Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure DSM-5

DSM-5 Category: Conditions for Further Study

Introduction

Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE) falls under the umbrella term Fetal Alcohol Syndrome (FAS). ND-PAE refers to children exposed prenatally to alcohol but who do not satisfy the full criteria for a diagnosis of FAS. As a result, a second group called the Neurodevelopmental Disorder-Prenatal Alcohol Exposure emerged. The profession created FAS to encompass all individuals across a wide continuum of clinical deficits related to prenatal alcohol exposure. Building on the wide range of public health and mental health, medical professionals agree that ND-PAE is a serious problem (Brown, Grant, & Clarren, 2014). Experts in FASD estimate the FASD rate conservatively to be at least 9.1 of every 1,000 births annually. In other words, in the United States alone, there are roughly 40,000 new cases of ND-PAE annually. A recent PubMed query of the term "fetal alcohol syndrome" culled roughly 4,000 articles. According to the DSM-5, the extant literature includes alcohol-related teratogenicity, functional deficits in the child's neurodevelopmental outcomes, along with the child's cognitive and behavioral ability (Rich and Brown, 2013).

Symptoms of Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure

Rich and Brown (2013) comment that the relationship between neurodevelopmental disorders and prenatal alcohol exposure (ND-PAE) are conditions needing further study (DSM-5, page 798). ND-PAE appears in the category "Specified Other Neurodevelopmental Disorder," code 315.8 (page 86). The DSM-5 delivered a stand-alone diagnostic code that enables clinical tracking and epidemiologic monitoring of fetal alcohol spectrum disorder (FASD). According to "Alcoholism: Clinical" (2010) occasionally, children with heavy ND-PAE will meet the criteria for Fetal alcohol syndrome (FAS). The DSM-5 offers helpful guidelines on how to conceptualize FASD's neurobehavioral sequelae. These are diagnosed as "Neurodevelopmental Disorder Associated with Prenatal Alcohol Exposure" (ND-PAE).

According to the CDC (2011), a person with an FASD might have any of the following or a combination thereof:

• abnormal facial features, such as a smooth ridge between the nose and upper lip (the ridge called the philtrum)
• small head size
• shorter-than-average height
• low body weight
• poor coordination
• hyperactive behavior
• poor memory
• difficulty in school (especially with mathematics)
• learning disabilities
• speech and language delays
• intellectual disability or low IQ
• poor reasoning and judgment skills
• sleep and sucking problems as a baby
• vision or hearing problems
• problems with the heart, kidneys, or bones

Affected children typically exhibit considerable difficulty with nearly all aspects of their behavior ranging from learning and remembering things to applying what they have learned to everyday experiences, paying attention, and controlling their emotions and urges (Brown, Grant, & Clarren, 2014). The DSM-5 explains that the brain damage in ND-PAE affects everything about the way the developing child functions. Because brain damage is irreparable and permanent, putting legal intervention into context requires recognition of the signs of ND-PAE and providing external supports in a structured environment to compensate for the individual's deficits.

Principal neurocognitive deficits specific to ND-PAE include learning problems that not only impede academic achievement but also impair the child's ability to learn routines and social rules in both the home and in the community (Brown, Grant, & Clarren, 2014). Because of attention and memory deficits, affected youth have considerable difficulty remembering multistep instructions. According to the DSM-5, coping with change is difficult for children with ND-PAE because each new context requires new behavioral routines that are unknown. In these settings, the child with ND-PAE becomes overwhelmed, cognitively speaking. Children with FASD often compensate for their learning deficits by mimicking what they observe around them, and this characteristic must be kept in mind vis-à-vis placement and legal disposition.

Self-regulation deficits among children with FASD involve their ability to control their emotions, moods, and urges along with their behaviors. Brown, Grant, and Clarren (2014) explain that it is common for children with ND-PAE to have an over-sensitivity to stimuli (internal and external) and these children may become upset, angry, and frustrated with little provocation, thereby resulting in overreaction. Among very young children, these overreactions may look like a tantrum. However, during late childhood, overreactions may manifest in aggressive behavior toward oneself or others. The DSM-5 states that FASD children have difficulty foreseeing consequences and appreciating the effect of their behavior on themselves, as well as others. Therefore, making mid-course corrections is virtually impossible for FASD individuals. Behavioral self-regulation problems can include one's inability to delay gratification, resulting in boundary violations. Theft is commonplace, and so is sexually inappropriate behavior once the child enters puberty.

Because of the multiple cognitive deficits, children with ND-PAE tend to be developmentally delayed in adaptive functioning, including social, practical, and language skills. In addition, attention, language, memory, and executive function deficits may negatively impact legal competencies. The DSM-5 explains that the social development delays common to ND-PAE make it difficult for these individuals to establish and maintain relationships. Developmental delays in socialization affect moral maturity. Most adults with FASD operate socially and emotionally as though they were very young children, particularly in unfamiliar situations where appropriate conduct has not been practiced and well learned.

Cause and Prevention

ND-PAE and other FASDs are the result of a woman drinking alcohol during pregnancy. The DSM-5 states that the amount of alcohol that the medical community considers safe to drink during pregnancy remains uncertain. According to the DSM-5, there is no appropriate time during pregnancy when a woman can consume alcohol. Further, if a woman thinks she might become pregnant, she should not consume any alcoholic beverage. This is because a woman might be pregnant for several weeks and not know it. According to the CDC (2011), half of all pregnancies in the United States were accidental.

Treatment of Neurobehavioral Disorder Associate with Prenatal Alcohol Exposure

Brown, Grant, and Clarren (2014) conclude that among children with neurodevelopmental disorders, children affected with FASD may be the most challenging to parent, educate, and to treat due to their challenging behaviors. That said, medical professionals developed effective interventions that might improve the quality of life for affected youth and those in their lives. A structured, stable, and protective social network containing compassionate and educated caregivers is the most important component to successful intervention.

The DSM-5 states that even if the child has not received a formal diagnosis, she or he might quality for early intervention treatment services. The Individuals with Disabilities Education Act (IDEA) requires that persons younger than three years of age who are at risk of having developmental delays may be eligible for services. The early intervention system of the home state of the child will assist with having the child evaluated and can provide services if the child meets qualifications for assistance.

The Centers for Disease Control and Prevention (CDC; 2011) presents information on various ways of treating the symptoms associated with ND-PAE. Children with ND-PAE can have both physical and intellectual disabilities along with behavioral and learning problems, and so it is impossible to generalize treatment efforts. Symptoms in any of these large categories range from mild to severe, which is why treatments should be individualized and catered to each patient. The CDC offers a mobile app for iPhone and Android users called "CDC Fetal Alcohol Spectrum Disorders Application (FASD)" to assist parents, physicians, and caregivers of persons with ND-PAE or other forms of FASD.

Several types of treatments exist for persons with ND-PAE and other FASDs. These methods for managing ND-PAE fall into the following five categories:

1. Medical Care
2. Medication
3. Behavior and Education Therapy
4. Parent Training
5. Alternative Approaches

Medical Care

Persons affected by ND-PAE have the same health and medical needs as persons without ND-PAE. The DSM-5 states that, like everyone else, ND-PAE patients need vaccinations, good nutrition, exercise, hygiene, baby care, and primary medical care. However, ND-PAE issues specific to their disorder must be addressed and monitored by a current doctor or through referral to a specialist. As stated above, the treatment needed is specific to the individual's needs based on that patient's symptoms. The CDC (2011) lists the following types of medical specialists that might be involved

• Pediatrician
• Primary care provider
• Dysmorphologist
• Otolaryngologist
• Audiologist
• Immunologist
• Neurologist
• Mental health professionals (child psychiatrist and school psychologist, behavior management specialist, and psychologist)
• Opthalmologist
• Plastic surgeon
• Endocrinologist
• Gastroenterologist
• Nutritionist
• Geneticist
• Speech-language pathologist
• Occupational therapist
• Physical therapist

Medication

The DSM-5 states that there are no medications approved to treat ND-PAE specifically or other FASDs. However, several medications might help improve some of the symptoms associated with ND-PAE and other FASDs. Some examples include stimulants, antidepressants, neuroleptics, and anti-anxiety drugs.

Behavior and Education Therapy

According to the CDC (2011), behavior and education therapy perform important functions as part of treating children with ND-PAE. There are substantial venues of support for persons with ND-PAE developmental disabilities; however, research supports the effectiveness of only a few specific to children with ND-PAE. The DSM-5 lists the following behavior and education therapies that have been proven to be effective according to research:

Friendship training—For many children with ND-PAE, making and keeping friends and socializing with others in general is difficult. Friendship training instructs children with ND-PAE how to interact appropriately with friends, how to enter a group of children already at play, how to coordinate and handle in-home play dates, and how to avoid and work through conflicts.

Specialized math tutoring—This treatment method offers specialized teaching strategies and tools to help the child with ND-PEA be more successful at math.

Executive functioning training—Executive functioning teaches behavioral awareness and self-control, and it improves executive functioning skills, including memory, cause and effect, reasoning, planning, and problem solving.

Parent-child interaction therapy—Parent-child interaction therapy strives to improve the parent-child relationship create a positive discipline program and reduce behavior problems in children with ND-PAE. Parents acquire new skills from a coach.

Parenting and behavior management training—This behavioral and learning management therapy provides comfort to caregivers, helps to meet the family's needs, and develops strategies that reduce problem behaviors of the child.

Parent Training

Traditional parenting practices might not be effective for children with ND-PAE. Parent training therapy teaches parents about their child's disability and gives them various ways to work efficiently with their child. This therapy exists in both group situations or with individual families. Programs offering Parent Training specialize in the following:

• Concentrate on the child's strengths and talents
• Accept the child's limitations
• Be consistent with everything (discipline, school, behaviors)
• Use concrete language and examples
• Use stable routines that do not change daily
• Keep it simple
• Be specific—say exactly what one intends
• Structure your child's world to provide a foundation for daily living
• Use positive reinforcement often (praise, incentives)
• Supervise: friends, visits, and routines
• Repeat, repeat, repeat

Alternative Approaches

As with any medical condition, injury, or disability, periodically untested treatments enter the discussion through informal networks. The DSM5 identifies such therapies as alternative treatments. The child's doctor should be consulted before commencing any alternative treatment. Some of the alternative treatments used by persons with ND-PAE and other FASDs include:

• Biofeedback
• Auditory training
• Relaxation therapy, visual imagery, and meditation (especially for sleep problems and anxiety)
• Creative art therapy
• Yoga and exercise
• Acupuncture and acupressure
• Massage, Reiki, and energy healing
• Vitamins, herbal supplements, and homeopathy
• Animal-assisted therapy

References

Alcoholism: Clinical & Experimental Research. (2010). Creating a preliminary neurobehavioral profile of fetal alcohol spectrum disorders. Retrieved from http://www.sciencedaily.com/releases/2010/06/100621173725.htm

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Brown, N. N., Grant, T., & Clarren, S. (2014). Fetal Alcohol Spectrum Disorders: What judges and other legal professionals need to know. Retrieved from http://www.casaforchildren.org/site/c.mtJSJ7MPIsE/b.8968411/k.629D/JP2_Brown_Clarren_Grant.htm

Centers for Disease Control and Prevention. (2011). Fetal Alcohol Spectrum Disorders (FASDs). Retrieved from http://www.cdc.gov/ncbddd/fasd/facts.html

Rich, S., & Brown, N. N. (2013). New DSM code should benefit clinicians, researchers. Psychiatric News. doi: 10.1176/appi.pn.2013.11a18

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