Psychiatry Advisor: What are specific tips for providers on how to ensure adequate screening and intervention for FAS?


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Dr Elliott: One of the things providers should be aware of is the prevalence of FASD and that the effects of prenatal alcohol on the developing fetus are greater than what was initially estimated. If they work with kids, they will see children affected by prenatal alcohol use in their practice. Next, providers can educate themselves on the cardinal facial characteristics, learning difficulties, and common behavioral challenges seen in children with FASD. Even if a provider is not comfortable making a diagnosis, picking up the signs for when a referral is warranted is a good first step. There are many great resources available for providers to educate themselves on FASD. The American Academy of Pediatrics and the National Organization on Fetal Alcohol Syndrome have a wealth of information available for clinicians and families. 

Dr Popova: First, all pregnant women should be screened for alcohol use with validated screening tools, which have been found to be effective – such as T-ACE, TWEAK, CAGE, AUDIT, S-MAST, and B-MAST. Pregnant women and women of childbearing age at risk for alcohol use disorder should receive early brief interventions. Stopping alcohol consumption at any point during pregnancy will improve the outcomes for the child.

Second, a screening of people who might be at risk for the effects of prenatal alcohol exposure is an essential step to identify and refer them for FASD diagnosis as early as possible. The screening can be conducted in different systems such as schools, mental health facilities, corrections, social services, and children in care. There are some simple screening tools, such as the Neurobehavioural Screening Tool and FASD Screening and Referral Tool for Youth Probation Officers, that show some promise. The FAS facial photographic screening tool was found to be effective in foster children and school-age children populations. There is ongoing research on determining novel effective and efficient tools for improving screening and diagnosis of FASD, such as biomarkers, brain imaging, and DNA micro-array techniques.

It is essential that people diagnosed with FASD and their families be provided with resources and services that will improve their outcomes. It is also crucial to improve training of healthcare and other professionals in identifying, diagnosing, and treating people with FASD.

Psychiatry Advisor: What should be next steps for research in this area?

Dr Elliott: We continue to work on refining our understanding on the identification of [alcohol-related neurodevelopmental disorder]. This is when an individual has the behavioral and cognitive characteristics, as well as significant prenatal exposure, but lacks the hallmark facial and growth characteristics. This is the most difficult group to diagnose.

We need more work on what FASD looks like in adulthood. Many of us who research FASD specialize in pediatrics and child development. More work on the support [that is] needed and challenges faced by individuals with FASD in adulthood would be extremely helpful. Continued work on how to best get out the public health message of the dangers of drinking during pregnancy [is needed]. 

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Dr Popova: Efforts need to be made by countries to obtain their own prevalence data on both alcohol use during pregnancy and FASD in not only the general population, but in all special populations — aboriginal, correctional, psychiatric care, low socioeconomic status, and children in care populations — which will provide a basis for public health policy, health care planning, and resource allocation for prevention initiatives. Further, evidence-based prevention strategies targeting alcohol use during pregnancy need to be established, and surveillance of FASD is urgently needed. It is also important for the predictive utility of the various diagnostic guidelines to be determined, so that a universal set of diagnostic criteria can be established.

The most important point to take from this paper is that a clear and consistent message needs to be relayed to pregnant women and women of childbearing age across the globe: There is no safe amount of alcohol or safe time to drink during pregnancy or when planning to become pregnant. By not consuming alcohol during pregnancy or while planning to get pregnant, you avoid the risk of [FASD developing in] your child. FASD is a very serious disabling condition, so please be safe and stay away from alcohol during your entire pregnancy. If you choose to drink during your pregnancy, you place your baby at risk for FASD.

References

  1. Williams JF, Smith VC; the Committee on Substance Abuse. Fetal alcohol spectrum disorders. Pediatrics. 2015;136:e1395-1406.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing; 2013:798-801.
  3. Centers for Disease Control and Prevention. Fetal alcohol spectrum disorders: diagnosis. https://www.cdc.gov/ncbddd/fasd/diagnosis.html. Updated June 3, 2014. Accessed September 15, 2017.
  4. Hoyme HE, Kalberg WO, Elliott AJ, et al. Updated clinical guidelines for diagnosing fetal alcohol spectrum disorders. Pediatrics. 2016;138:e20154256.
  5. Centers for Disease Control and Prevention. Fetal alcohol spectrum disorders (FASDs): data & statistics. https://www.cdc.gov/ncbddd/fasd/data.html. Updated June 6, 2017. Accessed September 15, 2017.
  6. Lange S, Probst C, Gmel G, Rehm J, Burd L, Popova S. Global prevalence of fetal alcohol spectrum disorder among children and youth: a systematic review and meta-analysis. JAMA Pediatr. 2017;171(10):948-956.
  7. May PA, Baete A, Russo J, et al. Prevalence and characteristics of fetal alcohol spectrum disorders. Pediatrics. 2014;134:855-866.
  8. Popova S, Lange S, Shield K, et al. Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis. Lancet. 2016;387:978-987.