Wednesday, May 29, 2013

Fetal Alcohol Spectrum or Reactive Attachment Disorder?

I just sent the following email off to one of the author of this article (another article by the same author on the same topic can be found here). This study proposes a screening questionnaire for FASD that distinguishes FASD kids from ADHD kids and normal controls, but which has a worrying degree of overlap with questionnaires for Reactive Attachment Disorder.

"I read your 2006 article about the behavioral phenotype of FASD, and I have some concerns about how specific those behaviors are to FASD.

FASD children, by definition, are born to mothers who have a problem with alcohol. This places these children at considerable social risk as well. Many FASD children become victims of neglect and abuse, and many experience foster care as well, often with repeated changes in placement. Streissguth et al (2004) found a significant correlation between adverse post-natal life events and the FASD child's risk of multiple bad outcomes, including trouble with the law, developing alcohol/drug problems themselves, and displaying sexual behavior problems. This emphasizes the importance of controlling for post-natal environmental adversity in understanding FASD.

Unfortunately, your study compared FASD children to children with ADHD and to typically developing controls - both groups which are significantly less likely to have experienced postnatal environmental adversity of the type usually seen among FASD children. This raises the important question of whether your findings reflect FASD or the impact of trauma and attachment disruption.

Indeed, when I compared your FASD screening items to the Relationship Problems Questionnaire by Minnis et al (2002), a screening scale for Reactive Attachment Disorder, two items are present in both scales - 'acts younger than his/her age' and lacks conscience or 'doesn't show guilt after misbehaving'. Many of the other items in your scales are also commonly reported among children with Reactive Attachment Disorder, including many who have no prenatal alcohol exposure.

Therefore, I recommend you assess which behaviors distinguish FASD children from other children who have experienced unstable, neglectful and/or abusive postnatal environments, such as foster children, maltreated children or older adopted children."

This seems to be a common problem. It seems obvious to me, but so many people, when they hear that a child was prenatally exposed to alcohol, seem to forget that the child's postnatal environment matters as well. FASD children, like any other child, will be adversely affected by abuse, neglect, or frequent placement changes. And the very circumstances that cause FASD also tend to cause abuse, neglect and placement changes.

Unless the FASD child in question was early-adopted or raised by a mother who sobered up shortly after birth and had no other major problems, you have to consider that this child's behavior could be influenced by trauma and/or attachment issues. Don't leap to a neuropsychological explanation for all of it.


Blogger Dr. Becker-Weidman said...

At my clinic ( we frequently find that children adopted from countries where there is a high rate of alcohol use (ex: Russia) have both FASD and RAD. Appropriate testing and a thorough assessment can help distinguish the two. In our comprehensive assessment we screen for a variety of mental health issues, attachment, neuropsychological issues, executive function, and sensory-integration.

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