Cost of specialized addiction treatment of clients with fetal alcohol spectrum disorder in Canada

The role of general practitioners in Reunion in detecting alcohol use in pregnant women and identifying fetal alcohol spectrum disorder: a qualitative study

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) is the leading cause of non-genetic intellectual disability and social maladjustment in children. International guidelines recommend abstinence from alcohol during pregnancy. Réunion is the most affected of all French regions with an estimated Fetal Alcohol Spectrum (FAS) prevalence of 1.2‰ births. General practitioners (GPs) are at the forefront of identifying patients with FASD.

OBJECTIVE

To understand how GPs identify FASD.

METHODS

Qualitative study using a grounded theory approach, through semi-structured face-to-face interviews with GPs. Interviews were conducted with the aim of reaching theoretical saturation. These were transcribed verbatim and then analyzed by four researchers to ensure triangulation of the data.

RESULTS

GPs reported barriers to the identification of FASD: challenges in overcoming social taboos and paradoxical injunctions, the influence of limited knowledge and experience, non-specific and highly variable symptoms, ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team and lengthy consultations. Conversely, they felt competent to identify neurodevelopmental disorders of any cause, but were concerned about the long waiting time to access specialized care. From the perspective of GPs, it is crucial to prioritize promotion and training aimed at improving the identification and coordination of care pathways for children diagnosed with neurodevelopmental disorders, such as FASD.

Integrated Supports for Women and Girls Experiencing Substance Use and Complex Needs

There is strong research to support integrated and gender-sensitive harm reduction approaches for supporting women, girls, and gender diverse people. For individuals who are pregnant, flexible and integrated treatment approaches may be especially important. In this study, we report on an integrated program in rural Canada designed to support pregnant women, girls, and gender diverse people experiencing substance use and other complex needs. Program data (N = 393) from the 2nd Floor Women's Recovery Centre (2nd Floor) at the Lakeland Centre for Fetal Alcohol Spectrum Disorder (LCFASD) was analyzed with several aims. Study goals were to (1) describe characteristics and needs of clients, (2) identify factors associated with program completion, and (3) for a subset of clients, examine resources, wellbeing, and social and behavioral outcomes after treatment. Clients (Mage = 27.4 years, range 15-64) presented at the 2nd Floor with complex medical and mental health needs, and experiences of significant socioenvironmental adversity. However, almost two-thirds (63.4%) successfully completed the program, which was more likely for clients who had stable housing at intake and a possible or confirmed diagnosis of FASD. After treatment, clients reported high levels of wellbeing, and most were connected to health care and community resources. In the year after program completion, clients who were contacted for follow-up maintained strong connection to resources and reported notable improvements in social and behavioral functioning. Many were working or volunteering, most were in stable home environments, rates of substance use and legal involvement were substantially reduced, and many clients were actively caring for their children. This study offers important findings to inform future research, practice, and policy for supporting health and wellbeing for women, children, families, and communities.

Alcohol's Impact on the Fetus

BACKGROUND

Alcohol is a teratogen and prenatal exposure may adversely impact the developing fetus, increasing risk for negative outcomes, including Fetal Alcohol Spectrum Disorder (FASD). Global trends of increasing alcohol use among women of childbearing age due to economic development, changing gender roles, increased availability of alcohol, peer pressure and social acceptability of women's alcohol use may put an increasing number of pregnancies at risk for prenatal alcohol exposure (PAE). This risk has been exacerbated by the ongoing COVID-19 pandemic in some countries.

METHOD

This literature review presents an overview on the epidemiology of alcohol use among childbearing age and pregnant women and FASD by World Health Organization regions; impact of PAE on fetal health, including FASD; associated comorbidities; and social outcomes.

RESULTS/CONCLUSION

The impact of alcohol on fetal health and social outcomes later in life is enormous, placing a huge economic burden on countries. Prevention of prenatal alcohol exposure and early identification of affected individuals should be a global public health priority.

The best possible start: A qualitative study on the experiences of parents of young children with or at risk for fetal alcohol spectrum disorders

BACKGROUND

The developmental outcomes and life course trajectories of young children with or at-risk for fetal alcohol spectrum disorders (FASD) can be optimized when individual and family needs are identified early and met with family-centered early intervention (EI) services. However, little is known about access to and quality of EI services with this high-needs population.

METHOD

Twenty-five biological or adoptive parents of children with or at high risk for FASD, living in the greater area of Seattle, Washington participated in this qualitative study. Three focus groups were conducted using a semi-structured interview guide. Participants described their experience with EI, as well as other supports and challenges faced in their child's first three years of life. Interviews were audio recorded, transcribed verbatim and coded using phenomenological methods. Themes that were consistent across participant groups emerged from the data, as well as themes that showed differences among participant experiences.

RESULTS

Common EI supports and needs between biological and adoptive parent groups were identified. In addition, perspectives and needs unique to each parent group were revealed. Themes were identified and organized into three categories: (1) child needs; (2) parent needs and priorities; and (3) EI capacity. When parents talked about their child's cognitive, physical, communication or adaptive development, they all discussed how EI was meeting those needs. In contrast, when parents expressed concern for their child's social-emotional development, a description of how EI was supporting these needs was missing from the conversation. Parents appreciated when EI providers were truthful, provided anticipatory guidance, and connected them with supports for their own social-emotional well-being. Yet there were unmet needs for respite care, and parents expressed that support for basic needs related to child or family survival was not consistently recognized as a top priority for families. This high-risk group of young children and their parents also encountered a multitude of transitions in their child's early years and later. Parents wanted more support navigating these transitions as they entered or moved through different systems of care.

CONCLUSIONS

Parents appreciated and endorsed the importance of EI with its provision of individualized, family-centered supports and resources. Examination of the gaps and unmet needs that are common and distinct underscore the importance of an FASD-informed approach to EI. Study findings provide insight into areas for which EI enhancements could be developed in order to tailor supports for the complex needs of this diverse population of children and parents.

A Multicountry Updated Assessment of the Economic Impact of Fetal Alcohol Spectrum Disorder: Costs for Children and Adults

AIM

To conduct a systematic review and quantitative analysis of the world literature on the economic impact of fetal alcohol spectrum disorder (FASD).

METHODS

A comprehensive literature review was conducted using multiple electronic databases and reference materials.

RESULTS

Thirty-two studies from 4 countries met the inclusion criteria (United States [n = 20], Canada [n = 9], Sweden [n = 2], and New Zealand [n = 1]). The studies reported the economic impact of FASD on health care, special education, residential care, criminal justice system, productivity losses due to morbidity and premature mortality, productivity losses of caregivers of children with FASD, and intangible costs. The economic estimates vary considerably due to the different methodologies used by different studies. The mean annual cost for children with FASD was estimated to be $22,810 and for adults $24,308. Residential costs for children with FASD were 4-fold greater than for adults with FASD. The costs of lost productivity for adults were 6.3-fold greater than for children.

CONCLUSIONS

The data on the economic burden of FASD are scarce, and the existing estimates likely underestimate the full economic impact of this disorder on the affected individuals, their caregivers, and society. However, the current research is sufficient to demonstrate that FASD is a serious public health problem associated with tremendous economic burden.

Opioid agonist therapy during residential treatment of opioid use disorder: Cohort study on access and outcomes

OBJECTIVE

To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion.

DESIGN

Retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016.

MAIN OUTCOME MEASURES

Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models.

RESULTS

Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38).

CONCLUSION

This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT-the first-line treatment of opioid use disorder-while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.

Policymakers' Perspectives Towards Developing a Guideline to Inform Policy on Fetal Alcohol Spectrum Disorder: A Qualitative Study

Fetal alcohol spectrum disorder (FASD) has a high prevalence in South Africa, especially among the poor socioeconomic communities. However, there is no specific policy to address FASD. Using a qualitative study design, we explored the perspectives of policymakers on guidelines/policies for FASD, current practices and interventions, and what practices and interventions could be included in a policy for FASD. The data analysis was done using the Framework Method. Applying a working analytical framework to the data, we found that there is no specific policy for FASD in South Africa, however, clauses of FASD policy exist in other policy documents. Preventive services for women and screening, identification, assessment, and support for children are some of the current practices. Nevertheless, a multi-sectoral collaboration and streamlined program for the prevention and management of FASD are aspects that should be included in the policy. While there are generic clauses in existing relevant policy documents, which could be attributed to the prevention and management of FASD, these clauses have not been effective in preventing and managing the disorder. Therefore, a specific policy to foster a holistic and coordinated approach to prevent and manage FASD needs to be developed.

Special Education of Children with Fetal Alcohol Spectrum Disorder

The current study aimed to estimate the cost associated with special education among children (5 to 14 years) with Fetal Alcohol Spectrum Disorder (FASD) in elementary and middle school by sex, age group, and province and territory in Canada. It was estimated that there were 6,520 students with FASD receiving special education in Canada in 2011-2012. The cost of special education among these students was 53.5 million Canadian dollars. Implications for decision- and policymakers, educational systems and school staff are discussed.

Comorbidity of fetal alcohol spectrum disorder: a systematic review and meta-analysis

BACKGROUND

Fetal alcohol spectrum disorder (FASD) is related to many comorbidities because of the permanent effects of prenatal alcohol exposure on the fetus. We aimed to identify the comorbid conditions that co-occur in individuals with FASD and estimate the pooled prevalence of comorbid conditions occurring in individuals with fetal alcohol syndrome (FAS).

METHODS

We did a systematic literature search of studies reporting on the comorbidity and cause of death in individuals with FASD using multiple electronic bibliographic databases, searching for studies published up to July, 2012. We included original research published in a peer-reviewed journal in the English language. We used the following criteria for determining study quality: use of an established FASD diagnostic guideline, study setting, method of data collection, and sample size. All comorbid disease conditions were coded according to the International Classification of Diseases, tenth revision (ICD-10). To estimate the pooled prevalence of comorbid conditions found to co-occur in individuals with FAS, we did meta-analyses assuming a random-effects model.

FINDINGS

Of 5068 studies found, 127 met eligibility criteria for data extraction. From those studies, we identified 428 comorbid conditions co-occurring in individuals with FASD, spanning across 18 of 22 chapters of the ICD-10. The most prevalent disease conditions were within the sections of congenital malformations, deformities, and chromosomal abnormalities, and mental and behavioural disorders. 33 studies reported data for frequency in a total of 1728 participants with FAS. The five comorbid conditions with the highest pooled prevalence (between 50% and 91%) included abnormal results of function studies of peripheral nervous system and special senses, conduct disorder, receptive language disorder, chronic serous otitis media, and expressive language disorder.

INTERPRETATION

The high prevalence of comorbid conditions in individuals with FASD highlights the importance of assessing prenatal alcohol exposure as a substantial clinical risk factor for comorbidity. The harmful effects of alcohol on a developing fetus represent many cases of preventable disability, and thus, alcohol use during pregnancy should be recognised as a public health problem globally.

FUNDING

Public Health Agency of Canada.

The Economic Burden of Fetal Alcohol Spectrum Disorder in Canada in 2013

AIM

To estimate the economic burden and cost attributable to Fetal Alcohol Spectrum Disorder (FASD) in Canada in 2013.

METHODS

This cost-of-illness study examined the impact of FASD on the material welfare of the Canadian society in 2013 by analyzing the direct costs of resources expended on health care, law enforcement, children and youth in care, special education, supportive housing, long-term care, prevention and research, as well as the indirect costs of productivity losses of individuals with FASD due to their increased morbidity and premature mortality.

RESULTS

The costs totaled approximately $1.8 billion (from about $1.3 billion as the lower estimate up to $2.3 billion as the upper estimate). The highest contributor to the overall FASD-attributable cost was the cost of productivity losses due to morbidity and premature mortality, which accounted for 41% ($532 million-$1.2 billion) of the overall cost. The second highest contributor to the total cost was the cost of corrections, accounting for 29% ($378.3 million). The third highest contributor was the cost of health care at 10% ($128.5-$226.3 million).

CONCLUSIONS

FASD is a significant public health and social problem that consumes resources, both economic and societal, in Canada. Many of the costs could be reduced with the implementation of effective social policies and intervention programs.

Cost attributable to Fetal Alcohol Spectrum Disorder in the Canadian correctional system

Prenatal alcohol exposure is the leading identifiable cause of intellectual disability in the Western world and may result in Fetal Alcohol Spectrum Disorder (FASD). Individuals with FASD have a higher risk of being involved in the legal system, either as offenders or as victims. Therefore, the aim of the current study was to estimate the direct cost for youths (12-17 years old) and adults (18+ years old) with FASD to the Canadian correctional system in 2011/2012. The prevalence of FASD in the Canadian correctional system, obtained from the current epidemiological literature, was applied to the average number of youths and adults in the correctional system in 2011/2012. The average daily cost for corrections was then applied to the estimated number of youths and adults with FASD in custody. The cost of corrections among youths with FASD in Canada in 2011/2012 was calculated to be approximately $17.5M Canadian dollars (CND; $13.6M CND for males and $3.8M CND for females) and among adults with FASD was estimated to be about $356.2M CND ($140M CND for provincial and territorial custody and $216.2M CND for federal custody). The study findings emphasize the need to raise awareness regarding the prevalence of FASD in the correctional system. It is crucial to incorporate FASD screening and intervention strategies as early as possible in the criminal justice process.

Canadian Children and Youth in Care: The Cost of Fetal Alcohol Spectrum Disorder

BACKGROUND

A high prevalence of prenatal alcohol exposure has been reported among children in care and thus, the risk of fetal alcohol spectrum disorder (FASD) in this population is high.

OBJECTIVE

The purpose of the current study was to estimate the number of children (0-18 years) in care with FASD and to determine the associated cost by age group, gender, and province/territory in Canada in 2011.

METHODS

The prevalence of children in care by province/territory was obtained from the Canadian Child Welfare Research Portal, and the number of children in care with FASD for each province/territory was estimated from available epidemiological studies. In order to calculate the total cost per province/territory, the cost per individual per day, by age group, was applied to the respective number of children in care with FASD.

RESULTS

The estimated number of children in care with FASD ranged from 2,225 to 7,620, with an annual cost of care ranging from $57.9 to $198.3 million Canadian dollars (CND). The highest overall cost ($29.5 to $101.1 million CND) was for 11-15 year-olds.

CONCLUSION

The study findings can be used to demonstrate the substantial economic burden that FASD places on the child welfare system. Attention towards the needs of this population and prevention efforts to reduce FASD incidence in Canada, and other countries are urgently needed.