fasd in a correctional population: preliminary results from an incidence study patricia macpherson...
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FASD in a Correctional Population:FASD in a Correctional Population:Preliminary Results from an Incidence Study Preliminary Results from an Incidence Study
Patricia MacPherson Patricia MacPherson
Addictions Research CentreAddictions Research CentreCorrectional Service CanadaCorrectional Service Canada
Albert E. ChudleyAlbert E. Chudley
University of ManitobaUniversity of Manitoba
Addictions Research Centre23 Brook St., Montague, PEI C0A 1R0
Purpose of Talk
To review population incidence studiesTo review correctional systems incidenceTo review research study objectives and methodologyTo review preliminary results
Project TeamCo-Investigators
Patricia MacPherson, M.Sc. & Brian Grant, Ph.D, (ARC) Albert Chudley, MD, University of Manitoba
Clinical NeuropsychologistAndrea Kilgour, Ph.D, University of Manitoba
Field Staff Kim Spiers (SMI), Dawn Harmer (Winnipeg Parole)
Data quality/ data managementCharlotte Fraser, MA (ARC)
Secondary Disabilities
A result of the interaction between primary disabilities (behavioural and neuropsychological problems) with adverse environments
Secondary Disabilities
Academic failureMental health disordersAddictionSexual devianceInability to live independentlyProblems with the justice system
Encounters with the lawConfinement
Prevalence
Health CanadaFAS: 1 – 3 per 1000 live birthsFASD: 9 per 1000 live births
Rate varies dramatically in special populations
Less than 1 to 190 per 1000 live births
Incidence in Offender SamplesEstimates of incidence in offenders vary, with study limitations
psychiatric referralsyoung 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 PopulationConry and Fast, 1999
287 young offenders remanded to a forensic psychiatric inpatient assessment unit23% (3 FAS; 67 FAE)
DOJ BC 2005: probation officer referrals48 referrals, 21 assessments: 17 ARND; no FAS
Burd (2003): survey of Canadian correctional facilities13 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
VictimizationPrison routine / rulesWanting to fit inInappropriate sharing of informationInappropriate social behaviours
Challenges for Corrections
How to identify affected individualsNumber of offenders with FASDHow to adapt current programsHow best to accommodateManagement in the institution and communityReducing risk of re-offending; keeping the community safe
Purpose of CSC Research
Determine incidenceIdentify scope of the problemAppropriate resource allocationDevelop targeted interventions
Develop a screening instrument Identify offenders for further assessment Integrate into intake assessment process.
Potential benefits of a diagnosisNew 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 ToolsThe Alcohol Related Neurodevelopmental Disability (ARNDD) Behavioral Checklist (Burd, 1999)
Administered by specialized clinician
The FASNET Assessment tool (BC FASNET) - 244 itemsversion 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 SampleOffenders processed by Winnipeg Parole Office
30 and under; Over 18 month periodNew admissions transferred to Stony Mountain Institution
Aboriginals are over-represented in our sample (60% vs. 17%)
Everyone is asked to participateStatistical 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: MediumAs of April 6, 2004 Rated capacity: 546
Number of inmates: 506
Why Stony Mountain?
Participant RecruitmentRemand Centre/Headingley Correctional Centre:
Parole officer conducts preliminary assessment with newly sentenced offendersExplains that research assistant will be coming to see them
Research Assistant:Explain the study to offenders both verbally and in writingAudiotapes consent interviewObtains signed consent
Information Sources – Community
28 Behavioural IndicatorsJudgment, distractability, mood swings, hyperactivity, financial, consequences.
Historical IndicatorsAdopted, foster care, developmental challenges, school disruption, mental health
Maternal consumption of alcohol
Information collected from the offender, parole officers, collateral sources
Information Sources - InstitutionMedical 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
IntelligenceWASI
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
DiagnosisCase 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
All participants :Received letter from physician stating resultsReceived certificate of appreciation for participationWith positive neuropsychological findings, letter from psychologist detailing results
Debriefing
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
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
Once a year for two years
Those diagnosed with FASD
Brief Questionnaire (approximately 10 minutes)
AdjustmentViews on participation in studyValue or benefit of their experience with the Research Liaison Officer
Follow-up
Results
Study Sample
165 offenders were asked to participate over the study period (April 2005-September 2006)
106 agreed (64%)11 withdrew4 participants had invalid CNS results58 declined
Final Study Sample : 91 participants
Demographics for final sample (n=91)
66% Aboriginal 34% Métis32% First Nation
25% Caucasian
9% Other racial groups (Black, East Indian, Chinese)
Demographics continued
53% single46% common law
Average age 24, SD 2.85Range 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 information16% 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 contact7% difficult to reach9% no contact information3% language barrier
13% declined
Birth/Hospital RecordsAll 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=126Relation 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 Mother
Collateral Collateral
Drink when offender was young
Y Y Y
Frequency 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
Tobacco; Cannabis; Prescription
drugs
Reporting on prenatal alcohol exposureOffender
50%
7%
43%
YesNoUnknown
Collateral
51%
22%27%
Mother
90%
10%
Yes=6Yes=20
Yes=9
Reported Prenatal Alcohol Exposure
Drinking Questions
Collateral (N = 20) %
Mother (N = 9) %
Drink during full pregnancy
45 11
Drink during part of pregnancy
25 67
Drink 2-3 times per week
25 0
Drink 2-4 times per month
15 33
Binge Drinking (> 5 drinks)
41 56
Results from diagnostic assessments
9 offenders diagnosed in one of the FASD categories (10%)
1 pFAS8 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 Physical Exam
FASD 29.4 +/- 1.3 29.4 +/- 1.3Possible 29.4 +/- 1.6 29.1 +/- 1.5CNS-other 29.8 +/- 1.2 30.1 +/- 1.3Normal 30.0 +/- 1.8 30.3 +/- 1.4
Analysis of palpebral fissure length (PFL)
Mean pfl scores across alcohol exposure
ReportPhysical Exam
Alcohol (17) 29.2 +/- 1.5 28.6 +/- 1.5No Alcohol (74) 29.9 +/- 1.5 29.3 +/- 1.5
Analysis of palpebral fissure length (pfl)
Mean pfl scores across racial groups
Report Physical Exam
Caucasian 29.9 +/- 1.6 29.1 +/- 1.7First Nations 29.1 +/- 1.5 28.8 +/- 1.3Métis 30.1 +/- 1.3 29.3 +/- 1.6Other 30.3 +/- 1.4 30.4 +/- 1.2
Average Scores on Behavioural Items
103
8176
69
0
20
40
60
80
100
120
A B C D
Avera
ge S
co
re
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 pTrouble 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 pHas 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 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).
Average Score on Historical Items
4
2
1 1
0
1
2
3
4
5
A B C D
Avera
ge S
co
re
9 questions: max score = 11
Historical checklist items n=92Item Pearson r pEver 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
0
10
20
30
40
50
60
70
80
90
High Risk High Need
Perc
ent
FASD Unknown CNS - Other Normal
*
*
X2(6,91)=16.67, p<.01; X2(6,91)=17.58, p<.01
Criminogenic need areas for FASD–affected offenders (compared to others in study group, n=91)
0 20 40 60 80 100
Associates
Attitude
Community Functioning
Substance Abuse
Marital/ Family
Personal Emotional
Employment
Percent
*
*
*p<.01
Characteristics of FASD groupAll 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
0
20
40
60
80
100
Youth CourtHistory
15 or MoreConvictions -
Youth
Previous AdultProvincial
Term
15 or MoreConvictions -
Adult
Perc
ent
FASD Possible CNS-Other Normal
*
*
* p<.01
Limitations of the study
Small “n”Surprising proportion of non-participationEthnic mix at Stony not representative of general correctional institutions in other parts of CanadaCurrent definition of “Brain domains” in diagnostic guidelines may limit recognition of some FASD affected individuals
ConclusionsThe 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
ConclusionsThere 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