The evaluation and care of children with suspected fetal alcohol spectrum disorders in the pediatric medical home: The importance of therapeutic alliance, longitudinal surveillance and trauma-informed care.

The evaluation and management of children with prenatal alcohol exposure and suspected fetal alcohol spectrum disorders (FASD) requires a multidisciplinary approach, grounded in the pediatric medical home. This process begins with the primary care provider who is often the initial point of contact for children presenting with developmental and behavioral concerns. An evaluation for a FASD requires the primary care provider to consider the effects of biological risk factors (e.g. genetic and mental health risks, maternal pregnancy risks, and history or prenatal substance exposures), and the role of co-occurring complex trauma, for which a trauma-informed, family-centered approach is necessary to mitigate secondary morbidities, and optimize future outcomes. In this article, we will present a holistic approach to evaluating a child with a suspected alcohol-related diagnosis, beginning with the diagnostic interview which centers on building a therapeutic alliance with the child and family grounded in a framework of trauma-informed care. We will consider the role of equifinality and multifinality in the evaluation of children with developmental and behavioral concerns and suspected prenatal alcohol exposure. We will briefly review the Collaboration on FASD Prevalence (CoFASP) Clinical Diagnostic Guidelines for FASD, and review the neurobehavioral deficits associated with prenatal alcohol exposure and their developmental emergence across the childhood spectrum, with suggestions for monitoring and intervention in primary care. We will also highlight neurobehavioral similarities between FASDs and other neurodevelopmental disorders, and we will discuss the importance of trauma-informed care to foster resilience and optimize future outcomes across the developmental lifespan in children and families with FASDs.