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

1
FASD in a Correctional PopulationPreliminary
Results from an Incidence Study

• Patricia MacPherson
• Addictions Research CentreCorrectional Service
  Canada
• Albert E. Chudley
• University of Manitoba

Addictions Research Centre23 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/er
  71.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
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
28
Debriefing

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

29
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

30
Disclosure

• 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

31
Follow-up

• 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

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 (n91)

• 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 (n194 range 0 7)
• 61 of collaterals participated (n118)
• 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
  (n70)
• 69 agreed to participate (n48)
• 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 n126
Other includes foster care worker, other
professional, friend, or cousin
40
(No Transcript)
41
Reporting on prenatal alcohol exposure
Yes20
Yes6
Yes9
42
Reported Prenatal Alcohol Exposure
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 (plt.0001)
• Physical exam and photometric reports
• r0.74 (plt.0001)

46
Analysis of palpebral fissure length (PFL)

• Mean pfl scores across outcomes
• Report Physical Exam
• FASD 29.4 /- 1.3 29.4 /- 1.3
• Possible 29.4 /- 1.6 29.1 /- 1.5
• CNS-other 29.8 /- 1.2 30.1 /- 1.3
• Normal 30.0 /- 1.8 30.3 /- 1.4

47
Analysis of palpebral fissure length (PFL)

• Mean pfl scores across alcohol exposure
• Report Physical Exam
• Alcohol (17) 29.2 /- 1.5 28.6 /- 1.5
• No Alcohol (74) 29.9 /- 1.5 29.3 /- 1.5

48
Analysis of palpebral fissure length (pfl)

• Mean pfl scores across racial groups
• Report Physical Exam
• Caucasian 29.9 /- 1.6 29.1 /- 1.7
• First Nations 29.1 /- 1.5 28.8 /- 1.3
• Métis 30.1 /- 1.3 29.3 /- 1.6
• Other 30.3 /- 1.4 30.4 /- 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
• Cronbachs coefficient alpha .90
• 17 out of 28 items correlated with FASD diagnosis

51
Behavioural indicators offender self report
(top 5 items)
n91
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) n90
54
Behavioural indicators combined (all reports
n260)
55
Reported alcohol use (any source)

• Prenatal alcohol reported by any source was
  correlated with alcohol score on 4-digit code
  (r0.70, plt.0001)
• Mothers use of alcohol when offender was young
  was correlated with 4 digit alcohol score
  (r0.42, plt.0001).

56
Average Score on Historical Items
9 questions max score 11
57
Historical checklist items n92
58
Overall risk and need for outcome groups


X2(6,91)16.67, plt.01 X2(6,91)17.58, plt.01
59
Criminogenic need areas for FASDaffected
offenders (compared to others in study group,
n91)


plt.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 (n8) 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


plt.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