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

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

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

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

Key Message FASD occurs in the context of social determinants of health and in all populations where alcohol is used

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

Key Message • 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

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 Sentinel Facial Features Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure • Head circumference • Timing • Height & Weight • Dose • Pattern

FASD: Key Diagnostic Features Sentinel Facial Features Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure • Head circumference • Timing • Height & Weight • Dose • Pattern

FASD: Key Diagnostic Features Sentinel Facial Features Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure • Head circumference • Timing • Height & Weight • Dose • Pattern

FASD: Key Diagnostic Features Sentinel Facial Features Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure Substantial variability • Head circumference • Timing • Height & Weight between individuals • Dose • Pattern

FASD: Key Diagnostic Features Sentinel Facial Features Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure • Head circumference • Timing • Height & Weight • Dose • Pattern

FASD: Key Diagnostic Features Facial Dysmorphology Neurodevelopmental Impairment • Smooth philtrum • Cognition • Thin upper lip • Affect • Short palpebral fissures • Behaviour Growth Prenatal Alcohol Exposure • Head circumference • Timing • Height & Weight • Dose • Pattern

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

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

Cognitive Profile National Cohort of Canadian children (ages 5 – 18) 1 with FASD ( n = 87) and Controls ( n = 110) Control ARND 0,5 pFAS FAS 0 z-score -0,5 -1 -1,5 -2 AS IN-N IN-I IN-S AA RS MN MND DR BR AR QC WID VSP Word EF ATTN MEM Working WM VSP Math NUM READ Attention Memory Executive Functioning ID Memory McLachlan et al., (2017) Advances in Neurodevelopmental Disorders

Neurobehavioral Disorder Associated with PAE ND-PAE More than Minimal PAE Neurocognitive Adaptive Self-Regulation (1+) Functioning (1+) Functioning (1+) Social Comm. & Mood or Attention Global Executive Communication Learning Interaction Behaviour Deficit Intellectual Functioning Daily Living Impulse Visual-Spatial Memory Motor Skills Skills Control Reasoning • Currently: Specifier for “Other Specified Neurodevelopmental Disorder, Associated with Prenatal Alcohol Exposure [code 315.8, p. 86] 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 Streissguth et al., 2004 ( n = 253) Ages 21+ Trouble with the Law 82 78  Charged, arrested and/or convicted:  67% adolescents 87% adults 61 60 60 49  Risk Factors : Low % life in stable home 35 Older age at diagnosis FAE  Protective Factors : IQ < 70

Comorbidity and Complexity  High rates of adversity, including criminal justice system involvement Streissguth et al., 2004 ( n = 253) 82 78 61 60 60 49 35

Comorbidity and Complexity  Physical and mental health needs are complex, with comorbidity estimated at over 90% Depression, Anxiety Sleep Seizure Disorders Disorders ADHD Frequent Dental, Infections Palate Additional Dysmorphology Popova et al. 2016, ; Pei et al., 2011

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

Contact and Prevalence 4% 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

Contact and Prevalence 4% 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

Contact and Prevalence 4% 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

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

Quick Geography Reminder…. Fact Facts • Smallest Canadian 6,122 km 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

Cognitive Profile 0 FASD -0,5 Deferred -1 z Not -1,5 Diagnosed -2 -2,5 -3 Cognition Academics Attention Memory Executive Functioning McLachlan, 2017; McLachlan et al., Under Review

Complex Neurocognitive Needs % Domains Impaired in Justice-Involved Youth Neurocognitive Domains Impaired Bower et al., (2018) 100 FASD 100 Diagnosed 80 Deferred Not Diagnosed 80 Not Diagnosed 60 % 60 40 94% had serious 40 neurocognitive problems 20 20 34% had IQ <70 0 0 0 ≤ 2 ≥ 3 0 ≤ 2 ≥ 3 McLachlan, 2017; McLachlan et al., Under Review