Definition of FASD HHS, Services Administration FASD Centers for Excellence “Fetal alcohol spectrum disorders” (FASD) is an umbrella term describing the range of effects that can occur in an individual whose mother drank alcohol during pregnancy. These effects may include physical, mental, behavioral, and/or learning disabilities with possible lifelong implications. The term “FASD” is not intended for use as a clinical diagnosis. Source: Bertrand, et al., 2004.
Fetal Alcohol Syndrome (FAS) One of the FASD conditions Characterized by: Certain facial features Growth deficiency Central nervous system dysfunction HHS, Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorders Center for Excellence
Facial Anomalies in the Young Child Diagnostic Criteria Associated Features Epicanthal folds Flat midface Low nasal bridge Short nose Minor ear anomalies Micrognathia 1. Short palpebral fissures 2. Flat philtrum 3. Thin upper lip Streissguth (1994)
Common Terms for Other FASD Conditions Fetal alcohol effects (FAE) Alcohol-related birth defects (ARBD) Alcohol-related neurodevelopmental disorder (ARND) Partial FAS (pFAS) HHS, SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence
U.S. Surgeon General (1981): Health Advisory “Alcohol consumption during pregnancy, especially in the early months, can harm the fetus.” Significantly decreased birth weight with only 1 ounce/day of absolute alcohol (2 drinks). Heavy drinkers risk bearing children with FAS, a “syndrome…. characterized by central nervous system disorders, growth deficiencies, a specific cluster of facial abnormalities, and other malformations, particularly skeletal, urogenital, and cardiac.” Even if they do not bear a child with full FAS, women who drink heavily are more likely to bear children with one or more of the birth defects included in FAS (e.g., microcephaly).
1988 Alcoholic Beverage Labeling Act (USC 27, Section 213): GOVERNMENT WARNING LABEL: “According to the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects….”
Fetal Alcohol Spectrum Disorders (FASD) Of the 5 specific syndromes (per IOM, 1996), all but #2 require confirmed maternal drinking: 1) Fetal Alcohol Syndrome (FAS) with confirmed maternal drinking 1) FAS without confirmed maternal drinking 2) Partial FAS (PFAS) with confirmed maternal drinking 3) Alcohol Related Neurodevelopmental Disorder (ARND) 4) Alcohol Related Birth Defects (ARBD)
FASD Diagnoses That Do NOT Require Full Facial Criteria & Growth Deficit per IOM, 1996 Both diagnoses require confirmed maternal drinking, plus: #3 Partial FAS some facial abnormalities, AND growth deficit, OR structural/neurological abnormalities, OR cognitive-behavioral abnormalities #4 Alcohol Related Neurodevelopmental Disorder (ARND) structural brain damage, OR cognitive-behavioral abnormalities
Fact: Studies have found that people who abuse drugs almost always abuse alcohol along with the drugs.
CDC (2004): Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis Diagnostic guidelines mandated by Congress for training and standardization purposes Improved measurement precision of the 4 FAS diagnostic criteria (face, growth, CNS, mom’s drinking)
U.S. Surgeon General (2005): Health Advisory Alcohol consumed during pregnancy increases the risk of alcohol related birth defects, including growth deficiencies, facial abnormalities, central nervous system impairment, behavioral disorders, and impaired intellectual development. No amount of alcohol consumption can be considered safe during pregnancy. Alcohol can damage a fetus at any stage of pregnancy. Damage can occur in the earliest weeks of pregnancy, even before a woman knows that she is pregnant. The cognitive deficits and behavioral problems resulting from prenatal alcohol exposure are lifelong.”
The Problem Continues Source: Office of Applied Studies, 2003 and 2005 (SAMHSA) Alcohol Use by Pregnant Women Percent
Mental Health’s Response to Diagnosis 1977:FAS is listed in ICD-9 (760.71: Conditions Originating in Perinatal Period) 1992: FAS is listed in ICD-10 (760.71) 2000:no listing in DSM-IV-TR except ref to ICD-9 and ICD-10 Codes (Appendix G) ??DSM-V?
Menses – beginning of Last Normal Menstrual Period (LNMP) day 1 4 weeks post-LNMP ( first missed period) day 17 day 22 8 weeks post-LNMP (second missed period) day 26 Most Vulnerable Period of Embryo Development embryo age = days after fertilization age post LNMP = embryo age + 2 weeks day 32 2 weeks post-LNMP day 9 day 42
A Critical Point of Vulnerability in embryos only 3-4 weeks old 22 day old human embryo ( about 3 mm. long, the length of the ear on the US dime) brain
Teratogen Sensitivity Various parts of the embryo are more sensitive to teratogens at different stages of development Reprinted from Feldman et al., 2003
Normal Brain / FAS Brain Permission to use photo on file.
Excessive cell death Reduced cell proliferation Migrational errors in brain development Inhibition of nerve growth factor Disruption of neurotransmitters HOW DOES ALCOHOL CAUSE BRAIN DAMAGE? CAUSES: ALCOHOL CAUSES:
Corpus Callosum = Central Relay Station Left Brain Language Math Logic Right Brain Spatial abilities Visual Imagery Music Face recognition
Corpus Callosum Abnormalities Mattson, et al., 1994; Mattson & Riley, 1995; Riley et al., 1995
Take-Home Message: All FASD Diagnoses May Involve Brain Damage to Multiple Brain Structures Any amount of prenatal alcohol exposure can cause brain damage Effects of that brain damage can cause a whole array of neurodevelopmental deficits which last a lifetime Brain damage and its associated functional impairments are relevant to defense
Damage to the Central Nervous System per CDC Diagnostic Guidelines (2004) Types of CNS damage: Structural anomalies Neurological deficits Functional performance substantially below that expected for an individual’s age, schooling, or circumstances HHS, Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorders Center for Excellence
10 “Primary Disability” Domains Achievement (learning disabilities, specific math deficit) Adaptive Behavior (communication, social skills) Attention/Hyperactivity (ADD/ADHD) Cognition (abstract/sequential thinking) Language (receptive/expressive skills) Memory (encoding, working memory) Motor Skills (coordination, balance, control) Sensory Integration (visual-spatial learning) Social Skills (social perception, boundaries) Executive Skills (judgment, reasoning, impulse control)
Social Skill Deficits Lack of stranger fear Often scapegoated Naïve and gullible Immature Lack of self-awareness Lack of other-awareness (boundary problems, empathy deficit) Excessive demand for attention Poor social cognition Clinically significant inappropriate interactions
Executive Functions A complex group of Cognitive Abilities Self-Regulation of Behaviors/Feelings Sequencing of Behaviors Cognitive Flexibility Response Inhibition Planning Organization of Behavior involving an Integrative Process Perception Attention Memory Motor General Intelligence and a “Future” Orientation Goal Directed Delayed Gratification
Executive Skill Deficits Poor organization, planning, strategy use Concrete thinking Lack of inhibition Difficulty grasping cause & effect Inability to delay gratification Difficulty following multistep instructions Difficulty changing strategies mid-stream (perseveration) Poor judgment Inability to learn from experience “Fight or flight” panic under pressure
Infancy and Early Childhood Fitful sleep patterns Poor suck reflex Poor muscle tone, which can delay walking and toilet training Small in height and weight Severe temper tantrums Overly sensitive or under-responsive to stimulation Lack of stranger anxiety Possible attachment difficulties HHS, Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorders Center for Excellence
Middle Childhood Possible hyperactivity Poor memory Lack of impulse control Poor social skills Failure to understand consequences Very concrete thinking Onset of academic problems HHS, Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorders Center for Excellence
Adolescence Less obvious FAS facial features Growth deficits diminish and sometimes evolve into obesity Secondary disabilities (alcohol and drug use, depression, depression and other mental illness) Poor judgment and impulsivity legal problems
Chronological vs Developmental Age Timelines Chronological Age -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- 18 Expressive Language -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- 23 Social Maturity -- -- -- -- -- -- -- -- -- -- 12 Math Skills -- -- -- -- -- 8 Reading Decoding -- -- -- -- -- -- -- -- -- -- -- -- -- 14 Reading Comprehension -- -- -- 9 HHS, SAMHSA Fetal Alcohol Spectrum Disorders Center for Excellence Source: Malbin, 2002. Used with permission from Diane Malbin, MSW. Typical developmental variability seen in adolescents with an FASD.
Misconception: Functional damage in FAS is greater than in the other FASD conditions Fact : Research shows that while this may be true on average, individuals with conditions other than full FAS can experience significant brain damage and neurobehavioral deficits (i.e., “primary disabilities”).
Misconception: FASD = Mental Retardation Fact: Only 25% of individuals diagnosed with full FAS are mentally retarded.
More Important Than IQ: Discrepancies Between IQ level and adaptive skills Between IQ level and academic achievement Between Verbal IQ and Performance IQ Uneven profile of cognitive abilities
Moderating Factors Dose of exposure Timing of exposure Pattern of exposure Duration of exposure Genetic susceptibility Maternal age and metabolism Nutrition/prenatal environment Postnatal parenting environment
PREVALENCE Secondary Disabilities OF SECONDARY DISABILITIES Across the Life Span 100 90 80 70 60 50 40 30 20 10 Ages 6-51 (n=408-415) Ages 21-51 (n=89-90) % Mental Health Problems Disrupted School Experience Trouble With the Law Confinement Inappropriate Sexual Behavior Alcohol & Drug Problems Dependent Living Problems with Employment Ages 6 - 51 Ages 21 - 51
Risk Factors for Secondary Disabilities Not raised in a stable, nurturing home Not diagnosed with/ FAS by age 6 Physical or sexual abuse in childhood Lack of Developmental Disabilities services in childhood (intervention and treatment)
Pre-Assessment Screening: Birth Mom Reports of substance abuse during pregnancy Collateral/self reports of maternal alcoholism or drug addiction Reports of substance abuse at any point in life Substance-related medical problems Death from alcohol-related causes Involvement with substance abusing partners Substance abuse treatment Cognitive impairment Criminal history (look for DUIs, prostitution, substance- related arrests) CPS history (e.g., client removed from home during childhood) Psychiatric history Extensive medical history
Pre-Assessment Screening: Record Review Prematurity / birth complications / seizures Failure to thrive or childhood growth deficiency (short and/or thin) Developmental delays Speech and language services in elementary school Learning disabilities / Special Education Poor grades, low achievement test scores relative to IQ Childhood behavior problems in school ADD / ADHD Childhood mental health diagnoses (ODD, CD) Difficult client to work with?
Criminal Behaviors Impulsive criminal acts in juvenile years (e.g. stealing items with little value) Exploitation by more sophisticated criminals History of illogical or impulsive crimes involving obvious risk of apprehension Repeated low-level offenses that do not escalate over time, followed by “uncharacteristic” major felony (instant offense) Crime-related behaviors triggered by panic or excessive fright
Arrest Behaviors Immediate waiving of rights Naïve cooperation with “friendly” law enforcement officers Guileless confessions that most offenders would never make Behavioral regression (childlike) Confessing to improbable offenses or offense behaviors (sometimes false confession)
More Arrest Behaviors Flat affect: cognitive inability to appreciate significance of offense conduct No remorse: cognitive inability to appreciate effects of offense behavior on others Cognitive inability to grasp seriousness of penalties/sentences Inappropriate smiling or laughing
Incarceration Behaviors Multiple (and odd) suicide gestures, often dramatic Transparent malingering behavior Adjustment problems in jail, sometimes followed by better adjustment in prison than on the street (positive response to structure) Victimized by other inmates Failure on community supervision / multiple technical violations
Defense Interview Behaviors Client seems oblivious to severity of charges Client freely admits but cannot explain offense behavior Client seems overly compliant; trust is immediately instilled Affect is incongruent with gravity of situation
Generally Accepted Standard for FASD Assessment: Multidisciplinary Lifelong functional deficits (document review) to establish pre-existing condition and current functional assessment (neuropsychological testing) Physical examination & facial analysis by M.D. (with possible diagnosis) Differential diagnosis: assessment for structural brain damage, consideration of genetic/medical factors, consideration of environmental factors
Possible Diagnostic Team Members in Clinical Settings Geneticist Developmental pediatrician Dysmorphologist Speech-language pathologist Occupational and physical therapists Psychologists Neurologists and neuropsychologists Psychiatrists Nurses, social workers, and other licensed behavioral health specialists Education consultants HHS, Substance Abuse and Mental Health Services Administration Fetal Alcohol Spectrum Disorders Center for Excellence
FASD Experts FASDExperts.com Multidisciplinary forensic team experienced in FASD diagnosis and testimony Over 25 forensic felony cases to date (mostly capital offenses) spanning all legal phases: pre-trial consultation and assessment, sentencing mitigation, habeas, post- conviction Team members: Natalie Novick Brown, PhD (psychologist) Paul Connor, PhD (neuropsychologist) Richard Adler, MD (psychiatrist)
FASD Experts: Assessment Objectives Psychologist: (1) Determines presence of lifelong functional impairments (primary disabilities) rather than learned behavior and rules out environmental explanations for instant offense behavior, (2) Rules in maternal drinking (if appropriate) Neuropsychologist: Determines presence of current functional impairments MD: Conducts physical assessment, reviews reports of functional deficits, and diagnoses
Psychologist: Record Review prenatal records medical records from birth (include siblings) birth mom’s hospital records (delivery) school records (client & siblings) mental health records (including raw data from testing) adoption / foster care records State Child/Family Services records military records arrest records (juvenile & adult, including INSTANT OFFENSE) juvenile commitment/DOC records baby / childhood photos
Psychologist: Collateral Interviews birth mother / father (if available) relatives adoptive / foster family (if applicable) teachers / school psychologists mental health providers neighbors / family friends
CDC Guidelines for Cognitive- Behavioral Deficits Functional Deficits IQ 2 SD below average Deficits 1 SD below average in at least 3 domains Cognitive or developmental deficits Executive functioning deficits Motor functioning delays Problems with attention or hyperactivity Social skills Other, such as sensory problems, pragmatic language problems, memory deficits, etc.
Neuropsychologist: Testing A battery of tests incorporating many of the most salient clinical tests based on 30+ years of research experience in FASD: IQ Achievement Learning and Memory (verbal and visual) Attention Motor Coordination Executive Functions
Neuropsychologist: Tests IQ: WAIS-III, Woodcock Johnson-III Memory / Attention: California Verbal Learning Test, Rey Complex Figure Test, Green’s Word Memory Test, Conner’s Continuous Performance Test Motor Coordination: Grooved Pegboard, Finger Tapping, Grip Strength Executive Functions: Trail Making Test, Controlled Oral Word Association Test, Ruff’s Figural Fluency Test, Stroop Test, Consonant Trigrams Test, Wisconsin Card Sorting Test, Tower of London, Iowa Gambling Test
CDC Guidelines for Cognitive-Behavioral Deficits Functional Deficits IQ 2 SD below average Deficits 1 SD below average in at least 3 domains: Cognitive or developmental deficits Executive functioning deficits Motor functioning delays Problems with attention or hyperactivity Social skills Other, such as sensory problems, pragmatic language problems, memory deficits, etc.
M.D.: Diagnosis Reviews Psychologist’s / Neuropsychologist’s reports of lifelong/current functional deficits Reviews client’s / birth mom’s medical records Performs H&P Renders FASD diagnosis (if appropriate)
M.D.: Diagnostic Report (sample) “It is my opinion, with reasonable medical certainty, that Mr. XXX has Fetal Alcohol Syndrome (FAS). His examination revealed the following: Facial abnormalities characteristic of FAS (4-Digit Diagnostic Code System, Astley & Clarren, 3 rd Edition, 2004) – see pictures on page 3 of 4: A smooth philtrum – 4 out of 5 A thin upper lip – 5 out of 5 Marked “lip circularity” – 5 out of 5 Small palpebral fissures: 28 mm horizontally x 8mm vertically (both eyes)
M.D. Diagnostic Report – cont. Small stature and low weight for age: 63” tall (below 5 th percentile) 130 # (below 5 th percentile)
M.D. Diagnostic Report – cont. CNS abnormalities: Spelling at the 1 st percentile (2 nd Grade Equivalent) on the WRAT-3 (Wide Range Achievement Test, Revision 3) – as tested by Dr. Natalie Novick Brown on July 3, 2007, Arithmetic at the 1 st percentile (2 nd Grade Equivalent) on the WRAT-3 (Wide Range Achievement Test, Revision 3) – as tested by Dr. Natalie Novick Brown on July 3, 2007, A history of enrollment in Special Education since approximately 4 th grade. A report of prior and present attentional deficits, including a markedly abnormal Conners’ Continuous Performance Test – II consistent with a clinical profile. Significant functional deficits reflected in the Vineland Adaptive Behavior Scales (VABS) in all tested domains (Communication, Daily Living Skills, Socialization) at the 1 st to 2 nd percentile, as reported by Dr. Natalie Novick- Brown on September 23, 2007.
Testimony M.D. Diagnosis/Differential Diagnosis Psychologist Nexus: how permanent brain damage caused lifelong functional impairments that also affected instant offense behavior
Take Home Message: 1)FASD = brain damage that is permanent, lifelong, and not apparent from IQ alone (or FASD diagnosis alone) 2) Birth mom does not have to be an obvious alcoholic 3)FASD = mental defect involving impaired judgment, reasoning, and impulse control and is therefore a defense issue
Contact Info (intake): Natalie Novick Brown, PhD Program Director/Chief Psychologist FASD Experts (fasdexperts.com) 425-275-1238 / email@example.com@yahoo.com