Perspectives of French General Practitioners Regarding their Role in Detecting Alcohol Consumption in Pregnant Women and Identifying Individuals with Fetal Alcohol Spectrum Disorders: A Qualitative Study

doi:10.21203/rs.3.rs-3157430/v1

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Perspectives of French General Practitioners Regarding their Role in Detecting Alcohol Consumption in Pregnant Women and Identifying Individuals with Fetal Alcohol Spectrum Disorders: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-3157430/v1

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published 06 Dec, 2023

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Background: Foetal Alcohol Spectrum Disorder (FASD) is the leading cause of non-genetic mental disability and social maladjustment in children. International guidelines recommend zero alcohol during pregnancy. Reunion is the most concerned from all the French regions with an estimated Foetal Alcohol Spectrum (FAS) prevalence of 1.2‰ births. General practitioners (GPs) are at the forefront of identifying patients with FASD.

Objective: To understand how GPs identify FASD.

Methods: Qualitative study with a grounded theory approach, through semi-structured face-to-face interviews with GPs. The interviews were conducted with the aim of reaching the theoretical saturation. These were transcribed into verbatim and then analysed by four researchers to ensure the triangulation of the data.

Results: The GPs reported obstacles to identify FASD: challenges in addressing taboos and paradoxical injunctions in society, the influence of limited knowledge and experience, non-specific and highly varying symptoms, ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team and lengthy consultations. Conversely, they felt competent to identify neurodevelopmental disorders of all causes but were concerned about the long waiting period to access to specialized care. As per GPs' perspective, it is crucial to prioritize the promotion and training aimed at enhancing the identification and coordination of care pathways for children diagnosed with neurodevelopmental disorders, such FASD.

fetal alcohol spectrum disorders

general practitioners

qualitative research

Exploring GPs' representations of the identification of Foetal Alcohol Spectrum Disorders in the general population is a new approach in the scientific literature, which is more interested in targeted populations such as Canadian Aboriginals and Australian Aboriginals, or in specialist care.
The obstacles and motivations encountered by general practitioners in identifying foetal alcohol spectrum disorders will enable decision makers and institutions to consider deploying the resources needed to improve identification.
The results help to emphasise the importance of primary care in identifying disorders at an early, undifferentiated stage.

Fetal alcohol spectrum disorder (FASD) is a group of disorders that occur in a child whose mother drank alcohol during pregnancy. Several forms of damage are reported:

Fetal alcohol syndrome (FAS) is said to be "complete" if it includes growth retardation, craniofacial dysmorphia and neurodevelopmental disorders. It is called "partial FAS" when it is a more moderate form without these three developmental abnormalities (1, 2).
Alcohol-Related Neurodevelopmental Disorder (ARND): manifested by psycho-affective disorders, adjustment disorders related to memory problems, attention, behaviour with hyperactivity, socialization with difficulties in social interactions (3, 4).
Alcohol-Related Birth Defects (ARBD): are malformations mainly cardiac and musculoskeletal as a consequence of alcohol consumption during the first trimester of pregnancy (3, 4).

Excessive drinking/excessive alcohol consumption almost always results in FAS. Since it is impossible to define thresholds at which it would consistently occur (5, 6), the French recommendation is "zero alcohol during pregnancy" (4, 7, 8).

FAS is a major public health problem. It is considered as the leading cause of preventable non-genetic mental disability at birth and social maladjustment of the child: disruptions in schooling, unemployment, mental health problems or trouble with the law (9, 10).

A meta-analysis published in 2017 by Popova et al, estimated the prevalence of FAS at 0.146 per 100 people worldwide (11). Between 2006 and 2013 in France, the diagnosis of FASD in the neonatal period involved 0.48 per 100 births, including 0.7 per 100 people of FAS. This incidence is poorly known and probably underestimated. Among the French regions Reunion is the most affected one by this syndrome (12).

Several studies, primarily utilizing questionnaires, have consistently indicated that general practitioners (GPs) exhibit hesitancy in addressing the issue of alcohol consumption during pregnancy. The reasons were multiple: lack of time, lack of knowledge of the syndrome due to lack of training, difficult diagnosis due to the great variability of symptoms, difficulty in discussing the subject of alcohol with patients for fear that they would feel stigmatized (13–15).

Reunion, situated in the Indian Ocean, is an overseas territory of France characterized by a diverse and multicultural population. The region faces significant challenges related to socio-economic precarity and illiteracy rates. The local culture is deeply intertwined with secular knowledge, predominantly centered around the cultivation of sugar cane and the consumption of rum. Notably, the taxation on alcohol is low, and there is a prevalent presence of alcohol advertising in the area.

Previous research has predominantly focused on the detection abilities of different healthcare disciplines such as paediatricians, midwives, psychiatrists, among others, regarding patients with FASD. However, limited attention has been given to the challenges faced by GPs in identifying individuals with FASD, despite their privileged position in monitoring families, which presents a unique opportunity for early identification of neurodevelopmental disorders.

The aim of the present study was to better understand the difficulties experienced by GP in identifying pregnant women who drink alcohol and in identifying people with FASD during the paediatric or adult periods.

Study design and setting

The study was conducted in Reunion, a French region, where the prevalence of FASD is considered to be the highest in the country.

Two studies were carried out jointly by two researchers on the same sample of GPs. The first one conducted by François Baelen (FB) aimed to understand the obstacles and motivations faced by general practitioners in Reunion in preventing FASD while the second one was conducted by Louise Delfarguiel (LD) on detecting alcohol consumption in pregnant women and identifying individuals with FASD. This study followed a cross-sectional qualitative design, guided by the principle of grounded theory. This re-search approach was selected to comprehensively investigate the perceptions of GPs regarding the identification of FASD. By adopting this methodology, the study aimed to uncover obstacles and motivations in an unbiased manner, allowing for a thorough examination of the subject without exerting any influence on the responses provided by the participants.

Sampling procedure

The sampling was theoretical, constructed and adapted as the study progressed in order to recruit a diverse population of physicians according to age, gender, number of years in practice, type and mode of practice, and location (east, west, north and south of the region). Each physician was contacted individually by phone or e-mail. Only volunteers were selected to participate in the study. The criteria for non-inclusion were refusal to participate and GPs with a particular mode of practice or practicing exclusively un-scheduled care.

Interview procedure

Two frameworks were developed by the two researchers using open-ended questions. They were then modified according to the emergence of concepts and the construction of the theory (Appendix n°1).

Data collection used individual face-to-face semi-structured interviews at the physicians' workplaces or via videoconference recorded by the two researchers. At the be-ginning of each interview, the GP's consent was collected. The interviews began with the collection of demographics: age, gender, number of years in practice, etc. The personal data (surname, first name, etc.) of the GPs were not recorded in order to limit the risk of identification. The interviews were numbered and transcribed anonymously. All audio-visual and voice recordings were destroyed at the end of the transcription process.

Data analysis

The analysis used the principle of anchored theorization. The interviews were transcribed in verbatim and coded using Nvivo® version 11.3 software in an open-ended manner at first, and then gradually organized into an axial coding. As this analysis progressed, a categorization of these codings brought out concepts that were related. Theoretical saturation of the data was sought through additional interviews. The analysis of the interviews was done by four researchers (LD, FB) involved in the data collection and then the results were analysed as well by two other researchers (SL and MS) to ensure the triangulation of the data.

Ethics

An anonymization step was performed during the data processing in order to avoid any personal data capture. In accordance with current regulations, a request for compliance with the reference method (MR004) was submitted to the Commission nationale de l'informatique et des libertés (CNIL), registered under number 2219132v0.

Initially, 31 GPs were contacted to participate in this study. In the end, 20 interviews were recruited. Of the remaining 11 GPs, some did not respond due to a lack of time and interest in the subject, others responded favourably, but further data collection was no longer necessary because the theoretical saturation of data had been reached.

On average, the interviews lasted 21 minutes (min-max = 12–38) for 9 women and 11 men. The average age of the GPs at the time of the interviews was 44.7 years (min = 30; max = 67) with an average number of years in practice of 18.8 years (min = 2; max = 39).

Interviews were conducted until theoretical data saturation occurred at the 15th interview. The last 5 interviews were conducted to verify the absence of new data useful for theory construction.

INSERT Table 1 HERE -

Table 1

Characteristics of the included population of general practitioners
	Gender	Age years	Years of practice	Place of exercice	Duration of interview Minutes	Place of interview
GP 1	M	30	2	Saline les Hauts	21	Medical office
GP 2	M	30	2	Saint Paul	26	Medical office
GP 3	M	60	30	Les Avirons	22	Medical office
GP 4	F	35	3	Sainte Marie	18	Video conferencing
GP 5	M	62	31	Saint Denis	32	Medical office
GP 6	F	47	17	Grand Bois	18	Medical office
GP 7	F	41	12	Saint Pierre	15	Medical office
GP 8	F	55	22	Piton St Leu	26	Medical office
GP 9	F	64	39	Saint Benoit	38	Video conferencing
GP 10	M	46	17	Salazie	26	Video conferencing
GP 11	M	64	35	Saint Joseph	12	Medical office
GP 12	M	55	26	Tampon	13	Medical office
GP 13	F	47	19	Le Port	13	Medical office
GP 14	M	67	36	Le Port	18	Medical office
GP 15	M	31	4	Saint Pierre	20	Medical office
GP 16	F	45	17	Etang Sale	16	Medical office
GP 17	M	59	30	Saint Joseph	26	Medical office
GP 18	F	38	10	Saint Joseph	16	Medical office
GP 19	M	42	15	Saint Joseph	23	Medical office
GP 20	F	39	9	Etang Sale	17	Medical office
F = Female; M = Man; Video conferencing = remote video recording

General practitioners (GPs) face numerous and diverse obstacles when it comes to identifying pregnant women who consume alcohol and individuals with FASD during paediatric and adulthood stages. These obstacles stem from both intrinsic factors associated with the GP profession and extrinsic factors tied to the societal context, particularly on Reunion. Intrinsic obstacles relate to the challenges inherent in the role of a general practitioner, while extrinsic barriers arise from the prevailing taboo surrounding alcohol, particularly concerning pregnant women, and the social characteristics specific to Reunion.

Taboo, denial and society's paradoxical injunctions

The notion that alcohol is taboo in society, particularly among women, led to a denial of patients' consumption: "I think that women don't talk too much about it... it's true that uh... we feel that it's taboo for women more than for men." (GP 15). A denial in some GPs, who even though they were aware of their prejudices, said that they were less likely to broach the subject and to underestimate alcohol consumption in this population: "It is said that alcoholism is more hidden, more secretive among women, that they talk about it less and it is true that, as a result, it is a problem that I broach even less often with women" (GP 19).

GPs also expressed a feeling of powerlessness in the face of society's paradoxical injunctions regarding the advertising of alcohol in Reunion: "There are more ads for rum than for FAS..." (GP 1). In spite of this, the alcohol prevention campaigns were considered by the doctors to be effective, leading to a good awareness of the population about the dangers of alcohol in general: "We have the impression that there is still a better knowledge on the part of the general public." (GP 11).

On the whole, the GPs considered that patients were well aware of the importance of not drinking alcohol during pregnancy thanks to mass prevention campaigns: "I think that today the majority of women know that they should not drink alcohol during pregnancy... well, there are a lot of messages that are being passed around lately... on the radio, on billboards as well..." (GP 7).

Alcohol and tobacco were often discussed at the first consultation at the beginning of the pregnancy, and then less or no longer at all during the follow-up: "Often at the pregnancy discovery interview with the prescription of beta-HCG and then afterwards, we give the little booklet and there, we explain the risks during pregnancy in terms of food, tobacco, alcohol” (GP 20).

The GPs advocated zero alcohol during pregnancy: "I tell her that from now on, it's zero... we have to set the bar on alcohol" (GP 6)

Limited knowledge and experience

Recognition differs according to the personal experience of each physician. Many of the FASD physicians considered FAS to be a syndrome rarely seen in general practice: "Well, FAS, I don't see it... or I miss it completely..." (GP 7). The low prevalence of FAS means that GPs had little experience with the subject. They reported not thinking about identifying it despite its high local incidence. "Afterwards, it is not something that I tend to spot in babies, even though I do a lot of paediatrics and prevention in children" (GP 19)

This little experience led to a general lack of knowledge of the signs that can identify FASD: "Well, how can I put it... FAS is still a bit strange to me. Well, it's clear that I feel like I don't know enough about it overall..." (GP 7). This lack of knowledge was accentuated by the great variability of unspecific symptoms that make it up: "Afterwards, it's probably more complex... there are several forms and it's not 1 or 0. It's polymorphic." (GP 3).

Overall, the GPs said they lacked training on the subject: "I don't feel that I am particularly trained now" (GP 14).

Overall, they deplored a gradual decrease in pregnancy follow-up consultations as they became the domain of midwives and gynaecologists. GPs are consulted by patients for acute pathological episodes: "Pregnant women, it's true that we don't see them that much. We see them a little bit from time to time ... yeah, when they are sick ... well, often, it is rather the gynaecologists who follow them" (GP 16).

Non-specific and highly varying symptoms

The diagnosis of FAS was often made beforehand by other health professionals: "So I didn't make a diagnosis, in the sense that the children I know who have it, the diagnoses were always made beforehand" (GP 19) and "They are screened before they come to the GP by the paediatrician in town or at the hospital" (GP 1).

Many had doubts about the care pathway once the diagnosis has been made: "I'm really embarrassed because ... There was REUNISAF before... and now I don't know...” (GP 6) and "Oh no, I don't know... maybe the children's hospital... no, I don't know, I'd have to look, I don't know" (GP 9).

Ambiguous classification and method of diagnosis

According to the participants, physicians' goals should rather be focused on identifying acquisitional delays in general, in order to refer the child early for appropriate diagnosis and management: "As a general practitioner, honestly, we'll do our job of alerting as soon as we realize there's a psychomotor delay or whatever but ... like for anything I mean no more FAS than anything else" (GP 13) or "I'm qualified to assess the child's development, which makes me refer them to the specialist who's going to do their job of diagnosing a developmental disorder, and in the spectrum of the developmental disorder, there may be FAS." (GP 19)

Lengthy consultations

It was all the more complex to identify this syndrome because the duration of a consultation is limited: "It's true that when you have a consultation where you go from one to the next, to ask yourself questions, you need to have time.” (GP 11).

The GPs reported obstacles to the identification of FASD was the taboo and society's paradoxical injunctions, the limited knowledge and experience, the non-specific and highly varying symptoms, ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team and the length of consultations. The study findings revealed that GPs did not prioritize the identification of FASD in adults and expressed scepticism regarding the effectiveness of treatment, considering the disorder as irreversible. In contrast, GPs felt confident in identifying neurodevelopmental disorders resulting from various causes but expressed concerns about the extended waiting times for accessing specialized care.

Taboo, denial and society's paradoxical injunctions

Practicing in Reunion means considering local particularities. In Reunion, it is traditional to consume alcohol for social reasons (family celebrations or others), but also for therapeutic reasons (alcohol as a remedy in traditional medicine). A study carried out among Reunionese women with children suffering from FASD revealed a feeling of shame and guilt leading to a denial of their alcohol consumption. Indeed, the patients reported that it took a long time before they admitted that their drinking was excessive and spoke of "alcoholism" (16). This denial among patients in Reunion is consistent with the observations of the GPs who found screening for addictive behaviours difficult because they were hidden by the patients themselves.

The GPs highlighted another significant aspect of Reunion, which is the pervasive presence of alcohol advertising that actively promotes its consumption. The GPs noted that this advertising environment plays a role in encouraging the use of alcohol among the population. The major impact of these advertising campaigns on the population results in a feeling of worthlessness of prevention among general practitioners (18). This is encouraged by the low price of alcohol and by the multiplication of sales outlets (17). This could be an obstacle to the role of GPs in preventing the harmful effects of alcohol, as they do not feel supported by the local public authorities.

Limited knowledge and experience

An Australian study revealed that health professionals did not systematically pre-vent alcohol use during pregnancy because they felt that pregnant women knew about the harmful effects of alcohol on the foetus and consequently had stopped drinking (19). This is consistent with the findings of the present study that GPs felt that prevention campaigns were effective and that patients were well educated on the subject. They were also aware that they had prejudices about alcohol use among women in general, leading to an underestimation of alcoholism in this population. GPs encountered challenges when addressing addictive behaviours in women and faced difficulties in referring them to suitable services for support. Nonetheless, the GPs acknowledged the existence of validated questionnaires designed to assist in diagnosing pathological alcohol consumption, which they utilized during consultations to aid in the assessment process, such as AUDIT, T-ACE, TWEAK, CAGE, etc. (20, 21).

The participating GPs emphasized the importance of addressing alcohol consumption during the initial pregnancy consultation. This particular moment was identified as a critical opportunity for providing lifestyle instructions and guidance, prompting the GPs to actively inquire about alcohol consumption during this early stage of care. Many brief alcohol interventions for pregnant women are effective in increasing abstinence during pregnancy and preventing FASD but even a single question about alcohol consumption during pregnancy can be impactful (22). They were able to use the pregnancy booklets, which mentions alcohol consumption (23). On the whole, they advocated the "zero alcohol during pregnancy" recommended in France as in many other countries, for example the United States, Canada and Australia. On the other hand, they tended not to ask the question again during pregnancy follow-up for various reasons, such as the fact that follow-up is increasingly done by other professions such as midwives or gynaecologists. GPs were seeing patients mainly for acute illness and not for follow-up (13, 19).

Consistent with prior research, previous studies have reached a consensus regarding the central role played by GPs in the prevention and identification of FASD. These studies have acknowledged and supported the significant contribution of GPs in both preventing FASD cases through appropriate counselling and education, as well as in identifying individuals at risk or already affected by the disorder (24, 25). However, very few GPs said they had been confronted to patients affected by these disorders during their career. As a result, they did not feel competent to deal with this disorder due to lack of experience (13, 14, 19). They requested more training on the subject (26). This lack of knowledge of FAS was also described by the GPs participating in the study, in fact, during the inter-views they always used the acronym "FAS" and not "FASD" to describe Foetal Alcohol Spectrum Disorder. They also did not mention ARBD and ARND. This lack of precision in terms could reflect a lack of information or the deleterious effect of the lack of consensus on the precise naming of this disorder in nosographical classifications (27). The DSM-V proposes: "Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)" (28). The ICD-10 with the code Q86.0 uses: "FAS (dysmorphic)" (28) without further precision.

Non-specific and highly varying symptoms

Health care professionals had difficulties identifying FASD because of the high varying symptoms, the lack of standardized diagnostic tools, and a time-limited consultation (14, 19, 30, 31).

A study comparing 5 diagnostic methods (31–34) concluded that neither method was better than the others for diagnosing FASD versus other neurodevelopmental disorders, but also between FAS, ARND and ARBD, and that it would be interesting to create a standardized diagnostic method in order to have a single reference (30, 34)

Lack of consensus about the classification and method of diagnosis

Several attempts at classification have also been proposed in order to evaluate the degree of severity of the effects of alcohol on the foetus and to make a diagnosis: Dehaene proposed FAS type I, II, III, IV according to the importance of the dysmorphic damage and the knowledge of prenatal exposure to alcohol (35). The Institute of Medicine classification (30, 32, 35) established in 1996 refers to FAS with or without maternal alcohol exposure, partial FAS, ARBD, ARND; a revision of this classification was published in 2005 and 2016, which is more precise in the diagnosis and more easily applicable clinically (32). This non-exhaustive list of terms surrounding the acronym "FAS" helps us to understand the difficulty of GPs in identifying this disorder.

The lack of knowledge of local specialized referral health care providers for patients diagnosed with FASD was reported in the present study as well as in the previous studies (12, 14). The availability of specialized units included in the care pathway is recognized as an obstacle to the identification of FASD. However, GPs in Reunion could find advice from the Plateforme de coordination et d'orientation (PCO) for neurodevelopmental disorders (NDD) (35), the FASD resource center (36), or dedicated associations to orient their patients, but they were not aware of their existence.

It is even more difficult to improve the prognosis with a late diagnosis, for example in adulthood. Moreover, in this study, GPs mentioned adults with FASD very little and spoke more frequently about identification in the paediatric population, suggesting that there is an underestimation of the prevalence of undiagnosed FASD (37, 38). FASD may be responsible for subsequent secondary disabilities such as disruptions in schooling, unemployment, mental health problems, trouble with the law, inappropriate sexual behaviour, addictions, etc. Even if treatment is less effective because it is delayed, a diagnosis of FASD made in adulthood would make it possible to obtain support (human, financial, legal, etc.), improve quality of life and, consequently, the prognosis (39). It would be important to make GPs aware of the importance of identifying FASD, including in adulthood.

GPs agreed that their role was more important in the identification and referral of children with FASD in general than in FASD itself. Indeed, they objected that in practice a FASD was difficult to diagnose for various reasons already discussed: time constraints, knowledge or the need for a multidisciplinary team. Rare GPs feel confident in recognizing and referring children with FASD (40). Moreover, the 20 compulsory examinations of the child are completely reimbursed by the health insurance as well as the use of the health booklet could be an aid in the identification of the delay in acquisitions.

Lengthy consultations

The average consultation time for a French GP is 17 minutes (41). This is not optimal for the identification of FASD in infants, children and adolescents. Alcohol consumption by women of childbearing age who wish to become pregnant could be investigated using screening tools such as AUDIT, T-ACE, TWEAK, CAGE, etc. (20, 21).

Strengths and limitations of the study

The strength of this study is the focus on GPs’ interpretation of their clinical role in identifying patients with FASD. We interviewed patients from a wide range of the French region with the highest prevalence of FAS, with a higher probability for GPs to meet patients with FASD.

Among the limitations of the study, three of the interviews were conducted at the physicians' place of work between consultations or at the end of the day, which may have had an influence on the length and quality of the interviews. Finally, the interviewed population could sometimes have answered a little less spontaneous and more thoughtful. A more relaxed attitude was regularly observed at the end of the recording with some-times more spontaneous discussions. Furthermore, it is noteworthy that more than one-third of the contacted GPs expressed disinterest in participating in the study. This potential sampling bias raises the concern that the GPs who did participate may have had a greater interest or motivation in identifying alcohol consumption in pregnant women or FASD. As a result, the findings should be interpreted considering this potential bias, which may limit the generalizability of the study's results to the broader GP population.

Implications for practice and research

The study has highlighted several potential perspectives for practice based on its findings, which include:

Providing training to general practitioners (GPs) in early identification and intervention for alcohol consumption in both the general population and specifically among pregnant women (for e.g. asking even a single question about alcohol use during pregnancy).
Focusing on the identification and coordination of care pathways for children affected by neurodevelopmental disorders (NDDs) such as Foetal Alcohol Spectrum Disorders (FASD).
Actively identifying and referring adults suspected of having FASD for further evaluation and support.
Implementing educational initiatives targeting young women in middle and high school to raise awareness about the risks associated with alcohol consumption during pregnancy.

Furthermore, future studies are recommended to consider patients' perspectives on the role of GPs in identifying FASD or other NDDs. It is also suggested to conduct consensus-building approaches to develop a standardized assessment tool for diagnosing FASD in Réunion, ensuring consistency and reliability in the diagnostic process. These recommendations aim to improve the identification, intervention, and support provided by GPs for individuals affected by FASD and other NDDs.

Reunion is the French region with the highest documented prevalence of FASD. However, the GPs reported difficulties in identifying patients, due to a lack of knowledge and experience, but also due to the difficulty of diagnosis with a great variability and lack of specificity of FASD symptoms, and the absence of a consensus on the classification or diagnosis of FASD. They reported a lack of knowledge about caregiving strategies and local providers. It is highly important to limit alcohol advertising, reinforce prevention messages about alcohol use among pregnant women and to have a well-identified care pathway to which GPs could refer their patients with NDD in order to benefit from an early functional assessment and care.

Ethical Approval: In accordance with current regulations, a request for compliance with the reference method (MR004) was submitted to the Commission nationale de l'informatique et des libertés (CNIL), registered under number 2219132v0.

Competing interests: the authors declare that they have no competing interests.

Authors’ contributions: SL conducted this study with LD and François Bealen (FB) who did not participate in the writing of the article. MS lead the research and made significant contributions to the writing of the article. All authors read and approved the final manuscript.

Funding: This research received no external funding. SL is a doctoral thesis student funded by the Doctoral School of the University of Réunion.

Availability of data and materials: The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

Acknowledgments: The corresponding author would like to thank Dr Denis Pouchain for his review of the article.

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Perspectives of French General Practitioners Regarding their Role in Detecting Alcohol Consumption in Pregnant Women and Identifying Individuals with Fetal Alcohol Spectrum Disorders: A Qualitative Study

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