Written A. Hanlon-Dearman, S.Longstaffe and M. Millar
The new Canadian guidelines for FASD diagnosis (Cook et al “Fetal Alcohol Spectrum Disorder: A guideline for diagnosis across the lifespan, ” CMAJ2015) were published online in December 2015. These guidelines build on the original 2005 guidelines through an extensive review of the published evidence and consultation with clinicians across Canada. They include new recommendations for diagnostic terminology, expand the description of brain domains to be considered in assessment, provide additional recommendations on prenatal alcohol exposure, and broaden the considerations for diagnosing infants, young children, adolescents and adults.
The Manitoba FASD Centre team and its network have reviewed the new guidelines in detail to arrive at a common understanding of their application within the Manitoba context. We would recommend that readers review the complete guidelines and their appendix carefully.
The multidiciplinary approach is supported in the new guidelines as the standard for assessing and diagnosing children and adults.
The core diagnostic team members in the Manitoba context include:
- Diagnostic coordinators, including network diagnostic coordinators
- Social workers
- Developmental pediatricians
- Speech-language pathologists
- Occupational therapists
- FASD educator
- Manager and administrative team
New changes in the 2015 diagnostic guidelines include:
New Diagnostic Terminology
FASD is now the recommended diagnostic term. The new guidelines also describe two forms of FASD, namely:
- FASD with sentinel facial findings (i.e. short palpebral fissures, smooth philtrum and thin upper lip).
- FASD with no sentinel facial findings.
The Manitoba FASD Centre will use the broad diagnostic term FASD and will refer to the presence of sentinel facial findings in the complete medical report to physicians/primary care providers only.
Other Non-Diagnostic Terminology
The new guidelines refer to the designation of “At risk for neurodevelopmental disorder and FASD associated with prenatal alcohol exposure.” This designation is not a diagnostic term and the Manitoba FASD team decided that this designation will not be used in Manitoba at this time.
Criteria for Diagnosis, Old and New
Growth: The growth criterion has been removed from the new guidelines because it is not deemed to be specific to alcohol exposure. However, the comprehensive pediatric medical assessment by the Manitoba team will continue to measure and consider growth as important to both overall assessment of health and as part of considering differential diagnoses.
Brain Domains: The following bolded brain domains (now 10) have been revised or added and will be considered by the Manitoba team:
- Motor Skills (used to be hard and soft neurologic signs; the most controversial has been the removal of the sensory domain, which the Manitoba team has decided to continue to measure and considers important to understanding the individual’s functioning.
- Neuroanatomy/Neurophysiology (brain structure and functioning)
- Language (originally communication)
- Academic achievement
- Attention (originally ADHD)
- Executive function, including impulse control (and now includes hyperactivity)
- Affect regulation (includes anxiety, depression and mood dysregulation that meet DSM-V criteria)
- Adaptive behaviour, social skills, or social communication
Severe impairment, >/=2 standard deviations in formal testing in three or more domains is required by the new guidelines.
Prenatal Alcohol Exposure:
Prenatal alcohol exposure is more specifically defined, reinforcing the importance of reliable confirmation based on best evidence and leaving room for continued review as new evidence becomes available. The Manitoba team has worked extensively to develop processes that consider the alcohol history provided based on this best evidence and continues to partner with families, agencies and community professionals in developing sensitive history taking and support of mothers who are concerned about prenatal alcohol exposure in pregnancy.
The Manitoba diagnostic team and network are committed to on-going discussion and review of the guidelines, along with continuing education and review of new evidence as it becomes available. We are committed to the incorporation of new evidence for best practice at all levels of assessment and support, in the best interest of individuals and families we serve.