Attention problems may be overreported in children with fetal alcohol syndrome disorder

It may seems a very specific group of children targeted in this study, but actually I think the way of thinking can be relevant beyond this target group and is an interesting point of view: researchers from McGill suggest that there may be an overreporting of attention problems in children with FASD (fetal alcohol syndrome disorder), simply because parents and teachers are using a misplaced basis for comparison. They are testing and comparing children with FASD with children of the same physical or chronological age, rather than with children of the same mental age, which is often quite a lot younger.

From the press release:

Ellen’s (not her real name) adoptive parents weren’t surprised when the school counselor suggested that she might have attention deficit hyperactivity disorder (ADHD). Several professionals had made this suggestion over the years. Given that homework led to one explosion after another, and that at school Ellen, who is eleven, spent her days jiggling up and down in her seat, unable to concentrate for more than ten minutes, it seemed a reasonable assumption. Yet her parents always felt that ADHD didn’t quite capture the extent of Ellen’s issues over the years. Fortunately the school counsellor was familiar with fetal alcohol spectrum disorder (FASD). When she learned that Ellen’s birth mother had consumed alcohol during pregnancy, she raised the possibility that Ellen’s problems could be attributable to FASD and referred her for further assessment.

It’s a familiar story, and most of us reading about Ellen would assume that she did indeed suffer from ADHD.

“Because the link between fetal alcohol syndrome and ADHD is so commonly described in the literature, both parents and teachers are more likely to expect these children to have attention problems,” says Prof. Jacob Burack, a professor in McGill’s Dept. of Educational and Counselling Psychology and the senior author on a recent study on the subject. “But what teachers often don’t recognize is that although the child they are dealing with is eleven years old in chronological terms, they are actually functioning at the developmental age of an eight-year old. That’s a pretty big difference. And when you use mental age as the basis of comparison, many of the attention problems that have been described in children with FASD no longer seem of primary importance.”

The researchers recruited children with FASD whose average chronological age was just under twelve years old. But their average mental age, determined by standard tests, was actually closer to nine-and-a-half years old. (The children were recruited through the Asante Centre for Fetal Alcohol Syndrome in British Columbia, and though the number of children studied may appear small, this is a fairly typical size for studies on FASD, given the difficulties of the diagnostic process.)

These children were then compared with children who were developing typically and whose average chronological age was about eight-and-a-half years old and whose average mental age was similar to that of the group of children diagnosed with FASD.

After using tests to measure specific aspects of attention, the researchers then compared the performance of children with FASD on these tests with the results of children of the same mental age. What they found was that while children like Ellen had difficulties with certain kinds of attention skills, notably in terms of shifting attention from one object to another, there were other areas, such as focus, where they had no significant difficulties at all. So, if we were to compare these aspects of attention to a hockey game, typically these children would have no difficulty focusing on the puck in the arena, but would have problems following the puck being passed from one player to another.

This suggests to Dr. Kimberly Lane, the PhD student who conducted the research, that there is a need to develop a more nuanced understanding of attention skills. “We use words like attention loosely, but it’s really an umbrella term that covers various aspects of attending to different people or events or environments,” says Dr. Lane. “By using more complex assessment techniques of various aspects of attention it will be possible to get a better picture of the attention difficulties faced by children with FASD,” she adds.

“But no matter what the tests say, it’s important for teachers and parents to understand that.the difficulties these children have with attention may be less important than their more general problems, and we need to work with them as they are.”

Abstract of the research:

Parental reports of attention problems and clinical symptomatology of ADHD among children with fetal alcohol syndrome disorder (FASD) were assessed in relation to performance on standardized subtests of attentional control/shifting and selective attention from the Test of Everyday Attention for Children (TEA-Ch; Manly et al., 1998). The participants included 14 children with FASD with a mean chronological age (CA) of 11.7 years and a mean mental age (MA) of 9.7 years, and 14 typically developing (TD) children with no reported history of prenatal exposure to alcohol or attention problems with a mean CA of 8.4 years and a mean MA of 9.6 years. The children with FASD were rated by their caregivers as having clinically significant attention difficulties for their developmental age. The reported symptomatology for the majority of the children with FASD were consistent with a diagnosis of ADHD, combined type, and only one child had a score within the average range. These reports are consistent with the finding that the children with FASD demonstrated difficulties with attentional control/shifting, but inconsistent with the finding that they outperformed the TD children on a test assessing selective attention. These findings are considered within the context of the complexity in understanding attentional functioning among children with FASD and discrepancies across sources of information and components of attention.

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