1. DSM-5 Update CIFASD Julie A. Kable, Ph.D. Assistant Professor
Department of Psychiatry and Behavioral Sciences,
Emory University School of Medicine
Atlanta, GA

2. ICCFASD Diagnostic Issues Work Group DSM-5 Revision Subcommittee (Originated 2010)
Mary O'Connor (U. California at Los Angeles)
Julie Kable  (Emory University)
Heather Carmichael Olson (U. of Washington)
Sarah Mattson (San Diego State University)
Blair Paley (U. California at Los Angeles)
Edward Riley (San Diego State University)
Sally Anderson (NIAAA, NIH)
Kenneth R. Warren (NIAAA,NIH)
Special thanks to Bridget Grant

3. Why was a DSM-5 Diagnosis needed for individuals with an FASD?
There was no specific mental health code that adequately documents the cognitive and mental health impact of PAE
Intellectual Deficiency
Cognitive impairment, NOS
Unspecified emotional and behavioral disturbance
ADD-ADHD
The existing diagnostic codes (760.71) do not adequately capture their mental health needs)
Children with FASD may not respond to treatment regimens developed using the existing codes similarly, which may lead to inappropriate treatments
When seeking mental health care (assessments or interventions), providers and families often struggle with obtaining appropriate reimbursement for habilitative care

4. DSM-5 Released May 2013
Need to advance the science so it is accepted completely as a disorder and receives its own unique code
Pages

5. Classical Criteria for Psychiatric Diagnosis (Blashfield & Draguns, 1976)
Predictive validity-refers to the category being able to effectively predict the individual’s responsiveness to different treatments.
Coverage-the criteria being able to capture all individuals with the condition
Descriptive validity-refers to the homogeneity within the symptom categories but not necessarily across the symptom categories/domains
Reliability-see the same child/information and the diagnosis is made consistently by different clinicians
Team reports and independently reviewing by clinicians to get an estimate of reliability in making the diagnosis
Compare experienced vs non-experienced (related to FASD) mental health professionals in making the diagnosis

6. Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
Symptoms
History of More than Minimal Levels of PAE*
Domain: Neurocognitive Impairment
Global IQ (IQ < 70)
Executive function impairment
Learning impairment
Memory impairment
Visual spatial reasoning impairment
Domain: Impairment in Self-regulation
Impairment in mood or behavioral regulation
Attention deficits
Impairment in impulse control
Domain:
Deficits in Adaptive Functioning Skills
Communication deficit
Social impairment
Daily living skills impairment
Motor impairment
ND-PAE
* >13 drinks per month or more than 2 on one occasion

7. Latent TRAIT OF DISEASE SEVERITY
ND-PAE Disease Severity
No Symptoms
Extreme Symptoms
Individuals with a history of PAE are anticipated to have variability in ND-PAE symptomatology allowing for a comparison of cohesiveness and necessity of each item to identify the latent trait of disorder severity.

8. Symptom Mapping
This involves delineating how to positively endorse symptoms (code yes or no)
In a clinical context, symptoms are either present or absent based on history or data available from standardized testing
Existing databases can be used to assess the validity of the diagnosis with test results and data serving as symptom indicators
Deciding what the threshold is for clinical significance?
2.0 STD Units-probably too restrictive
1.5 STD Units
1.0 STD Units
Is the more restrictive criteria for adaptive functioning deficits needed?
AF 2 of 4- Need two symptoms with one from social or communication adaptive deficits
AF-1- Only need one symptom with no restrictions on which one
AF 2 of 4
AF 1
1.0 Cut-off
Model 1
Model 3
1.5 Cut-off
Model 2
Model 4

9. DAS IQ
KBIT COMPOSITE
CBCL Attention
Medical Dx or ADHD medications

10. % Positive Endorseme nt (1.5 SD) % Positive Endorseme nt (1.0 SD)
Domain
Symptom
Specific Measure n
% Positive Endorseme nt (1.5 SD)
% Positive Endorseme nt (1.0 SD)
Neurocognitive
Global Intellectual Functioning
DAS: GCA 56
21.4
K_BIT Composite 55
18.2
Executive Functioning
BRIEF Metacognitive Index
51.8
60.7
Impairment In Learning
TEMA SS
25.0
53.6
KEYMATH TOTAL SS 42
19.0
47.6
TERA SS
35.7
48.2
Receiving SPEC Ed 48
68.8
Has An IEP 47
72.3
Repeated a grade 45
31.1
Impairment In Memory
WISC_3 Letter Span
16.1
32.1
WISC-3 Spatial Span Total
19.6
33.9
WISC-3 Spatial Span Forward
WISC-3 Spatial Span Backwards
30.4
WIII-Auditory Working Memory
5.5
23.6
Impairment In Visual-Spatial Reasoning
K-BIT Matrices
41.8
Visual SS from VMI
41.1
57.1
DAS: Nonverbal
28.6
55.4
DAS: Spatial
WJIII-Spatial Relations
10.9
25.5
WJIII-Visual Matching
29.1
34.5

11. Specific Symptom Endorsement
Domain
Specific Symptom
% Positive Endorsement (1.5 SD)
% Positive Endorsement (1.0 SD)
Neurocognitive
Global Intellectual Functioning
26.8
Executive Functioning
51.8
60.7
Impairment In Learning
80.4
87.5
Impairment In Memory
33.9
Impairment In Visual-Spatial Reasoning
64.3
83.9
Self-Regulation
Impairment In Mood and Behavioral Regulation
85.7
89.3
Attention Deficit
82.1
92.9
Impairment In Impulse Control
69.6
76.8
Adaptive Functioning
Adaptive Communication Deficit
55.4
71.4
Adaptive Social Impairment
Adaptive Impairment In Daily Living
48.2
73.2
Adaptive Motor Impairment
53.6

12. Overall Domain and Diagnostic Endorsement
Breadth of coverage is good but not when 1. 5 cut-of used with 2 of 4 AF symptoms
Overall Domain and Diagnostic Endorsement
% Positive Endorsement (1.5 SD)
% Positive Endorsement (1.0 SD)
Neurocognitive
1 symptom
92.9
96.4
Self-Regulation
94.6
Adaptive Functioning
83.9
2 of 4 symptom
60.7
85.7
ND-PAE Diagnosis
3 Symptoms (1 AF)
82.1
89.3
3 Symptoms (2 of 4 AF)

13. IntERNAL Consistency of 12 Symptoms-CronBACH’s ALphA

14. Table 6. Equality of Group Means between Those Diagnosed or Not
Symptom
Threshold Symptoms (AF1) Test- Statistic
Threshold 1.5 Symptoms (AF2 of 4) Test-Statistic
Threshold 1.0 Symptoms (AF1) Test- Statistic
Threshold 1.0 Symptoms (AF2 of 4) Test-Statistic
NI_1
F (1,54)=4.67, p < .035
F (1,54)=10.5, p < .002
F (1,54)=2.5, p < .12
F (1,54)=4.1, p < .049
NI_2
F (1,54)=9.68, p < .003
F (1,54)=6.2, p < .016
F (1,54)=2.1, p < .15
F (1,54)=7.3, p < .009
NI_3
F (1,54)=7.85, p < .007
F (1,54)=1.3, p < .256
F (1,54)=2.7, p < .11
F (1,54)=0.9, p < .345
NI_4
F (1,54)=6.79, p < .012
F (1,54)=11.7, p < .001
F (1,54)=0.9, p < .347
F (1,54)=3.9, p < .054
NI_5
F (1,54)=6.76, p < .012
F (1,54)=9.8, p < .003
F (1,54)=15.9, p < .000
F (1,54)=15.3, p < .000
SR_1
F (1,54)=2.48, p < .121
F (1,54)=13.0, p < .001
SR_2
F (1,54)=9.76, p < .003
F (1,54)=5.1, p < .028
F (1,54)=7.7, p < .008
F (1,54)=3.8, p < .057
SR_3
F (1,54)=0.52, p < .473
F (1,54)=0.35, p < .852
F (1,54)=2.7, p < .104
F (1,54)=2.7, p < .103
AF_1
F (1,54)=11.93, p < .001
F (1,54)=68.9, p < .000
F (1,54)=23.1, p < .000
F (1,54)=8.5, p < .005
AF_2
F (1,54)=20.90, p < .000
F (1,54)=34.0, p < .000
F (1,54)=13.1, p < .001
F (1,54)=47.6, p < .000
AF_3
F (1,54)=7.87, p < .007
F (1,54)=35.5, p < .000
F (1,54)=32.6, p < .000
AF_4
F (1,54)=3.18, p < .080
F (1,54)=4.2, p < .046
F (1,54)=8.7, p < .005

15. Receiver Operative Curve Area Under the Curve Analysis by Cut-off Values Used on Standardized Measures

16. Relationship of Sum of Symptoms to Participant Characteristics
The sum of symptoms was not different between males and females using both cut-off values but did differ by race with more symptoms reported for African American children when using the 1.0 SD cut-off value.
The number of symptoms was not related to the child’s level of dysmorphia, number of custody placements, child protective services involvement, years of education, and household income.
The number of symptoms was positively related to the child’s age for both cut-off values (1.5 SD: r=.37, p < .006; 1.0 SD: r=.42, p < .001).

17. Next STEPS
Assess these characteristics in a sample with a greater dispersion of ND-PAE –an exposure sample with PAE (CoFASP sample)
Assess the symptoms and diagnostic formulations relative to its ability to differentiate from typical controls and other neurodevelopmental and behavior disorders (CIFASD sample)