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

Patricia MacPherson Patricia MacPherson

Addictions Research CentreAddictions Research CentreCorrectional Service CanadaCorrectional Service Canada

Albert E. ChudleyAlbert E. Chudley

University of ManitobaUniversity of Manitoba

Addictions Research Centre23 Brook St., Montague, PEI C0A 1R0

Purpose of Talk

To review population incidence studiesTo review correctional systems incidenceTo review research study objectives and methodologyTo review preliminary results

Project TeamCo-Investigators

Patricia MacPherson, M.Sc. & Brian Grant, Ph.D, (ARC) Albert Chudley, MD, University of Manitoba

Clinical NeuropsychologistAndrea Kilgour, Ph.D, University of Manitoba

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

Data quality/ data managementCharlotte Fraser, MA (ARC)

Secondary Disabilities

A result of the interaction between primary disabilities (behavioural and neuropsychological problems) with adverse environments

Secondary Disabilities

Academic failureMental health disordersAddictionSexual devianceInability to live independentlyProblems with the justice system

Encounters with the lawConfinement

Prevalence

Health CanadaFAS: 1 – 3 per 1000 live birthsFASD: 9 per 1000 live births

Rate varies dramatically in special populations

Less than 1 to 190 per 1000 live births

Incidence in Offender SamplesEstimates of incidence in offenders vary, with study limitations

psychiatric referralsyoung 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 PopulationConry and Fast, 1999

287 young offenders remanded to a forensic psychiatric inpatient assessment unit23% (3 FAS; 67 FAE)

DOJ BC 2005: probation officer referrals48 referrals, 21 assessments: 17 ARND; no FAS

Burd (2003): survey of Canadian correctional facilities13 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

VictimizationPrison routine / rulesWanting to fit inInappropriate sharing of informationInappropriate social behaviours

Challenges for Corrections

How to identify affected individualsNumber of offenders with FASDHow to adapt current programsHow best to accommodateManagement in the institution and communityReducing risk of re-offending; keeping the community safe

Purpose of CSC Research

Determine incidenceIdentify scope of the problemAppropriate resource allocationDevelop targeted interventions

Develop a screening instrument Identify offenders for further assessment Integrate into intake assessment process.

Potential benefits of a diagnosisNew 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 ToolsThe Alcohol Related Neurodevelopmental Disability (ARNDD) Behavioral Checklist (Burd, 1999)

Administered by specialized clinician

The FASNET Assessment tool (BC FASNET) - 244 itemsversion 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 SampleOffenders processed by Winnipeg Parole Office

30 and under; Over 18 month periodNew admissions transferred to Stony Mountain Institution

Aboriginals are over-represented in our sample (60% vs. 17%)

Everyone is asked to participateStatistical 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: MediumAs of April 6, 2004 Rated capacity: 546

Number of inmates: 506

Why Stony Mountain?

Participant RecruitmentRemand Centre/Headingley Correctional Centre:

Parole officer conducts preliminary assessment with newly sentenced offendersExplains that research assistant will be coming to see them

Research Assistant:Explain the study to offenders both verbally and in writingAudiotapes consent interviewObtains signed consent

Information Sources – Community

28 Behavioural IndicatorsJudgment, distractability, mood swings, hyperactivity, financial, consequences.

Historical IndicatorsAdopted, foster care, developmental challenges, school disruption, mental health

Maternal consumption of alcohol

Information collected from the offender, parole officers, collateral sources

Information Sources - InstitutionMedical 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

IntelligenceWASI

Wechsler Individual Achievement Test Second Edition Abbreviated

WIAT-II-R

Adaptive Behaviour Assessment System Second Edition

ABAS-II

Wechsler Memory Scale Third Edition Abbreviated

WMS-III-A

Wisconsin Card Sorting Test Revised WCST-R

Connors Continuous Performance Test CCPT

Rey Complex Figure Test and Recognition Trial

RCFT

DiagnosisCase 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

All participants :Received letter from physician stating resultsReceived certificate of appreciation for participationWith positive neuropsychological findings, letter from psychologist detailing results

Debriefing

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

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

Disclosure

Once a year for two years

Those diagnosed with FASD

Brief Questionnaire (approximately 10 minutes)

AdjustmentViews on participation in studyValue or benefit of their experience with the Research Liaison Officer

Follow-up

Results

Study Sample

165 offenders were asked to participate over the study period (April 2005-September 2006)

106 agreed (64%)11 withdrew4 participants had invalid CNS results58 declined

Final Study Sample : 91 participants

Demographics for final sample (n=91)

66% Aboriginal 34% Métis32% First Nation

25% Caucasian

9% Other racial groups (Black, East Indian, Chinese)

Demographics continued

53% single46% common law

Average age 24, SD 2.85Range 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 information16% 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 contact7% difficult to reach9% no contact information3% language barrier

13% declined

Birth/Hospital RecordsAll 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=126Relation With Alcohol

History% (n)

Without Alcohol History % (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 step parent

67 (4) 33 (2)

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 was young

Y Y Y

Frequency 2-4 month 2-3 week 2-4 month

Amount per occasion 12 beers > 5 >5 (2 -24’s)

Drink when pregnant with offender

U Y Y

Timing of alcohol consumption

U During full pregnancy (on and off during

whole pregnancy)

Not longer than the first 43 days of the 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; Prescription

drugs

Tobacco; Cannabis; Prescription

drugs

Reporting on prenatal alcohol exposureOffender

50%

7%

43%

YesNoUnknown

Collateral

51%

22%27%

Mother

90%

10%

Yes=6Yes=20

Yes=9

Reported Prenatal Alcohol Exposure

Drinking Questions

Collateral (N = 20) %

Mother (N = 9) %

Drink during full pregnancy

45 11

Drink during part of pregnancy

25 67

Drink 2-3 times per week

25 0

Drink 2-4 times per month

15 33

Binge Drinking (> 5 drinks)

41 56

Results from diagnostic assessments

9 offenders diagnosed in one of the FASD categories (10%)

1 pFAS8 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 +/- 1.3Possible 29.4 +/- 1.6 29.1 +/- 1.5CNS-other 29.8 +/- 1.2 30.1 +/- 1.3Normal 30.0 +/- 1.8 30.3 +/- 1.4

Analysis of palpebral fissure length (PFL)

Mean pfl scores across alcohol exposure

ReportPhysical Exam

Alcohol (17) 29.2 +/- 1.5 28.6 +/- 1.5No 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 +/- 1.7First Nations 29.1 +/- 1.5 28.8 +/- 1.3Métis 30.1 +/- 1.3 29.3 +/- 1.6Other 30.3 +/- 1.4 30.4 +/- 1.2

Average Scores on Behavioural Items

103

8176

69

0

20

40

60

80

100

120

A B C D

Avera

ge S

co

re

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 pTrouble following directions

.50 .0001

Problem with spelling

.42 .0001

Acts Impulsively .33 .001

Trouble completing tasks

.32 .001

Trouble staying on topic

.30 .001

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 pHas a poor attention span

.38 .0001

Has poor social skills .37 .0001

Has trouble following directions

.34 .001

Is easily distracted .33 .001

Talks a lot but says little

.33 .001

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

4

2

1 1

0

1

2

3

4

5

A B C D

Avera

ge S

co

re

9 questions: max score = 11

Historical checklist items n=92Item Pearson r pEver in foster care .51 .0001

# of times in care .63 .0001

Problems with school from an early age

.44 .0001

Treatment for a mental health problem

.25 .01

# of times in treatment .25 .01

Diagnosed with a developmental disability

.25 .01

Been told by a health professional that he/you might have FASD

.25 .01

Overall risk and need for outcome groups

0

10

20

30

40

50

60

70

80

90

High Risk High Need

Perc

ent

FASD Unknown CNS - Other Normal

*

*

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)

0 20 40 60 80 100

Associates

Attitude

Community Functioning

Substance Abuse

Marital/ Family

Personal Emotional

Employment

Percent

*

*

*p<.01

Characteristics of FASD groupAll 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

0

20

40

60

80

100

Youth CourtHistory

15 or MoreConvictions -

Youth

Previous AdultProvincial

Term

15 or MoreConvictions -

Adult

Perc

ent

FASD Possible CNS-Other Normal

*

*

* p<.01

Limitations of the study

Small “n”Surprising proportion of non-participationEthnic mix at Stony not representative of general correctional institutions in other parts of CanadaCurrent definition of “Brain domains” in diagnostic guidelines may limit recognition of some FASD affected individuals

ConclusionsThe 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

ConclusionsThere 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