Abstract

Aims: The objective of this study was to conduct a systematic review of the literature related to the measurement of the economic affect of Fetal Alcohol Spectrum Disorder (FASD) in different countries and to categorize the available literature. Methods: A systematic literature search of the studies apropos the economic bear on of FASD was conducted using multiple electronic bibliographic databases. Results: The literature on the economic burden of FASD is scarce. There are a express number of studies found in Canada and the The states, and data from the residual of the globe are absent. Existing estimates of the economic impact of FASD demonstrate pregnant cost implications on the individual, the family unit and gild. However, these estimates vary considerably due to the dissimilar methodologies used past different studies. Decision: Limitations and gaps in the existing methodologies of calculating the economic costs of FASD are discussed. It is axiomatic that there is an urgent need to develop a comprehensive and audio methodology for computing the economic touch on of FASD to the lodge.

INTRODUCTION

Fetal Alcohol Spectrum Disorder (FASD) is a serious public health, social and economic result that affects people throughout the world. FASD is a non-diagnostic umbrella term used to describe the range of disabilities that may affect people whose mothers consumed alcohol during pregnancy. This term covers several alcohol-related medical diagnoses, which include: fetal booze syndrome (FAS), partial fetal booze syndrome (pFAS), booze-related neurodevelopmental disorder (ARND) and alcohol-related nascence defects (ARBD). The disabilities involve a wide continuum of challenges from mild to very serious disabilities, which affect an private throughout the course of their life.

People who are affected by this disability near often experience an assortment of health issues such as birth defects, growth problems, cerebral delay, and speech communication and linguistic communication difficulties. Furthermore, those who are affected by FASD are also more than susceptible to cardiac anomalies, urogenital defects, skeletal abnormalities, and visual and hearing problems.

Due to the possibility of a wide range of disabilities, people who are affected by FASD may take special needs that require life-long help. Without the crucial support, people affected by FASD are at a high run a risk of developing secondary disabilities such as: mental wellness problems, trouble with the constabulary, dropping out of school, becoming unemployed, homeless and/or developing alcohol and drug problems. This in plow produces tremendous costs to the order.

Estimation of FASD cost, peculiarly lifetime toll, is key to describing the extent of the trouble and to evaluate the benefits to society of prevention programs and thus, useful from a public policy perspective (Harwood and Napolitano, 1985; Bloss, 1994; Public Health Bureau of Canada, 2008). According to the revised International Guidelines for Estimating the Costs of Substance Corruption ( Single et al., 2001), toll estimates assist to prioritize substance corruption issues, provide useful information for targeting programming and identify information gaps. The evolution of improved cost estimates too offers the potential to develop more consummate cost–benefit analyses of policies and programs aimed at reducing the harm associated with the use of psychoactive substances.

It is necessary to begin the discussion of economic cost studies with those from other professions past elaborating the assumptions and terms that the economists use. The International Guidelines ( Unmarried et al., 2001) outlines the written report of the economic costs of problems associated with the employ of psychoactive substances as follows: (i) a type of price-of-illness study (ii) in which the touch of substance abuse on the material welfare of a society is estimated past examining (iii) the social costs of resources expended for treatment, prevention, enquiry and police force enforcement, plus (iv) losses of production due to increased morbidity and mortality, plus (v) some measure for the quality of life years lost, relative to a counterfactual scenario in which in that location is no substance abuse. For further explanation of each part of the higher up statement please, come across a Supplementary data (Glossary of common terms used in economic cost studies adapted from Single et al., 2001).

Few studies to engagement take overviewed the literature on the toll associated with FASD in the United states (meet for instance, Lupton, 2003; Lupton et al., 2004). The objective of this study was to conduct a systematic review of the literature related to the measurement of the economical impact and toll drivers associated with FASD in unlike countries and to categorize the available literature.

METHODS

Systematic literature search

A systematic literature search of studies concerning the economic touch of FAS/FASD was conducted using multiple electronic bibliographic databases, including: Ovid MEDLINE, PubMed, EMBASE, Spider web of Science (including Science Citation Index, Social Sciences Citation Index, Arts and Humanities Commendation Index), PsycINFO, ERIC, CINAHL and OVID (combines several databases), Social Work Abstracts, Epscohost, the Cochrane Database of Systematic Reviews, Canadian Middle on Substance Abuse Library Collection Database, Centre for Addiction and Mental Health Library Database, Criminal Justice Abstracts and Google Scholar.

In addition, the post-obit economic databases were searched: the Booze Database ETOH (http://etoh.niaaa.nih.gov/Archive.htm) and the NHS EED (http://www.crd.york.ac.great britain/crdweb/).

Moreover, other spider web sites were searched for relevant literature: Alberta Alcohol and Drug Abuse Commission; Canadian Institutes of Health Research; Canadian Paediatric Order; Canadian Public Health Association; Centre of Excellence for Early Childhood Development; Centres for Excellence in Women's Health; Wellness Canada; Journal of Fetal Alcohol Research; National Eye on Birth Defects and Developmental Disabilities; Public Health Agency of Canada (PHAC); SAMHSA FASD Center for Excellence; Order of Obstetricians and Gynaecologists of Canada; Status of Women Canada; The Women's Addiction Foundation; HRSDC Part of Disability Issues; INAC; FNIHB; Centres for Excellence for Children with Special Needs and Centers for Disease Control and Prevention, USA.

In addition, transmission reviews of the content pages of the major epidemiological journals were conducted, likewise as citations in the relevant articles. Experts in the relevant field were also consulted in order to obtain more comprehensive data. The search was non limited geographically or to merely English language publications. The available published and unpublished literature was searched from January 1960 to July 2010, inclusive.

The search was conducted using multiple combinations of the following key words, in a systematic fashion:

  1. disease conditions: FASD, FAS, pFAS, fetal booze effects (FAE), ARND, ARBD, as well equally prenatal alcohol exposure, pregnancy and booze utilise/corruption;

  2. outcomes: disability, disability adjusted life years, quality adjusted life years, morbidity, premature mortality, potential years of life lost and productivity losses;

  3. cost: social cost, economical price, directly and indirect costs and intangible cost;

  4. systems/categories of cost: health intendance (hospitalization, hospital days, ambulatory care, emergency room visits, family unit physician visits and prescription drugs), mental wellness, addiction services, child welfare, early on childcare, education (special needs, assessment, suspensions, staff fourth dimension and salaries), social services (home support services, residential care and respite care).

Data extraction

Information from the identified studies was independently extracted past two investigators (D.B. and S.P.). Training of coders to achieve sufficient (>0.80) interrater reliability (IRR) was conducted. In gild to calculate IRR, Fleiss' kappa statistics using attribute agreement analytic method was used. All analyses related to IRR were computed using Minitab® statistical software (2007). A 3rd investigator (S.L.) checked the tabular array entries for accuracy, confronting the original article.

Using a standardized spreadsheet (MS-Excel), each study was coded for the post-obit variables: reference, year(s) of written report, state where the report was done, and direct, indirect and other cost drivers.

RESULTS

Initially, the literature search identified 233 abstracts. I hundred and xxx-eight abstracts were excluded because the studies were not concerning the economic touch on of FAS/FASD. Afterward reviewing the remaining 95 articles, 72 were excluded due to the absence of information on toll drivers associated with FASD. Upon farther screening, only xiii well-documented toll studies with comprehensive methodologies were selected for data extraction: 3 studies from Canada and 10 studies from the U.s.a.. In that location were no studies estimating the price of FASD plant for any other countries other than Canada and the U.s.a..

The results of the systematic search strategy are shown in Fig.1.

Fig. one.

Schematic diagram of the systematic search strategy.

Schematic diagram of the systematic search strategy.

Fig. ane.

Schematic diagram of the systematic search strategy.

Schematic diagram of the systematic search strategy.

Interrater reliability

There was a very loftier IRR (κ = 0.81, P < 0.0001) amidst the two reviewers across all variables coded. Discrepancies were reconciled by a third investigator (J.R.), independent of the first process.

Derivation of costs for comparison

All studies used the local currency for estimating costs and used the same currency year as the costing year. In club to facilitate comparison, the estimated costs in the Canadian studies were converted to May 2010 currency values, using the aggrandizement calculator of the Bank of Canada (http://www.bankofcanada.ca/en/rates/inflation_calc.html). The estimated costs in the United states of america studies were converted to June 2010 currency values using the currency aggrandizement rates calculated from the consumer price indexes supplied past U.s. Section of Labor (ftp://ftp.bls.gov/pub/special.requests/cpi/cpiai.txt).

Canadian studies (all costs in Canadian dollars)

The economic impact of FASD was measured in iii Canadian-based studies ( Stade et al., 2006, 2009; Thanh and Jonsson, 2009). Tablei presents the toll estimates of FASD from the Canadian studies.

Table ane.

Annual toll and lifetime costs (in Canadian dollars) per individual associated with FASD in Canadian studies

Reference Twelvemonth of study; province (if applicative) P/I per chiliad Age Direct cost, cost; percentage of total cost
 Indirect cost (productivity losses), cost; percent of total cost Other cost (out of pocket), cost; percent of total cost Almanac cost for all persons with FASD (95%  CI) Annual toll per individual (95% CI) Adapteda almanac cost for all persons with FASD (95% CI) Adjusteda annual cost per individual (95% CI)
Health intendance Education Social services Total direct costs
Stade et al. (2006) 2003 3 (P) one–21 $3976; 30.3% $4275; 32.6% $2866; 21.9% $11117; 84.8% $1055; eight.1% $936; 7.ane% $344.two Yard ($311.seven One thousand–$376.viii Grand) $xiv,342 ($12,986–$xv,698) $390.two M ($353.4 M–$427.2 K) $16,259 ($14,722–$17,796)
Stade et al. (2009) 2007 3 (P) 0–53 $6630; 35% $5260; 28% $4075; 18.8% $15,965; 82% $1431; half dozen.6% $2814; 13% $5.three B ($4.12 B–$6.iv B) $21,642 ($19,842–$24,041) $5.5 B ($4.three B–$half-dozen.7 B) $22,473 ($20,604–$24,965)
Thanh and Jonsson (2009) ( Stade et al., 2006, cost information used) 2002–2005 (2008 CND); Alberta 3 and ix (I) 0–71.6 Included; 30.3% Included; 32.6% Included; 21.9% 84.8% Included; 8.ane% Included; seven.1% $130 M–$400 Thousand (long-term cost); $48 Grand–$143 1000 (short-term cost) $one.1 M (lifetime cost per private) $148.iv 1000–$428.4 Grand (long-term price); $48.5 G–$144.v K (brusk-term toll) $1.12 M (lifetime toll per individual)
Reference Year of report; province (if applicative) P/I per 1000 Age Direct cost, cost; percentage of total cost
 Indirect cost (productivity losses), toll; per centum of total price Other cost (out of pocket), toll; per centum of total cost Annual toll for all persons with FASD (95%  CI) Annual cost per individual (95% CI) Adapteda annual cost for all persons with FASD (95% CI) Adjusteda annual cost per individual (95% CI)
Wellness care Instruction Social services Total direct costs
Stade et al. (2006) 2003 3 (P) 1–21 $3976; thirty.3% $4275; 32.6% $2866; 21.9% $11117; 84.8% $1055; 8.ane% $936; 7.1% $344.2 One thousand ($311.7 M–$376.8 1000) $14,342 ($12,986–$15,698) $390.two M ($353.4 M–$427.2 M) $xvi,259 ($xiv,722–$17,796)
Stade et al. (2009) 2007 3 (P) 0–53 $6630; 35% $5260; 28% $4075; 18.viii% $15,965; 82% $1431; vi.6% $2814; 13% $v.3 B ($iv.12 B–$6.4 B) $21,642 ($19,842–$24,041) $5.v B ($4.iii B–$6.7 B) $22,473 ($twenty,604–$24,965)
Thanh and Jonsson (2009) ( Stade et al., 2006, cost data used) 2002–2005 (2008 CND); Alberta three and ix (I) 0–71.half dozen Included; xxx.3% Included; 32.6% Included; 21.nine% 84.8% Included; viii.1% Included; 7.i% $130 M–$400 M (long-term price); $48 K–$143 One thousand (short-term price) $one.1 Grand (lifetime toll per individual) $148.four M–$428.4 M (long-term cost); $48.v M–$144.five K (short-term toll) $ane.12 M (lifetime cost per individual)

B, billion; I, incidence; M, million; P, prevalence.

aAdjusted for inflation (May 2010).

Table 1.

Annual price and lifetime costs (in Canadian dollars) per individual associated with FASD in Canadian studies

Reference Year of study; province (if applicable) P/I per 1000 Age Directly price, cost; percent of total price
 Indirect price (productivity losses), cost; percentage of total cost Other cost (out of pocket), cost; per centum of total cost Almanac cost for all persons with FASD (95%  CI) Annual toll per private (95% CI) Adjusteda annual toll for all persons with FASD (95% CI) Adjusteda annual cost per individual (95% CI)
Health care Pedagogy Social services Total direct costs
Stade et al. (2006) 2003 3 (P) 1–21 $3976; thirty.three% $4275; 32.6% $2866; 21.nine% $11117; 84.8% $1055; 8.i% $936; 7.1% $344.2 M ($311.7 1000–$376.eight Chiliad) $fourteen,342 ($12,986–$xv,698) $390.2 M ($353.iv Chiliad–$427.2 M) $16,259 ($fourteen,722–$17,796)
Stade et al. (2009) 2007 3 (P) 0–53 $6630; 35% $5260; 28% $4075; eighteen.8% $15,965; 82% $1431; half dozen.6% $2814; xiii% $v.iii B ($iv.12 B–$6.iv B) $21,642 ($nineteen,842–$24,041) $v.5 B ($4.3 B–$6.7 B) $22,473 ($twenty,604–$24,965)
Thanh and Jonsson (2009) ( Stade et al., 2006, toll information used) 2002–2005 (2008 CND); Alberta 3 and 9 (I) 0–71.6 Included; 30.three% Included; 32.six% Included; 21.9% 84.viii% Included; eight.1% Included; seven.1% $130 M–$400 M (long-term cost); $48 Grand–$143 M (short-term toll) $one.1 M (lifetime cost per individual) $148.4 Thousand–$428.4 M (long-term cost); $48.5 Chiliad–$144.five Yard (short-term cost) $1.12 1000 (lifetime cost per individual)
Reference Year of study; province (if applicable) P/I per thousand Age Direct cost, cost; percentage of total cost
 Indirect cost (productivity losses), cost; percentage of total cost Other cost (out of pocket), cost; percentage of full toll Annual cost for all persons with FASD (95%  CI) Annual cost per individual (95% CI) Adjusteda annual price for all persons with FASD (95% CI) Adjusteda almanac cost per private (95% CI)
Health intendance Education Social services Total direct costs
Stade et al. (2006) 2003 iii (P) 1–21 $3976; 30.iii% $4275; 32.6% $2866; 21.9% $11117; 84.eight% $1055; eight.ane% $936; seven.1% $344.2 M ($311.7 M–$376.8 M) $14,342 ($12,986–$15,698) $390.two K ($353.4 M–$427.ii Grand) $16,259 ($14,722–$17,796)
Stade et al. (2009) 2007 3 (P) 0–53 $6630; 35% $5260; 28% $4075; 18.8% $fifteen,965; 82% $1431; vi.6% $2814; xiii% $5.iii B ($4.12 B–$6.4 B) $21,642 ($19,842–$24,041) $5.5 B ($four.3 B–$6.7 B) $22,473 ($20,604–$24,965)
Thanh and Jonsson (2009) ( Stade et al., 2006, cost data used) 2002–2005 (2008 CND); Alberta 3 and nine (I) 0–71.half-dozen Included; 30.3% Included; 32.6% Included; 21.9% 84.8% Included; 8.1% Included; 7.1% $130 M–$400 M (long-term cost); $48 One thousand–$143 Thousand (brusque-term cost) $1.ane M (lifetime toll per private) $148.4 G–$428.4 M (long-term toll); $48.5 M–$144.v M (short-term cost) $1.12 M (lifetime toll per individual)

B, billion; I, incidence; Yard, million; P, prevalence.

aAdjusted for inflation (May 2010).

Stade et al. (2006) measured the economic impact of FASD for 2003 using a modified version of the Health Services Utilization Inventory ( Browne et al., 2001) on a sample of 148 parents (biological, adoptive or foster) who were either living with or responsible for the care and welfare of an FASD-affected child. Participants were between the ages of ane and 21, and were diagnosed with either FAS or FAE. At the patient level, the estimated total adapted annual cost associated with FASD per child was $14,342 [95% conviction interval (CI): $12,986–$xv,698]. At the population level, using a bourgeois prevalence rate of 3 per 1000 (the literature reports up to 9 per 1000 in Canada; Public Health Agency of Canada, 2003), the cost of FASD annually was $344.2 one thousand thousand (95% CI: $311,664,000–$376,752,000). This prospective cross-sectional enquiry written report estimated costs from the perspectives of the social club, the Ministry of Health and the patient/family unit. The cost components included were: direct costs, such equally medical care (hospital admissions, health professional person services and medication), educational services (home schooling, special schooling and residential programs), social services (respite care, foster care and legal aid), indirect costs (productivity losses; measured using the homo capital approach) and other costs (out-of-pocket).

Stade et al. (2009) attempted to overcome the limitations of their past study ( Stade et al., 2006) by including the cost for infants from the solar day of birth to one year of age, the price for adults across the historic period of 21 (up to the age of 53) and the price of children residing in institutions (for a total of 250 participants with diagnosed FAS, pFAS or ARND), as well equally by adding a few more toll components (due east.yard. residential programs, task education, institutionalization and authorities pensions). The adjusted annual cost of FASD at the patient level, for 2007, was estimated equally $21,642 (95% CI: $19,842–$24,041), while at the population level, the estimated adjusted annual cost was $5.3 billion (95% CI: $4.12 billion–$6.iv billion), for persons 0–53 years of historic period.

Thanh and Jonsson (2009) estimated two societal-perspective costs in Alberta, Canada: the annual long-term cost and the annual brusk-term cost of FASD. The annual long-term toll refers to the projected corporeality of coin incurred by the cohort of children born with FASD each year (lifetime cost), which was calculated using the FAS incidence rates of iii per g live births (lower rate) and 9 per 1000 alive births (upper rate) along with the total number of alive births per year in 2002–2005. The annual short-term cost refers to the corporeality of money incurred past people who are presently living with FASD, calculated using the FASD cost calculator developed by the FAS centre at the Academy of Dakota (available at http://www.online-clinic.com). The cost estimator included the following cost components: healthcare costs, special didactics, juvenile justice services, adult corrections and service delivery systems. The costs and disorder rates used in the figurer were in 1996/97 United States Dollar (USD), and were adapted to 2008 Canadian Dollar (CND) value using a 5% discount rate and a USD/CND exchange charge per unit of one.03. The lifetime cost of caring for each individual child built-in with FASD was estimated as ∼$1.one meg (annual cost per child was used from Stade et al., 2006): $15,812 × average historic period at expiry (71.6). The total annual cost of FASD (short-term price) for Alberta was estimated as $48 1000000 (based on the lower incidence rate) to $143 meg (based on the upper incidence rate), and the daily cost as $105,000 (lower incidence charge per unit) to $316,000 (upper incidence charge per unit). It is likewise worth noting that the long-term economical toll for the disorders associated with FASD rose from $130 to $400 million from 2002 to 2005, respectively.

USA studies (all costs in Us dollars)

The economic impact of FAS was measured in 10 American-based studies ( Harwood et al., 1984, 1998; Harwood and Napolitano, 1985; Abel and Sokol, 1987, 1991a,b; Weeks, 1989; Rice et al., 1990, 1991; Rice, 1993; Harwood, 2000, 2003). Please note that Harwood et al. (1984) and Harwood and Napolitano (1985) as well as Rice et al. (1990, 1991) were published in repetition. But two studies from the USA estimated the total lifetime cost for a person with FAS (Harwood and Napolitano, 1985; Weeks, 1989). Tableii presents the cost estimates of FAS from the USA studies.

Table two.

Almanac cost and lifetime cost (in US dollars) per individual associated with FAS in the USA studies

Reference Year of study; country P/I per 1000 Age Direct cost, cost; per centum of total cost
 Indirect cost (productivity losses), price; per centum of total price Other direct cost, toll; percentage of total cost Almanac price for all persons with FAS Lifetime cost per individual Adjusteda annual cost for all persons with FAS Adapteda lifetime cost per private
Wellness care Residential intendance and home intendance Special education Full straight costs
Harwood et al. (1984); Harwood and Napolitano (1985) 1980 one.0, five.0 and 1.67 (cost estimates based on 1.67) 0–65 $699 Thousand (children $125 Yard; adults $574 M); 22% HC and RC with day services: $694 G; 22% $990 1000; 31% $2.4 B; 75% $853.three M; 25% Not included $3.2 B $596,000 $eight.5 B $ane.half-dozen G
Abel and Sokol (1987) 1984 1.nine 0–21 Growth retardation: $118 M; Cleft palate, tetralogy of fallot and sensorineural anomalies: $18M; 42% 24-h RC due to MR: 109 M; semi-contained supervised support $75.eight G; 58% Not included $321 Grand Not included Not included $321 Thou n/a $674.ane M due north/a
Weeks (1989) 1988, Alaska one.67 0–65 Included Included Included due north/a Included Not included north/a $1.4 M n/a $2.5 One thousand
Abel and Sokol (1991a) (revision of 1987 study) 1984 0.33 0–21 Treatment cost: $sixteen.9 M; 22.7% 24-h RC due to MR: $57.7 G; 77.3% Not included $74.6 M Not included Not included $74.half-dozen M n/a $156.seven M n/a
Abel and Sokol (1991b) (revision of 1987 written report) 1987 1.9 0–21 Handling toll: $104.v M; 42% 24-h RC due to MR: $145.2 Chiliad; 58% Not included $249.7 M Not included Not included $249.7 M northward/a $479.4 M north/a
Rice et al. (1990, 1991) 1985 1.9 0–65 Treatment: $135 M; 8.four% RC for age 21+: $1287 B, 79.nine%; Full-time RC <21 years $110 Chiliad, 6.viii%; Semi-independent supervised intendance $76 M, four.7% Not included $1.6 B Not included Inquiry $3 M; 0.2% $one.6 B n/a $3.25 B n/a
Rice (1993) (update of Rice et al., 1990, 1991) 1990 1.9 0–65 Included Included Not included n/a Not included Included $ii.1 B n/a $3.6 B n/a
Harwood et al. (1998) (update of Harwood et al., 1984 and Harwood and Napolitano, 1985 written report) 1992 2 0–65 Included Included Included n/a Included Non included $1.nine B n/a $3.04 B northward/a
Harwood (2000) (update of Harwood et al.,1998) 1998 2 0–65 Included Included Included $2.9 B $1.25 B Not included $4.ii B n/a $five.5 B n/a
Harwood (2003) (updated Harwood, 2000) 2003 2 0–65 Included Included Included $three.9 B $one.5 B Non included $5.4 B north/a $half dozen.5 B n/a
Reference Year of written report; state P/I per k Age Straight cost, cost; percentage of full price
 Indirect price (productivity losses), cost; percentage of total cost Other straight cost, cost; percentage of total cost Annual toll for all persons with FAS Lifetime cost per individual Adjusteda almanac cost for all persons with FAS Adapteda lifetime cost per individual
Health care Residential care and domicile care Special pedagogy Total direct costs
Harwood et al. (1984); Harwood and Napolitano (1985) 1980 1.0, 5.0 and 1.67 (price estimates based on 1.67) 0–65 $699 M (children $125 M; adults $574 Grand); 22% HC and RC with day services: $694 M; 22% $990 M; 31% $two.4 B; 75% $853.3 M; 25% Not included $3.2 B $596,000 $eight.5 B $ane.half-dozen 1000
Abel and Sokol (1987) 1984 1.9 0–21 Growth retardation: $118 M; Crack palate, tetralogy of fallot and sensorineural anomalies: $18M; 42% 24-h RC due to MR: 109 M; semi-independent supervised back up $75.8 M; 58% Non included $321 One thousand Not included Not included $321 M n/a $674.1 M n/a
Weeks (1989) 1988, Alaska ane.67 0–65 Included Included Included north/a Included Non included n/a $ane.4 M n/a $two.5 M
Abel and Sokol (1991a) (revision of 1987 written report) 1984 0.33 0–21 Handling toll: $sixteen.9 K; 22.7% 24-h RC due to MR: $57.7 M; 77.three% Not included $74.6 Yard Not included Not included $74.6 K n/a $156.seven M n/a
Abel and Sokol (1991b) (revision of 1987 study) 1987 ane.ix 0–21 Handling cost: $104.5 One thousand; 42% 24-h RC due to MR: $145.ii Yard; 58% Not included $249.vii M Non included Not included $249.7 M n/a $479.4 M northward/a
Rice et al. (1990, 1991) 1985 one.ix 0–65 Treatment: $135 M; 8.four% RC for age 21+: $1287 B, 79.nine%; Full-fourth dimension RC <21 years $110 1000, six.8%; Semi-independent supervised care $76 M, 4.7% Not included $1.6 B Not included Research $three M; 0.two% $1.six B due north/a $3.25 B due north/a
Rice (1993) (update of Rice et al., 1990, 1991) 1990 1.9 0–65 Included Included Not included n/a Not included Included $2.i B north/a $three.6 B n/a
Harwood et al. (1998) (update of Harwood et al., 1984 and Harwood and Napolitano, 1985 study) 1992 2 0–65 Included Included Included n/a Included Non included $1.ix B northward/a $3.04 B due north/a
Harwood (2000) (update of Harwood et al.,1998) 1998 2 0–65 Included Included Included $2.9 B $one.25 B Not included $4.two B due north/a $5.5 B north/a
Harwood (2003) (updated Harwood, 2000) 2003 2 0–65 Included Included Included $3.ix B $1.5 B Not included $5.iv B north/a $half-dozen.5 B northward/a

B, billion; HC, abode care; I, incidence; Thou, million; MR, mental retardation; P, prevalence; RC, residential care.

aAdjusted for aggrandizement (June 2010).

Table two.

Annual cost and lifetime cost (in Usa dollars) per individual associated with FAS in the Us studies

Reference Year of study; land P/I per 1000 Age Straight cost, cost; percent of total price
 Indirect toll (productivity losses), price; percentage of full price Other directly cost, cost; percent of total cost Almanac cost for all persons with FAS Lifetime price per individual Adjusteda almanac price for all persons with FAS Adjusteda lifetime cost per private
Wellness care Residential care and home care Special education Full direct costs
Harwood et al. (1984); Harwood and Napolitano (1985) 1980 1.0, 5.0 and 1.67 (cost estimates based on 1.67) 0–65 $699 M (children $125 M; adults $574 M); 22% HC and RC with day services: $694 M; 22% $990 M; 31% $2.4 B; 75% $853.3 Chiliad; 25% Not included $three.2 B $596,000 $8.5 B $i.6 K
Abel and Sokol (1987) 1984 1.ix 0–21 Growth retardation: $118 K; Fissure palate, tetralogy of fallot and sensorineural anomalies: $18M; 42% 24-h RC due to MR: 109 One thousand; semi-contained supervised support $75.eight M; 58% Non included $321 K Not included Not included $321 M due north/a $674.1 M n/a
Weeks (1989) 1988, Alaska ane.67 0–65 Included Included Included n/a Included Non included due north/a $1.4 Chiliad north/a $ii.5 M
Abel and Sokol (1991a) (revision of 1987 study) 1984 0.33 0–21 Treatment toll: $16.9 Thousand; 22.seven% 24-h RC due to MR: $57.7 1000; 77.3% Non included $74.6 Yard Not included Not included $74.6 M northward/a $156.7 M due north/a
Abel and Sokol (1991b) (revision of 1987 study) 1987 1.9 0–21 Treatment cost: $104.v Thou; 42% 24-h RC due to MR: $145.2 M; 58% Not included $249.7 M Not included Not included $249.7 Thou n/a $479.4 One thousand n/a
Rice et al. (1990, 1991) 1985 1.9 0–65 Handling: $135 M; 8.four% RC for age 21+: $1287 B, 79.9%; Full-time RC <21 years $110 M, half-dozen.8%; Semi-independent supervised care $76 M, 4.7% Not included $1.6 B Non included Research $3 1000; 0.2% $1.half-dozen B n/a $3.25 B n/a
Rice (1993) (update of Rice et al., 1990, 1991) 1990 1.ix 0–65 Included Included Non included n/a Not included Included $ii.1 B n/a $3.6 B n/a
Harwood et al. (1998) (update of Harwood et al., 1984 and Harwood and Napolitano, 1985 study) 1992 2 0–65 Included Included Included n/a Included Not included $1.9 B n/a $3.04 B north/a
Harwood (2000) (update of Harwood et al.,1998) 1998 2 0–65 Included Included Included $2.ix B $1.25 B Not included $4.2 B due north/a $5.five B northward/a
Harwood (2003) (updated Harwood, 2000) 2003 2 0–65 Included Included Included $three.9 B $i.5 B Not included $5.4 B n/a $half-dozen.5 B north/a
Reference Year of study; state P/I per k Age Straight cost, cost; percentage of total cost
 Indirect cost (productivity losses), cost; percentage of full cost Other direct cost, cost; percentage of full cost Annual cost for all persons with FAS Lifetime cost per private Adjusteda annual toll for all persons with FAS Adjusteda lifetime cost per individual
Wellness care Residential care and home care Special educational activity Total directly costs
Harwood et al. (1984); Harwood and Napolitano (1985) 1980 1.0, v.0 and i.67 (cost estimates based on i.67) 0–65 $699 1000 (children $125 M; adults $574 M); 22% HC and RC with day services: $694 Thousand; 22% $990 M; 31% $two.4 B; 75% $853.three M; 25% Not included $3.ii B $596,000 $viii.5 B $1.6 M
Abel and Sokol (1987) 1984 i.nine 0–21 Growth retardation: $118 Chiliad; Crevice palate, tetralogy of fallot and sensorineural anomalies: $18M; 42% 24-h RC due to MR: 109 K; semi-independent supervised support $75.8 M; 58% Not included $321 M Non included Non included $321 K north/a $674.ane 1000 n/a
Weeks (1989) 1988, Alaska 1.67 0–65 Included Included Included due north/a Included Not included northward/a $1.four 1000 n/a $2.5 1000
Abel and Sokol (1991a) (revision of 1987 study) 1984 0.33 0–21 Treatment cost: $sixteen.nine Thousand; 22.7% 24-h RC due to MR: $57.7 M; 77.3% Non included $74.6 K Not included Not included $74.6 M north/a $156.7 M due north/a
Abel and Sokol (1991b) (revision of 1987 study) 1987 one.9 0–21 Treatment cost: $104.5 M; 42% 24-h RC due to MR: $145.2 Yard; 58% Not included $249.7 M Not included Not included $249.7 M n/a $479.4 M north/a
Rice et al. (1990, 1991) 1985 1.9 0–65 Handling: $135 M; 8.iv% RC for age 21+: $1287 B, 79.9%; Full-time RC <21 years $110 Thou, half dozen.8%; Semi-independent supervised intendance $76 Thou, iv.7% Not included $1.half-dozen B Not included Research $3 1000; 0.2% $1.6 B north/a $three.25 B n/a
Rice (1993) (update of Rice et al., 1990, 1991) 1990 ane.9 0–65 Included Included Not included n/a Not included Included $2.ane B n/a $3.vi B n/a
Harwood et al. (1998) (update of Harwood et al., 1984 and Harwood and Napolitano, 1985 study) 1992 two 0–65 Included Included Included n/a Included Not included $1.nine B northward/a $3.04 B n/a
Harwood (2000) (update of Harwood et al.,1998) 1998 2 0–65 Included Included Included $ii.ix B $1.25 B Not included $4.2 B n/a $v.5 B n/a
Harwood (2003) (updated Harwood, 2000) 2003 ii 0–65 Included Included Included $3.9 B $i.5 B Not included $5.four B n/a $half dozen.five B n/a

B, billion; HC, home care; I, incidence; Yard, million; MR, mental retardation; P, prevalence; RC, residential intendance.

aAdjusted for inflation (June 2010).

Using a societal perspective and data from Russell (1980), Harwood et al. (1984) and Harwood and Napolitano (1985) generated 1980 toll estimates of between $ane.937 billion and $nine.687 billion with a median estimate of $iii.236 billion, using culling FAS incidence rates (based on a review of prospective studies) of 1.0, v.0 and ane.67 per 1000 live births, respectively. The total lifetime cost was estimated at $596,000 per FAS birth. Costs included estimates of medical treatment, abode and residential care, special educational services and productivity losses for patients with FAS of all ages (0–65). Based on this lifetime judge, Lupton et al. (2004) demonstrated how these costs for one example of FAS are spread out over the person's lifetime. After adjustment for inflation the $596,000 in 1980 became $ii 1000000 in 2002. This estimate is composed of $one.6 one thousand thousand (80%) for wellness care, special education and residential care for individuals with mental retardation, and $0.4 million (20%) for productivity losses ( Lupton et al., 2004). Furthermore, the cumulative cost of one instance of FAS to historic period 65 would have a intermission downwardly as follows: $130,000 in the first 5 years, $360,000 in x years, $587,000 in 15 years and more than $1 million in 30 years ( Lupton et al., 2004).

Abel and Sokol (1987) measured the economic cost of FAS from the perspective of the wellness care system from birth to 21 years of age, and estimated that the economic burden of FAS in the Us was $321 one thousand thousand in 1984, using an incidence rate of one.ix per yard live births. The incidence charge per unit was an boilerplate fatigued from several prospective and retrospective studies. The study estimated the toll of providing specialized services for pre- and postal service-natal growth retardation requiring neonatal intensive care; surgical repair of FAS-related nascency defects and subsequent handling; intendance for FAS patients with moderate or severe cognitive disabilities; and the toll of semi-independent supervised support for mildly cognitively disabled patients with FAS.

In 1991, Abel and Sokol (1991a) revised their 1987 report, with a much lower and more conservative incidence charge per unit of 0.33 per 1000 live births; derived from prospective studies that were comprised of primarily Caucasian samples and did not include whatever other racial/ethnic groups (e.g. Native Americans). This study produced a much lower annual cost estimate of $74.6 1000000. More 77% of this economic burden was associated with residential intendance due to mental retardation of FAS individuals. All the same, Abel and Sokol (1991b) farther refined their methodology and the costs included and excluded. The updated 1987 annual guess of $250 million was, once again, based on an incidence rate of 1.9 per 1000 live births.

Once again, from the perspective of the health intendance system, Rice et al. (1990, 1991), using the method of Abel and Sokol (1987), estimated the almanac cost of treating birth defects associated with FAS in the USA in 1985 at $1.6 billion, based on an incidence charge per unit of ane.9 FAS cases per 1000 alive births. The toll drivers included the cost of care for FAS-related nascence defects and cognitive disability and residential care for patients with mental retardation over 21 years of age (up to age 65). And so, based on increasing population rates and healthcare costs, between 1985 and 1990, Rice (1993) projected a $2.1 billion annual cost for 1990.

Harwood et al. (1998) estimated the 1992 annual cost to exist $1.944 billion based on a prevalence charge per unit of ii.0 per 1000 live births. This study re-estimated: (i) the nature and cost of specific types of treatment, (ii) the proportion of FAS cases requiring services and (iii) the duration of services. This cost guess included the following drivers: treatment and intendance services to age 21, dwelling and residential intendance to age 65 of people with moderate to severe retardation, special teaching services and productivity losses.

Further, Harwood (2000, 2003) updated the 1992 written report by adjusting for the change in national wellness intendance expenditures, the consumer cost alphabetize for medical services, for changes in the USA adult population, and in the hourly compensation index for productivity losses. Based on these adjustments, estimated costs rose to $4.15 billion by 1998 (direct cost $2.nine billion; indirect cost $1.25 billion), and to $5.4 billion by 2003 (direct price $three.9 billion, 6.1% annual increment; indirect cost $1.l billion, iv% almanac increase).

A study by Weeks (1989) reported that a lifetime cost for each child born with FAS is $1,374 million in 1988. This study adjusted the methodology used by Harwood and Napolitano (1985) and included the post-obit costs: developmental inability services, special education, social service costs, adult vocational services and institutional care for mental retardation to age 65. This estimate is much higher than the study past Harwood and Napolitano (1985) estimate because costs in Alaska are generally higher than national costs.

Give-and-take

Based on the few existing studies for Canada and the USA, it is clear that FASD is a serious public health problem and is associated with tremendous monetary costs.

Even though many price components have been taken into business relationship in the reviewed studies, the total cost associated with FASD is still underestimated. This is primarily due to the fact that several cost components take non been included in the studies to date, likely because the data are not readily bachelor. Among those costs drivers ordinarily non included are: child welfare costs/payments, law enforcement costs, cost of research and prevention and intangible costs (i.e. the costs of pain and suffering), only to name a few. Information technology is a very difficult task to estimate the cost of FASD since the total toll accrues from many sectors of gild. Regardless, it is very important to include all price components (as long as it is possible to judge them in a reliable manner, but if not at least all cost components should, at the very least, be noted) in order to go a true and valid judge, or at least equally close to the reality as possible.

One important cost commuter—the child welfare organization—was non accounted for in any of the existing Canadian or United states of america estimates. However, there is reason to believe that children with FASD are overrepresented in the child welfare system and thus, must exist included to get a truthful cost estimate (Farris-Manning and Zandstra, 2003; Hutson, 2006). Specifically, Fuchs et al. (2010) reported that in Manitoba, Canada 17% of children in care are affected by diagnosed or suspected FASD. In Alberta, information technology was adamant that there are fifteen,032 children in the care of social services (Farris-Manning and Zandstra, 2003) and almost half of them have FASD (Hutson, 2006). In 1 of the first studies of its kind, Fuchs et al. (2008) reported the total almanac cost of children in care in Manitoba equally $9.5 1000000 for a sample of 400 children with FASD in 2006. These authors found that the daily toll of caring for a kid with FASD in the child welfare arrangement was $65 (or $23,760 per annum).

In add-on, police force enforcement toll was likewise not considered in the existing Canadian and The states estimates. Information technology is reported that about 50% of young offenders in Canada have FASD (Zakreski, 1998). In one American written report of 253 people with FAS or FAE, 60% reported always beingness charged, bedevilled or in trouble with the authorities for any of a list of criminal behaviors, and 42% of adults had been incarcerated for a law-breaking ( Streissguth et al., 1996).

There were several other of import price drivers non included in the USA estimates: medical services for concrete anomalies, special didactics, substance abuse, mental wellness and vocational services, services for balmy physical and learning disabilities and lost productivity of caregivers and FASD-affected persons. These insufficiencies have besides been noted in several reviews (come across Lupton, 2003; Lupton et al., 2004; Hutson, 2006). In addition, the existing Usa studies included the cost of FAS only. Still, the prevalence of FASD is suspected to be 10 times higher ( Sampson et al., 1997; May and Gossage, 2001; Astley, 2002), and therefore, the existing price figures are probable underestimated.

In the USA studies, in that location is a broad range in the reported total toll figures. For instance, the annual cost gauge by Abel and Sokol (1991a) was reported every bit $75 million for 1984 ($157 million adjusted for 2010), while Harwood (2003) reported $five.4 billion for 2003 ($6.5 billion adjusted for 2010). These cost disparities reflect the fact that the studies have used different methodologies and assumptions. For instance, the studies used different prevalence/incidence rates [e.one thousand. the incidence charge per unit was ranging in the USA studies from 0.33 to one.9 (Abel and Sokol, 1987, 1991a,b)], used dissimilar historic period categories and different cost components. Another mutual problem was that the USA studies used terms 'incidence' and 'prevalence' interchangeably (delight annotation that the authors of this newspaper used the original terminology from the studies). Therefore, it is not clear whether these cost studies were incidence or prevalence-based, which is very important from the economical point of view. The application of FAS prevalence rates to contemporary as well as older nativity cohorts can also contribute to the big ranges observed ( Lupton et al., 2004).

Another noted inconsistency was that the private cost drivers deemed for dissimilar proportions of the total cost in each of the reviewed studies. Methodological differences can probable account for the different proportions reported. If certain cost components are non included, and so other cost components volition account for a college percent of the overall cost, thus depicting an unrealistic flick.

Furthermore, studies that used a sample to draw conclusions on the total costs incurred (e.one thousand. Stade et al., 2006, 2009) used a method of convenience sampling, which, every bit a result, limits the generalizability of the Canadian studies.

Conclusion

Based on the observed literature, currently, there are no comprehensive assessments of the economic impact of FASD in Canada, the USA or whatever other land. The majority of the studies that do exist limit their range of the toll components included, are inconsistent with one some other or are only generalizable to certain populations. At that place is an urgent demand to provide an authentic cost estimate of FASD that would embrace all aspects of this disorder and the diverse sectors affected past this inability. A standardized arroyo would allow for proper comparisons beyond studies, both nationally and internationally. Information technology would as well allow for comparisons between FASD and other public health issues, which is ideally required if the results volition exist used in economic evaluations and resource resource allotment decisions.

Equally evident from the observed methodologies of the existing studies, the next stride is to develop a comprehensive and audio methodology for calculating the economical impact of FASD. The PHAC has undertaken the atomic number 82 in the evolution of a sound methodological approach for calculating the economic impact of FASD. The current authors will build this methodological model for Canada based on the guidelines developed from the start national Roundtable on The Development of a Canadian Model for Calculating the Economic Impact of FASD, which was held by PHAC on March 21–22, 2007 in Ottawa (Public Wellness Bureau of Canada, 2008). This cost-of-disease economic model will consider the systems that those with FASD come into contact with throughout their lives (i.due east. a life-cycle approach); the life/developmental stages of those affected; different levels of severity of inability; the direct and indirect costs to the systems, individuals and families, including the loss of productivity of parents/caregivers, and the lost potential of the afflicted individuals. An inclusive price estimate should not only take into consideration the costs accrued due to the affliction, merely should also account for preventative care, and the money that can be saved by constructive social policies and programs. It is hoped that this model will be appropriate not only for use in Canada, but for apply in other countries likewise.

An accurate and comprehensive economic impact approximate is crucial in order to illustrate to policy developers and decision-makers the extent of the problem. Thus, the importance of an economical impact model of FASD goes without saying. One time policy-makers can clearly see the affect of burden and price that FASD has on not only Canada, but throughout the world as well, prevention initiatives are probable to soon follow.

Funding

This piece of work was supported by the Public Health Bureau of Canada (contract #6D016-081841/001/SS). In addition, support to CAMH for salary of scientists and infrastructure has been provided by the Ontario Ministry building of Health and Long-Term Care. The views expressed in this manuscript do not necessarily reflect those of the Public Health Agency of Canada or of the Ministry of Wellness and Long-Term Care.

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    • Supplementary data