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AAP researchers release guidelines on new pediatric neurobehavioral disorder

Researchers associated with the AAP have published in Pediatrics guidelines for the diagnosis and management of the newly proposed mental diagnosis neurobehavioral disorder associated with prenatal alcohol exposure.

They grouped neurobehavioral disorder associated with prenatal alcohol exposure (ND-PAE) under the umbrella of fetal alcohol spectrum disorders (FASD), which also includes fetal alcohol syndrome (FAS), partial FAS and alcohol-related birth defects.

Basis of diagnostic criteria

The CDC reported that 10.2% of pregnant women consumed alcohol within the last 30 days and 3.1% reported binge drinking. Recent studies estimated that between 2% and 5% of school-aged children in the U.S. have FASD and that most of these children are not diagnosed. In addition, only 25% of children affected by alcohol exposure alcohol in utero show physical features of FASD. As a result, in 2011, the National Institute on Alcohol Abuse and Alcoholism and the CDC organized a group of researchers to evaluate the FASDs that lack physical features. They found that the three main features that affected this population were neuro-cognition, self-regulation and adaptive functioning. These features then formed the basis of the ND-PAE diagnostic criteria.

Diagnosis

Diagnosis of ND-PAE is appropriate if a child presents with impairment in neuro-cognition, impaired self-regulation, two impairments of adaptive functioning and a history of more than minimal exposure to alcohol in utero, as long as the disorder is not explained by other factors, such as genetic or teratogenic syndrome, according to Joseph H. Hagan Jr., MD, in the department of pediatrics at the University of Vermont College of Medicine, and colleagues. More than minimal exposure to alcohol was defined as at least 13 drinks per month during any month of pregnancy.

Neurocognitive impairment includes either global impairment, executive dysfunction, deficits in learning, memory problems or trouble with visual-spatial reasoning. These criteria can be assessed by standardized testing, clinical observation or clinical history. Approximately 86% of individuals with FASDs have an IQ in the low average or borderline ranges.

Self-regulation impairment includes difficulty regulating mood or behavior, attention deficits or poor impulse control. Early signs of mood and behavior regulation problems include sleep issues or severe reactions to discomfort for infants, extended tantrums for toddlers and increased incidence of externalizing behaviors as well as severe reactions to stress for older children.

Adaptive functioning impairment can occur either in communication, social communication and interaction, daily living skills or motor skills for very young children. Children might show difficulty in understanding figurative language — idioms, jokes or sarcasm — and social communication conventions, such as how to effectively enter a conversation. Socially, they can be overly friendly with strangers and have difficult learning social rules through experience — eg, how to join a group on the playground — placing them at high risk for bullying and being manipulated by others. While a child with ND-PAE might learn hygiene or house rules, maintaining those skills is a challenge. In addition, their motor skills are impaired at the fine motor level, such as writing, or gross motor level such as coordination and balance.

Differential diagnosis of ND-PAE is difficult because the disorder does not always present the same way in each child. For instance, comorbid conditions in a sample of children included mental retardation, sleep abnormalities, reactive attachment disorder, anxiety, PTSD, oppositional defiant disorder, language disorder, learning disability, depression, bipolar disorder, some features of autism and certain phobias. In addition, other conditions of enuresis, encopresis and eating disorders may be present depending on age.

Management of ND-PAE

Specific and targeted early interventions have shown to be the most effective for management of ND-PAE, while general special education and support services have also been shown to improve outcomes. Further, no medications have been indicated for ND-PAE.

For infants or preschoolers, early intervention might focus on general developmental skills. Occupational therapy is recommended for fine motor impairments, sensory integration issues and self-regulation problems. For older school-aged children, traditional mental health services and modified insight-based therapies can help. For the medical home provider, the most effective strategy is to provide the strengths and weakness of a child with ND-PAE in addition to symptoms when making a referral to mental health services.

“It often helps to explain to parents that structural brain abnormalities and the resulting neurobehavioral manifestations their child has might make him or her less responsive to pharmacotherapy than other children with a developmental disability,” the researchers wrote. “It is especially helpful for the clinician to explain that the vulnerabilities of a child with ND-PAE might not be readily recognizable by others. For example, the child’s good structural language skills and friendly nature can give a false impression of competence, and forgetting previously learned material might give a false impression of a defiant or oppositional disorder.” – by Will Offit

Disclosure: The researchers report no relevant financial disclosures.