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Section 13
The FASD and ADHD Link

Question 13 | Answer Booklet | Table of Contents

Clinical Implications.

• One implication of a link between fetal alcohol spectrum disorder (FASD) and attention-deficit hyperactivity disorder (ADHD) is that the ADHD is an earlier-onset, inattention subtype, with comorbid developmental, psychiatric, and medical conditions.
• There may also be a differential response to standard psychostimulants.
• Appropriate interventions can decrease the occurrence of well-described secondary disabilities that impede lifelong functioning.

FASD and ADHD Link
The proposed link between FASD and ADHD is based on the premise that the teratogenic effects of prenatal alcohol exposure disturb the neurochemical and structural environment of the developing fetal brain. Affected infants can have difficulty with mood and state regulation and self-soothing, as well as hypersensitivity to sensory stimuli, irritability, and hyperactivity. Infants exposed to prenatal alcohol can thus present a primary regulatory disorder from birth, with a difficult-to-settle or slow-to-warm temperament, followed by early-onset ADHD. Some of these clinical symptoms were initially shown in the Seattle Longitudinal Prospective Study, which described neonates at days 1 and 2. The study, which began in 1974, described infant problems in state regulation and habituation, as well as poor suck and long latency to suck.

Discussion
It is important to remember that there may be no link between FASD and ADHD. ADHD is a common condition, and adults with ADHD are more likely to drink and thereby pass the disorder on to their infants through genetic transmission. Nevertheless, the early onset, CNS dysfunction, complex learning disability, atypical medication response, and complicated psychiatric and medical comorbidity have many implications for management that distinguish children with FASD and ADHD from children with ADHD alone.

The implications of this possible link between FASD and ADHD have some practical consequences for clinical management. Patients often present with early-onset ADHD resulting from prenatal brain damage, and their reactions to medication are unpredictable. Thus, medication may sometimes increase a patient's impulsivity or aggressiveness, and an increase in the dosage may actually worsen the clinical situation, rather than alleviating it. Stimulant medication for children with FASD and ADHD should be considered as part of a multimodal treatment array. Ideally, management will include various treatment modalities, such as sensory integration, language therapy, special schooling, nonverbal play therapy, medication therapy, parent education, and supportive family therapy. Multimodal treatment to manage childhood ADHD has been recommended by the MTA Cooperative Group and the American Academy of Pediatrics. One study has indicated that it is unwise to use stimulants to help children cope with an unsafe environment, because ADHD high arousal-vigilance may have a protective role for the child in this environment. Therefore, removal of the ADHD symptoms may potentially decrease the child's wariness and so increase the risk of abuse.

The clinical presentation of ADHD in children with FASD is commonly seen with such comorbid developmental, psychiatric, and medical conditions. The complex learning disability in children with FASD can include an unrecognized mixed receptive-expressive language disorder that affects their social cognition and social communication. Children with FASD and ADHD are commonly quite talkative, and their lack of cognitive understanding, with inappropriate answers, can frequently be misdiagnosed as an oppositional defiant disorder. Commonly, the child will also show problems in working memory. A mathematics disorder is frequently seen, which may underpin an executive-function deficit in deductive reasoning. Thus, children with FASD often do not link cause and effect or respond to standard behavioural-management techniques. Judgement and self-awareness are also suspect, not just in childhood but throughout the lifespan. Morphological changes in the corpus callosum have been tied to the FASD complex learning disability.

The psychiatric comorbid disorders include; anxiety disorder (with panic attacks), mood disorder or affective instability, conduct disorder, psychotic disorder, and intermittent explosive disorder. Finally, comorbid medical conditions such as cardiac, renal, eye, or skeletal problems are often present and warrant specific interventions. Sometimes as well, there may be a complex partial or absence seizure disorder.
- O'Malley, Kieran D, Nanson, Jo; Clinical Implications of a Link Between Fetal Alcohol Spectrum Disorder and Attention-Deficit Hyperactivity Disorder; Canadian Journal of Psychiatry; May2002, Vol. 47, Issue 4

Personal Reflection Exercise #6
The preceding section contained information regarding a proposed link of ADHD to FASD. Write three case study examples regarding how you might use the content of this section in your practice.
Reviewed 2023

Update
Heated Behaviour in the Classroom for Children with FASD:
The Relationship between Characteristics Associated with ADHD,
ODD and ASD, Hot Executive Function and Classroom Based Reward Systems

- Carrick, A., & Hamilton, C. J. (2023). Heated Behaviour in the Classroom for Children with FASD: The Relationship between Characteristics Associated with ADHD, ODD and ASD, Hot Executive Function and Classroom Based Reward Systems. Children (Basel, Switzerland), 10(4), 685. https://doi.org/10.3390/children10040685

Peer-Reviewed Journal Article References:
Key, K. D., Ceremony, H. N., & Vaughn, A. A. (2019). Testing two models of stigma for birth mothers of a child with fetal alcohol spectrum disorder. Stigma and Health, 4(2), 196–203.

Keith, D. R., Skelly, J., Tang, K. J., Kurti, A. N., & Higgins, S. T. (2021). Household-smoking bans are associated with reduced nicotine exposure, increased smoking abstinence, and improved birth outcomes among pregnant women enrolled in smoking-cessation treatment. Experimental and Clinical Psychopharmacology, 29(4), 366–374.

Young, I. F., Sullivan, D., & Hamann, H. A. (2020). Abortions due to the Zika virus versus fetal alcohol syndrome: Attributions and willingness to help. Stigma and Health, 5(3), 304–314.

QUESTION 13
Why are children with FASD and ADHD frequently misdiagnosed as having an oppositional defiant disorder? To select and enter your answer go to Answer Booklet.