Fetal Alcohol Spectrum Disorders
in Justice and Correctional
Carey Szetela PhD
January, 2013
*Funding provided by the U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, Grant no. U84DD000882.
NPR: Supreme Court OKs
Foreign Lethal Injection Drug
Execution on Oct 26, 2010
National Public Radio Oct 27
“The judge who sentenced
Landrigan to death has
testified she would not
have imposed the death
penalty had Landrigan's
lawyer presented doctors'
reports and evaluations
that showed, at the time of
trial in 1990, that
Landrigan suffered from
fetal alcohol syndrome and
brain injuries.”
This undated photo shows Jeffrey
Landrigan, who was executed by
Arizona on Tuesday after a U.S.
Supreme Court decision lifted a stay
on his execution.
Fetal Alcohol Spectrum
Disorders (FASDs)
How are People Affected?
FASDs in Justice and
Correctional Systems
Consider Responses for FASDs
What are
Fetal Alcohol Spectrum Disorders?
• Range of effects that can occur in a person
whose mother drank alcohol during
pregnancy – can be mild to severe
• Physical
• Mental, Learning Disabilities
• Behavioral
• FASD is not a Diagnosis
• Includes FAS
Bertrand J, Floyd RL, Weber MK. Guidelines for Identifying and Referring Persons with Fetal
Alcohol Syndrome. Morbidity and Mortality Weekly Report. October 28, 2005 / 54;1-10.
Executive Functioning
Ability to maintain a problem solving set to attain a
future goal
– Requires planning, mental representation and
Deficits may include:
inadequate organization, planning, or strategy use
difficulty grasping cause and effect (consequences)
impaired judgment
concrete thinking (“take a cab home” = steal a cab)
lack of inhibition and ability to delay gratification
difficulty following multistep directions
inability to apply knowledge to new situations
(difficulty breaking routines)
J Bertrand, RL Floyd, MK Weber. Guidelines for Identifying and Referring Persons with
Fetal Alcohol Syndrome. MMWR. 2005.
Diagnostic Criteria for
Fetal Alcohol Syndrome (FAS)
With or w/o confirmed maternal alcohol exposure
1. Documented facial
2. Documented Growth
3. Documented CNS
abnormality (using strict,
measurable criteria)
• For diagnostic guidelines, google “CDC, FAS”
Photo © Teresa Kellerman, www.fasstar.com, used with permission.
Life with an FASD: The Story of Iyal
To find it, search on internet: CDC FASD Iyal
3 or 7 minutes
FASD Prevalence
Identified Cases
Hidden Cases
• FAS:
– 0.2 to 1.5 per 1000
– 2-7 per 1000**
• FASD all cases
– 1 per 100*
– 2-5 per 100**
• Higher prevalence in
specific subpopulations
* May et al, 2001. **May et al, 2009.8
A Hidden Epidemic
“This is a hidden epidemic, since
the clinical capacity to recognize
and diagnose these conditions is
simply not present.”*
*Clarren SK, Lutke J. Building clinical capacity for fetal alcohol spectrum disorder diagnoses
in western and northern Canada. Can J Clin Pharmacol. 2008 Summer;15(2):e223-37.
How are People Affected?
• FASD: 75-80% have IQ
above 70
• Function below IQ
– Adaptive Behavior
• May have Physical
– Growth, heart, skeletal
– Hearing, vision, dental
– Others
You May See…
Distractibility and Attention Problems
Easily Frustrated, Meltdowns, Tantrums
Sensory Integration Disorders
Poor Emotional Regulation, Impulse
You May See…
• Concrete Thinking, Trouble Recognizing
‘Boundaries’ and Abstractions
–(i.e., to understand and act on rules)
• Challenges with Social Skills
• Sleep Disorders
Example: Actual Age vs Adaptive Skills
Actual age
Physical Maturity
Expressive Language
Reading Ability
Money, Time concepts
Emotional Maturity
Social Skills
Living Skills
Be Aware of ‘Masking Factors’
• IQ higher than functional intelligence
• Verbal skills may be relatively high
• Areas of higher brain function allow person
to mask areas of deficit
• We may wrongly attribute difficulties to
family dysfunction
• Social expectations are higher than ability
• They may lack insight into their adaptive
problems – and want to be ‘normal’
Caregiver Survey:
415 People Aged 6-51 with FASD
• 94% ages 6–51 mental health problems
– 23% mental illness requiring inpatient care
• 83% experienced dependent living (adults)
• 79% have employment problems (adults) Ann Streissguth
Among age 12+
• 60% have trouble with the law
• 49% repeated inappropriate sexual behavior
• 61% disrupted school experience (ie drop out)
• 35% have alcohol / drug probs
Streissguth, AP, Bookstein, FL, Barr HM, et al. Risk factors for adverse life outcomes
in fetal alcohol syndrome and fetal alcohol effects. Develop Behav Peds 2004. 25:228-238.
Caregiver Survey:
FASD and Trouble with the Law
• 14% of children under 12
• 60% of adolescents and adults
– shoplifting / theft (36%)
– assault (17%)
– burglary (15%)
– domestic violence (15%)
• 12 years and older: 35% ever incarcerated
Streissguth, AP, Bookstein, FL, Barr HM, et al. Risk factors for adverse life outcomes
in fetal alcohol syndrome and fetal alcohol effects. Develop Behav Peds 2004. 16
Caregiver Survey:
Inappropriate Sexual Behavior ….
Defined as repeated behaviors
Difficulty with concept of physical boundaries
– standing too close, touching, shows of “affection”
• Children: 39%
• Age 12 + adults: 49%
• Similar prevalence male and female
• Promiscuity, Exposing Self, Inappropriate
Advances, Statutory rape (consensual)
• Non-consensual sexual offenses, usually with
victims in the age range of 5-10
Streissguth, AP, Bookstein, FL, Barr HM, et al. Risk factors for adverse life outcomes
in fetal alcohol syndrome and fetal alcohol effects. Develop Behav Peds 2004. 25:228-238.
Illegal Activities Can Involve
Crimes of impulsivity, opportunity
Often unplanned, inept
Goaded into crimes, not the ringleader
No exit strategy, more likely apprehended
Repeated offenses that do not escalate
May respond with “fight or flight” when
• Fulsome and guileless confessions
• May lack apparent guilt or remorse
See Kathryn Kelly, FASD Legal Issues Resource Center
Personal Failings?...
[Re a meeting with teachers following Adam’s
delayed entry to high school]
“We listened to a recital of Adam’s failures,
shortcomings, recalcitrance. He continually
forgot the combination for his locker, he touched
other students “inappropriately,” he was
perpetually late to class, he ate his lunch b/f
arriving at school, he could not stay in his
seat…. Yet he had the ability, each teacher
stressed– he simply didn’t choose to use it.”
from Michael Dorris, adoptive father of child with FASD. From The Broken Cord,
Harper and Row, 1989. p. 129.
…or Brain Disorder?
[of our 17 year old son, “Adam”]
“He takes something that doesn’t belong to
him, or he gets goaded into going to his
boss and saying cuss words he doesn’t
understand. Try to explain to that man
how bad judgment is not a matter of
simple intelligence or an indicator of a
rotten person, but just inability, absolute
from Michael Dorris, adoptive father of child with FASD. From The Broken Cord,
Harper and Row, 1989. p. 217.
How to Respond?
How to Initiate Evaluation
• Find out what you can about history of
maternal alcohol use in pregnancy
• Specialists may be: child developmental
specialist, geneticist, dysmorphologist,
psychiatrist, or FASD clinic
• Diagnosis involves multidisciplinary team:
ie, Medical, Psychiatry/Psychology, Social
• Sensitive Communication to affected
person, mother, family
If No Conclusive Evaluation…
• Evaluations may be
lacking or unavailable
• If evaluation is not
accessible, try to treat
“as if” they have an FASD
• Individuals and their
supports may have a
Liz Kulp, living
With an FASD
rapid positive response
to re-framing expectations to
meet the person’s abilities
Prevalence of FASD
in Corrections Settings
In response to a Q’airre to corrections
systems, of the 3mil+ offenders
represented, only 1 was reported to have
a diagnosis of FAS*
Nearly all affected people are undiagnosed
in corrections systems**
*Burd, Selfridge, Klug, Sakko. FAS in the US corrections system. 2003.
**Burd, Fast, Conry, Williams. Fetal Alcohol Spectrum Disorder as a marker for
increased risk of involvement with correction systems. J Psych and Law. 2010.
FASD Prevalence Estimates in
Correctional Systems: … Review*
• 6 of 54 studies met eligibility for review
• Prevalence ranges from:
– High: 23 per 100 (in Youth Psych Services
Inpatient Assessment Unit)
– Low: 1 per 100 (extrapolated from a general
population prevalence study)
– Mid: 3 small studies average rate of about 10
per 100 (n’s of 91, 137, 230)
*Popova S et al. Fetal Alcohol Spectrum Disorder Prevalence Estimates in
Correctional Systems: A Systematic Literature Review. Can J Public Health.
Correx Prevalence Review Con’t
• “The studies… to date lacked rigour, used
different methodologies, and had small
sample sizes, and therefore might not be
• “Precise evaluations are not yet feasible
since there are no widely used screening and
diagnostic tools to identify the number of
FAD-affected persons within the justice
system. However, some progress has been
Risks in Correctional Settings
• Distractibility and agitation lead to conflict
• Manipulation by fellow inmates
– Desire to please, to be liked
• Sexual exploitation
• Violation of regulations (repeated)
– Impaired comprehension of written materials
and verbal instructions
– Impulsivity
• Probation breaches
– Poor planning and time estimations
Burd, Fast, Conry, Williams. Fetal Alcohol Spectrum Disorder as a marker for increased27
risk of involvement with correction systems. J Psych and Law. 2010.
FASDs Should Serve
to Mitigate Sentences
Judges may see:
• Defiance of court orders
• Absence of remorse
• Criminal record of incorrigibility
…Leading to aggravated penalties
Instead, FASD should be a mitigating factor
M Green, “A Judicial Perspective,” FASD Symposium for Justice Professionals, 2006.
American Bar Association
Passed August 7, 2012
“…support training and awareness of FASD
…to promote appropriate legal representation
and advocacy for individuals with FASD and to
address the over-abundance of individuals with
FASD in the foster care system, the juvenile
justice system and the adult criminal court….”
Programmatic Check List
for treatment programs for people with FASD in corrections
✓ Duration—treatment or interventions need to last longer
✓ Make it concrete—picture guides are helpful for teaching key
✓ Small groups—allow more attention to topical material
✓ Anxiety increases impairment—especially important in treatment of
substance abuse, sexual abuse or PTSD
✓ One problem at a time—allow participants to learn and apply
solution before moving on to next topic
✓ Appreciate impairments—some problems cannot be treated and we
need to learn how to adapt to them and minimize their effects
✓ Aftercare is essential—improves generalization of learned behaviors
✓ Short directions—an essential key for successful interventions
✓ Mental health concerns—need appropriate treatment
Burd, Fast, Conry, Williams. Fetal Alcohol Spectrum Disorder as a marker for increased risk of
involvement with correction systems. J Psych and Law. 2010.
Strategies for Success
Align expectations with abilities
Highly structured environment and expectations
KISS, One step at a time (Keep It Super Simple)
Concrete language
Frequent reminders/prompts
Repetition, Reinforcement, Role Play
Appropriate medical management and
• Flexibility with behavior violations (no expulsions)
• Logical, immediate reward/correction systems
• Advocacy, team support, recognize strengths too!
SAMHSA, FASD Curriculum for Addiction Professionals, Level One and Two, and Tools for Success 31
Curriculum: Working with Youth and FASD in the Juvenile Justice System: www.samhsa.gov.
Downloadable Resources
• Tools for Success Curriculum: Working
with Youth and FASD in the Juvenile
Justice System
• Curriculum for Addictions
Professionals (with clients with FASDs)
• Southeastern Regional FASD Training Center
Tel: 615 327-5525 Web: www.sefasrtc.org
• CDC FAS Home Page at www.cdc.gov/fasd
• NOFAS (National Organization on FAS)
Phone: 202-785-4585 Web: www.nofas.org
• Health and Human Services (HHS), Substance
Abuse Mental Health Services Administration
(SAMHSA), FASD Curriculum for Addiction
Professionals”, Level One or Two:
• FASD and Criminal Justice 4-page Fact Sheet at:

Identifying and Caring for Inmates with Fetal Alcohol