Misattributions and Potential Consequences: The Case of Child Mental Health Problems and Fetal Alcohol Spectrum Disorders

Numerous Canadian agencies have prioritized services for people diagnosed with FAS and its broader construct FASD. This prioritization extends to prevention interventions aimed at reducing or eliminating PAE. The many difficulties identified as associated with FAS, FASD, and PAE is one of the justifications for this prioritization. Mental health symptoms and disorders are among the most commonly highlighted challenges experienced by people labelled with FAS or FASD or exposed to alcohol in utero. However, the extent of the relation between the FAS, FASD, and PAE cluster and mental health symptom and disorder clusters may be inflated secondary to at least 3 factors: diagnostic criteria overlap and etiologic assumptions, referral bias, and failure to control for confounding variables when assessing associations. Lack of awareness of these factors may lead to dissemination of misinformation, which could adversely distort the development and provision of mental health services.Diagnostic criteria for conditions falling under the FASD umbrella have been operationalized in several different guidelines. The 2005 Canadian guideline1 aimed, in part, to harmonize aspects of the 2 leading approaches at the time, that is, those of the Institute of Medicine2 and the Washington 4-digit diagnostic code.3 Guidelines typically include the complete syndrome, FAS, and require positive findings in 4 domains: problematic patterns of alcohol exposure in utero (for example, from maternal binge drinking), growth abnormalities (for example, low birth weight for gestational age), facial dysmorphology (for example, short palpebral fissures), and CNS neurodevelopment abnormalities (for example, microcephaly at birth).2 Guidelines then typically go on to describe various partial syndromes. In the case of the Canadian guideline, the following partial syndromes are included: FAS (without confirmed alcohol exposure), partial FAS, and ARND.1 Difficulties identified within children with high PAE, but who do not have classical dysmorphic manifestations, is used to support the inclusion of partial syndromes.4 However, this broadening likely contributes to problematic overlap with those children with mental health difficulties for whom PAE may be present but for whom it is not etiologic. This is particularly problematic as there is no consensus on a pathognomonic behavioural manifestation of PAE or FASD. Although some propose a unique mental health profile linked to FASD,5 such profiles are based on small clinical samples and do not appear to have been independently replicated using a nonreferred population. Nevertheless, a resulting 10-item screening tool appears to be receiving national promotion in Canada.6Concerns that weaknesses in the operationalization of partial FASD syndromes may lead to misattribution of PAE as causal for various difficulties (for example, behavioural problems) has been raised in critiques of the 2 dominant diagnostic approaches used in the field,2,3 that is, the US sources for the Canadian guidelines.7 The ARND diagnosis, within the Canadian guidelines, requires evidence of impairment in three or more of the following CNS domains: hard and soft neurologic signs; brain structure; cognition; communication; academic achievement; memory; executive functioning and abstract reasoning; attention deficit/hyperactivity; adaptive behavior, social skills, and social communication.1, p S12 However, abnormalities in 3 of the listed domains would also be commonly found in many children with various mental health disorders. PAE may not be uncommon in children with such problem clusters. However, the fraction for whom PAE is primarily etiologic is unknown, and to assume it is typically the leading etiology is highly problematic.8Complicating the picture is the inclusion of an etiologic variable, in this case PAE, in the diagnostic criteria for FASD. This is at odds with a key direction taken in psychiatry as reflected in contemporary versions of the DSM, that is, to avoid etiologic assumptions within diagnostic criteria. …

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