Reflections on the Updated CMAJ Guidelines for FASD Diagnosis

Canadian Medical Association Journal (CMAJ) has published new guidelines for the diagnosis of fetal alcohol spectrum disorder (FASD).  The guidelines, released 15 December 2015, are accessible here.  CMAJ also released a podcast discussing the updated diagnostic criteria, which is accessible here.  As a research assistant for Dr Michelle Stewart, I was also able to attend an informative training session hosted by Lakeland Centre for FASD which provided further information about the revised Canadian guidelines of FASD diagnosis.

The previous guidelines for the diagnosis of FASD were released in 2005.  Over the past ten years, clinicians have identified gaps and inconsistencies in the diagnosis process, and the research and literature concerned with FASD has developed substantially.  As a result, multiple concerns were identified which led to the development of a steering committee, the completion of a literature review and broad consultation, and ultimately the release of revisions to the 2005 guidelines for the diagnosis of FASD.

Although there are multiple specific updates to the guidelines (please refer to the CMAJ article for a full description), I will limit my discussion to those factors which are most salient to me after reviewing the guidelines and attending the training provided by Lakeland Centre for FASD.  I believe it is worth considering, at this time, that these diagnostic criteria are the result of direct feedback from clinicians and assessment teams in addition to advances in FASD research.  The effect of maternal alcohol consumption on prenatal development is a relatively recent area of study, and the advances in our understanding of FASD and related concerns have been substantial over the past ten years.  FASD is still not fully understood, and many questions remain.  Feedback on the updated guidelines and further research will continue to add to our understanding of FASD, maternal consumption of alcohol, and relevant social structures.

The recommendations of clinicians and assessment team, and the research regarding FASD, has influenced two major changes in the updated diagnostic guidelines.  Recent research suggests that maternal consumption of alcohol is “more primary in the development of [mental health problems], so these mental health problems can now be considered primary characteristics of FASD.  As a result, affect regulation and mental health problems have been added as one of the ten areas that diagnosticians examine when considering a diagnosis of FASD.  In addition, research has shown that growth deficits, which were included in the previous diagnostic guidelines, aren’t as common in individuals with FASD and are also not specific to FASD.  As such, the criteria of growth deficits has been removed in the new diagnostic guidelines.

The diagnostic nomenclature has been updated in the new diagnostic guidelines.  Individuals can be diagnosed with FASD with Sentinel Facial Features or FASD without Sentinel Facial Features.  There is also a new designation of At Risk for Neurodevelopmental Disorder and FASD, Associated with Prenatal Alcohol Exposure (please note that this is a designation, not a diagnosis).

The new diagnostic guidelines also recognize the inherent limitations associated with diagnosing infants and adults.  Infants are too young to complete many of the measures of CNS functions, while adults often have difficulty obtaining confirmation of prenatal exposure to alcohol and may experience various obstacles to assessment.

-Alexandra Johnson (Research Assistant for Dr. Michelle Stewart)

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