ND-PAE Differential Diagnoses and Co-Occurring Diagnoses

Differential Diagnosis

The diagnosis of ND-PAE encompasses the behavioral, developmental, and mental health aspects of FASDs.  Other FASD diagnoses, such as Fetal Alcohol Syndrome or Partial Fetal Alcohol Syndrome, include structural CNS abnormalities, physical features (e.g. cardinal facial dysmorphia, growth restrictions).  For children with both physical findings and neurodevelopmental findings, it is appropriate that a child be diagnosed with both ND-PAE and Fetal Alcohol Syndrome.

The DSM-5 task force established ND-PAE diagnostic criteria. View resources to assist in working with an individual and applying the diagnosis of Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure (ND-PAE).

Symptoms associated with the diagnostic criteria of ND-PAE may be observed in children with other disabilities. The diagnosis must be applied with care using all available information, especially with the prerequisite of a history of prenatal exposure to alcohol. View the specific criteria in Differential Diagnosis for ND-PAE that differentiates ND-PAE from other conditions (Autism Spectrum Disorder, ADHD, Global Development/intellectual Disability, Bipolar Disorder, and PTSD).

Differential diagnoses can be particularly challenging since the disorder does not always present the same way in all children due to differences in timing and amount of prenatal alcohol exposure as well as differences in genetic predispositions or postnatal environment.

There are three age-dependent neurocognitive domains of ND-PAE impairment: Neurocognition, Self-regulation, and Adaptive function. View ND-PAE Age Dependent Symptom Diagnosis Guidelines.

Co-occurring Mental Health Conditions

Fetal alcohol exposure damages the developing brain and may result in a variety of problem behaviors. Individuals with an FASD may also be diagnosed with co-occurring mental health conditions that are in fact, symptoms of their congenital neurodevelopmental disorder. A few examples are given below.

ADHD

Many children with an FASD present with short attention spans and are easily distracted. Attention deficits in children with an FASD derive from deficiencies in executive functioning, short-term memory, information encoding, the ability to shift attention flexibly, and arousal dysfunction, with slower gating of incoming stimulation and reduced capacity to inhibit attention to distracting stimuli.

Children with attention problems that are associated with ND-PAE have difficulty in shifting attention and encoding information they are attending to whereas children with attention problems not associated with ND-PAE have difficulty in establishing and maintaining attentions.

Neuropsychological testing may help determine a given child’s strengths and weaknesses in processing new stimuli.  Stimulant therapy may help with these symptoms, but efficacy will depend on the degree of neurologic compromise. <LINK to www. ABOUT FASDS/Health Supervision/Pharmocologic Interventions.>

View Differential Diagnosis for ND-PAE that delineates differences between ND-PAE and ADHD.

View AAP Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents

Anxiety and Emotional Dysregulation

Difficulties with disinhibition and adaptability combine in some children to produce symptoms of mood swings, often severe, and usually associated with a novel challenge, such as a change in schedule or parental discipline. Unless the caregivers are well prepared in advance, such situations may escalate to violence or property damage. Children may be diagnosed with Oppositional-Defiant Disorder or Conduct Disorder. Their disinhibition may be attributed to ADHD. Caregiver preparation and training, especially in techniques of de-escalation, can help. Mood stabilizing medication is occasionally used with FASD-related mood swings, but its efficacy has not been well studied in this population.

Depression

Children with ND-PAE may often have difficulty making and keeping friends and can withdraw from social interaction. This behavior, often characterized as depression, may in fact be symptomatic of the patient’s FASD-related difficulties in adaptability and communication. The patient with an FASD often has difficulty in “reading” social cues and responding appropriately, which when severe, can prompt concerns for an Autism Spectrum disorder.

Other Diagnoses

A host of other diagnostic terms may be used to describe aspects of the neurodevelopmental dysfunction associated with ND-PAE. Cognitive impairments can result in global or more specific learning disabilities such as Auditory Processing Disorders. Disinhibition and its associated hypersensitivity to stimulation may bring a diagnosis of Sensory Integration Disorder. Ongoing difficulties with caregivers may give rise to diagnoses of Reactive Attachment Disorder.

Screening for prenatal alcohol exposure should be part of a comprehensive diagnostic process for any child with behavioral symptoms.  If there is evidence of prenatal alcohol exposure, the child should be referred for neuropsychological testing to evaluate for an FASD. A child whose problems arise from an underlying brain injury are less resilient and require special care.

Trauma

Trauma is a common presence in children’s lives and is more so in those who have prenatal alcohol exposure. Adapting to a stressful world without sequelae is difficult, even with a fully functional brain. An individual with an FASD has permanent brain damage. A pre-existing neurodevelopmental condition such as ND-PAE may impair a child’s resilience in the face of trauma/toxic stress and magnify its consequences. The diagnosis of an FASD may help guide therapy because an individual may not be able to participate in usual age-appropriate trauma-related therapies because of developmental or cognitive challenges.

It is important to remember that early trauma is common and is often shared across generations. Adult caregivers as well as children may suffer its long-term effects. An awareness of these effects will assist practitioners in understanding and providing care for families.

Additional Information

• Trauma Informed Care and Resilience
• SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach
• Adverse Childhood Experiences (ACEs)
• Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician: Translating Developmental Science into Lifelong Health