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1 Fetal Alcohol Spectrum Disorders (FASD): Screening, Assessment, & Forensic Implications Natalie Novick Brown, PhDFASDExperts.comth Ave. NW, Suite 201Seattle, WA
2 Session Learning Objectives What is FASD?Why FASD is relevant in the legal contextDefense team pre-assessment screeningFormal assessment and diagnostic processFASD ExpertsI’m going to first take you through a quick course on Fetal Alcohol Spectrum Disorders and then explain why the brain damage associated with FASD conditions causes significant impairments in judgment, reasoning, and impulse control, making it relevant within the legal context. I’ll next talk about some of the red flags that indicate you may have a client with FASD and follow that up with what is now viewed as the standard methodology for assessing FASD. Finally, I’ll share with you the procedures my forensic assessment team uses to conduct forensic assessments in a variety of legal contexts, including post conviction.
3 Alcohol = TeratogenWe’ll start with a fundamental finding that has been replicated in thousands of research studies in humans and animals around the world. Alcohol affects prenatal development because it is a teratogen. Teratogens are substances that cross the placenta freely, disrupting whatever is developing at that moment in the embryo or fetus and causing damage. Other common teratogens are cocaine, influenza virus, chicken pox virus, syphilis, and Thalidomide. Even light drinking is associated with damage to the fetus. Binge drinking has been found to be particularly damaging.
4 Definition of FASD“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.Conditions caused by prenatal alcohol exposure are now referred to by a common term: FASDs. At a summit conference hosted by the National Organization on Fetal Alcohol Syndrome (NOFAS), representatives from the Centers for Disease Control and Prevention (CDC), National Institutes of Health, and Substance Abuse and Mental Health Services Administration, the term “FASD” and definition were unanimously agreed upon.FASD is not a diagnosis. It is a descriptive umbrella term that includes several different diagnostic conditions, such as Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorder. The diagnosis of a specific condition under the FASD umbrella does not indicate its severity. Many people mistakenly believe that FAS is the most severe form of FASD, but that is not necessarily true. Other forms of FASD can be just as severe.HHS, Services AdministrationFASD Centers for ExcellenceSource: Bertrand, et al., 2004.Competency 1: Introduction to FASD
5 Fetal Alcohol Syndrome (FAS) One of the FASD conditionsCharacterized by:Certain facial featuresGrowth deficiencyCentral nervous system dysfunctionAlthough FAS is the most commonly recognized term, it represents only a small group of individuals who are affected by prenatal alcohol exposure. The three characteristics listed here are stated in the Centers for Disease Control guidelines for FAS diagnosis. Many people focus on the facial features of FAS as they are the most visible indicators of the condition. However, since most individuals with an FASD do not have any FAS facial features, they cannot be identified easily as having an FASD by their looks.FAS is NOT universally more (or less) severe than other effects of prenatal alcohol exposure.Not all children with an FASD are alike or have all the possible characteristics. The effects range from mild to severe and may or may not include FAS facial features. They depend on the amount of alcohol used and the time at which it was used. They also depend on the mother’s diet, age, and drinking history, as well as the susceptibility of the fetus. Typically, children with an FASD have more physical, developmental, and behavioral problems than do other children. Growth deficiencies may include low birth weight and/or small size for age in weight and length.HHS, Substance Abuse and Mental Health Services AdministrationFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 1: Introduction to FASD
6 Facial Anomalies in the Young Child Diagnostic CriteriaAssociated FeaturesEpicanthal foldsFlat midfaceLow nasal bridgeShort noseMinor ear anomaliesMicrognathia1. Short palpebralfissuresThis is the face of FAS. The 3 facial abnormalities on the left are now what’s required for a full FAS diagnosis.2. Flat philtrum3. Thin upper lipStreissguth (1994)
7 Classic FAS “Facies”An old but excellent photograph of the face of FAS in a young child.
8 FAS in Different RacesHow FAS looks among children in different racial groups.
9 This is a Native American child with FAS This is a Native American child with FAS. Notice the small eye openings, epicanthal folds at the corners of his eyes, and no groove between his upper lip and nose.
10 Here is the same boy in his early teens Here is the same boy in his early teens. Notice the epicanthal folds are still visible, but there is now a relatively normal groove between his upper lip and nose. In puberty, both the facial abnormalities and the growth deficit tend to disappear.
11 Finally, here is the same individual as an adult Finally, here is the same individual as an adult. Notice that the facial abnormalities are virtually gone. This is common in FASD conditions, which makes detection challenging.
12 The photo on the right shows what the growth deficit looks like in children with FAS. These 4 pictures are of the same child with FAS. In the last photo, the child is entering puberty.
13 Common Terms for Other FASD Conditions Fetal alcohol effects (FAE)Alcohol-related birth defects (ARBD)Alcohol-related neurodevelopmental disorder (ARND)Partial FAS (pFAS)Although there is consensus now about the umbrella term for conditions caused by prenatal alcohol exposure, there is no consensus on what terms to use for specific diagnoses other than Fetal Alcohol Syndrome or FAS. Fetal alcohol effects (FAE) is an old term that was used from the 1970s to the mid-1990s. After 1996, when the IOM published its diagnostic guidelines, the term began to drop off because it was so vague. The rest of these terms were coined in 1996 by the IOM and are now used routinely by experts.Alcohol-related birth defects (ARBD) refers his term was coined by the Institute of Medicine in its 1996 volume on FAS to describe physical anomalies only that occurred with confirmed prenatal alcohol exposure.Alcohol-related neurodevelopmental disorder (ARND): This term was also coined by the Institute of Medicine. It refers to neurodevelopmental abnormalities or a complex pattern of behavioral or cognitive abnormalities that are inconsistent with developmental level and cannot be explained by familial background or environment alone.HHS, SAMHSAFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 1: Introduction to FASD
14 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 ofabsolute 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 drinkheavily are more likely to bear children with one or more of the birth defects included in FAS (e.g., microcephaly).In 1981, the U.S. government informed the public about the damaging effects of prenatal alcohol exposure. Note the emphasis in 1981 on physical manifestations of FAS. This Advisory was 8 years after the first published article in the United States on FAS. The timing of these events has implications for post-conviction cases.
15 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….”Throughout the 1980s, there were many published articles in both the scientific and lay press about the harmful effects of maternal drinking during pregnancy, and in 1988, the government passed a law mandating that warning labels appear on all alcoholic beverage containers. At this point, the lay public – including trial attorneys – should have known about the potentially damaging effects of maternal alcohol use.
16 Prenatal Alcohol Exposure = Birth Defects On wine bottles like the one shown here, the warning label appears above the price code.
17 Institute of Medicine (1996): “Of all the substances of abuse (including cocaine, heroin, and marijuana), alcohol produces by far the most serious neurobehavioral effects in the fetus.”Another milestone occurred in 1996 when the Institute of Medicine published diagnostic guidelines for 5 FASD conditions, including FAS and ARND. The 4 original diagnostic criteria – face, growth deficits, CNS abnormalities, and maternal exposure – were made more precise. The IOM also noted that of all the substances of abuse, alcohol was the most destructive to the fetus.
18 IOM Diagnostic Criteria (1996) These are the 5 FASD conditions listed in the 1996 IOM publication. The publication also gives specific diagnostic criteria for each, which this diagram summarizes. For example, Partial FAS (the third category) requires confirmed exposure plus some facial abnormalities and 1 or more abnormalities in the following 3 categories: growth deficits, CNS abnormalities, or cognitive abnormalities. ARND also requires confirmed exposure and CNS and cognitive abnormalities but does not require facial abnormalities or growth deficits.
19 Fetal Alcohol Spectrum Disorders (FASD) Of the 5 specific syndromes (per IOM, 1996), all but #2 require confirmed maternal drinking:Fetal Alcohol Syndrome (FAS) with confirmed maternal drinkingFAS without confirmed maternal drinkingPartial FAS (PFAS) with confirmed maternal drinkingAlcohol Related Neurodevelopmental Disorder (ARND)Alcohol Related Birth Defects (ARBD)In 1996, the Institute of Medicine published diagnostic criteria for 5 FASD conditions. The 2 diagnoses most often ascribed to adolescents and adults are #3 and #4. Sometimes, it is possible to diagnose full FAS (#1) in adults, although usually the abnormal facial features and growth deficit disappear during puberty. Diagnosis #2, FAS without confirmed maternal drinking, is extremely hard to diagnose in individuals past the age of puberty.
20 FASD Diagnoses That Do NOT Require Full Facial Criteria & Growth Deficit per IOM, 1996 Both diagnoses require confirmed maternal drinking, plus:#3 Partial FASsome facial abnormalities, ANDgrowth deficit, ORstructural/neurological abnormalities, ORcognitive-behavioral abnormalities#4 Alcohol Related Neurodevelopmental Disorder (ARND)structural brain damage, ORDespite the fact that puberty tends to erase the physical manifestations of FAS, there are still 2 diagnoses that may be appropriate – neither of which requires all 3 facial abnormalities. These are the FASD diagnoses most relevant in the legal context.
21 Misconception: Children born of women who abuse drugs are not at risk for FASD conditions. Fact: Studies have found that people who abuse drugs almost always abuse alcohol along with the drugs.A common misperception is that individuals whose mothers abused drugs are not at risk for FASD. In fact, it is rare for people to use drugs without also abusing alcohol. For example, alcohol is often used as a way to come down gradually off a crack high.
22 CDC (2004): Fetal Alcohol Syndrome: Guidelines for CDC (2004): Fetal Alcohol Syndrome: Guidelines for Referral and DiagnosisDiagnostic guidelines mandated by Congress for training and standardization purposesImproved measurement precision of the 4 FAS diagnostic criteria (face, growth, CNS, mom’s drinking)In 2004, the CDC published specific and measurable diagnostic criteria for FAS. These criteria included CNS abnormalities, which apply to the 2 FASD diagnoses that are typically given to adolescents and adults: Partial FAS and ARND. A little later, I’ll be showing you examples of these criteria used in a recent case my diagnostic team worked on.
23 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.”A year after the CDC published the more precise FAS diagnostic criteria, the Surgeon General issued a second national health advisory. Note that unlike the first advisory back in 1981, this one focused heavily on the CNS deficits rather than the physical manifestations of FASD.
24 The Problem Continues Source: Office of Applied Studies, 2003 and 2005 (SAMHSA) Alcohol Use by Pregnant WomenPercentUnfortunately, despite all the government attention to the problem, women still drink during pregnancy. The top line represents the percent of pregnant women who drink alcohol, despite all that is now known about the damaging effects. The bottom line represents the percentage of pregnant women who binge drink.
25 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?Internationally, the ICD has noted an FAS diagnosis in its manual beginning as early as In contrast, the DSM – which focuses on mental health diagnoses – has been diligent, to say the least.
26 Most Vulnerable Period of Embryo Development embryo age = days after fertilizationMenses –beginningof Last NormalMenstrualPeriod (LNMP)day 1day 9day 172 weekspost-LNMPday 22day 26Here’s a large part of the problem. Alcohol can cause irreversible brain damage prior to the time that pregnancy is first suspected. It is typically not until after the first missed period that women begin to consider they might be pregnant, and many wait until they miss their second period before they verify the pregnancy.4 weekspost-LNMP( first missed period)day 32age post LNMP = embryo age + 2 weeksday 428 weekspost-LNMP(second missed period)
27 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)brainOn the left is an embryo about 3-4 weeks old, which is within the period when it is most vulnerable to the teratogenic effects of alcohol. To give you a sense of the size of the embryo, on the right is a dime and the white area in front of the ear is the embryo on the left.
28 Teratogen Sensitivity This chart shows what areas in the fetus are most affected by alcohol exposure. At the top of the chart is the age of the embryo, which becomes a fetus after the 8th week. Because major structures form during the first 6-8 weeks of pregnancy, major structural abnormalities can also occur during that time if alcohol exposure occurs. The CNS begins developing almost immediately. It is the top bar in the middle of the chart. The most vulnerable period for the CNS is Week 3 to Week 5, which is typically before a woman knows she’s pregnant.Teratogen SensitivityVarious parts of the embryo are more sensitive to teratogens at different stages of developmentReprinted from Feldman et al., 2003
29 Normal Brain / FAS Brain The brain on the left is from a baby who died of non-FASD causes at 6 weeks of life. The brain on the right is from a baby the same age who died of FASD-related causes.Permission to use photo on file.
30 • Reduced cell proliferation • Migrational errors in brain development HOW DOES ALCOHOL CAUSEBRAIN DAMAGE?ALCOHOL CAUSES:• Excessive cell death• Reduced cell proliferation• Migrational errors in brain development• Inhibition of nerve growth factor• Disruption of neurotransmittersThese are some of the things that alcohol exposure causes in developing organisms. All of these damaging effects occur in the developing brain.
31 This is a diagram of a normal brain This is a diagram of a normal brain. Note the light-colored, inverted C-shaped structure in the middle. That’s the corpus callosum. In the normal brain, it’s a C-shaped cluster of neural fibers that sits between the two lobes of the brain and is responsible for communication between the lobes. This is one of the brain structures that is frequently damaged by prenatal alcohol exposure.
32 Corpus Callosum = Central Relay Station Left Brain Right Brain LanguageMathLogicRight BrainSpatial abilitiesVisual ImageryMusicFace recognitionThe corpus callosum is one of the most studied brain structures in FASD research. The corpus callosum not only enables communication between the two lobes of the brain, it also sends impulses to the frontal lobes, which are responsible for higher order skills called executive functions. Competent, goal-directed behavior requires intact communication between the corpus callosum and frontal lobes.
33 Corpus Callosum Abnormalities Agenesis of the corpus callosum, while not common, occurs in FAS cases (~6%) more frequently than in the general population (0.1%) or in the developmentally disabled population (2-3%). In fact it has been suggested that FAS may be the most common cause of agenesis of the corpus callosum. The top left picture, is a control brain. The other images are from children with FAS. In the top middle the corpus callosum is present, but it is very thin at the posterior section of the brain. In the upper right the corpus callosum is essentially missing. The bottom two pictures are from a 9 year old girl with FAS. She has agenesis of the corpus callosum and the large dark area in the back of her brain above the cerebellum is a condition known as colpocephaly. It is essentially empty space. Our forensic assessment team, FASD Experts, includes analysis of the corpus callosum in cases that we’re involved in.ReferencesMattson, S. N., Jernigan, T. L., & Riley, E. P. (1994a). MRI and prenatal alcohol exposure. Alcohol Health & Research World, 18(1),Mattson, S. N., & Riley, E. P. (1995). Prenatal exposure to alcohol: What the images reveal. Alcohol Health & Research World, 19(4),Riley, E. P., Mattson, S. N., Sowell, E. R., Jernigan, T. L., Sobel, D. F., & Jones, K. L. (1995). Abnormalities of the corpus callosum in children prenatally exposed to alcohol. Alcoholism: Clinical and Experimental Research, 19(5),Mattson, et al., 1994; Mattson & Riley, 1995; Riley et al., 1995
34 Take-Home Message:All FASD Diagnoses May Involve Brain Damage to Multiple Brain StructuresAny amount of prenatal alcohol exposure can cause brain damageEffects of that brain damage can cause a whole array of neurodevelopmental deficits which last a lifetimeBrain damage and its associated functional impairments are relevant to defenseThe important thing to remember is: no matter what the FASD diagnosis, there is likely to be some kind of brain damage because the CNS develops throughout pregnancy. And if there is brain damage, there is likely to be functional deficits that are detectable throughout the individual’s life, up to and including the instant offense.
35 Damage to the Central Nervous System per CDC Diagnostic Guidelines (2004) Types of CNS damage:Structural anomaliesNeurological deficitsFunctional performance substantially below that expected for an individual’s age, schooling, or circumstancesThis is how the CDC diagnostic guidelines address the brain damage associated with FASD conditions.Structural abnormalities may include head circumference at or below the 10th percentile or damage to brain structures such as the corpus callosum, which are observable through electronic imaging such as MRI. Neurological deficits might involves seizures or other soft neurological signs, such as problems with coordination, motor control, or visual-motor abilities. Functional deficits include cognitive or developmental deficits; executive functioning deficits; motor functioning delays; short attention span, hyperactivity or excessive passivity, social skills deficits; or deficits in other areas, such as sensory problems, pragmatic language problems, and memory deficits.HHS, Substance Abuse and Mental Health Services AdministrationFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 2: Identification of FASD and Diagnosis of FAS
36 Conceptually, this is what the process looks like, and this is the terminology used in FASD research. Primary disabilities refers to the functional deficits and developmental delays that are caused by the brain damage. Because of their impairments, affected individuals exhibit dysfunctional behaviors in their efforts to try to assimilate in society, which leads to secondary disabilities such as trouble with the law.
37 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)According to the literature, these are the 10 areas most significantly impacted by prenatal alcohol exposure. Two of the areas most relevant in the legal context are the last 2 on the list: social skills and executive functioning.
38 Social Skill Deficits Lack of stranger fear Often scapegoated Naïve and gullibleImmatureLack of self-awarenessLack of other-awareness (boundary problems, empathy deficit)Excessive demand for attentionPoor social cognitionClinically significant inappropriate interactionsThese are some of the social skill deficits typically seen in individuals with FASD. You might recognize some of these social skill deficits in some of your clients.
39 Executive Functions A complex group of Cognitive Abilities Self-Regulation of Behaviors/FeelingsSequencing of BehaviorsCognitive FlexibilityResponse InhibitionPlanningOrganization of Behaviorinvolving an Integrative ProcessPerceptionAttentionMemoryMotorGeneral Intelligenceand a “Future” OrientationGoal DirectedDelayed GratificationExecutive functioning is another area that is impacted in FASD. Executive functioning is critical to competent, pro-social, legal behavior because it involves skills necessary for judgment, reasoning, and impulse control.
40 Executive Skill Deficits Poor organization, planning, strategy useConcrete thinkingLack of inhibitionDifficulty grasping cause & effectInability to delay gratificationDifficulty following multistep instructionsDifficulty changing strategies mid-stream (perseveration)Poor judgmentInability to learn from experience“Fight or flight” panic under pressureWhen executive functioning is impaired, this is what you get. What this means in a forensic context is that individuals with FASD do NOT lack the ability to plan. Rather, they tend to perseverate. Once they get an urge to do something, they focus on that goal with a single-minded intensity that blocks out rational consideration of all other factors. In a recent case I testified in, a young man diagnosed with FAE engaged in several different sexual offenses in order to obtain his goal of connecting sexually with a female – something he had never been able to do in his life due to his social skill deficits. In 3 of his cases, he peered under the stall in a women’s bathroom on a college campus. Each time he did this, he was arrested and charged, but he continued to do it (perseveration) because of his single-minded objective at the time: seeing what a naked female body looked like. Unable to consider the consequences of engaging in this illegal behavior, his “planning” for each subsequent case involved changing the location each time. Similarly, he also arranged to meet a 14 y/o female he met in an Internet chat room in order to have sex with her, not knowing that the 14 y/o was actually a police detective. Now, at age 28, he still has never had sexual contact with a female, and he is about to serve a prison sentence on the latter conviction.
41 Infancy and Early Childhood Fitful sleep patternsPoor suck reflexPoor muscle tone, which can delay walking and toilet trainingSmall in height and weightSevere temper tantrumsOverly sensitive or under-responsive to stimulationLack of stranger anxietyPossible attachment difficultiesFASD-related behaviors change over time. These are some of the symptoms I see when I conduct a forensic document review for functional deficits, beginning in early childhood. Infants born with an FASD may have a difficult first few months. Some may show behaviors related to alcohol withdrawal. Symptoms may include seizures, sleeping difficulties, stomach problems, and fussiness.Infants may be born with low birth weights and may have difficulty getting adequate nourishment due to a poor suck reflex. Many infants with an FASD show irritability, jitteriness, sleep disorders, excessive crying, and sensitivity to sound and light. Older infants tend to be easily upset, easily distractible, and hyperactive and have a poor attention span and developmental delays.Toddlers often do not develop the stranger anxiety that is a common milestone in normal early childhood development.Early childhood is when attachment difficulties can become very apparent.HHS, Substance Abuse and Mental Health Services AdministrationFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 1: Introduction to FASD
42 Middle Childhood Possible hyperactivity Poor memory Lack of impulse controlPoor social skillsFailure to understand consequencesVery concrete thinkingOnset of academic problemsSchool-age children with an FASD may continue to grow slowly and appear to be malnourished.The early school years (age 6 to 11) are often characterized by problems related to predicting outcomes and understanding consequences, outbursts in behavior, hyperactivity, impulsivity, lack of boundaries, memory problems, and delay in physical maturity.The complex school environment may be especially challenging, and children may feel overwhelmed. Anger, frustration, and temper tantrums may occur, which may be signs that the child is having difficulty.HHS, Substance Abuse and Mental Health Services AdministrationFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 1: Introduction to FASD
43 Adolescence Less obvious FAS facial features Growth deficits diminish and sometimes evolve into obesitySecondary disabilities (alcohol and drug use, depression, depression and other mental illness)Poor judgment and impulsivity legal problemsAdolescence is the most challenging time for youngsters with FASDs.Facial features and growth:Adolescents with an FASD may look like typical teenagers, but their developmental level may be that of a younger child.With changes during puberty, it is harder to recognize the face of FAS.Some boys tend to stay smaller, while girls mature quickly and may have trouble with obesity.Secondary disabilities begin to emerge in adolescence:Poor judgment and impulsivity: Adolescents may display problem behaviors seen as lying or stealing.Depression: Depression and other mental health problems may become more pronounced during the adolescent period of physical and emotional change.Alcohol and drug use: People with an FASD are at greater risk than those without an FASD to develop alcohol and/or drug problems.Competency 1: Introduction to FASD
44 Chronological vs Developmental Age TimelinesChronological AgeExpressive LanguageSocial MaturityMath SkillsReading DecodingReading ComprehensionThe greatest gaps between age and development occur during adolescence (Malbin, 2002). For example, an 18-year-old with an FASD may function at a much lower developmental age.Typical developmental variability seen in adolescents with an FASD.Source: Malbin, Used with permission from Diane Malbin, MSW.HHS, SAMHSAFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 1: Introduction to FASD
45 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”).It is mistakenly believed that if an individual meets criteria for a full FAS diagnosis, he has more brain damage and is more damaged functionally than someone diagnosed with another FASD condition such as ARND. This is not the case. Recall from the previous slide that facial features are formed in the period between the 8th and 12th weeks of gestation, but the brain is formed throughout the entire period of gestation, and the most critical period of brain development is in the first few weeks of gestation. Thus, someone with an ARND diagnosis could actually have more severe brain damage than someone with a full FAS diagnosis.
46 Misconception: FASD = Mental Retardation Fact: Only 25% of individuals diagnosed with full FAS are mentally retarded.Only a minority of individuals diagnosed with an FASD condition are mentally retarded.
47 In fact, as this slide shows, the average IQ for individuals diagnosed with FAS is 80, which is between the Borderline and Low Average range. The average IQ for individuals with other FASD conditions is 90, which is between the Low Average and Average range. Average IQ ranges from 90 to 110. As you can see from the right side of the distributions, many individuals diagnosed with FAS and other FASD conditions have relatively high IQs. Unfortunately, the higher the IQ, the more problems a person has because society’s expectations are higher, and the deficits are presumed to be volitional. The young man I talked about earlier with the multiple sexual offenses has an IQ in the High Average range.
48 More Important Than IQ: Discrepancies Between IQ level and adaptive skillsBetween IQ level and academic achievementBetween Verbal IQ and Performance IQUneven profile of cognitive abilitiesThus, rather than IQ, discrepancies are the problem in FASD: discrepancies between IQ and adaptive skills, between IQ and achievement, and even between skill levels on the IQ test. I frequently see significant splits between Verbal and Performance IQs where the individual is able to communicate and sound “normal” in a conversation but is significantly impaired in terms of his ability to reason and use good judgment.
49 These are results from a UW study in the 1990s that shows the discrepancies. On the left is the FAS group; on the right is the FAE group. On the bottom are the tests that were administered. Note the similarity across the 2 groups: both groups score higher on the IQ test than they do in terms of achievement – measured by the WRAT – and adaptive functioning – measured by the Vineland or VABS.
50 Moderating Factors Dose of exposure Timing of exposure Pattern of exposureDuration of exposureGenetic susceptibilityMaternal age and metabolismNutrition/prenatal environmentPostnatal parenting environmentThese are some of the things that can affect functional deficits in either a positive or negative direction. Note that all of these factors are outside the control of the defendant in a legal case.
51 Secondary Disabilities OF SECONDARY DISABILITIES PREVALENCESecondary Disabilities OF SECONDARY DISABILITIESAcross the Life Span100908070605040302010AgesAges%If FASD is not diagnosed and treated in early childhood, 1 or more of these outcomes is likely. In 1996, a landmark study found a number of outcomes strongly associated with lack of diagnosis and treatment in individuals with FASD. This study was conducted by Dr. Ann Streissguth’s group at the UW, and it involved 415 subjects diagnosed with FAS or FAE, ages These outcomes began to emerge in adolescence in individuals diagnosed with FASD conditions who did not receive early diagnosis and treatment in childhood.Mental Health ProblemsDisrupted School ExperienceTrouble With the LawConfinementInappropriate Sexual BehaviorAlcohol & Drug ProblemsDependent LivingProblems with EmploymentAges 6-51 (n= ) Ages (n=89-90)
52 Risk Factors for Secondary Disabilities Not raised in a stable, nurturing homeNot diagnosed with/ FAS by age 6Physical or sexual abuse in childhoodLack of Developmental Disabilities services in childhood (intervention and treatment)These were the specific risk factors that were discovered in this study.
53 Pre-Assessment Screening: Birth Mom Reports of substance abuse during pregnancyCollateral/self reports of maternal alcoholism or drug addictionReports of substance abuse at any point in lifeSubstance-related medical problemsDeath from alcohol-related causesInvolvement with substance abusing partnersSubstance abuse treatmentCognitive impairmentCriminal history (look for DUIs, prostitution, substance- related arrests)CPS history (e.g., client removed from home during childhood)Psychiatric historyExtensive medical historyThere are a number of things that might alert you to the possibility that your client may have an FASD condition. For example, someone might have reported that the birth mom was an alcoholic at some point in her life. She may have received treatment or died from an alcohol-related condition such as cirrhosis. Her criminal history might contain evidence of alcohol-related offenses. If her children were removed by the state, often CPS records will contained information about her alcohol and/or drug use. The birth mom’s psychiatric and medical records also can be good sources of information.
54 Pre-Assessment Screening: Record Review Prematurity / birth complications / seizuresFailure to thrive or childhood growth deficiency (short and/or thin)Developmental delaysSpeech and language services in elementary schoolLearning disabilities / Special EducationPoor grades, low achievement test scores relative to IQChildhood behavior problems in schoolADD / ADHDChildhood mental health diagnoses (ODD, CD)Difficult client to work with?Prior to hiring experts, your defense team can look for some of these red flags in your clients’ histories. Even as few as 1-2 of these factors might indicate the presence of an FASD condition.
55 Criminal BehaviorsImpulsive criminal acts in juvenile years (e.g. stealing items with little value)Exploitation by more sophisticated criminalsHistory of illogical or impulsive crimes involving obvious risk of apprehensionRepeated low-level offenses that do not escalate over time, followed by “uncharacteristic” major felony (instant offense)Crime-related behaviors triggered by panic or excessive frightThe offense behavior of your client is another place to screen for the possibility of an FASD. In particular, look for behavior that is illogical or silly. Also look for evidence that your client was involved with co-defendants who more sophisticated. Panic-driven behaviors during a crime can also be a red flag.
56 Arrest Behaviors Immediate waiving of rights Naïve cooperation with “friendly” law enforcement officersGuileless confessions that most offenders would never makeBehavioral regression (childlike)Confessing to improbable offenses or offense behaviors (sometimes false confession)At the arrest stage, individuals with FASD conditions typically waive their rights immediately and begin talking to police in an effort to please the authority figure. They are naïve and tend to give immediate confessions. They sometimes confess to things they did not do, again in an effort to please the investigator and get out of the interrogation room. They do not realize the legal implications of their confessions and often do not really comprehend Miranda warnings.
57 More Arrest BehaviorsFlat affect: cognitive inability to appreciate significance of offense conductNo remorse: cognitive inability to appreciate effects of offense behavior on othersCognitive inability to grasp seriousness of penalties/sentencesInappropriate smiling or laughingOther FASD behaviors that are red flags include lack of remorse because of deficient abstract thinking and unusual affect.
58 With respect to unusual affect, this is an example of how an individual with FASD might appear in court during his arraignment.
59 Incarceration Behaviors Multiple (and odd) suicide gestures, often dramaticTransparent malingering behaviorAdjustment problems in jail, sometimes followed by better adjustment in prison than on the street (positive response to structure)Victimized by other inmatesFailure on community supervision / multiple technical violationsOther red flags might be seen in your client’s behavior in jail. Just because an individual has an FASD doesn’t mean he cannot manipulate. People learn at a very young age how to manipulate. Thus, this kind of behavior is well within the functional repertoire of individuals with FASDs. Often, it’s the only way he knows how to communicate his distress.
60 Defense Interview Behaviors Client seems oblivious to severity of chargesClient freely admits but cannot explain offense behaviorClient seems overly compliant; trust is immediately instilledAffect is incongruent with gravity of situationDuring your initial interviews with your clients, these are some behaviors you might see that would be consistent with an FASD condition.
61 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 factorsMultidisciplinary team assessment is now generally accepted in the FASD field. This is because the impairments are multi-faceted and involve physical manifestations as well as functional, neurodevelopmental manifestations. Only specialists trained in dysmorphology and neurodevelopmental assessment and who understand the effects of prenatal alcohol exposure are qualified to diagnose these disorders. They will also be able to recognize alternative syndromes and neurodevelopmental conditions.Competency 2: Identification of FASD and Diagnosis of FAS
62 Possible Diagnostic Team Members in Clinical Settings GeneticistDevelopmental pediatricianDysmorphologistSpeech-language pathologistOccupational and physical therapistsPsychologistsNeurologists and neuropsychologistsPsychiatristsNurses, social workers, and other licensed behavioral health specialistsEducation consultantsThis slide shows examples of specialists involved in diagnosing FASD in children. To date, FASD Experts – the multidisciplinary team I am a part of – is the only known team of experts who focus on adolescent and adult assessment in the forensic context.HHS, Substance Abuse and Mental Health Services AdministrationFetal Alcohol Spectrum Disorders Center for ExcellenceCompetency 2: Identification of FASD and Diagnosis of FAS
63 FASD Experts FASDExperts.com Multidisciplinary forensic team experienced in FASD diagnosis and testimonyOver 25 forensic felony cases to date (mostly capital offenses) spanning all legal phases: pre-trial consultation and assessment, sentencing mitigation, habeas, post- convictionTeam members:Natalie Novick Brown, PhD (psychologist)Paul Connor, PhD (neuropsychologist)Richard Adler, MD (psychiatrist)To date, we have several victories or partial victories, including a case where a 15 y/o with a murder charge was not remanded to adult court, another case where an FASD diagnosis resulted in a jury finding that the defendant had a mental defect, a third case involving a man on death row where a judge granted a habeas petition due to an FASD condition, a fourth case where because of defense evaluations done by our team the state was required to employ an expert on developmental disabilities as their prosecution expert, and a fifth case where analysis of brain damage to the corpus callosum was instrumental in obtaining a hung jury.
64 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 diagnosesThese are the objectives in each component of our assessment process. As the chief psychologist on our team, I review records to determine if there is evidence of lifelong functional impairments. I also review information regarding the birth mom to determine if she drank or likely drank during her pregnancy. The neuropsychologist on our team assesses the client for current evidence of functional impairments, which should be consistent with the lifelong picture in FASD. The MD on our team conducts a history and physical, including taking facial measurements, reviews the reports of the psychologist and neuropsychologist, and makes a diagnosis, if appropriate.
65 Psychologist: Record Review prenatal recordsmedical 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 recordsState Child/Family Services recordsmilitary recordsarrest records (juvenile & adult, including INSTANT OFFENSE)juvenile commitment/DOC recordsbaby / childhood photosThese are some of the records that I might review during the lifelong functional assessment phase. Note the childhood photos at the bottom of the list. The best photographs are of the client’s full face, without a smile.
66 Psychologist: Collateral Interviews birth mother / father (if available)relativesadoptive / foster family (if applicable)teachers / school psychologistsmental health providersneighbors / family friendsIf the defense team hasn’t already done conducted collateral interviews, this is something else I might do as part of my functional assessment process.
67 Psychologist: Testing Functional Assessment:Adaptive skills assessment (Vineland)Executive skills (BRIEF-A)Differential Diagnosis:Mental illness (SCL-90-R)Personality disorders (MCMI-III, SCID-II)Fetal Alcohol Behavior Scale (UW)My functional assessment includes adaptive testing with the Vineland as well as other tests.
68 CDC Guidelines for Cognitive-Behavioral Deficits Functional DeficitsIQ 2 SD below averageDeficits 1 SD below average in at least 3 domainsCognitive or developmental deficitsExecutive functioning deficitsMotor functioning delaysProblems with attention or hyperactivitySocial skillsOther, such as sensory problems, pragmatic language problems, memory deficits, etc.In this testing, I am looking for adaptive and executive skill deficits across the client’s lifetime, and I am applying the specific diagnostic criteria provided in the CDC’s 2004 guidelines.
69 Psychologist: Test Summary This kind of chart summarizes the testing that is done during the psychologist’s assessment. Findings are expressed in a way that is consistent with CDC guidelines and facilitates analysis for deficits.
70 Neuropsychologist: Testing A battery of tests incorporating many of the most salient clinical tests based on 30+ years of research experience in FASD:IQAchievementLearning and Memory (verbal and visual)AttentionMotor CoordinationExecutive FunctionsOur neuropsychologist not only administers a standard neuropsych battery but also includes specific tests that were found in the research to be particularly sensitive to the effects of prenatal alcohol exposure.
71 Neuropsychologist: Tests IQ: WAIS-III, Woodcock Johnson-IIIMemory / Attention: California Verbal Learning Test, Rey Complex Figure Test, Green’s Word Memory Test, Conner’s Continuous Performance TestMotor Coordination: Grooved Pegboard, Finger Tapping, Grip StrengthExecutive 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 TestThese are the tests that our neuropsychologist Dr. Paul Connor uses.
72 CDC Guidelines for Cognitive-Behavioral Deficits Functional DeficitsIQ 2 SD below averageDeficits 1 SD below average in at least 3 domains:Cognitive or developmental deficitsExecutive functioning deficitsMotor functioning delaysProblems with attention or hyperactivitySocial skillsOther, such as sensory problems, pragmatic language problems, memory deficits, etc.And these are the CDC diagnostic guidelines that govern whether there are deficits consistent with FASD in his test results.
73 Neuropsychologist: Test Summary This is how he summarizes his test results so that deficits can be quickly observed. In this chart, for example, there are multiple deficits that meet the threshold according to the CDC guidelines. The threshold is any score that falls 1 or more standard deviations below the mean. The mean is the pink horizontal line that runs across the chart at the “0” point.
74 M.D.: DiagnosisReviews Psychologist’s / Neuropsychologist’s reports of lifelong/current functional deficitsReviews client’s / birth mom’s medical recordsPerforms H&PRenders FASD diagnosis (if appropriate)The MD on our team, Dr. Rich Adler, reviews my report and that of Dr. Adler, reviews medical records, performs a history and physical where he measures the client’s facial characteristics, and renders an FASD diagnosis if appropriate.
75 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, 3rd Edition, 2004) – see pictures on page 3 of 4:A smooth philtrum – 4 out of 5A thin upper lip – 5 out of 5Marked “lip circularity” – 5 out of 5Small palpebral fissures: 28 mm horizontally x 8mm vertically (both eyes)This is an excerpt from one of Dr. Adler’s forensic reports. Here, he is describing the facial characteristics that are still observable in the client.
76 M.D. Diagnostic Report – cont. Small stature and low weight for age:63” tall (below 5th percentile)130 # (below 5th percentile)Here, he is describing the client’s growth deficit in terms of DCD criteria.
77 M.D. Diagnostic Report – cont. CNS abnormalities:Spelling at the 1st percentile (2nd 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 1st percentile (2nd 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 4th 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 1st to 2nd percentile, as reported by Dr. Natalie Novick-Brown on September 23, 2007.Here, although it may be difficult to read, is his summary of the specific deficits that he obtained from my functional assessment.
78 Differential Diagnosis M.D.Assesses other pre-/peri-/post-natal factors & addresses competing medical/genetic hypothesesPsychologistAssesses environmental factors (e.g., traumas, neglect, etc.) & addresses competing psychosocial hypothesesTwo members on our forensic assessment team address differential diagnosis.
79 Testimony Diagnosis/Differential Diagnosis Psychologist M.D.Diagnosis/Differential DiagnosisPsychologistNexus: how permanent brain damage caused lifelong functional impairments that also affected instant offense behaviorThe testimony process might look like this in general. The MD on our team testifies about the diagnostic elements and the diagnosis; the psychologist testifies about how the instant offense behavior is indicative of functional impairments that are consistent with the client’s lifelong history of functional impairment (the nexus).
80 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 alcoholic3) FASD = mental defect involving impaired judgment, reasoning, and impulse control and is therefore a defense issue