• unlimited access with print and download
    $ 37 00
  • read full document, no print or download, expires after 72 hours
    $ 4 99
More info
Unlimited access including download and printing, plus availability for reading and annotating in your in your Udini library.
  • Access to this article in your Udini library for 72 hours from purchase.
  • The article will not be available for download or print.
  • Upgrade to the full version of this document at a reduced price.
  • Your trial access payment is credited when purchasing the full version.
Buy
Continue searching

Identifying the Characteristics of Fetal Alcohol Spectrum Disorders (FASD) among Children with Attention-Deficit/Hyperactivity Disorder

ProQuest Dissertations and Theses, 2011
Dissertation
Author: Fumio Someki
Abstract:
Fetal alcohol spectrum disorder (FASD), characterized by various levels of dysmorphia and behavioral and cognitive dysfunctions, is the result of prenatal alcohol exposure. FASD characteristics can be masked by many other conditions. As a result, early identification of FASD is often difficult, leading to a delay of children with FASD receiving necessary services. However, screening children with attention-deficit/hyperactivity disorder (ADHD), which is the major comorbid disorder of FASD, may enable the identification of children with FASD earlier than screening all children in schools. Therefore, the purpose of this study was to examine the differences between children with ADHD only and children with FASD and ADHD in terms of adaptive functioning, behavioral characteristics, and academic performance that impact school outcomes and can be recognized in classrooms. This study conducted a review of the medical records of 149 individuals with single ADHD diagnosis and 189 individuals with dual diagnosis of FASD and ADHD ( Mage = 11.25, SD = 2.12). Results of analysis of covariance analysis indicated: (1) no difference in adaptive functioning between the dual diagnosis group and the single diagnosis group, (2) the dual diagnosis group exhibited significantly more externalizing behaviors than the single diagnosis group, but the difference between the two groups regarding internalizing behaviors was not significant, (3) there was no significant differences between the two groups on reading and mathematics. Differences in characteristics between the two groups and implications for future research are also discussed.

iv Table of Contents Acknowledgements ............................................................................................... i

Abstract ............................................................................................................... iii

Table of Contents ................................................................................................ iv

List of Tables ....................................................................................................... vii

Chapter 1 Introduction ........................................................................................................... 1

Research Questions and Hypotheses ................................................................... 4

Chapter 2

Literature Review.................................................................................................. 7

Fetal Alcohol Spectrum Disorder (FASD) ................................................................... 8

Essential Features of FASD .................................................................................. 8

Subtypes of FASD and Diagnostic Criteria............................................................ 9

Problems of Early Diagnosis/Identification .......................................................... 11

Early Identification of Children with FASD ................................................................ 12

Developmental Psychopathology ........................................................................ 12

Risk Factors and Protective Factors of Good Prognosis ..................................... 13

Prenatal Risk and Protective Factors of Children with FASD .............................. 15

Identifying Children with Single ADHD Diagnosis and Dual Diagnosis .................... 17

Adaptive Functioning ........................................................................................... 18

Behavioral Characteristics ................................................................................... 23

Academic Performance ....................................................................................... 29

Methodological Issues in FASD Studies ............................................................. 35

Study Rationale and Purpose ................................................................................... 37

v Chapter 3

Methods .............................................................................................................. 40

Participants ................................................................................................................ 40

Measures ................................................................................................................... 41

Scales of Independent Behavior - Revised (SIB-R). ........................................... 41

Child Behavior Checklist (CBCL) and Teacher Report Form (TRF). ................... 44

Woodcock Johnson Tests of Achievement- Third Edition (WJ III ACH). ............. 45

Study Procedures ...................................................................................................... 46

Data Analysis ............................................................................................................ 46

Chapter 4 Results ............................................................................................................... 52

Demographics of the Participants ............................................................................. 52

Underlying Assumptions for ANCOVA ...................................................................... 56

Potential Indicators for Identifying Children with Dual FASD and ADHD Diagnosis Group ..................................................................................................................... 61

Chapter 5

Discussion .......................................................................................................... 70

Demographics of the Participants ............................................................................. 70

Potential Indicators for Identifying Children with Dual FASD and ADHD Diagnosis Group ..................................................................................................................... 71

Adaptive functioning ............................................................................................ 71

Behavioral Characteristics ................................................................................... 73

Academic Performance ................ エラー ! ブックマークが定義されていません。

Study Limitations and Implications for Future Research ............................................ 79

vi References ......................................................................................................... 83

Appendix ............................................................................................................ 98

vii List of Tables Chapter 3 Table 3.1 ...................................... エラー ! ブックマークが定義されていません。

Table 3.2 ............................................................................................................ 43

Table 3.3 ............................................................................................................ 51

Chapter 4 Table 4.1 ............................................................................................................ 53

Table 4.2 ............................................................................................................ 55

Table 4.3 ...................................... エラー ! ブックマークが定義されていません。

Table 4.4 ............................................................................................................ 58

Table 4.5.…………………………………………………………………………….....60

Table 4.6………………………………………………………………………………..62

Table 4.7………………………………………………………………………………..63

Table 4.8………………………………………………………………………………..64

Table 4.9………………………………………………………………………………..64

Table 4.10………………………………………………………………………………66

Table 4.11………………………………………………………………………………66

Table 4.12………………………………………………………………………………67

Table 4.13………………………………………………………………………………67

Table 4.14………………………………………………………………………………68

Table 4.15………………………………………………………………………………68

1 Chapter 1 Introduction Fetal alcohol spectrum disorder (FASD) is characterized by various levels of dysmorphia and behavioral and cognitive dysfunctions due to prenatal alcohol exposure (Institute of Medicine, 1996). Although this disorder is preventable, it remains the largest cause of mental retardation (i.e., cognitive disabilities; Friend, 2010). Every year, more than 500,000 fetuses (approximately 13% of all births) are exposed to alcohol during pregnancy in the United States (Centers for Disease Control, 2002). Among these children who were exposed to alcohol during pregnancy, approximately 10 per 1,000 live births have some form of FASD (May & Gossage, 2001). FASD poses a significant issue in today's society. The appearance rate of FASD is continuing to rise, and the median of estimated costs of FASD is approximately 3.6 million dollars per year in the United States (Lupton, Burd, & Harwood, 2004). Because of behavioral and cognitive dysfunctions caused by prenatal alcohol exposure, children with FASD need various levels of support such as special education services and medication. Nevertheless, many children with FASD do not receive the necessary support until when their behavior problems become salient during adolescence. Additionally, there is no particular category to serve FASD in special education under the current law, the Individuals with Disabilities Education Improvement Act (2004). Although many children with FASD may receive services under the Other Health Impairments category, the number of children who do receive services under this category is still low. If they have a comorbid condition (e.g., mental retardation), they could receive services for that condition, but not all children with FASD have such a comorbid condition. Most children/adolescents with FASD receive services under the

2 category of emotional behavioral disorder at a later age when they begin to exhibit significant behavioral problems due to having difficulties in life. Because many adolescents with FASD exhibit significant behavioral problems, this population is overrepresented in the juvenile justice system (Fast, Conry, & Loock, 1999). They often have legal issues and are more susceptible to behavior that harms self and others compared to those without FASD. Fast et al. (1999) reported that of the 287 adolescents (aged 12 to 18) in their study who were remanded for a forensic psychiatric/psychological evaluation, 67 (23.3%) had a diagnosis of FASD. If adolescents with FASD could have been diagnosed and received sufficient intervention services earlier, it is possible that they could have fewer legal issues and incidents of problem behavior. Therefore, it is critical that children/adolescents with FASD start receiving necessary educational services as early as possible to remediate their problem behavior. Given that educators are usually the ones who first recognize that children with FASD have educational needs, they can refer these children to medical professionals for further examination. FASD is a medical diagnosis and requires assessments by medical professionals. To appropriately diagnose and start intervening early with children with FASD, it is critical to raise awareness about FASD among professionals, especially educators, because they are often the first people to recognize the difficulties these children encounter. In particular, focusing on the differences between children with FASD and attention-deficit/ hyperactivity disorder (ADHD; hereafter referred to as the dual diagnosis), and children with ADHD only (i.e., single ADHD diagnosis without prenatal alcohol exposure) could provide potential indicators for identifying children with FASD among children with ADHD at an early age. There are few previous studies that have compared children with FASD and children with single ADHD diagnosis. Furthermore,

3 most studies examined their performance using laboratory tests (e.g., continuous performance test) or individually administered tests (e.g., Wechsler Intelligence Scale for Children, Wisconsin Card Sorting Test). In sum, identifying these children’s difficulties in different areas (e.g., cognitive functioning, executive functioning) as measured by the above mentioned tests may be problematic, because it would be difficult to administer such tests to all children with ADHD. Therefore, it is important to focus on areas that educators can recognize and follow-up by screening to examine the differences between these two populations. Educators may be able to detect signs of difficulty children with FASD and ADHD evidence in the following areas: (1) adaptive functioning, (2) behavioral characteristics (e.g., aggressive behavior and rule-breaking behavior), and (3) academic performance (e.g., reading, math, and writing). An emphasis on these specific areas may be important for educators to understand the diverse needs of children with FASD and inform instruction. Previous research that examined children with ADHD and children with FASD on the three areas mentioned above revealed that both children with ADHD and children with FASD exhibited diminished adaptive functioning (Jirikowic, Olson, & Kartin, 2008; Stein, Szumowski, Blondis, & Roizen, 1995). However, adaptive functioning of children with FASD appeared to be even more impaired, particularly in the interpersonal area, when compared to children with ADHD (Thomas, Kelly, Mattson, & Riley, 1998). When compared to normally developing children, both children with ADHD and children with FASD showed significantly higher externalizing behaviors and comorbidity of disorders pertaining to internalizing behaviors (e.g., mood disorders; Berkeley, 2006; Brown et al. 1991). However, when children with FASD were compared directly to children with ADHD on these behaviors, the results were incongruent. That is, children with ADHD exhibited significantly more internalizing behaviors than children with FASD, whereas

4 children with FASD exhibited significantly more externalizing behaviors than children with ADHD (e.g., Coles et al., 1997; Greenbaum et al., 2009). Regarding academic achievement, both children with ADHD and children with FASD often struggle with core academic subjects (Barkeley, 2006; Coles et al., 1997). However, children with ADHD evidence more difficulties during elementary school, particularly in reading (e.g., Frazier, Youngstrom, Glutting, & Watkins, 2007). In contrast, children with FASD struggle more during adolescence, particularly in mathematics (e.g., Olson, Feldman, Streissguth, Sampson, & Bookstein, 1998). Research Questions and Hypotheses The aim of the present study was to examine whether adaptive functioning, behavioral characteristics, and academic performance can be used to identify children with dual FASD and ADHD diagnosis (i.e., the dual diagnosis group) among children with single ADHD diagnosis (i.e., the single diagnosis group). As such, this study explored the following research questions: (1) What are the differences in adaptive functioning between the dual diagnosis group and the single diagnosis group? (2) What are the differences in behavioral characteristics between the dual diagnosis group and the single diagnosis group? (3) What are the differences in academic performance between the dual diagnosis group and the single diagnosis group? For the first research question, the hypothesis was that although both groups may exhibit difficulties in adaptive functioning, the dual diagnosis group would exhibit more significant difficulties in the area of socialization. Previous studies have shown that

5 children/individuals with FASD exhibit low levels of adaptive functioning, especially when compared to their cognitive functioning (i.e., IQ) (e.g., Jirikowic et al., 2008; Streissguth, et al., 1991). Furthermore, children with prenatal alcohol exposure exhibit noticeable difficulties in the area of socialization, especially in the interpersonal area (Thomas et al., 1998). Children with ADHD were also known to demonstrate diminished adaptive skills, often in the low-average to borderline range, despite having average intelligence (e.g., Barkley, Fischer, Edelbrock, & Smallish, 1990; Stein et al., 1995). For the second research question on behavioral characteristics, the hypothesis was that the single ADHD diagnosis group would exhibit significantly more internalizing behavior, but the dual diagnosis group would exhibit significantly more externalizing behavior. With regard to internalizing behavior, two studies reported that children with single ADHD diagnosis exhibited significantly more problems in internalizing behavior than children with FASD (Coles, et al., 1997; Greenbaum, Stevens, Nash, Koren, & Rovet, 2009). However, the findings on externalizing behavior, which is the major characteristic of both ADHD and FASD, were contradictory. On the one hand, Coles et al. (1997) reported that children with single ADHD diagnosis exhibited significantly more problems in externalizing behavior on the child behavior checklist (CBCL). On the other hand, Greenbaum et al. (2009) reported that there were no significant differences between the two groups based on parental report. Moreover, educators reported children with FASD exhibited significantly more externalizing behavior than children with single ADHD diagnosis. Children with FASD also exhibited significantly more behavior problems on the Social Skills Rating Scale based on both parental and teacher report. For the third research question, the hypothesis was that the dual diagnosis group would perform significantly lower on mathematics but perform significantly higher on reading. For example, Coles et al. (1997) compared children with FASD whose

6 ADHD status was unreported and children with ADHD who did not suffer from prenatal alcohol or drug exposure and found that children with FASD scored significantly lower on mathematics assessments, whereas children with single ADHD diagnosis scored significantly lower on reading assessments. Other research indicated that although children with FASD were able to read, write, and count numbers, they had difficulty with calculation and estimation skills (Kopera-Frye, Dehaene, & Streissguth, 1996). In contrast, children with ADHD exhibited the most difficulty in reading, followed by mathematics, and then spelling (Frazier et al., 2007).

7 Chapter 2 Literature Review Fetal alcohol spectrum disorder (FASD), characterized by various levels of dysmorphia and behavioral and cognitive dysfunctions (Institute of Medicine, 1996), is the result of prenatal alcohol exposure. Although the effects of prenatal alcohol exposure on fetus have been described from the time of Aristotle (Abel, 1999), FASD has not been studied extensively. The number of children diagnosed with FASD has been increasing, and as of 2000, stands at about 10 per 1000 live births, which translates into about 40,000 babies per year in the United States (May & Gossage, 2001). Adolescents with FASD are overrepresented in the juvenile justice system (Fast, Conry, & Loock, 1999). Approximately 60 percent of adolescents and adults with FASD encounter trouble with the law, and 30 percent have alcohol and/or drug-related problems (Streissguth, Barr, Kogan, & Bookstein, 1996). They often have legal issues and are more susceptible to criminal behavior compared to those without FASD. Fast et al. (1999) reported that of the 287 adolescents (aged 12 to 18) in their study who were remanded for a forensic psychiatric/psychological evaluation, 67 (23.3%) had a diagnosis of FASD. Unfortunately, it is very difficult to effectively intervene with this population once they begin to exhibit problem behavior. Although these children are in need of various levels of support, there is no particular category to serve them in special education under the current law, the Individuals with Disabilities Education Improvement Act (2004). Most children/adolescents with FASD receive services under the category of emotional behavioral disorder at a later age when they begin to exhibit significant behavior problems due to having difficulties in life. Thus, it is critical for them to start receiving

8 necessary educational services as early as possible. Educators are usually the ones who first recognize that children with FASD have unique needs and refer them to medical professionals for further assessment. This chapter presents an overview of FASD, including a description of the essential features, diagnostic criteria, and subtypes of FASD, as well as issues related to early identification of FASD. Next, risk factors and protective factors that affect future outcomes of children with psychopathology (e.g., FASD) are discussed. Finally, previous studies that focused on adaptive functioning, behavioral characteristics, and academic performance of children with FASD are reviewed, particularly in comparison with normally developing children and children with ADHD (attention-deficit/hyperactivity disorder) followed by a discussion of the major scales used to measure these three areas. Fetal Alcohol Spectrum Disorder (FASD) Essential Features of FASD FASD is characterized by a spectrum of dysmorphia and behavioral and cognitive dysfunctions due to prenatal alcohol exposure. Four essential features of FASD (originally referred to as fetal alcohol syndrome or FAS) were first introduced in 1996 by the Institute of Medicine. They included (a) growth deficiency, (b) characteristics of FAS facial phenotype (i.e., upper lip thinness, philtrum smoothness, and smallness of palpebral fissures), (c) central nervous system (CNS) abnormalities (i.e., damage/dysfunctions), and (d) prenatal alcohol exposure (Institute of Medicine, 1996). Typically, physicians or pediatricians who specialize in FASD are the ones who gather evidence of growth deficiency and FAS facial phenotype. CNS abnormalities are determined based on structural damage to the brain, as well as the results of

9 developmental and neuropsychological tests that measure IQ, executive functioning, and behavioral and social development. To meet the criteria for CNS abnormalities, children must exhibit a pattern of developmental behavioral or cognitive abnormalities (e.g., impairment in judgment, complex problem solving, abstraction, metacognition, and arithmetic skills; higher-level receptive and expressive language deficits; disordered behavior). Subtypes of FASD and Diagnostic Criteria In 2004, the Centers for Disease Control and Prevention proposed that FASD includes four diagnostic categories: fetal alcohol syndrome (FAS), partial FAS, alcohol related birth defect, and alcohol related neurodevelopmental disorder (Hoyme et al., 2005). In addition, the term fetal alcohol effects (FAE) has been used for diagnosing those individuals who do not meet the diagnostic criteria for FAS. However, the ambiguity of the FAE diagnosis (e.g., Aase, Jones, & Clarren, 1995) has led to the disuse of this term. The diagnosis of FASD is determined on the basis of a combination of the four essential features: growth deficiency, FAS facial phenotype, CNS abnormalities, and prenatal alcohol exposure (Bertrand et al., 2004). Specifically, growth deficiency is verified with growth retardation in height or weight that is below the 10th percentile. Characteristics of FAS facial phenotype (i.e., dysmorphia) include thin vermillion border (i.e., upper lip), smooth philtrum (i.e., vertical groove in the upper lip), and small palpebral fissures (i.e., the opening for the eyes between the eyelids). Vermillion border thinness and philtrum smoothness is rated from 1 to 5 based on the “Lip-Philtrum Guide” (Astley & Clarren, 1999). A rating of 1 indicates that the formation of vermillion border or philtrum is within the normal range, whereas a rating of 2 or 3 indicates between normal

10 and atypical, and a rating of 4 or 5 is considered dysmorphic. Smallness of palpebral fissures is determined by a criterion of below the 10th percentile based on age and racial norms. CNS abnormalities (i.e., damage/dysfunction) are determined in several ways. CNS abnormalities related to structure may include small overall head circumference (i.e., below the 10th percentile for those who do not exhibit growth deficiency, or the 3rd percentile for those who exhibit growth deficiency) or observable brain abnormalities (e.g., reduction in size or change in shape of the corpus callosum, cerebellum, or basal ganglia) as assessed by imaging techniques. From a neurological perspective, CNS abnormalities can indicate neurological problems such as seizures that are not due to a potential insult or fever or other soft neurological signs (e.g., problems in coordination, visual motor difficulties). With regard to function, CNS abnormalities can entail a global cognitive deficit (i.e., low IQ) or deficits in three or more specific functional domains such as cognition, executive functioning, motor functioning, attention and hyperactivity, social skills, and other domains (e.g., sensory, memory). Functional problems are measured by standardized measures (e.g., Wechsler Intelligence Scale for Children, fourth edition, Wisconsin Card Sorting Test) and determined based on the norms. In addition to these three diagnostic criteria (growth deficits, all three facial abnormalities, and CNS abnormalities), confirmed prenatal alcohol exposure is preferred but not necessary for diagnosis of FAS. The criteria for partial FAS consist of at least two facial abnormalities, CNS abnormalities, and confirmed prenatal alcohol exposure (Hoyme et al., 2005). The criteria for alcohol related birth defect are at least two facial abnormalities, more than one congenital structural defect including malformations or displasias (i.e., an abnormality in maturation of cells within a tissue), and confirmed prenatal alcohol exposure (Hoyme et al., 2005). The criteria for alcohol related

11 neurodevelopmental disorder include two or more domain deficits in CNS functioning and confirmed alcohol exposure (Hoyme et al.). Problems of Early Diagnosis/Identification Of the four defining features of FASD, growth deficiencies may occur due to many reasons. During pregnancy, prenatal smoking, poor prenatal nutrition, or genetic disorders can lead to growth retardation or deficiencies. After birth, one of the major reasons for growth deficiencies is insufficient nutrition, including the condition stemming from the poor sucking responses of infants (National Center on Birth Defects and Developmental Disabilities, 2004). Thus, it is impossible to identify children with FASD solely by examining growth deficiencies. Additionally, facial phenotype can be masked by birth trauma or other syndromes/disorders (Bertrand et al., 2004; Jones, 1997). CNS abnormalities can be detected at an early age when children with FASD exhibit global cognitive deficit or significant developmental delays, but can be difficult to detect early if cognitive abnormalities are present in areas that require higher-level functions such as executive functions. Lastly, the core feature of FASD - prenatal alcohol exposure - is also hard to detect. If a child is adopted or in foster care, for instance, detailed information about the birth mother, such as presence of prenatal alcohol exposure is not always available. Even if it is possible to interview the birth mother, mothers tend to underreport the levels of drinking during pregnancy (Ernhart, Morrow-Tlucak, Sokol, & Martier, 1988). In general, retrospective interviews about alcohol consumption during pregnancy are not accurate. All these factors make it difficult to diagnose FASD at an early age, which leads to the failure of early intervention to remediate difficulties in the various domains encountered by children with FASD.

12 Early Identification of Children with FASD An important aspect of early diagnosis of FASD is adequate referral of children who may have FASD to medical professionals for evaluation. The referral process may require screening children with attention-deficit/hyperactivity disorder (ADHD), a population that overlaps with children with FASD. A recent report revealed that almost 95 percent of children with FASD also have ADHD (Fryer, McGee, Matt, Riley, & Mattson, 2007). As such, there is a high likelihood (95%) of identifying children with FASD by carefully screening children with ADHD. Unfortunately, a lack of awareness about FASD often results in children with FASD being diagnosed as having only ADHD. Some researchers argue that if a child has both FASD and ADHD diagnosis, medical treatment, particularly, needs to focus on FASD, because reaction to medication was reportedly different for children with single ADHD diagnosis and those with the dual FASD and ADHD diagnosis (O’Malley & Nanson, 2002). Although methylphenidate (i.e., stimulants) is known to be effective for children with ADHD (Connor, 2006), O’Malley, Koplin, and Dohner (2000) found that children with FASD responded better to dextroamphetamine (79%) than to methylphenidate (22%). This difference in response to medication suggests that children with single ADHD and those with the dual diagnosis are qualitatively different from a biological perspective. Developmental Psychopathology Early identification of children with FASD is critical in order to remediate the specific academic, behavioral, and social problems that they encounter. A theory of developmental psychopathology may serve to explain why early intervention is critical for a good prognosis. Developmental psychopathology, based on the ideas of psychopathology and developmental psychology, is “the study of the origins and course

13 of individual patterns of behavioral maladaption” (Sroufe & Rutter, 1984, p. 265). Psychopathology focuses on the manifestation of causes and course of psychopathology (i.e., mental disorders) to explain why individuals develop mental disorders and the type of pathways a disorder may take (e.g., conduct disorder in childhood often leads to antisocial personality disorder in adulthood). Developmental psychology focuses on an individual’s development from infancy to late adulthood, for example (Rutter & Sroufe, 2000). Development is an active and dynamic process, whereby individuals perceive and respond to experiences in their environment. Not only do individuals respond to the various experiences, but also are affected differentially by such experiences (Rutter & Sroufe, 2000). From a developmental psychopathology perspective, no single starting point (i.e., birth) reaches the same ending point (i.e., outcomes). For instance, monozygotic twins who share the same genetic factors (i.e., starting points) could likely end up with one being a criminal and another a successful business person (i.e., ending points). Outcomes are not only limited to occupation, but also can indicate status such as academic achievement, prosocial and antisocial behavior, and psychopathology. Even when the starting point is exactly the same, there are many pathways individuals may take and various outcomes are possible based on their pathways. Additionally, more than one pathway may reach a particular outcome (e.g., good grades, antisocial personality disorder). The path that an individual takes is often influenced by a combination of both risk and protective factors. Risk Factors and Protective Factors of Good Prognosis Risk factors and protective factors are very important when considering prognosis of individuals with psychopathology. While risk factors such as low socioeconomic status

14 (SES), low birth weight, maltreatment, violence, parental divorce, and poor parenting are predictors of poor outcomes, (Maesten & Garmezy, 1985), a combination of risk factors has multiplicative rather than additive effects on outcomes (Streissguth & Kanter, 1997). That is, the effect of one individual holding two risk factors is more than twice the effect of one individual holding a single risk factor. For instance, the overall amount of impact of risk factors on one person with both ADHD and FASD is more than that of the combined impact of the same factors on one person with ADHD or FASD alone. Unfortunately, many risk factors often co-occur (e.g., Maesten & Wright, 1998). Protective factors are on the opposite side of the continuum of risk factors (e.g., good parenting vs. poor parenting), and lowering risks often means increasing protective factors (Maesten, 2001). Developmental psychopathology perceives comorbidity of disorders either as the result of the same set of intercorrelated risk factors or a sequence of the risk mechanism leading to one form of psychopathology that could result in another form of psychopathology (Rutter & Sroufe, 2000). For instance, hyperactivity and inattention are risk factors for later development of antisocial behavior (Farrington, Loeber, & van Kammen, 1990). At the same time, hyperactivity and antisocial behavior are known to have different developmental paths (Ferguson & Horwood, 1993). That is, hyperactivity in itself is a marker for childhood disruptive behavior, but the persistence of such disruptive behavior leading to antisocial behavior depends not only on hyperactivity but also on other risk and protective factors (Rutter & Sroufe, 2000). In particular, experiences in early life play important roles on later antisocial behavior (Rutter, 1981). As such, having FASD (i.e., psychopathology) is an additional risk factor for children with ADHD. Therefore, identifying the presence of FASD early and providing these children with necessary supports are likely to increase protective factors.

Full document contains 164 pages
Abstract: Fetal alcohol spectrum disorder (FASD), characterized by various levels of dysmorphia and behavioral and cognitive dysfunctions, is the result of prenatal alcohol exposure. FASD characteristics can be masked by many other conditions. As a result, early identification of FASD is often difficult, leading to a delay of children with FASD receiving necessary services. However, screening children with attention-deficit/hyperactivity disorder (ADHD), which is the major comorbid disorder of FASD, may enable the identification of children with FASD earlier than screening all children in schools. Therefore, the purpose of this study was to examine the differences between children with ADHD only and children with FASD and ADHD in terms of adaptive functioning, behavioral characteristics, and academic performance that impact school outcomes and can be recognized in classrooms. This study conducted a review of the medical records of 149 individuals with single ADHD diagnosis and 189 individuals with dual diagnosis of FASD and ADHD ( Mage = 11.25, SD = 2.12). Results of analysis of covariance analysis indicated: (1) no difference in adaptive functioning between the dual diagnosis group and the single diagnosis group, (2) the dual diagnosis group exhibited significantly more externalizing behaviors than the single diagnosis group, but the difference between the two groups regarding internalizing behaviors was not significant, (3) there was no significant differences between the two groups on reading and mathematics. Differences in characteristics between the two groups and implications for future research are also discussed.