**3. A four domain clinical model**

A previously published model describes four domains of clinical functioning impacting an individual's adaptive functions. These domains may be scaffolded by family, school, therapeutic, or community supports to improve an individual's adaptive functions. The clinical presentation may manifest as a plethora of externalizing neurobehavioral symptoms masking intrinsic neurodevelopmental deficit. This model can help elucidate the domains of functional deficits to help scaffold the child, adolescent, or young adult with appropriate systems of care to reduce their sensory overstimulation, social pragmatic issues, and/or frustration from neurocognitive issues to minimize outbursts. For example, a child may be having mood outbursts or rage due to hypersensitivity to crowded places (school bus, classroom, playground, lunchroom), people (facial expressions, voice tone, body odor, etc.), sounds (sirens, TV, voice frequency or volume, screechy noises, chalkboard, etc.), smells (food odors, body odor, smoke, decaying trash, sewer, public bathroom, etc.) (**Figure 2**).

**Figure 2.** *Four domain model of neurodevelopmental issues.*

*Perspective Chapter: Autism Spectrum Disorder Neurophenotype with Preconceptional… DOI: http://dx.doi.org/10.5772/intechopen.108820*

### **3.1 Social communication (social intellect)**

Speech and language pragmatics, receptive and expressive language deficits, nonverbal cue recognition, facial expressions, body language, and a variety of other social communication issues can be affected by prenatal alcohol exposure. Social misperceptions, suspiciousness, feeling judged and scrutinized by peers, misunderstanding constructive criticism, personalizing negative comments, over-reacting to social slights are common consequences of the miswiring of neural networks important in social cognition. From an early age, social communication issues are tied to maladaptive attachment behaviors as the individual may lack a social smile, eye contact, and typical attachment behaviors. During early childhood and latency years, these deficits leave the individual vulnerable to social problems and negative peer interactions. By middle school, atypical social interactions leave the adolescent vulnerable to bullying and harassment by peers who misunderstand their social deficits and mood dysregulation or have outpaced them in their social and emotional functioning. Affected individuals' atypical reactions to social slights may cause social disenfranchisement and maladaptive peer interactions (e.g., friends' anger and/or hurt feelings, estrangement from social groups, fear responses in peers, etc.). Often, alexithymia (difficulty recognizing their own emotions and that of others) and poor social perceptions lead family and friends feeling they lack empathy and compassion. Socially awkward facial expressions and nonverbal cues may lead others (e.g., teachers, principals, administrators) to feel they are narcissistic, callous and unemotional. Because of lack of understanding social risk and subtleties of community safety, often these individuals are at risk of having predatory behavior perpetrated against them. Their social dysmaturity makes relationships with younger individuals feel more comfortable, which can lead to inappropriate interactions with peers.

#### **3.2 Neurocognitive (general intellect and executive functions)**

Only 10–15% of individuals affected by prenatal alcohol exposure have intellectual disability (IQ at or below 75 per DSM-5) according to research by the National Institutes on Alcohol Abuse and Alcoholism. Executive functioning issues (organization, planning, time management, working memory, problem solving, visual spatial planning, etc.) are more common sequelae of prenatal alcohol exposure, with attention deficits associated with as little as 1 drink per day or up to 7 drinks per week. Hyperactivity and impulsivity (failure to inhibit unwanted behaviors) lead the individual to be seen as willful and destructive, immature or dysmature, and unable to self-regulate at home, in the classroom, and in the community. These subtle yet important neurodevelopmental functions leave the individual prone to learning challenges, academic failure, vocational problems, and difficulties transitioning into young adulthood. Often, their faulty ego strength masks their challenges, leading to a sense of "false bravado." The resulting subconscious over-inflation of their strengths to hide their challenges can lead the individual to appear haughty, grandiose, narcissistic, and flamboyant. Faulty information processing combined with impulsivity, deficits in consequential thinking and understanding social risk may lead the individual to confabulate, steal, cheat, or be vulnerable to predatory behavior.

#### **3.3 Sensory and motor (sensorium and kinesthetic intellect)**

Our somatosensory, cranial nerves, and voluntary nervous systems are as intricately wired and vulnerable to the effects of prenatal alcohol exposure as our higherlevel brain functions. In fact, the midline brain defects linked to prenatal alcohol exposure from the neural crest cell migration all the way to development of the brain, cranial nerves, somatosensory and motor neurons can be affected by alcohol. Hence, hyper- and hyposensitivities to noise, texture, temperatures, and even interoceptive signals can lead to sensory integration issues. Interoceptive deficits can cause difficulty accurately perceiving signals from the digestive system (e.g., normal digestive sensations from peristalsis, gas, bloating, indigestion, stomach aches, hunger cues), rectum and bladder (defecation and urination signals). These interoceptive signaling issues often lead to emotional outbursts due to lack of understanding of the source of the discomfort and/or frustration/embarrassment due to voiding accidents. Children with interoceptive deficits may have delays in bowel and bladder control, nocturia, fecal smearing (caused by overflow incontinence), somatosensory complaints, and heightened stress response or mood dysregulation caused by hypersensitivities to environmental stimuli.

### **3.4 Emotional regulation (emotional quotient)**

Prenatal alcohol exposure affects the sympathetic and parasympathetic nervous system, leading to emotional dysregulation, autonomic arousal (fight or flight response), sleep–wake cycle disturbances, and a variety of mood problems. Often, affected individuals are irritable, easily frustrated, annoyed, and provoked into heightened stress response by facial expressions, sensory overstimulation, or unpreferred activities. Their emotional dysmaturity leads them to seem years younger than their chronological age, to revert to more primitive mood states during stressful situations, and to be overreactive to discomfort and distress. They are perceived as infants and toddlers as emotionally dysregulated, fussy, hyper-reactive, clingy, and easily fatigued.
