Q: My daughter has a diagnosis of RAD. She is adopted from another country and we have no access to her birth history. She has some of the symptoms of FAS but not enough to get a diagnosis. How can I tell if her behavior problems are due entirely to RAD or to brain damage from alcohol exposure? What symptoms are indicative of prenatal alcohol exposure in the absence of specific physiological symptoms? I can see that RAD could easily be a secondary disorder to FAS.

A: If birth history is not known, the following three criteria must be present to determine a diagnosis of FAS: low birth weight, certain facial characteristics, and evidence of central nervous symptom damage. Only about 10% of the FASD (Fetal Alcohol Spectrum Disorder) population can meet these three criteria. But all of them have significant neurological symptoms (brain damage - we might as well call it what it is).

RAD is occasionally seen among children with FASD. Although most kids with FASD do not have RAD, almost all of them have SOME attachment issues, such as being too friendly to strangers, and inappropriately affectionate.

I don't think anyone has formally determined if there are universal neurological symptoms for FASD, but in my opinion, most of the individuals with FASD that I know show many of the following "soft signs":

• Immature social/emotional development: friends are younger, shunned by peers of same age, overly friendly to strangers, no long-term healthy "best friend"
• Emotional lability: can't hide feelings, rollercoaster emotions, feelings are "out there"
• Poorly developed conscience: conscience development of a 6-year-old, lacks mature altruism, rather self-centered, lies to cover up mistakes
• Lack of consistent impulse control: sometimes can control impulse, sometimes cannot, more likely to control impulse in presence of an authority figure, sometimes there is a gap between thought and action
• Inability to learn from consequences: knows the rules, understands cause and effect, doesn't make the connection at the time of action, or doesn't remember the rules or consequences, or thinks "This time I might not get caught."
• Good expressive language skills: can talk the talk but can't walk the walk, verbal skills much better than writing skills, good articulation masks poor comprehension.
• Artistic: likely to have some unusual talent, even with poor fine motor skills, may be good artist, or excel in music, or be good in mechanics.
• Attention and short-term memory deficits: not always hyperactive, but cannot stay focused, easily distracted by external stimuli, can remember events from past but not rules from yesterday.
• Inappropriate social interactions: stands too close, stares, interrupts, forgets manners, cannot act as a true friend, cannot keep confidences, shares personal information, inappropriate sexual behavior.
• Difficulty managing money: spends paycheck right away, cannot plan or carry through with a monthly budget, cannot distinguish the value of $5,000 vs $500,000, makes extravegant purchases beyond means.
• Poor concept of time: difficulty keeping appointments, lives in the moment, forgets what happened yesterday; cannot plan well for the future.
• Grandiose ideas that they cannot attain: unrealistic life goals, unrealistic self-image, distorted view of themselves and the world.
• Poor judgment: difficulty making wise decisions, lack of common sense, inability to accurately assess risk factors.
• Vulnerability and naiveté: easily influenced or manipulated by others, impressionable, follows unhealthy leaders, cannot easily distinguish truth from lies, trusts without merit, may confess to crimes not committed.

All of the above set the individuals up to fail. They end up making the same mistakes again and again. They are the ones who are easily involved in wrongdoing and the first ones to get caught.

It is hard to prove that a person with the above symptoms truly has FASD without documentation of prenatal exposure, because there are other disorders in which the person might display the same symptoms. I guess in any case, if the symptoms are identified as factors that interfere with the individual's ability to function successfully in life, and the cause is acknowledged as neurological dysfunction, and the gaps between apparent intelligence and functional ability is recognized, then the cause is not as important as helping everyone understand and accept the nature of the person's disability, whatever the cause. Similar symptoms can occur with prolonged alcohol/drug use, RAD, Bipolar, etc. But based on my personal observations, I would say that if a person has 10 out of these 14, he or she probably has some degree of FASD.

These symptoms pertain mostly to teens and adults. They may become more evident as young children approach adolescence. For a child of 6, I would be looking for stunted social development (acts like a 3 year old), poor fine motor skills (cannot color in the lines), responds to music and rhythm, attaches to anyone (or no one), prefers to play with 3-4 year olds, has 2-year-old tantrums, cannot follow 2 or 3 step directions, etc. But if your daughter has a diagnosis of RAD, that is probably going to be the focus of treatment. It should be noted that there is a significant link between mental health disorders and prenatal exposure to alcohol. It is unfortunate that she suffers from a mental health disorder, but this does qualify for services in the mental health system. However, it should be noted by whoever is giving treatment or writing up plans or making decisions about her care that FASD is a possibility, and that if it is a case of RAD combined with FASD, they need to take that into consideration because treatment for only RAD might not be effective, and could even cause further problems. Some of her issues might stem from pre-placement trauma, but a lot of it could be due to brain damage before birth. FAS should be seen as the umbrella disorder from which ADHD, learning disorders, behavior disorders and attachment disorders all stem. Even if you cannot prove there was alcohol exposure, it only makes sense to assume it could be a possible cause.

Remember, in a majority of cases of child abuse, neglect, or trauma, there is alcohol involvement by one or both parents, and the child should be considered at risk of possible prenatal alcohol effects. It doesn't hurt to assume that and to adjust expectations and modify treatment strategies. Children with other disabilities or with no disabilities seem to respond favorably to techniques suggested for kids with FAS. To deny the possibility could set her up for more serious problems in the future. Prevention of secondary disabilities should be a primary concern.