Diagnosis of fetal alcohol spectrum disorder: current practices and future considerations

Combining neuroanatomical features to support diagnosis of fetal alcohol spectrum disorders

AIM

To identify easily accessible neuroanatomical abnormalities useful for diagnosing fetal alcohol spectrum disorders (FASD) in fetal alcohol syndrome (FAS) but more importantly for the probabilistic diagnosis of non-syndromic forms (NS-FASD).

METHOD

We retrospectively collected monocentric data from 52 individuals with FAS, 37 with NS-FASD, and 94 paired typically developing individuals (6-20 years, 99 males, 84 females). On brain T1-weighted magnetic resonance imaging, we measured brain size, corpus callosum length and thicknesses, vermis height, then evaluated vermis foliation (Likert scale). For each parameter, we established variations with age and brain size in comparison individuals (growth and scaling charts), then identified participants with abnormal measurements (<10th centile).

RESULTS

According to growth charts, there was an excess of FAS with abnormally small brain, isthmus, splenium, and vermis. According to scaling charts, this excess remained only for isthmus thickness and vermis height. The vermis foliation was pathological in 18% of those with FASD but in no comparison individual. Overall, 39% of those with FAS, 27% with NS-FASD, but only 2% of comparison individuals presented with two FAS-recurrent abnormalities, and 19% of those with FAS had all three. Considering the number of anomalies, there was a higher likelihood of a causal link with alcohol in 14% of those with NS-FASD.

INTERPRETATION

Our results suggest that adding an explicit composite neuroanatomical-radiological criterion for FASD diagnosis may improve its specificity, especially in NS-FASD.

WHAT THIS PAPER ADDS

Neuroanatomical anomalies independent of microcephaly can be measured with clinical-imaging tools. Small-for-age brain, small-for-brain-size callosal isthmus or vermian height, and disrupted vermis foliation are fetal alcohol syndrome (FAS)-recurrent anomalies. Associations of these anomalies are frequent in fetal alcohol spectrum disorder (FASD) even without FAS, while exceptional in typically developing individuals. These associations support higher likelihood of causal link with alcohol in some individuals with non-syndromic FASD. A new explicit and composite neuroanatomical-radiological criterion can improve the specificity of FASD diagnosis.

Capturing invisibility: child welfare social worker's interventions and assessment planning in presentations of fetal alcohol spectrum disorder(s)

Purpose

Child welfare services (CWSs) globally continue to absorb high rates of children living with or suspected of fetal alcohol spectrum disorder (FASD). Such high prevalence rates render CWS with major ethical and moral dilemmas of meeting complex needs. Currently, many jurisdictions are challenged by diagnostic capacity and cost implications of formal FASD diagnosis. This paper aims to recommend a screening protocol to address management gap between FASD initial presentation and formal diagnosis.

Design/methodology/approach

This is a follow-up paper from a grounded-theory study of a sample (N = 18) of child welfare social workers (CWSWs), allied health professionals and foster parents. A stepwise protocol was developed through systematical interpretation of the final data.

Findings

The application of a five-step screening protocol would greatly support CWSW in meeting the needs of children with suspected FASD. This CWSWs-led assessment model incorporates a clinical evaluation to exclude neurodevelopmental conditions caused by known genetic disorders, followed by behavioral and neurocognitive psychosocial assessments.

Research limitations/implications

This study had several limitations. Firstly, as a specific social work-based sample, it is not necessarily representative of the wider population of social workers globally due to different cultural responses to FASD in CWSs. The transferability of findings will have to be considered due to cultural variations concerning FASD.

Practical implications

By offering a management and nonlabeling approach, this five-step screening protocol offers a delineated pathway for CWSW and addresses the major professional frustrations while seeking to plan safe care for a child suspected of having FASD.

Social implications

The research offers a pragmatic low-cost to society to alleviate the mounting social and monetary implications of FASD. A large percentage of children impacted by prenatal alcohol exposure do not qualify under formal clinical diagnostic guidelines. Leaving these children without intervention is problematic. The recommendation of this study addresses this critical gap in services. The primary aim is to alleviate the burden on this cohort of vulnerable children by offering nonlabeling neurodevelopmental screening.

Originality/value

The direct implications of FASD and how it impacts CWS are well documented. However, few studies focus on the critical interface of FASD and the role of CWSW responsible for planning their safe care. This paper offers a novel pragmatic and functional multistep protocol to aid CWSW in this complex area of practice.

FASD prevalence among children and youth: results from the 2019 Canadian Health Survey on Children and Youth

INTRODUCTION

The lack of national fetal alcohol spectrum disorder (FASD) prevalence estimates represents an important knowledge gap.

METHODS

Using data from the 2019 Canadian Health Survey on Children and Youth, the prevalence of FASD was examined by age, sex and Indigenous identity. Median age of diagnosis and comorbid long-term health conditions were also assessed.

RESULTS

The prevalence of FASD among Canadian children and youth living in private dwellings was 1 per 1000 (0.1%). The prevalence was significantly higher among those who identified as Indigenous and lived off reserve (1.2%).

CONCLUSION

These findings are in keeping with FASD prevalence studies that used similar passive surveillance methods. They provide a starting point to better understanding the prevalence and burden of FASD in Canada.

FASD prevalence among children and youth: results from the 2019 Canadian Health Survey on Children and Youth

INTRODUCTION

The lack of national fetal alcohol spectrum disorder (FASD) prevalence estimates represents an important knowledge gap.

METHODS

Using data from the 2019 Canadian Health Survey on Children and Youth, the prevalence of FASD was examined by age, sex and Indigenous identity. Median age of diagnosis and comorbid long-term health conditions were also assessed.

RESULTS

The prevalence of FASD among Canadian children and youth living in private dwellings was 1 per 1000 (0.1%). The prevalence was significantly higher among those who identified as Indigenous and lived off reserve (1.2%).

CONCLUSION

These findings are in keeping with FASD prevalence studies that used similar passive surveillance methods. They provide a starting point to better understanding the prevalence and burden of FASD in Canada.

Teacher-Reported Prevalence of FASD in Kindergarten in Canada: Association with Child Development and Problems at Home

The prevalence of Fetal Alcohol Spectrum Disorder (FASD) may be underestimated as it can be difficult to diagnose in early childhood possibly reflecting unique developmental trajectories relative to other Neurodevelopmental Disabilities (NDDs). Using data collected via the Early Development Instrument (EDI) between 2010 and 2015, we examined the prevalence of kindergarten children with FASD and their concurrent developmental outcomes. We found that the prevalence of FASD ranged from 0.01 to 0.31%. A greater percentage of children with FASD had teacher-reported home problems that interfered with their classroom functioning. Overall children with FASD had higher mean scores on the developmental domains compared to children with NDDs. Results of the current study can inform strategies and policies for early identification and intervention.

Fetal Alcohol Spectrum Disorder: Embryogenesis Under Reduced Retinoic Acid Signaling Conditions

Fetal Alcohol Spectrum Disorder (FASD) is a complex set of developmental malformations, neurobehavioral anomalies and mental disabilities induced by exposing human embryos to alcohol during fetal development. Several experimental models and a series of developmental and biochemical approaches have established a strong link between FASD and reduced retinoic acid (RA) signaling. RA signaling is involved in the regulation of numerous developmental decisions from patterning of the anterior-posterior axis, starting at gastrulation, to the differentiation of specific cell types within developing organs, to adult tissue homeostasis. Being such an important regulatory signal during embryonic development, mutations or environmental perturbations that affect the level, timing or location of the RA signal can induce multiple and severe developmental malformations. The evidence connecting human syndromes to reduced RA signaling is presented here and the resulting phenotypes are compared to FASD. Available data suggest that competition between ethanol clearance and RA biosynthesis is a major etiological component in FASD.

Recent advances in fetal alcohol spectrum disorder for mental health professionals

PURPOSE OF REVIEW

Understanding the pathophysiologic, diagnostic, and treatment implications of the interface between mental disorder and the consequences of Prenatal Alcohol Exposure (PAE) is important for mental health professionals (MHP) seeking to provide the most effective care. This review was written to highlight the importance of identifying and intervening with regards to the unique mental health and medical needs of individual with PAE.

RECENT FINDINGS

Over the last year, research has identified differences in the diagnostic criteria for Neurodevelopmental Disorder Associated with PAE (ND-PAE)/Fetal Alcohol Spectrum Disorder (FASD) and called for standardization, given that diagnosis is the main route to appropriate support. Care will improve with advances in epigenetic, neuroimaging, and electrophysiological discoveries regarding the consequences of PAE. For example, recent progressions allow for improved detection of alterations in DNA methylation and functional connectivity between cortical and deep grey matter. Therapeutic innovations targeting specific neurocognitive impairment and ligand-specific symptom clusters, as well as lifelong multidisciplinary interventions to support patients, were reported as producing effective outcomes.

SUMMARY

Developments in genetics, epigenetics, imaging, and interventions are relevant to the current knowledge of FASD. MHP are encouraged to recognize the importance of understanding unique considerations for this population, including forensic implications and the whole-body impacts of FASD, which could assist in reducing stigma and improving quality of care.