Can a child or adolescent with fetal alcohol spectrum disorder also have attention‑deficit/hyperactivity disorder?

Can You Have FASD and ADHD?

Yes, a child can absolutely have both FASD and ADHD as separate, coexisting diagnoses—these are not mutually exclusive conditions, and clinical guidelines explicitly recognize that other disorders can coexist with FASD. 1

Guideline-Based Framework for Comorbidity

The CDC guidelines for diagnosing FAS explicitly state that "a complete diagnosis should identify and specify other disorders that can coexist with FAS (e.g., autism, conduct disorder, or oppositional defiant disorder)." 1 This principle extends across the entire FASD spectrum, not just full FAS.

The key clinical principle is that clinicians must consider organic causes, environmental contributions, and comorbidity for both inclusive and exclusive purposes when evaluating for FASD. 1

Critical Diagnostic Distinctions

Attention Deficits in FASD vs. ADHD

The 2005 CDC guidelines make a crucial distinction: attention problems in FASD are treated as a primary deficit resulting from alcohol-related CNS damage rather than a secondary mental health concern. 1 However, this does not preclude a separate ADHD diagnosis when criteria are met.

When Both Diagnoses Apply

A child can receive both diagnoses when:

• Prenatal alcohol exposure is confirmed and the child meets FASD diagnostic criteria (facial features, growth deficits, and/or CNS abnormalities including attention deficits ≥1.5 SD below the mean) 1
• The child also independently meets DSM criteria for ADHD with symptoms that may overlap with but are not fully explained by the FASD diagnosis 1

Neurocognitive Profiles Differ Between Groups

Research demonstrates that FASD and ADHD have distinct neurocognitive patterns despite overlapping symptoms: 2, 3, 4

• Children with FASD show significantly greater overall executive function deficits compared to ADHD (effect size d = 0.25 difference) 3
• FASD children perform significantly worse on Full-Scale IQ, Verbal Comprehension, Perceptual Reasoning, and Working Memory compared to ADHD 5
• FASD shows distinct patterns on letter fluency tasks and Trail Making Test-B that differ from ADHD 2
• Children with FASD demonstrate significantly higher levels of atypicality and aggression relative to ADHD alone 5

Clinical Pitfalls to Avoid

Common diagnostic error: Assuming that attention deficits in a child with prenatal alcohol exposure automatically mean the attention problems are solely due to FASD, thereby missing a comorbid ADHD diagnosis that might benefit from specific ADHD interventions. 1

Another pitfall: Diagnosing ADHD without screening for FASD when there are red flags (growth deficits, facial features, developmental delays) or unknown/suspected prenatal alcohol exposure history. 4, 5

Practical Assessment Approach

When evaluating a child with attention problems:

1. Obtain detailed prenatal exposure history including maternal alcohol use patterns 1
2. Assess for FASD facial features: small palpebral fissures, smooth philtrum, thin vermillion border 1
3. Document growth parameters: height, weight, and head circumference relative to norms 1
4. Conduct comprehensive neurocognitive testing to identify the specific pattern of deficits (FASD typically shows broader cognitive impairment) 2, 3, 5
5. Apply DSM criteria for ADHD independently of FASD assessment 1

The comorbid FASD + ADHD group shows a distinct profile: significantly weaker verbal comprehension than ADHD alone, and significantly higher hyperactivity and withdrawal relative to ADHD alone. 5 This suggests the combination creates additive or synergistic impairments requiring recognition of both diagnoses for optimal intervention planning.