Fetal Alcohol Spectrum Disorder in Forensic and Correctional - - PowerPoint PPT Presentation

Fetal Alcohol Spectrum Disorder in Forensic and Correctional Contexts

Kaitlyn McLachlan, Ph.D., C. Psych

5th Bergen International Conference on Forensic Psychiatry Wednesday, October 24th, 2018

Outline

Introduction to FASD Relevance & Research in Criminal Contexts Gaps and Needs 1 2 3

Outline

Introduction to FASD Relevance & Research in Criminal Contexts Gaps and Needs 1 2 3

Fetal Alcohol Spectrum Disorder

Cognitive, emotional, behavioural, and physical health-related deficits following prenatal alcohol exposure (PAE) (Cook et al., 2015; Hoyme et al., 2016)

 Alcohol is an equal opportunity teratogen that can significantly impact fetal development through entire pregnancy  No safe time, no safe amount

Society of Obstetrics and Gynaecology Canada, JOGC, 2010

Prevalence

Increasing recognition, estimates conservative Canada & US general population: 2 - 5%

(May et al., 2009; 2014; 2018; Popova et al., 2018)

Worldwide Variability

 FAS: 14.6 per 10,000 (95% CI 9.4-23.3; Popova et al., 2017)  Country-specific population-based studies using active case ascertainment are necessary

FASD occurs in the context

• f social determinants of

health and in all populations where alcohol is used

Key Message

Costs in Canada (2013)

~$1.8 Billion ($1.3 – $2.3)

• 1. Productivity losses due to disability,

premature mortality ~$532m – $1.2b

• 2. Corrections ~$378.3m
• 3. Health care ~$128.5 – $226.3 m

Adapted from Popova et al., 2016 Alcoh Alcoh, 51(3), 367-375

• FASD has historically been a highly stigmatizing condition
• It is critical to approach conversations and practice in a sensitive manner

aiming to reduce stigma and increase engagement

Key Message

Diagnostic Approaches

• Multiple systems: Best practices use multidisciplinary teams, complex

physical and neurodevelopmental assessment

Diagnostic Approaches

• Multiple systems: Best practices use multidisciplinary teams, complex

physical and neurodevelopmental assessment

FASD with Sentinel Facial Features FASD without Sentinel Facial Features

Cook et al., 2015, CMAJ

FASD: Key Diagnostic Features

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

Sentinel Facial Features

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

FASD: Key Diagnostic Features

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

Sentinel Facial Features

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

FASD: Key Diagnostic Features

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

Sentinel Facial Features

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

FASD: Key Diagnostic Features

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

Substantial variability between individuals

Sentinel Facial Features

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

FASD: Key Diagnostic Features

Sentinel Facial Features

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

FASD: Key Diagnostic Features

Facial Dysmorphology

• Smooth philtrum
• Thin upper lip
• Short palpebral fissures

Neurodevelopmental Impairment

• Cognition
• Affect
• Behaviour

Prenatal Alcohol Exposure

• Timing
• Dose
• Pattern

Growth

• Head circumference
• Height & Weight

Key Message

Most people with FASD do not present with obvious physical signs

Commonly impacted brain domains

Motor Skills Neuroanatomy/physiology Cognition Language Academic Achievement Memory Attention Executive function Affect regulation Adaptive behaviour

• 2
• 1,5
• 1
• 0,5

0,5 1 AS IN-N IN-I IN-S AA RS MN MND DR BR AR QC WID EF ATTN MEM WM VSP NUM READ z-score Control ARND pFAS FAS

McLachlan et al., (2017) Advances in Neurodevelopmental Disorders

Cognitive Profile

National Cohort of Canadian children (ages 5 – 18) with FASD (n = 87) and Controls (n = 110)

Executive Functioning Attention Memory Working Memory VSP Math Word ID

Neurobehavioral Disorder Associated with PAE

• Currently: Specifier for “Other Specified Neurodevelopmental Disorder, Associated with Prenatal

Alcohol Exposure [code 315.8, p. 86]

ND-PAE

More than Minimal PAE Neurocognitive Functioning (1+)

Global Intellectual Executive Functioning Learning Memory Visual-Spatial Reasoning

Self-Regulation (1+) Adaptive Functioning (1+)

Mood or Behaviour Attention Deficit Impulse Control Communication Social Comm. & Interaction Daily Living Skills Motor Skills

American Psychiatric Association, DSM-V, 2013

Comorbidity and Complexity

High rates of additional pre and postnatal adversity

 Additional teratogen exposure  Exposure to stress/violence  Poor prenatal health care/maternal nutrition status  Pre-term birth & birth complications

Comorbidity and Complexity

High rates of adversity, including criminal justice system involvement

61 60 60 49 35 82 78

Ages 21+

Streissguth et al., 2004 (n = 253)

Trouble with the Law

 Charged, arrested and/or convicted:  67% adolescents 87% adults  Risk Factors: Low % life in stable home Older age at diagnosis FAE  Protective Factors: IQ < 70

Comorbidity and Complexity

High rates of adversity, including criminal justice system involvement

61 60 60 49 35 82 78

Streissguth et al., 2004 (n = 253)

Comorbidity and Complexity

Depression, Anxiety

Sleep Disorders Seizure Disorders ADHD

Additional Dysmorphology

Frequent Infections

Dental, Palate

Physical and mental health needs are complex, with comorbidity estimated at over 90%

Popova et al. 2016, ; Pei et al., 2011

Outline

Introduction to FASD Relevance & Research in Criminal Contexts Gaps and Needs 1 2 3

Contact and Prevalence

NA General Pop Inpatient Youth Forensic Male Corrections Youth Corrections Female Corrections

Bower et al., 2018; Clarren et al., 2015; Fast et al., 1999; Forrester et al., 2015; May et al., 2014; 2018; MacPherson et al., 2011; Popova et al. 2011; 2017; 2018; Streissguth et al., 2004; McLachlan et al., under review

4%

Contact and Prevalence

NA General Pop Inpatient Youth Forensic Male Corrections Youth Corrections Female Corrections

Bower et al., 2018; Clarren et al., 2015; Fast et al., 1999; Forrester et al., 2015; May et al., 2014; 2018; MacPherson et al., 2011; Popova et al. 2011; 2017; 2018; Streissguth et al., 2004; McLachlan et al., under review

4%

Contact and Prevalence

NA General Pop Inpatient Youth Forensic Male Corrections Youth Corrections Female Corrections

Bower et al., 2018; Clarren et al., 2015; Fast et al., 1999; Forrester et al., 2015; May et al., 2014; 2018; MacPherson et al., 2011; Popova et al. 2011; 2017; 2018; Streissguth et al., 2004; McLachlan et al., under review

4%

Estimating Prevalence in a Northern Canadian Correctional Population

AIM: Estimate the prevalence of FASD and neurocognitive deficits in a northern Canadian adult correctional jurisdiction

 Explore neurocognitive profile in those diagnosed with FASD vs. those without

APPROACH: Prospective case ascertainment design using Canadian FASD Diagnostic Guidelines (Chudley et al., 2005)

McLachlan, 2017; McLachlan et al., Under Review

6,122 km

Quick Geography Reminder….

Fact Facts

• Smallest Canadian

territorial population (~36,000)

• Population concentrated

in single city (~70%)

• Complex government

structure

McLachlan, 2017; McLachlan et al., Under Review

Design and Method

McLachlan, 2017; McLachlan et al., Under Review

Sample

N = 80 (18% of population, 92% retention)

McLachlan, 2017; McLachlan et al., Under Review

Findings

68.8%  FASD Ruled Out

McLachlan, 2017; McLachlan et al., Under Review

Findings

17.5%  FASD Diagnosed 86% No Physical Features 2 cases previously identified

McLachlan, 2017; McLachlan et al., Under Review

Findings

13.8%  Deferred

McLachlan, 2017; McLachlan et al., Under Review

Findings

31.2%  FASD & At Risk

McLachlan, 2017; McLachlan et al., Under Review

• 3
• 2,5
• 2
• 1,5
• 1
• 0,5

FASD Deferred Not Diagnosed

Cognitive Profile

Cognition Academics Attention Memory Executive Functioning

z

McLachlan, 2017; McLachlan et al., Under Review

Complex Neurocognitive Needs

20 40 60 80 100 ≤ 2 ≥ 3

FASD Deferred Not Diagnosed

Neurocognitive Domains Impaired

20 40 60 80 100 ≤ 2 ≥ 3

Diagnosed Not Diagnosed

% Domains Impaired in Justice-Involved Youth Bower et al., (2018)

McLachlan, 2017; McLachlan et al., Under Review

94% had serious neurocognitive problems 34% had IQ <70

%

Complex Neurocognitive Needs

20 40 60 80 100 ≤ 2 ≥ 3

Diagnosed Not Diagnosed

% Domains Impaired in Justice-Involved Youth Bower et al., (2018)

McLachlan, 2017; McLachlan et al., Under Review

% 20 40 60 80 100 ≤ 2 ≥ 3

FASD Deferred Not Diagnosed

Neurocognitive Domains Impaired

Complex Neurocognitive Needs

20 40 60 80 100 ≤ 2 ≥ 3

FASD Deferred Not Diagnosed

Neurocognitive Domains Impaired

20 40 60 80 100 ≤ 2 ≥ 3

Diagnosed Not Diagnosed

Neurocognitive Domains Impaired

McLachlan, 2017; McLachlan et al., Under Review Bower et al, 2018; BMJ Open

76% had serious neurocognitive problems

% %

• Individuals with FASD have significant and important strengths, in

addition to difficulties. It is important to use strength-based language, and focus on resilience

Key Message

McLachlan, 2017

Strengths

Legal Implications

FASD has been considered in a range of Canadian and international legal cases in the context of:

 Sentencing (mitigation vs. aggravation; adult sentences for youth)  Voluntary waiver, Competency to stand trial, Execution  Criminal responsibility

FASD is relevant in risk assessment, management, and correctional and forensic intervention for both youth and adults

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

• Increased risk of poor

rights comprehension

• High rates of false

confessions

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

• Limitations in

adjudicative competence

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

• Limited evidence to

support effective intervention and management programs

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

• Limited evidence

and community based supports

Contact Points

Corrado & McCuish, 2015, Flanagan et al., 2018; McLachlan, 2012; McLachlan et al., 2014, 2018

• Increased risks and

criminogenic needs

Risks and Clinical Needs of Justice- Involved Youth with FASD (ages 12-23)

10 20 30 40 50 60 70 80 90 100

Physical Abuse Sexual Abuse Emotional Abuse Neglect Child Welfare Psych Hosp Psych Meds Suicide Attempt Substance Tx Overdose Homeless

Percent (%) FASD Comparison * * * * (N = 100)

McLachlan, et al., in preparation

* * p < .05

Risks and Clinical Needs of Justice- Involved Youth with FASD (ages 12-23)

10 20 30 40 50 60 70 80 90 100

Physical Abuse Sexual Abuse Emotional Abuse Neglect Child Welfare Psych Hosp Psych Meds Suicide Attempt Substance Tx Overdose Homeless

Percent (%) FASD Comparison * * * * (N = 100)

McLachlan, et al., in preparation

* * p < .05

• Earlier first arrest age (14 vs. 15)
• 92% rated high risk to re-offend
• No difference in offence ‘type’
• More rapid and higher recidivism

rates

• Significantly higher rates of

transition to adult justice system

McLachlan, Gray, Roesch, Viljoen, & Douglas, Psychol. Assess, 2018

Offending Profiles

Historical, clinical, behavioural, orientation factors rates significantly higher in youth with FASD

McLachlan, Gray, Roesch, Viljoen, & Douglas, Psychol. Assess, 2018

Risk Factors: SAVRY & YLS/CMI Ratings

2 4 6 8 10 12 14 16 Hist Soc/Cont Ind/Clin Protective 1 2 3 4 5

* * * * * * SAVRY YLS/CMI

Historical, clinical, behavioural, orientation factors rates significantly higher in youth with FASD

McLachlan, Gray, Roesch, Viljoen, & Douglas, Psychol. Assess, 2018

Risk Factors: SAVRY & YLS/CMI Ratings

2 4 6 8 10 12 14 16 Hist Soc/Cont Ind/Clin Protective 1 2 3 4 5

* * * * * * SAVRY YLS/CMI

Historical, clinical, behavioural, orientation factors rates significantly higher in youth with FASD

McLachlan, Gray, Roesch, Viljoen, & Douglas, Psychol. Assess, 2018

Risk Factors: SAVRY & YLS/CMI Ratings

2 4 6 8 10 12 14 16 Hist Soc/Cont Ind/Clin Protective 1 2 3 4 5

* * * * * * SAVRY YLS/CMI

• Protective factors inversely linked with

recidivism risk and aggression (McLachlan

et al., 2018)

• Hope, willingness to change, and

resilience linked with positive

• utcomes (Pei et al., 2016; Rogers et al., 2013)
• Early diagnosis, lower substance

use associated with reduced justice contact (Currie et al., 2016; Streissguth, 2004)

Protective Factors

Screening is Critical

Failure to identify and attend to specialized neurocognitive, risk-related and clinical needs, likely contributes to increased recidivism and victimization risk Entrenched criminal justice involvement linked with poor health, social, and economic outcomes Screening in high risk populations is a challenge

 Limitations: knowledge/skills, training, resources, validated screening tools

Screening Tools

Self-Report Questionnaires Structured Interviews

Brief Screening Checklist (MacPherson et al., 2011)

• Self-report tool with 46-items spanning

behavioural, historical, and maternal alcohol use risk factors

Life History Interview (Grant et al., 2013)

• Brief semi-structured client-centred interview

canvasing key behavioural and historical risk markers for FASD

Informant-Rated Biomarker Approaches

Asante FASD Screening Tool (Conry & Asante, 2010)

• Structured checklist with referral criteria spanning

personal and behavioural risk factors associated with FASD, designed to be completed by youth probation officers Portable Eyetracking and EEG DNA Methylation Neuroinflammation Single-cell epigenetic changes

Brief Screening Checklist

Study 1

• Self-report
• 46 items, 3 domains
• Prospective design

with gold standard validation

• Results:
• Sensitivity &

Specificity < 60%

Item Revision

• Selected 8 items

best differentiating diagnostic groups

• Findings
• 92% sensitivity
• 70% specificity

Study 2

• Self-report, new

cohort (N = 37)

• 8 items, 3 domains
• Cross sectional design

with known diagnostic

• utcomes
• Results
• 93% sensitivity
• 92% specificity

McLachlan, 2017; McLachlan in preparation

Eyetracking and EEG

McLachlan, et al., 2018; Xiu et al., 2018; Xiu et al., in preparation

 Justice-involved adults with FASD show higher proportion of direction errors in the antisaccade task compared to controls

EEG Recording during Antisaccade Task

McLachlan, et al., 2018; Xiu et al., 2018; Xiu et al., in preparation

 Healthy controls exhibited decrease in absolute power of EEG selectively in lower frequency bands (0 – 10 Hz) approximately 300 ms before central fixation disappearance  Change was delayed and significantly weaker in justice- involved adults with FASD, suggesting impaired learning/task adaptation

CJS Control FASD

Outline

Introduction to FASD Relevance & Research in Criminal Contexts Gaps and Needs 1 2 3

Key Gaps and Needs

Need for empirical work in the justice context, particularly in adults (with links to other sectors) Efforts to validate FASD screening tools and approaches for justice contexts Additional guidance and clarity on the impact of FASD across adjudicative, correctional, and treatment contexts Evidence is needed to support effective policy decisions for screening, assessment, and intervention (e.g., unique needs?)

Wide Ranging calls for Policy Change

• FASD in the criminal justice context is a major public health issue
• Further training can enhance clinical skill in forensic and

correctional contexts

• More research is needed to systematically inform key challenges

and needs

• Policy responses must be intersectoral and evidence-based

Take Home Messages

• Collaborators:
• Queen’s University: James Reynolds, Gunnar Blohm, Cindy Xiu, Deng
• McMaster University: Michael Amlung, Gary Chaimowitz
• University of British Columbia: Tim Oberlander, Ursula Brain
• University of Alberta: Jacquie Pei, Gail Andrew, Allison McNeil
• Simon Fraser University: Ron Roesch, Jodi Viljoen, Kevin Douglas,

Billie Joe Rogers

• Supporting Participants, Families, Agencies, and Communities

Acknowledgements

Canadian Foundation for Fetal Alcohol Research

Thank you!

kmclac02@uoguelph.ca Helpful Resources: https://canfasd.ca/ https://knowfasd-webpro.ualberta.ca/