GPs reported that obstacles to the identification of FASD were the taboo and the paradoxical injunctions of society, the limited knowledge and experience, the non-specific and highly variable symptoms, the ambiguous classification and method of diagnosis involving the mobilization of a multidisciplinary team, and the length of consultations. The results of the study showed that GPs did not prioritize the identification of FASD in adults and expressed skepticism about the effectiveness of treatment, believing the disorder to be irreversible. In contrast, GPs were confident in identifying neurodevelopmental disorders resulting from a variety of causes, but were concerned about the long waiting times for access to specialist care.

Taboo, denial and paradoxical social injunctions

Practicing in Réunion means taking local specificities into account. 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. In fact, the patients reported that it took them a long time to admit that their drinking was excessive and to speak of "alcoholism" [21]. This denial among patients in La Réunion is in line with the observations of the GPs, who found it difficult to screen for addictive behavior because it was hidden by the patients themselves.

GPs highlighted another important aspect of La Réunion, namely the ubiquitous presence of alcohol advertising, which actively promotes its consumption. The GPs noted that this advertising environment plays a role in encouraging alcohol consumption among the population. The strong impact of these advertising campaigns on the population leads the general practitioners to feel that prevention is worthless [22]. This is encouraged by the low price of alcohol and the multiplication of outlets [23]. This could be an obstacle to the role of GPs in preventing the harmful effects of alcohol, as they do not feel supported by local public authorities.

Limited knowledge and experience

An Australian study found that health professionals did not systematically prevent alcohol use during pregnancy because they believed that pregnant women knew about the harmful effects of alcohol on the fetus and had stopped drinking as a result [24]. This is consistent with the results of the present study, in which GPs believed that prevention campaigns were effective and that patients were well informed on the subject. They were also aware that they had prejudices about alcohol consumption among women in general, which led to an underestimation of alcoholism in this population. GPs found it challenging to address women's addictive behavior and had difficulty referring them to appropriate services for support. Nevertheless, GPs acknowledged the existence of validated questionnaires to assist in the diagnosis of pathological alcohol use, which they used during consultations to aid in the assessment process, such as AUDIT, T-ACE, TWEAK, CAGE, etc. [25, 26].

Participating GPs emphasized the importance of addressing alcohol use during the initial pregnancy consultation. This particular moment was identified as a critical opportunity to provide lifestyle advice and guidance, prompting GPs to actively inquire about alcohol use at 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 use during pregnancy can be powerful [27]. They were able to use the pregnancy booklets, which mention alcohol consumption [28]. Overall, they supported the "zero alcohol during pregnancy" policy recommended in France and in many other countries, such as 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, including the fact that follow-up is increasingly carried out by other professionals, such as midwives or gynecologists. GPs saw patients mainly for acute illness and not for follow-up [14, 24].

Consistent with previous research, studies to date have reached a consensus on the central role of GPs in the prevention and detection of FASD. These studies have recognized and supported the significant contribution of GPs in both preventing cases of FASD through appropriate counseling and education, and in identifying individuals at risk or already affected by the disorder [29, 30]. However, very few GPs reported having seen patients with these disorders during their careers. As a result, they did not feel competent to deal with this disorder due to lack of experience [13, 15, 24]. They requested more training on the subject [31]. This lack of knowledge about FAS was also described by the GPs participating in the study, in fact, during the interviews they always used the acronym "FAS" and not "FASD" to describe Fetal Alcohol Spectrum Disorder. They also did not mention ARBD and ARND. This lack of precision in terminology may reflect a lack of information or the detrimental effect of the lack of consensus on the precise nomenclature of this disorder in nosographic classifications [32]. The DSM-V proposes: "Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE)" [33]. The ICD-10 uses the code Q86.0: "FAS (dysmorphic)" [34] without further precision.

Nonspecific and highly variable symptoms

Healthcare professionals have difficulties in identifying FASD because of the wide variety of symptoms, the lack of standardized diagnostic tools, and the limited time available for consultation [15, 24, 35, 36].

A study comparing 5 diagnostic methods [36,37,38,39] concluded that none was better than the others for diagnosing FASD versus other neurodevelopmental disorders, but also among FAS, ARND, and ARBD, and that it would be interesting to create a standardized diagnostic method to have a single reference [35, 39].

Lack of consensus on classification and diagnostic method

Several attempts at classification have been proposed to assess the severity of the effects of alcohol on the fetus and to make a diagnosis: Dehaene proposed FAS type I, II, III, IV according to the severity of dysmorphic damage and the knowledge of prenatal alcohol exposure [40]. The 1996 Institute of Medicine classification [35, 37, 40] 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 diagnosis and easier to apply 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 has been reported in the present study as well as in previous studies [12, 15]. The availability of specialized units included in the care pathway is recognized as an obstacle to the identification of FASD. However, GPs in Réunion could seek advice from the Coordination and Orientation Platform for Neurodevelopmental Disorders (PCO) [40], the FASD Resource Centre [41] or specialized associations for the orientation of their patients, but they were not aware of their existence.

It is even more difficult to improve the prognosis if the diagnosis is made late, for example in adulthood. In addition, GPs in this study rarely mentioned adults with FASD and more often spoke about identification in the pediatric population, suggesting that the prevalence of undiagnosed FASD is underestimated [42, 43]. FASD may be responsible for subsequent secondary disabilities such as disruptions in schooling, unemployment, mental health problems, trouble with the law, inappropriate sexual behavior, 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, improve prognosis [44]. 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 identifying and referring children with FASD in general than in FASD itself. In fact, they objected that FASD is difficult to diagnose in practice 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 [14]. In addition, the 20 obligatory examinations of the child are fully reimbursed by the health insurance and the use of the health booklet could be an aid in identifying the delay in acquisition.

Lengthy consultations

The amount of time spent on prevention in the consultations of French general practitioners remains low compared with the time spent on curative care. The results of the study Pelletier-Fleury N and Al suggest that 50% of GPs report little or no primary prevention activity in almost 75% of their daily consultations [45].

The average consultation time for a French GP is 17 minutes [46]. 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. [25, 26].

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 Fetal 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.