Fetal Alcohol Spectrum Disorder in a correctional population

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					         FASD in a Correctional Population:
     Preliminary Results from an Incidence Study


                                         Patricia MacPherson
                                      Addictions Research Centre
                                      Correctional Service Canada
Addictions Research Centre
23 Brook St., Montague, PEI C0A 1R0
                                           Albert E. Chudley
                                        University of Manitoba
Purpose of Talk
   To review population incidence studies
   To review correctional systems
   incidence
   To review research study objectives and
   methodology
   To review preliminary results
Project Team
  Co-Investigators
     Patricia MacPherson, M.Sc. & Brian Grant, Ph.D, (ARC)
     Albert Chudley, MD, University of Manitoba

  Clinical Neuropsychologist
     Andrea Kilgour, Ph.D, University of Manitoba

  Field Staff
     Kim Spiers (SMI), Dawn Harmer (Winnipeg Parole)

  Data quality/ data management
     Charlotte Fraser, MA (ARC)
Secondary Disabilities
   A result of the interaction between
   primary disabilities (behavioural and
   neuropsychological problems) with
   adverse environments
Secondary Disabilities
   Academic failure
   Mental health disorders
   Addiction
   Sexual deviance
   Inability to live independently
   Problems with the justice system
     Encounters with the law
     Confinement
Prevalence
   Health Canada
     FAS:        1 – 3 per 1000 live births
     FASD:       9 per 1000 live births


   Rate varies dramatically in special
   populations
     Less than 1 to 190 per 1000 live births
Incidence in Offender Samples
   Estimates of
   incidence in
   offenders vary,
   with study
   limitations

   psychiatric
   referrals
   young offenders         Streissguth, 1997
Boland et al., (1998).

“Although  there is
substantial evidence
suggesting a link
between FASD and
crime…. there are no
known studies
reporting the
prevalence of FASD
in prisons.”

http://www.csc-scc.gc.ca/text/rsrch/reports/r71/er71.pdf
Correctional Population
   Conry and Fast, 1999
      287 young offenders remanded to a forensic psychiatric
      inpatient assessment unit
      23% (3 FAS; 67 FAE)

   DOJ BC 2005: probation officer referrals
     48 referrals, 21 assessments: 17 ARND; no FAS

   Burd (2003): survey of Canadian correctional facilities
      13 of 148,797 diagnosed cases in Canada; prevalence rate
      of 0.087 per 1000, below the estimated incidence rate of
      the American and Canadian population of FAS or FASD of
      1-3 per 1000 and 9.1 per 1000
Challenges in the prison
environment
   Victimization
   Prison routine / rules
   Wanting to fit in
   Inappropriate sharing of information
   Inappropriate social behaviours
Challenges for Corrections
   How to identify affected individuals
   Number of offenders with FASD
   How to adapt current programs
   How best to accommodate
   Management in the institution and
   community
   Reducing risk of re-offending; keeping the
   community safe
Purpose of CSC Research
   Determine incidence
     Identify scope of the problem
     Appropriate resource allocation
     Develop targeted interventions
   Develop a screening instrument
     Identify offenders for further assessment
     Integrate into intake assessment process.
Potential benefits of a diagnosis
   New way to understand difficulties
     Paradigm shift in attitudes of guards, case
     management/ and program staff, judges,
     parole officers and offender


   Open doors for service and provides
   impetus for development of appropriate
   services for the affected individual
Potential benefits of a diagnosis
   New strategies in the institution and in
   the community upon release
     Peer counselors, mentors, adapted training
     programs (employment, life skills,
     education etc.)


   Reduce recidivism
Screening Tools
   The Alcohol Related Neurodevelopmental Disability (ARNDD)
   Behavioral Checklist (Burd, 1999)
      Administered by specialized clinician

   The FASNET Assessment tool (BC FASNET) - 244 items
      version had been adapted for Genesis House but is not vaildated

   The Fetal Alcohol Exposure Risk Assessment for Adoldescents
   and Adults (LaDue et al., 1999 )
      - heavily reliant on physical measurements

   The Fetal Alcohol Behavior Scale (Streissguth, 1998)
      No longer used

   The GGPC FASD Screening Tool (Prediger , 2003)
      Requires extensive file review for each case; still in development
Study Sample
Offenders processed by Winnipeg Parole Office
  30 and under;
  Over 18 month period
  New admissions transferred to Stony Mountain Institution


Aboriginals are over-represented in our sample (60%
vs. 17%)
  Everyone is asked to participate
  Statistical methods will be used to generalize to CSC
  population

Women are not purposely excluded, SMI is a male
facility
STONY MOUNTAIN INSTITUTION MEDIUM-SECURITY PENITENTIARY
                    Facility Characteristics
                      Date opened: 1876
                     Security level: Medium
                      As of April 6, 2004
                      Rated capacity: 546
                    Number of inmates: 506
Why Stony Mountain?
Participant Recruitment
   Remand Centre/Headingley Correctional Centre:
     Parole officer conducts preliminary assessment with newly
     sentenced offenders
     Explains that research assistant will be coming to see them

   Research Assistant:
     Explain the study to offenders both verbally and in writing
     Audiotapes consent interview
     Obtains signed consent
Information Sources – Community
   28 Behavioural Indicators
      Judgment, distractability, mood swings, hyperactivity,
      financial, consequences.

   Historical Indicators
      Adopted, foster care, developmental challenges, school
      disruption, mental health

   Maternal consumption of alcohol

   Information collected from the offender, parole
   officers, collateral sources
Information Sources - Institution
   Medical Intake Interview

   FASD Facial Photographic Analysis Software

   Physical exam
      Facial measurements, about 10 minutes

   Neuropsychological testing
      IQ; executive functioning; visual and auditory memory;
      social adaptive functioning
              Fetal Alcohol Syndrome
Facial Photographic Analysis Software
                Susan Astley, University of Washington
Summary report
FASD Neuropsychological Test Battery
  Wechsler Abbreviated Scale of Intelligence      WASI
  Wechsler Individual Achievement Test Second     WIAT-II-R
     Edition Abbreviated
  Adaptive Behaviour Assessment System Second     ABAS-II
     Edition
  Wechsler Memory Scale Third Edition             WMS-III-A
     Abbreviated
  Wisconsin Card Sorting Test Revised             WCST-R
  Connors Continuous Performance Test             CCPT
  Rey Complex Figure Test and Recognition Trial   RCFT
Diagnosis
   Case Conference to determine outcome
       • Doctor
       • Psychologist
       • Research Liaison Officer

   Information from all sources will be compiled
       • Checklists (community)
       • Medical records
       • Medical intake interview
       • Photometric report
       • Physical/neuropsychological evaluations
 Chudley et. al., 2005. Fetal alcohol spectrum disorder:
Canadian guidelines for diagnosis. CMAJ; 172 (suppl 5)
Four Research Outcomes
       Research Outcome
  A    Diagnosis in one of the FASD
       categories
  B    Does not meet diagnostic criteria but
       remains a possibility

  C    No FASD-related diagnosis but other
       impairments noted

  D    Normal
Debriefing
  All participants :
    Received letter from physician stating
    results
    Received certificate of appreciation for
    participation
    With positive neuropsychological findings,
    letter from psychologist detailing results
Debriefing
   If no FASD diagnosis, Research Liaison
   Officer debriefed participants



   If an FASD-related diagnosis is made, the
   diagnostic team was present for debriefing
   and will explain results to participant
Disclosure
  Participants decided if they want their
  results disclosed to CSC

    Results placed on CSC file
     • Health care
     • Psychology
     • Case management

    Used by case management team

    Were offered Research Liaison Officer support
Follow-up
   Once a year for two years

   Those diagnosed with FASD

   Brief Questionnaire (approximately 10
   minutes)

     Adjustment
     Views on participation in study
     Value or benefit of their experience with the
     Research Liaison Officer
Results
Study Sample
  165 offenders were asked to participate over
  the study period (April 2005-September 2006)

    106 agreed (64%)
    11 withdrew
    4 participants had invalid CNS results
    58 declined


  Final Study Sample : 91 participants
Demographics for final sample
(n=91)
   66% Aboriginal
     34% Métis
     32% First Nation


   25% Caucasian

   9% Other racial groups (Black, East Indian,
   Chinese)
Demographics continued
   53% single
   46% common law

   Average age 24, SD 2.85
     Range in age between 19-30yrs
Summary of collateral information
   Average of 2 per participant (n=194; range 0 – 7)

   61% of collaterals participated (n=118)
     46% participated with maternal alcohol information
     16% participated without maternal alcohol information

   28% unable to contact
     15% no valid contact information
     13% difficult to reach

   10% declined
Summary of maternal information
   77% of offenders provided mother as a contact
   (n=70)

   69% agreed to participate (n=48)

   16% unable to contact
     7% difficult to reach
     9% no contact information
     3% language barrier

   13% declined
Birth/Hospital Records
    All participants agreed to allow access
    to birth records
      72% of records received


    96% of mothers agreed to release
    records related to their pregnancy
      63% of pregnancy records received
 Summary of Collaterals Participating n=126
Relation                           With Alcohol                        Without Alcohol
                                     History                               History
                                      % (n)                                % (n)
Aunt/Uncle                               93 (26)                              7 (2)
Sibling                                  81 (21)                             19 (5)
Father                                   95 (20)                              5 (1)
Grandparent                              92 (11)                              8 (1)
CLW, spouse                               36 (9)                             64 (16)
Foster, adopted or                        67 (4)                             33 (2)
step parent
Other*                                    38 (3)                             62 (5)

* Other includes foster care worker, other professional, friend, or cousin
Maternal Indicator Summary
                      Offender     Mother       Collateral             Collateral


Drink when offender       Y                          Y                       Y
    was young

Frequency              2-4 month                  2-3 week              2-4 month
Amount per occasion    12 beers                     >5                  >5 (2 -24‟s)
Drink when pregnant       U                          Y                       Y
    with offender

Timing of alcohol         U                 During full pregnancy   Not longer than the
    consumption                                    (on and off           first 43 days of
                                                  during whole           the pregnancy.
                                                   pregnancy)
Frequency                 U                      2-4 month          Less than once per
                                                                            month
Amount per occasion       U                  Unsure of amount               1-2
Binge drinking            U                        Unsure                  Never
Other drug use           N/A                Tobacco; Cannabis;      Tobacco; Cannabis;
                                                 Prescription         Prescription drugs
                                                    drugs
Reporting on prenatal alcohol exposure
   Offender                                 Collateral
                           Yes
              7%           No
                           Unknown
                                                         27%     22%


     50%           43%                      Yes=20
                            Yes=6                              51%




                             Mother
                                             10%




                         Yes=9        90%
     Reported Prenatal Alcohol Exposure
Drinking Questions    Collateral     Mother
                     (N = 20) %    (N = 9) %
Drink during full       45            11
pregnancy
Drink during part       25            67
of pregnancy
Drink 2-3 times         25            0
per week
Drink 2-4 times         15            33
per month
Binge Drinking (>       41            56
5 drinks)
Results from diagnostic assessments
   9 offenders diagnosed in one of the FASD
   categories (10%)
     1 pFAS
     8 ARND


   16 offenders in the „Possible‟ category (18%)
     Not enough information to confirm or rule out a
     diagnosis
Results from diagnostic assessments

   39 offenders in the “CNS deficits – not
   alcohol related” category (43%)

   27 offenders in the “Normal” category
   (30%)
Analysis of palpebral fissure length
(PFL)
   Two independent raters on photometric
   software
     r= 0.88 (p<.0001)


   Physical exam and photometric reports
     r=0.74 (p<.0001)
Analysis of palpebral fissure length
(PFL)
  Mean pfl scores across outcomes

            Report                  Physical Exam
  FASD      29.4 +/-   1.3          29.4 +/- 1.3
  Possible  29.4 +/-   1.6          29.1 +/- 1.5
  CNS-other 29.8 +/-   1.2          30.1 +/- 1.3
  Normal    30.0 +/-   1.8          30.3 +/- 1.4
Analysis of palpebral fissure length
(PFL)
  Mean pfl scores across alcohol exposure

                    Report         Physical Exam
  Alcohol (17)      29.2 +/- 1.5   28.6 +/- 1.5
  No Alcohol (74)   29.9 +/- 1.5   29.3 +/- 1.5
Analysis of palpebral fissure length
(pfl)
  Mean pfl scores across racial groups

                   Report           Physical Exam
  Caucasian        29.9 +/-   1.6   29.1 +/- 1.7
  First Nations    29.1 +/-   1.5   28.8 +/- 1.3
  Métis            30.1 +/-   1.3   29.3 +/- 1.6
  Other            30.3 +/-   1.4   30.4 +/- 1.2
Average Scores on Behavioural
Items
               120
                        103
               100
   Average Score




                                  81
                   80                       76
                                                      69

                   60

                   40

                   20

                    0
                        A         B         C         D

                              28 questions: max score = 140
Behavioural indicators
   Behavioural items on offender self
   report scale highly intercorrelated;
     Cronbach‟s coefficient alpha .90


   17 out of 28 items correlated with FASD
   diagnosis
Behavioural indicators:
offender self report (top 5 items)
  Item                    Pearson r     p
  Trouble following          .50      .0001
  directions
  Problem with spelling      .42      .0001

  Acts Impulsively           .33      .001

  Trouble completing         .32      .001
  tasks
  Trouble staying on         .30      .001
  topic

  n=91
Behavioral indicators;
collateral reports
   Items on collateral scale also highly
   intercorrelated
     Alpha = 0.91


   18 items correlated with FASD diagnosis
Behavioural indicators:
collateral report (top 5 items) n=90
  Item                     Pearson r     p
  Has a poor attention        .38      .0001
  span
  Has poor social skills      .37      .0001

  Has trouble following       .34      .001
  directions
  Is easily distracted        .33      .001

  Talks a lot but says        .33      .001
  little
Behavioural indicators combined
(all reports; n=260)
 Item                               Pearson r
                                   (p<.0001)
 Has trouble following direction      .31
 Has poor social skills               .27
 Has a poor attention span            .25
 Has trouble completing tasks         .25
 Talks a lot but says little          .25
 Acts impulsively                     .25
 Has poor judgement                   .24
 Is easily distracted                 .23
 Has temper tantrums                  .23
 Is unaware of consequences           .23
 Has trouble staying on topic         .23
Reported alcohol use (any source)
   Prenatal alcohol reported by any source
   was correlated with alcohol score on 4-
   digit code (r=0.70, p<.0001)

   Mother‟s use of alcohol when offender
   was young was correlated with 4 digit
   alcohol score (r=0.42, p<.0001).
Average Score on Historical
Items
                  5
                      4
                  4
  Average Score




                  3
                          2
                  2
                                     1          1
                  1

                  0
                      A   B          C          D


                          9 questions: max score = 11
Historical checklist items n=92
Item                                 Pearson r     p
Ever in foster care                     .51      .0001
# of times in care                      .63      .0001
Problems with school from an            .44      .0001
early age
Treatment for a mental health           .25       .01
problem
# of times in treatment                 .25       .01
Diagnosed with a developmental          .25       .01
disability
Been told by a health professional      .25       .01
that he/you might have FASD
Overall risk and need for outcome
groups               FASD        Unknown        CNS - Other   Normal
                90

                80                                        *
                70   *
                60
      Percent




                50

                40

                30

                20

                10

                 0

                             High Risk                        High Need
 X2(6,91)=16.67, p<.01; X2(6,91)=17.58, p<.01
 Criminogenic need areas for FASD–affected
 offenders (compared to others in study group, n=91)

            * Employment
 * Personal Emotional
        Marital/ Family
       Substance Abuse
Community Functioning
                 Attitude
               Associates

                            0   20   40             60   80   100
   *p<.01
                                          Percent
Characteristics of FASD group
   All had less than grade 10 and 67% (6) had
   less than grade 8 education

   None had a skill, trade or profession

   All were unemployed at time of arrest and
   33% (3) had no employment history

   None had participated in employment
   programs prior to incarceration
Characteristics cont.
  All offenders were rated by intake parole officers as
  having poor problem solving abilities and unable to
  generate choices

  Almost all (n=8) were rated as having poor problem
  recognition abilities and unaware of consequences of
  their actions

  All were described as having poor stress management
  and poor conflict resolution

  Two had a current or prior mental health diagnosis and
  four were currently prescribed medication
Criminal History
                             FASD       Possible    CNS-Other      Normal
    100
               *
          80
                             *
Percent




          60

          40

          20

           0
               Youth Court    15 or More     Previous Adult    15 or More
                 History     Convictions -     Provincial     Convictions -
                                Youth            Term            Adult
* p<.01
Limitations of the study
   Small “n”
   Surprising proportion of non-participation
   Ethnic mix at Stony not representative of
   general correctional institutions in other parts
   of Canada
   Current definition of “Brain domains” in
   diagnostic guidelines may limit recognition of
   some FASD affected individuals
Conclusions
   The incidence of FASD is ten times greater in Stony
   Mountain Institution compared to the general
   population

   This is a minimum estimate of incidence as we
   followed a conservative diagnostic approach

   The photometric analysis highly correlates with the
   physical exam

   A history of prenatal alcohol exposure is associated
   with smaller PFL but this was not clinically or
   statistically significant
Conclusions
   There are no clinically or statistically significant
   differences between PFLs and ethnic groups

   There are specific items on the BSC screening tool
   that are highly correlated with an FASD-related
   diagnosis

   Some characteristics of these offenders on the
   Offender Intake Assessment may distinguish them
   from the rest of the offender population

   This study will allow us to develop a reliable
   screening tool for the identification of risk for an
   FASD-related diagnosis in the offender population
Next Steps
   Analysis needs to be completed to determine
   sensitivity and specificity of the modified
   screening tool, neuropsychological results,
   etc.

   Replicate study at another federal institution
   to validate results in order to generalize to
   the Canadian offender population
Thank you!




     Addictions Research Centre
     Correctional Service Canada
     Montague PEI