1. FASD in a Correctional Population: Preliminary Results from an Incidence Study Patricia MacPherson Addictions Research Centre Correctional Service Canada Albert E. Chudley University of Manitoba Addictions Research Centre 23 Brook St., Montague, PEI C0A 1R0

2. Purpose of Talk To review population incidence studies To review correctional systems incidence To review research study objectives and methodology To review preliminary results

3. Project Team Co-Investigators Patricia MacPherson, M.Sc. & Brian Grant, Ph.D, (ARC) Albert Chudley, MD, University of Manitoba Clinical Neuropsychologist Andrea Kilgour, Ph.D, University of Manitoba Field Staff Kim Spiers (SMI), Dawn Harmer (Winnipeg Parole) Data quality/ data management Charlotte Fraser, MA (ARC)

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

5. Secondary Disabilities Academic failure Mental health disorders Addiction Sexual deviance Inability to live independently Problems with the justice system Encounters with the law Confinement

6. Prevalence Health Canada FAS:1 – 3 per 1000 live births FASD: 9 per 1000 live births Rate varies dramatically in special populations Less than 1 to 190 per 1000 live births

7. Incidence in Offender Samples Estimates of incidence in offenders vary, with study limitations psychiatric referrals young offenders Streissguth, 1997

8. 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

9. Correctional Population Conry and Fast, 1999 287 young offenders remanded to a forensic psychiatric inpatient assessment unit 23% (3 FAS; 67 FAE) DOJ BC 2005: probation officer referrals 48 referrals, 21 assessments: 17 ARND; no FAS Burd (2003): survey of Canadian correctional facilities 13 of 148,797 diagnosed cases in Canada; prevalence rate of 0.087 per 1000, below the estimated incidence rate of the American and Canadian population of FAS or FASD of 1-3 per 1000 and 9.1 per 1000

10. Challenges in the prison environment Victimization Prison routine / rules Wanting to fit in Inappropriate sharing of information Inappropriate social behaviours

11. Challenges for Corrections How to identify affected individuals Number of offenders with FASD How to adapt current programs How best to accommodate Management in the institution and community Reducing risk of re-offending; keeping the community safe

12. Purpose of CSC Research Determine incidence Identify scope of the problem Appropriate resource allocation Develop targeted interventions Develop a screening instrument Identify offenders for further assessment Integrate into intake assessment process.

13. Potential benefits of a diagnosis New way to understand difficulties Paradigm shift in attitudes of guards, case management/ and program staff, judges, parole officers and offender Open doors for service and provides impetus for development of appropriate services for the affected individual

14. 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

15. Screening Tools The Alcohol Related Neurodevelopmental Disability (ARNDD) Behavioral Checklist (Burd, 1999) Administered by specialized clinician The FASNET Assessment tool (BC FASNET) - 244 items version had been adapted for Genesis House but is not vaildated The Fetal Alcohol Exposure Risk Assessment for Adoldescents and Adults (LaDue et al., 1999 ) - heavily reliant on physical measurements The Fetal Alcohol Behavior Scale (Streissguth, 1998) No longer used The GGPC FASD Screening Tool (Prediger, 2003) Requires extensive file review for each case; still in development

16. Study Sample Offenders processed by Winnipeg Parole Office 30 and under; Over 18 month period New admissions transferred to Stony Mountain Institution Aboriginals are over-represented in our sample (60% vs. 17%) Everyone is asked to participate Statistical methods will be used to generalize to CSC population Women are not purposely excluded, SMI is a male facility

17. STONY MOUNTAIN INSTITUTION MEDIUM-SECURITY PENITENTIARY Facility Characteristics Date opened: 1876 Security level: Medium As of April 6, 2004 Rated capacity: 546 Number of inmates: 506

18. Why Stony Mountain?

19. Participant Recruitment Remand Centre/Headingley Correctional Centre: Parole officer conducts preliminary assessment with newly sentenced offenders Explains that research assistant will be coming to see them Research Assistant: Explain the study to offenders both verbally and in writing Audiotapes consent interview Obtains signed consent

20. Information Sources – Community 28 Behavioural Indicators Judgment, distractability, mood swings, hyperactivity, financial, consequences. Historical Indicators Adopted, foster care, developmental challenges, school disruption, mental health Maternal consumption of alcohol Information collected from the offender, parole officers, collateral sources

21. Information Sources - Institution Medical Intake Interview FASD Facial Photographic Analysis Software Physical exam Facial measurements, about 10 minutes Neuropsychological testing IQ; executive functioning; visual and auditory memory; social adaptive functioning

22. Fetal Alcohol Syndrome Facial Photographic Analysis Software Susan Astley, University of Washington

23. Summary report

24. FASD Neuropsychological Test Battery Wechsler Abbreviated Scale of Intelligence WASI 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

25. Diagnosis Case Conference to determine outcome Doctor Psychologist Research Liaison Officer Information from all sources will be compiled Checklists (community) Medical records Medical intake interview Photometric report Physical/neuropsychological evaluations

26. Chudley et. al., 2005. Fetal alcohol spectrum disorder: Canadian guidelines for diagnosis. CMAJ; 172 (suppl 5)

27. Four Research Outcomes Research Outcome ADiagnosis in one of the FASD categories BDoes not meet diagnostic criteria but remains a possibility CNo FASD-related diagnosis but other impairments noted DNormal

28. All participants : Received letter from physician stating results Received certificate of appreciation for participation With positive neuropsychological findings, letter from psychologist detailing results Debriefing

29. 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

30. 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

31. Once a year for two years Those diagnosed with FASD Brief Questionnaire (approximately 10 minutes) Adjustment Views on participation in study Value or benefit of their experience with the Research Liaison Officer Follow-up

32. Results

33. Study Sample 165 offenders were asked to participate over the study period ( April 2005-September 2006) 106 agreed (64%) 11 withdrew 4 participants had invalid CNS results 58 declined Final Study Sample : 91 participants

34. Demographics for final sample (n=91) 66% Aboriginal 34% Métis 32% First Nation 25% Caucasian 9% Other racial groups (Black, East Indian, Chinese)

35. Demographics continued 53% single 46% common law Average age 24, SD 2.85 Range in age between 19-30yrs

36. Summary of collateral information Average of 2 per participant (n=194; range 0 – 7) 61% of collaterals participated (n=118) 46% participated with maternal alcohol information 16% participated without maternal alcohol information 28% unable to contact 15% no valid contact information 13% difficult to reach 10% declined

37. Summary of maternal information 77% of offenders provided mother as a contact (n=70) 69% agreed to participate (n=48) 16% unable to contact 7% difficult to reach 9% no contact information 3% language barrier 13% declined

38. Birth/Hospital Records All participants agreed to allow access to birth records 72% of records received 96% of mothers agreed to release records related to their pregnancy 63% of pregnancy records received

39. Summary of Collaterals Participating n=126 RelationWith Alcohol History % (n) Without Alcohol History % (n) Aunt/Uncle93 (26)7 (2) Sibling81 (21)19 (5) Father95 (20)5 (1) Grandparent92 (11)8 (1) CLW, spouse36 (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

40. Maternal Indicator Summary OffenderMotherCollateral Drink when offender was young YYY Frequency2-4 month2-3 week2-4 month Amount per occasion12 beers> 5>5 (2 -24’s) Drink when pregnant with offender UYY Timing of alcohol consumption UDuring full pregnancy (on and off during whole pregnancy) Not longer than the first 43 days of the pregnancy. FrequencyU2-4 monthLess than once per month Amount per occasionUUnsure of amount1-2 Binge drinkingUUnsureNever Other drug useN/ATobacco; Cannabis; Prescription drugs

41. Reporting on prenatal alcohol exposure Yes=6 Yes=20 Yes=9

42. Reported Prenatal Alcohol Exposure Drinking QuestionsCollateral (N = 20) % Mother (N = 9) % Drink during full pregnancy 4511 Drink during part of pregnancy 2567 Drink 2-3 times per week 250 Drink 2-4 times per month 1533 Binge Drinking (> 5 drinks) 4156

43. Results from diagnostic assessments 9 offenders diagnosed in one of the FASD categories (10%) 1 pFAS 8 ARND 16 offenders in the ‘Possible’ category (18%) Not enough information to confirm or rule out a diagnosis

44. Results from diagnostic assessments 39 offenders in the “CNS deficits – not alcohol related” category (43%) 27 offenders in the “Normal” category (30%)

45. 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)

46. Analysis of palpebral fissure length (PFL) Mean pfl scores across outcomes ReportPhysical Exam FASD29.4 +/- 1.329.4 +/- 1.3 Possible29.4 +/- 1.629.1 +/- 1.5 CNS-other29.8 +/- 1.230.1 +/- 1.3 Normal30.0 +/- 1.830.3 +/- 1.4

47. Analysis of palpebral fissure length (PFL) Mean pfl scores across alcohol exposure ReportPhysical Exam Alcohol (17)29.2 +/- 1.528.6 +/- 1.5 No Alcohol (74)29.9 +/- 1.529.3 +/- 1.5

48. Analysis of palpebral fissure length (pfl) Mean pfl scores across racial groups ReportPhysical Exam Caucasian29.9 +/- 1.629.1 +/- 1.7 First Nations 29.1 +/- 1.528.8 +/- 1.3 Métis30.1 +/- 1.329.3 +/- 1.6 Other30.3 +/- 1.430.4 +/- 1.2

49. Average Scores on Behavioural Items 28 questions: max score = 140

50. 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

51. Behavioural indicators: offender self report (top 5 items) ItemPearson r p Trouble 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

52. Behavioral indicators; collateral reports Items on collateral scale also highly intercorrelated Alpha = 0.91 18 items correlated with FASD diagnosis

53. Behavioural indicators: collateral report (top 5 items)n=90 ItemPearson r p Has 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

54. Behavioural indicators combined (all reports; n=260) ItemPearson 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

55. 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).

56. Average Score on Historical Items 9 questions: max score = 11

57. Historical checklist items n=92 ItemPearson r p Ever 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

58. Overall risk and need for outcome groups * * X 2 (6,91)=16.67, p<.01; X 2 (6,91)=17.58, p<.01

59. Criminogenic need areas for FASD–affected offenders (compared to others in study group, n=91) * * *p<.01

60. Characteristics of FASD group All had less than grade 10 and 67% (6) had less than grade 8 education None had a skill, trade or profession All were unemployed at time of arrest and 33% (3) had no employment history None had participated in employment programs prior to incarceration

61. 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

62. Criminal History * * * p<.01

63. Limitations of the study Small “n” Surprising proportion of non-participation Ethnic mix at Stony not representative of general correctional institutions in other parts of Canada Current definition of “Brain domains” in diagnostic guidelines may limit recognition of some FASD affected individuals

64. Conclusions The incidence of FASD is ten times greater in Stony Mountain Institution compared to the general population This is a minimum estimate of incidence as we followed a conservative diagnostic approach The photometric analysis highly correlates with the physical exam A history of prenatal alcohol exposure is associated with smaller PFL but this was not clinically or statistically significant

65. Conclusions There are no clinically or statistically significant differences between PFLs and ethnic groups There are specific items on the BSC screening tool that are highly correlated with an FASD-related diagnosis Some characteristics of these offenders on the Offender Intake Assessment may distinguish them from the rest of the offender population This study will allow us to develop a reliable screening tool for the identification of risk for an FASD-related diagnosis in the offender population

66. 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

67. Thank you! Addictions Research Centre Correctional Service Canada Montague PEI