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O’Malley on ADHD in FASD

January 17, 2012

Chapter 4 of Kieran O’Malley’s ADHD and Fetal Alcohol Spectrum Disorders is the most comprehensive research-based discussion I’ve found about the unique challenges ADHD poses in FASD. It was published in 2007, so there is more recent research than O’Malley reviews here.

Even so, if I had access to this article before we began following up on the recommendation from the FASD specialist that we consider medication management for Hope’s ADHD, I would have been much better prepared. So here’s my recommendation: if you think ADHD is part of your prenatally exposed child’s picture, either request O’Malley’s book through your library system, or request a photocopy of Chapter 4. (I’ll give the how-to’s at the end of this post.)

O’Malley clearly lays out the differences between ADHD that is genetically inherited (the type most professionals see) and ADHD resulting from the acquired brain injury of prenatal alcohol exposure. If my experience is any indication, you may find an obviously intelligent psychiatrist assuring you that ADHD is ADHD; prenatal exposure is irrelevant. According to the research O’Malley summarizes, that isn’t true. He finds that unlike typical ADHD,  in FASD ADHD has early onset, often manifesting in infancy as a baby’s being difficult to settle and/or slow to warm up. He also notes that in FASD, the specific type of ADHD is not evenly distributed, but  is skewed toward the hyperactive and impulsive types.

Me: Between early onset and a tendency to manifest as hyperactive and/or impulsive is it any wonder these kids are so challenging as toddlers?

That’s another of O’Malley’s points. Statistically, in FASD, ADHD is more likely to occur along with other psychiatric issues like mood disorder, anxiety disorder, or conduct (intermittent explosive) disorder. Like ADHD, these disorders are often not diagnosed until a child is older. Yet like ADHD in FASD, the neuro-biological roots of these disorders (except where, coincidentally, they might be genetically inherited) stem from the acquired brain injury caused by prenatal exposure. Therefore, they are also present from birth.

Authors of several other articles in O’Malley’s book point to the same thing: prenatally exposed kids are at risk before they are born and longitudinal studies show that children who will be later diagnosed with FASD (not all are) show symptoms from infancy. So families should not have to wait until elementary school for diagnosis and appropriate intervention. Yet almost universally, parents of challenging prenatally exposed kids find their concerns minimized by professionals who reassure them their child may yet outgrow the challenges.

This is a tragedy because, as O’Malley also points out, kids with FASD and ADHD are uniquely prone to an overlay of attachment issues –and not just when they are born into a chaotic family environment and/or suffer disruptions when they are removed from that home. Even when placed in functional families, exposed kids are at risk for less than secure attachment due to their parents/caregiver’s ongoing struggle to attach to a child whose behaviors stress the whole family system.

My thought: So by not taking parent’s concerns seriously, primary care physicians compound the stress by disempowering parents trying to seek help. At the same time, primary care doctors can hardly be blamed when there is no consensus outside the FASD field that exposed kids should be considered high risk from birth and should be early candidates for early intervention. The goal of early intervention is not to’heal’ the brain injury, but to empower parents to understand and to cope with the effects of it so as to minimize secondary disabilities like ambivalent attachment.

One other key observation O’Malley makes: adults who have genetically inherited ADHD are more likely to consume alcohol in risky patterns than adults who do not have ADHD. Therefore some kids who are prenatally exposed to alcohol may carry the genes for ADHD, while other exposed kids may have ADHD acquired secondary to prenatal exposure. This makes managing the child’s ADHD with medication quite challenging when the family history of ADHD is unknown.

More on O’Malley’s observations and cautions on ADHD medication in the presence of FASD in Part II of this post.


How to order a copy (often free) of this or any other chapter from O’Malley’s book (or any other book, or of a research article in a journal) via your library without leaving home:

  • Go to the table of contents for O’Malley’s book on Goggle Books by clicking here and scrolling back to the Table of Contents. Identify the chapter(s) you want. (Note that Chapters 1-3 can be read on line via that link.) [If you want a journal article, at this point, search for the name of the journal, not the article.]
  • Leave that window open and open your state library’s lending network portal in another window. (Often you’ll find that link on your home library’s web page on the request a book screen.) In Minnesota, that network is called MNLink.
  • Search for O’Malley’s book using the author and title. (On MNLink you’ll get a shorter list of results using the “Advanced Search”  feature.)
  • Select any copy of the book from the list. Then select  “request” (MNLink calls this “Get it.”) If you do nothing else but confirm at that point, you will be requesting the whole book.
  • However you can request a photocopy of a chapter by filling in the form with the author/article name/ page numbers information you glean from O’Malley’s table of contents –the reason you left that browser window open. [Or for a journal article, by filling in those specifics about the article you want.]
  • Confirm your request for that part and submit the request.
  • A photocopy of the chapter will be delivered to your library for you.

Why would you want to order a chapter instead of requesting the whole book? In this case, there are so few copies of O’Malley’s book owned by libraries that you may have to wait a while for your turn. Second, if you order a chapter or two of highest interest to you, you’ll be able to keep the photocopy, not have to find time to go out and copy it yourself when it is time to send the book back to the Library.

A warning: The last half of Chapter 6 is missing from my library copy and the way it trails off with a long ellipse, I think the defect is in the electronic file from which all the copies were probably printed.


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