What is ND-PAE and how is it Related to FASD?

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The DSM-5 was released in May 2013 and with it came a revision of criteria for the diagnosis and classification of many psychiatric disorders.  Among them a new proposed criteria was included relevant to alcohol related deficits in children, which is Neurobehavioral Disorder Associated  With Prenatal Alcohol Exposure (ND-PAE) (DSM-5, pgs 798-801). This proposed criteria was included in order to better serve the complex mental health needs of individuals diagnosed with alcohol related deficits, which the previous diagnosis of 760.71 – Alcohol affecting fetus or newborn via placenta or breast milk was unable to adequately capture.  

In contrast, ND-PAE “is a new clarifying term, intended to encompass the full range of developmental disabilities associated with exposure to alcohol in utero.” ND-PAE can be diagnosed “both in the absence and in the presence of the physical effects of prenatal alcohol exposure” (pg. 799). In other words, the child doesn’t have to have FAS dysmorphology (facial features) to qualify for the ND-PAE diagnosis. The idea behind the introduction of ND-PAE was to improve the treatment options (e.g., pharmacological, behavioral, etc) available to individuals with alcohol related deficits.

Proposed Diagnostic Criteria:

Characterized by childhood onset with significant impairment in a variety of domains (e.g., social, academic, etc), which are not due to other medical genetic, and acquired conditions or postnatal neglect (differential diagnosis), it encompasses the following:

A. Exposure to alcohol during gestation (including even before pregnancy) based on

  • Maternal self-report of alcohol use in pregnancy
  • Review/access to various records (e.g., medical, court, etc)
  • Clinical observations

B. Impaired neurocognitive functioning as evidenced via any of the following:

  • Intellectual disability (IQ <70)
  • Poor executive function skills
  • Learning disability
  • Memory impairment
  • Visual spatial impairment

C. Self-regulation deficits as evidenced via any of the following:

  • Mood/behavior disorder
  • Attention deficits
  • Poor impulse control

D. Adaptive functioning impairment (*must have either 1 or 2)

  • Communication impairment (delayed/impaired language)*
  • Social pragmatic language impairment (impaired social skills)*
  • Difficulty managing activities of daily living
  • Impaired motor skills

 

While DSM-5 asserts that ND-PAE can be diagnosed  “regardless of socioeconomic or cultural backgrounds” (p.799) the Associated supporting features for ND-PAE diagnosis include

  • Children with known parental alcohol/substance  abuse (past/present)
  • Children with parental mental illness
  • Children with known exposure to domestic or community violence, neglect or abuse
  • Children with disrupted caregiver experiences
  • Children with multiple out-of-home placements

Comorbidity 

Psychiatric difficulties have been identified in more than 90% of individuals with histories of significant prenatal alcohol exposure” (pg. 800) with common co-occuring conditions being:

  • ADHD
  • Oppositional defiant disorder
  • Conduct disorder

However, the DSM-5 questions “the appropriateness of these diagnoses” in view of “significant impairments in general intellectual and executive functioning that are often associated with prenatal alcohol exposure” (pg. 800-801). Other co-occuring conditions include mood disorders such as bipolar and depressive disorders. Furthermore, children with  ND-PAE at at significant increased risk for “later tobacco, alcohol, and substance use disorders”(pg. 801).

Functional Consequences of ND-PAE

  • Lifelong consequences” including
    • Disrupted school experiences
    • Employment difficulties
    • Legal difficulties
    • Incarceration and/or psychiatric hospitalization
    • Dependent living conditions

So what does this all mean?

ND-PAE  is currently NOT an official psychiatric disorder with its own ICD-9 code. Rather it is listed in Section III of the DSM-5 which lists conditions on which future research is encouraged in order to better understand them and potentially officially include them in future editions of the DSM.  Thus the ND-PAE criteria is currently not intended for clinical use. However, clinicians can use the ICD-9 code: 315.8 (ICD-10 code F88) – “Other Specified Neurodevelopmental Disorder” (DSM-5, pg. 86) by citing specific reasons in support of diagnosis of prenatal alcohol exposure.

Why is ND-PAE important?

Individuals impacted by alcohol related deficits are notoriously underserved when it comes to  access to specialized multidisciplinary professionals trained in diagnosing and treating alcohol related deficits. This results in the lack of the following:

  • Receipt of comprehensive multidisciplinary assessments
  • Receipt of necessary therapies
  • Recognition of deficits in the school and community 
  • School and community based advocacy
  • Transitional support for independent living 
  • Appropriate mental health services for co-morbid conditions 

By including the ND-PAE  in the manual, the DSM-5 is “recognizing” its importance and is attempting “to stimulate future research” (pg. 732). It is also sending an important message to both the public (by acknowledging it) and the scientific community (by asking for more research to support it) that individuals with alcohol related disabilities deserve to receive appropriate treatment services in order to attain their maximum potential.   Hopefully, the inclusion of ND-PAE in the DSM-5 will ultimately lead to qualitative life changes of individuals living with FAS and their families. 

What do you think about the inclusion of proposed criteria for ND-PAE  in the DSM-5? Please share your opinions in the comments section below.

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). Washington, DC: Author.

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