FASD in a Correctional Population:
Preliminary Results from an Incidence Study
Patricia MacPherson
Addictions Research Centre
Correctional Service Canada
Addictions Research Centre
23 Brook St., Montague, PEI C0A 1R0
Albert E. Chudley
University of Manitoba
Purpose of Talk
To review population incidence studies
To review correctional systems
incidence
To review research study objectives and
methodology
To review preliminary results
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)
Secondary Disabilities
A result of the interaction between
primary disabilities (behavioural and
neuropsychological problems) with
adverse environments
Secondary Disabilities
Academic failure
Mental health disorders
Addiction
Sexual deviance
Inability to live independently
Problems with the justice system
Encounters with the law
Confinement
Prevalence
Health Canada
FAS:
FASD:
1 – 3 per 1000 live births
9 per 1000 live births
Rate varies dramatically in special
populations
Less than 1 to 190 per 1000 live births
Incidence in Offender Samples
Estimates of
incidence in
offenders vary,
with study
limitations
psychiatric
referrals
young offenders
Streissguth, 1997
Boland et al., (1998).
“Although
there is
substantial evidence
suggesting a link
between FASD and
crime…. there are no
known studies
reporting the
prevalence of FASD
in prisons.”
http://www.csc-scc.gc.ca/text/rsrch/reports/r71/er71.pdf
Correctional 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
Challenges in the prison
environment
Victimization
Prison routine / rules
Wanting to fit in
Inappropriate sharing of information
Inappropriate social behaviours
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
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.
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
Potential benefits of a diagnosis
New strategies in the institution and in
the community upon release
Peer counselors, mentors, adapted training
programs (employment, life skills,
education etc.)
Reduce recidivism
Screening 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
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
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
Why Stony Mountain?
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
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
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
Fetal Alcohol Syndrome
Facial Photographic Analysis Software
Susan Astley, University of Washington
Summary report
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
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
Chudley et. al., 2005. Fetal alcohol spectrum disorder:
Canadian guidelines for diagnosis. CMAJ; 172 (suppl 5)
Four Research Outcomes
Research Outcome
A
Diagnosis in one of the FASD
categories
B
Does not meet diagnostic criteria but
remains a possibility
C
No FASD-related diagnosis but other
impairments noted
D
Normal
Debriefing
All participants :
Received letter from physician stating
results
Received certificate of appreciation for
participation
With positive neuropsychological findings,
letter from psychologist detailing results
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
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
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
Results
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
Demographics for final sample
(n=91)
66% Aboriginal
34% Métis
32% First Nation
25% Caucasian
9% Other racial groups (Black, East Indian,
Chinese)
Demographics continued
53% single
46% common law
Average age 24, SD 2.85
Range in age between 19-30yrs
Summary of collateral information
Average of 2 per participant (n=194; range 0 – 7)
61% of collaterals participated (n=118)
46% participated with maternal alcohol information
16% participated without maternal alcohol information
28% unable to contact
15% no valid contact information
13% difficult to reach
10% declined
Summary of maternal information
77% of offenders provided mother as a contact
(n=70)
69% agreed to participate (n=48)
16% unable to contact
7% difficult to reach
9% no contact information
3% language barrier
13% declined
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
Summary of Collaterals Participating n=126
Relation
With Alcohol
History
% (n)
Without Alcohol
History
% (n)
Aunt/Uncle
93 (26)
7 (2)
Sibling
81 (21)
19 (5)
Father
95 (20)
5 (1)
Grandparent
92 (11)
8 (1)
CLW, spouse
36 (9)
64 (16)
Foster, adopted or
step parent
67 (4)
33 (2)
Other*
38 (3)
62 (5)
* Other includes foster care worker, other professional, friend, or cousin
Maternal Indicator Summary
Offender
Collateral
Collateral
Y
Y
Y
2-4 month
2-3 week
2-4 month
Amount per occasion
12 beers
>5
>5 (2 -24’s)
Drink when pregnant
with offender
U
Y
Y
Timing of alcohol
consumption
U
During full pregnancy
(on and off
during whole
pregnancy)
Not longer than the
first 43 days of
the pregnancy.
Frequency
U
2-4 month
Less than once per
month
Amount per occasion
U
Unsure of amount
1-2
Binge drinking
U
Unsure
Never
Other drug use
N/A
Tobacco; Cannabis;
Prescription
drugs
Drink when offender
was young
Frequency
Mother
Tobacco; Cannabis;
Prescription drugs
Reporting on prenatal alcohol exposure
Collateral
Offender
Yes
No
Unknown
7%
50%
43%
27%
Yes=20
Yes=6
51%
Mother
10%
Yes=9
22%
90%
Reported Prenatal Alcohol Exposure
Drinking Questions
Collateral
(N = 20) %
Mother
(N = 9) %
Drink during full
pregnancy
Drink during part
of pregnancy
45
11
25
67
Drink 2-3 times
per week
Drink 2-4 times
per month
25
0
15
33
Binge Drinking (>
5 drinks)
41
56
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
Results from diagnostic assessments
39 offenders in the “CNS deficits – not
alcohol related” category (43%)
27 offenders in the “Normal” category
(30%)
Analysis of palpebral fissure length
(PFL)
Two independent raters on photometric
software
r= 0.88 (p<.0001)
Physical exam and photometric reports
r=0.74 (p<.0001)
Analysis of palpebral fissure length
(PFL)
Mean pfl scores across outcomes
Report
FASD
29.4 +/Possible
29.4 +/CNS-other 29.8 +/Normal
30.0 +/-
1.3
1.6
1.2
1.8
Physical Exam
29.4 +/- 1.3
29.1 +/- 1.5
30.1 +/- 1.3
30.3 +/- 1.4
Analysis of palpebral fissure length
(PFL)
Mean pfl scores across alcohol exposure
Alcohol (17)
No Alcohol (74)
Report
Physical Exam
29.2 +/- 1.5
29.9 +/- 1.5
28.6 +/- 1.5
29.3 +/- 1.5
Analysis of palpebral fissure length
(pfl)
Mean pfl scores across racial groups
Caucasian
First Nations
Métis
Other
Report
29.9 +/29.1 +/30.1 +/30.3 +/-
1.6
1.5
1.3
1.4
Physical Exam
29.1 +/- 1.7
28.8 +/- 1.3
29.3 +/- 1.6
30.4 +/- 1.2
Average Scores on Behavioural
Items
120
103
Average Score
100
81
80
76
69
60
40
20
0
A
B
C
D
28 questions: max score = 140
Behavioural indicators
Behavioural items on offender self
report scale highly intercorrelated;
Cronbach’s coefficient alpha .90
17 out of 28 items correlated with FASD
diagnosis
Behavioural indicators:
offender self report (top 5 items)
Item
Pearson r
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
Behavioral indicators;
collateral reports
Items on collateral scale also highly
intercorrelated
Alpha = 0.91
18 items correlated with FASD diagnosis
Behavioural indicators:
collateral report (top 5 items) n=90
Item
Pearson r
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
Behavioural indicators combined
(all reports; n=260)
Item
Pearson r
(p<.0001)
Has trouble following direction
.31
Has poor social skills
.27
Has a poor attention span
.25
Has trouble completing tasks
.25
Talks a lot but says little
.25
Acts impulsively
.25
Has poor judgement
.24
Is easily distracted
.23
Has temper tantrums
.23
Is unaware of consequences
.23
Has trouble staying on topic
.23
Reported alcohol use (any source)
Prenatal alcohol reported by any source
was correlated with alcohol score on 4digit code (r=0.70, p<.0001)
Mother’s use of alcohol when offender
was young was correlated with 4 digit
alcohol score (r=0.42, p<.0001).
Average Score on Historical
Items
5
Average Score
4
4
3
2
2
1
1
1
C
D
0
A
B
9 questions: max score = 11
Historical checklist items n=92
Item
Pearson 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
Overall risk and need for outcome
groups
FASD
Unknown
CNS - Other
Normal
90
*
80
Percent
70
*
60
50
40
30
20
10
0
High Risk
X2(6,91)=16.67, p<.01; X2(6,91)=17.58, p<.01
High Need
Criminogenic need areas for FASD–affected
offenders (compared to others in study group, n=91)
* Employment
* Personal Emotional
Marital/ Family
Substance Abuse
Community Functioning
Attitude
Associates
0
*p<.01
20
40
60
Percent
80
100
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
Characteristics cont.
All offenders were rated by intake parole officers as
having poor problem solving abilities and unable to
generate choices
Almost all (n=8) were rated as having poor problem
recognition abilities and unaware of consequences of
their actions
All were described as having poor stress management
and poor conflict resolution
Two had a current or prior mental health diagnosis and
four were currently prescribed medication
Criminal History
100
FASD
Possible
CNS-Other
Normal
*
Percent
80
*
60
40
20
0
Youth Court
History
* p<.01
15 or More
Convictions Youth
Previous Adult
Provincial
Term
15 or More
Convictions Adult
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
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
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
Next Steps
Analysis needs to be completed to determine
sensitivity and specificity of the modified
screening tool, neuropsychological results,
etc.
Replicate study at another federal institution
to validate results in order to generalize to
the Canadian offender population
Thank you!
Addictions Research Centre
Correctional Service Canada
Montague PEI