IMAGINE THE POSSIBILITIESNew Study Documents Differences Between ADHD and FAS
by Jocie DeVries
(reprint from FAS Family Resource Institute newsletter F.A.S. Times)
A few months ago I asked my husband, Don, how he would describe the difference between the disability behaviors of our son, Rusty (who has FAS) and our daughter, Loree (who has attention deficit/hyperactivity disorder, ADHD). Don looked at me with a quizzical expression and said, "Well, they aren't anything alike; what prompted you to ask such a question?"
I explained that often times service providers at our trainings and policy makers in the legislature ask us what the difference is between FAS/E and ADHD. "I agree with you," I continued, "that it's not the same at all; but how would you describe the difference?"
After pondering the question for awhile he said, "Well, with ADHD, a person is very impulsive and without forethought; they jump into all kinds of situations. A while later they start thinking about it and realize what they did wasn't a very good idea. They can go back and think through whatever problems developed because of their impulsivity. With FAS, they do things impulsively but on their own they can't go back and figure out the situation. For example, remember how we finally figured out that Loree's (ADHD) mind runs double speed? It was so clear after she got her license to drive and we had to ride with her. Riding with her made us crazy because our minds don't process things as fast as Loree's mind does. She went as fast as possible and almost tailgated the car in front of her. She was impatient and thought everyone else was going too slowly. Eventually, Loree was able to recognize the potential for danger and subsequently developed coping skills for her hyperactive driving.
"However Rusty's FAS caused him to process information very slowly or not at all. Remember the time that Rusty threw a water balloon and hit the Metro bus? The noise startled the driver enough to cause a collision with a General Telephone truck. Even though Rusty was arrested by the police for "wreckless endangerment" he was incapable of reasoning out the situation on his own. The problem was not that his mind was 'racing;' his mind never did figure out that his behavior caused the bus accident! Loree is impulsive but in developmental thought processes, she's an adult. Rusty is legally an adult but the characteristics of FAS leave him without the mental capacity to sort through, reason out and take responsibility for his behavior."
However, the public discussion about distinguishing between ADHD and FAS/E continues because these differences have not been documented. This issue is critical because it is only through understanding the diagnosis (or dual diagnoses) that we are able to determine appropriate expectations and treatment directions.
Currently, many parents claim that professionals usually have an 18 month learning curve before they "get the picture" and begin to understand children with FAS/E and their families. One of the primary goals of the FAS Family Resource Institute has been to offer education, information and intervention tools to service providers so that this learning curve can be shortened and appropriate crisis intervention plans can be implemented. We are excited about the promise and possibilities of a new study which documents the differences between FAS/E and ADHD.
In the February, 1997 issue of Alcoholism: Clinical and Experimental Research, we discovered a very interesting article, "A Comparison of Children Affected by Prenatal Alcohol Exposure and Attention Deficit, Hyperactivity Disorder." 1 Researchers involved in this study asked the same question that parents, service providers and state legislators have been asking us, is ADHD a primary behavioral symptom of FAS/E or are they both independent diagnoses which can coexist?
The article begins by explaining that there are a lot of different "behaviors" that are called attention problems. The study started with the idea that there are two ways to measure attention functioning:
- There is the traditional method using clinical judgment and observational measures and checklists which describe behavior, commonly used for the diagnosis of ADHD. The problem with this method is that the same types of observable behaviors can have many different causes, not just attentional difficulties;
- But there is also a model of attention assessment developed by Mr. Mirsky and his colleagues2 which is based on four factors: the ability to focus, the ability for sustained concentration, the ability to encode (involving sequential memory and learning) and the ability to shift from one subject to another without undue stress.
The authors state, "In the development of this model, neuro- psychological tests have been used to measure these four aspects of attention. The advantage of examining attention in this way is that it provides a method to discriminate different functions underlying the child's behavior and performance and, therefore, may help in refining treatment and educational interventions. If children with a diagnosis of FAS or evidence of other alcohol effects are more impacted in specific brain areas, ...certain neuropsychological measures [would be] performed less well. If these functions can be identified, deficits characteristic of alcohol exposure may be specified."
The result of the study confirms the personal experience that we had with our three adopted children and their respective diagnoses, as well as the collective experience of parents who call the crisis and referral line at the FAS Family Resource Institute. That is, that FAS and ADHD are independent diagnoses which can coexist. The study suggests that alcohol-affected children do not have the same neurocognitive and behavioral characteristics as children with a primary diagnosis of ADHD.
Personally, I found it fascinating that the researchers discovered that children with FAS did not perform as well on "encoding" as the children with ADHD because that was the characteristic that Don had been describing. The article concluded by stating that both children with FAS and children with ADHD are equally impaired intellectually but there is "little similarity in their pattern of responses." The authors concluded: "children with ADHD are best identified by:
whereas those with FAS appear to have deficits in:
- behavior checklists and
- measures of the ability to focus and sustain attention,
The authors also state that "the ADHD-diagnosed children in this study were responsive to Ritalin.... It appears that, when their attention is focused, such children perform relatively well on the encoding dimension... In contrast, children with FAS/FAE [who did not have the dual diagnosis of ADHD] were able to focus and maintain their attention very well [very true of Rusty in a small self-contained classroom] but were not able to encode the information they attended to or to use new information meaningfully in problem solving."
- visual/spatial skills,
- encoding of information
- flexibility in problem solving" [emphasis mine]
This study is exciting for several reasons: First, it may provide information to parents and service providers as to why medications are helpful to some children and not to others. For example, a child may have FAS/E disabilities and ADHD. Medication would help the child focus but not necessarily help them reason better.
Secondly, for years we parents have wanted a behavioral assessment tool that would be sensitive enough to distinguish between FAS/E and other behavioral disorders such as attachment disorders, ADHD or Post-Traumatic Stress. Many parents understand the difference because like Don and me, they adopted children who had all of the above, and it is agonizing to have to go through months and years of therapy with each new social worker or psychologist before they "get the picture." This study may truly be the light at the end of the tunnel. Imagine the possibilities if researchers could "prove" neurological disabilities in individuals without dysmorphic facial features.
Finally, Mirsky's model of evaluating attention may be an effective method of documenting disability in children with FAS/E. This could provide a new avenue of eligibility for services which currently rely only on IQ scores.
We are pleased that researchers are now documenting what parents have known for a long time. There are even signs that parents may play an increasing role in future research projects! Some professionals have learned to "listen to the mothers" as described in the article on page 4. Parents have had very positive support from certain professionals, but we have a long way to go with others. So we keep on educating.
1 "A Comparison of Children Affected by Prenatal Alcohol Exposure and Attention Deficit, Hyperactivity Disorder" by Claire D. Coles, Kathleen A. Platzman, Cheryl L. Raskind-Hood, Ronald T. Brown, Arthur Falek, and Iris E. Smith (pages 150-152, 159, 160). Reprint requests may be addressed to: Claire D. Coles, Ph.D. Human and Behavior Genetics Laboratory, Georgia Mental Health Institute, 1256 Briarcliff Road, NE, Atlanta, Georgia. 30306
2 Mirsky AF, in Integrated Theory and Practice in Clinical Neuropsychology, Hillsdale NJ, Lawrence Erlbaum Associates, 1989.
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