-24.6 times higher), children in foster or adoptive care (5.2-67.7 times higher), correctional (30.3 times higher), low socioeconomic status (23.7 times higher), and psychiatric care (18.5 times higher).

To learn more about the latest updates on FASD, including the implications of these recent findings for clinical practice, Psychiatry Advisor spoke with study co-author Svetlana Popova, MD, PhD, MPH, a senior scientist at the Centre for Addiction and Health’s Institute for Mental Health Policy Research and associate professor at the Dalla Lana School of Public Health, Epidemiology Division, and the Factor-Inwentash Faculty of Social Work at the University of Toronto; and Amy Elliott, PhD, a senior scientist and founding senior director of the Center for Health Outcomes and Population Research (CHOPR) at Sanford Research, and professor and co-division chief for pediatric research at the University of South Dakota Sanford School of Medicine. Dr Elliott is one of the co-authors of the 2016 diagnostic guidelines.

Psychiatry Advisor: Have there been any recent updates in our understanding of FASD?

Dr Elliott: Our understanding of FASD is growing exponentially each year. Investigations into how often FASDs occur in the general population found much higher rates than what was previously reported. We estimate between 2.4% to 4.8% of the general population is affected by prenatal alcohol exposure.⁷ Last year, a group of experts in the field revised the diagnostic criteria to further help clinicians identify affected individuals earlier.⁴ 

Psychiatry Advisor: Dr Popova, what are the clinical implications of your recent findings?

Dr Popova: It is hoped that providing worldwide estimates of the prevalence of FASD will highlight the urgent need to establish universal screening and diagnosis. Improving screening and diagnosis would promote access to interventions and resources that might subsequently reduce the occurrence of the numerous “secondary disabilities,” such as mental health problems and substance abuse issues.

Further, coupled with our findings that the most prevalent comorbid conditions among individuals with FASD are within the mental and behavioral disorders chapter of the [International Classification of Diseases-10th edition], mental health professionals will frequently come into contact with children affected by FASD.⁸ Mental health professionals working in early intervention, serving children with mental health and behavioral problems, developmental delays, and children in foster care or juvenile corrections settings may have significantly high rates of FASD in their caseload.