Functional impairment, not FASD
===============================

* Benjamin J. Klein

The publication of new guidelines for fetal alcohol spectrum disorder (FASD) raises concerns about the ongoing push for FASD-specific assessment and support programs.1 Many 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.2

FASD is clinically indistinguishable from other causes of neurobehavioural disorders (e.g., antenatal alcohol or other teratogens, complex trauma, genetic).3 Treatment for neurobehavioural disorders is nonspecific (e.g., environmental supports) and based on function (e.g., cognitive, memory, executive, self-regulation). Emphasizing an etiologic label with no specific treatment is misleading to the public and unethical.

Function-based, nonmedical diagnosis-specific services are compatible with a vigorous public health program in preventing antenatal alcohol exposure. Basing resources on an etiologic label marginalizes individuals with neurobehavioural disabilities without a unifying diagnostic label.

FASD-specific programs will increase wasteful diagnosis-seeking behaviour (as seen in autism spectrum disorder). A universal FASD-specific diagnostic program based on current guidelines is not tenable4 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 for those who are in the “at risk of FASD” category.5 Ironically, FASD-specific programs will exclude many who are affected by antenatal alcohol but do not meet the 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, nonetiologic diagnosis-based services for all people with neurobehavioural disorders. Prioritization for assessment and intervention programs should be based on severity of functional disability, not on etiology. Diagnosticians need to focus on functional impairment rather than often futile (and sometimes damaging) attempts to attribute causality.

## References

1.  Cook JL, Green CR, Lilley CM, et al., for the Canada Fetal Alcohol Spectrum Disorder Research Network. Fetal alcohol spectrum disorder: a guideline for diagnosis across the lifespan. CMAJ 2016;188:191–7.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODgvMy8xOTEiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTg4LzE0LzEwMzUuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Rosenbaum P, Gorter JW. The ‘F-words’ in childhood disability: I swear this is how we should think! Child Care Health Dev 2012;38:457–63.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1111/j.1365-2214.2011.01338.x&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=22040377&link_type=MED&atom=%2Fcmaj%2F188%2F14%2F1035.2.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000304753900001&link_type=ISI) 

3.  Malone M, Koren G. Alcohol-induced behavioural problems in fetal alcohol spectrum disorders versus confounding behavioural problems. J Popul Ther Clin Pharmacol 2012;19:e32–40.
    
    

4.  Goulden KJ. Are FASD guidelines practical and sustainable? CMAJ 2005;173:1070–1.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMjoiMTczLzkvMTA3MC1hIjtzOjQ6ImF0b20iO3M6MjQ6Ii9jbWFqLzE4OC8xNC8xMDM1LjIuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

5.  McLennan JD. Alcohol-exposed? Next. CMAJ 2015;187:682–3.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODcvOS82ODIiO3M6NDoiYXRvbSI7czoyNDoiL2NtYWovMTg4LzE0LzEwMzUuMi5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=)