The American Bar AssociationFetal Alcohol Spectrum Disorder Resolution

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Engendering Hope & Delivering PromiseNW Law & Mental Health Conference ~ March 13,

2020

The Opportunity

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Created by the CBA and ABA ResolutionsSupporting the Multnomah County Re-entry Strategic Plan

& Senate Bill 1008

Growing Positive Community Norms

Judges, Lawyers, Probation Officers, Child Welfare, Behavioral Health & Law Enforcement In Concert with Communities, Families & Natural Helpers

Learning Landscape❖ FASD as an invisible, life-long disability

❖ Prenatal exposure to alcohol is the leading cause of intellectual disabilities in the US.

❖ Today’s presentations will offer some clinical, research and evidence based practice, and some anecdotal stories that inform promising “practice-based” evidence.

❖ Strategies and stories will reflect a relational approach that meets people “where they are”, using observation, over time and across different settings to identify the strengths and challenges that will inform a collaborative circle of services and integrated support.

❖ Early Intervention provides powerful tools and strategies for mitigating secondary characteristics. Equally important, it contributes to positive parenting and skill-building.

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FAS and FASDWhat are they?

•The consequence of prenatal exposure to alcohol•Neuro-behavioral expressions of alcohol as a teratogen•Morphologic & physiologic expressions of alcohol as an embryonic teratogen SLBK

❖ Behavioral health issues for adults impacted by an FASD create a disproportionate load on social service and justice resources.

❖ When we have the privilege to participate in the lives of families, we are given the opportunity to help identify the strengths and gifts of individuals, families, their communities and their culture. We are also charged with the responsibility to engage in an approach that simultaneously embraces clinical practice and cultural congruence.

❖ Studies demonstrate that current best practice for effective strategies include neuro and enviro trauma-informed FASD training and delivery in culturally congruent screening and assessment; generating collaborative and integrated programming service and delivery.

❖ Relational engagement is essential to successful provider service outcomes.

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❖ Recognize and know the signs of FASD as they are expressed:

• Perseveration• Gullibility• Poor judgement• Impulsiveness• Inability to link or predict cause and effect• Inability to identify dangerous situations or people/lack of boundaries

• Inability to anticipate/understand consequences (multiple arrests for similar crimes)

• Much better expressive than receptive language• Literal/concrete thinking/misinterpretation• Behavioral echolalia• Sensorial reactiveness • Confabulation

❖ Involvement in legal issues may be the first opportunity generating assessment and diagnosis of F.A.S.D. and the development of appropriate interventions and strategies.

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Neuro-behavioral Consequences❖ Impact of alcohol as a teratogen is most

manifest within the structure and function of the brain.

❖ Neuro-cognitive and behavioral consequences of prenatal alcohol exposure create the primary and most devastating impacts of an FASD across the life span

Domains of Impact• adaptive behavior (communication, social skills)• attention/hyperactivity/impulsivity• cognition (abstract/sequential thinking)• language (processing/receptive/expressive skills)• memory (encoding/retrieval/working memory)• motor skills (coordination, vestibular development, balance)

• sensory integration (visual-spatial-motor learning/tactile)• social skills (social perception, boundaries)• executive skills (judgement, reasoning, impulse control)SLBK

Understanding what it does and does not mean• It is not about being smart or stupid • It is about organic brain damage and about different ways of learning, seeing and processing (understanding).

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Expressions and Implications•confounding comorbidities•co-occurring DSM diagnosis

• ASD• ADHD• Anxiety Disorder• Bi-Polar issues• Depression

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Potential Impacts of an FASDPersonal:

• helpful and caring• good artist • good musician• visual learner• like people• get into trouble• hard to sit still• hard to listen and understand• want to please• in trouble with the law• use substances• caught up in violence• feel like a failure• can’t keep a job• have to keep moving/homeless• depressed• poor judgment/no cause and effect• hopelessness SLBK

FASD hijacks the midbrain:

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Limbic system is on a “roller coaster”

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Can’t retrieve what isn’t stored.SLBK

Need external scaffolding structure

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Secondary Characteristics

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Feelings of failure depression, mental health and substance issues

Frustrated communication tantrum, “oppositional defiant disorder”

Difficulties in processing, school and job failure memory and cognition

Impulsivity and reactivity legal issues and involvement in corrections

Need for social and inappropriate sexual behaviors physical reinforcement

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S.P.S.Sensorial Processing

Self-regulation

• rates of recidivism

• vulnerability to victimization

• vulnerability to becoming an offender or perpetrator

• rates of sexual abuse

❖ Increases in…

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FASD Expressions Within the Context of Justice

❖ Some stats…

• out of 415 adolescents involved with the law, 60% were screened and diagnosed with F.A.S.D. (UW)

• in a sampling of adult prison populations in which screening and diagnosis for an F.A.S.D. occurred, 87-92% of the inmates received an F.A.S.D. diagnosis

• in collected studies of North American indigenous peoples, it appears that approximately 57-82% of adults incarcerated, receiving assessment and diagnosis, were identified as having an F.A.S.D.

• added costs in social services, approximately 2.5-4.5 million dollars per individual with an F.A.S.D.

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❖ Some major impacts…

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Lack of impulse control and trouble understanding the future consequences of current behavior

TIP/SAMSHA

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Trouble understanding what constitutes criminal behavior (for example, a youth with F.A.S.D. may not see any problem driving a car he knows was stolen if he wasn’t the one who stole it)

TIP/SAMSHA

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Difficultly planning, connecting cause and effect, empathizing (particularly if the experience is not explained in a very concrete way), taking responsibility, delaying gratification, and making good judgments.

TIP/SAMSHA

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Tendency toward explosive episodes, often triggered by sensory overload, slower rates of processing the information around them, and/or feeling “stupid”.

TIP/SAMSHA

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Vulnerability to peer pressure and influence (e.g., may commit a crime to please friends), and high levels of suggestibility.

TIP/SAMSHA

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Lower level of moral maturity (due in part to social information processing deficits).

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Consider potential expressions associated with co-occurring issues such as ASD

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“Putting them [individuals with F.A.S.D.] in jail is just sort of a band-aid on an open wound sometimes. Now the wound is always going to be open, but I guess a more successful approach would be to make the wound non-inhibiting. So something that’s peripheral to their life in the sense that they find a way to live despite it, a way to function despite it.”

- Yukon Justice Professional

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Risk Factors Aligning with F.A.S.D.Mental health disorders

Alcohol & substance use disorders

Trauma or abuse

Lack of social support

Bonding and attachment disorders

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Protective Factors Aligning with F.A.S.D.

Family & parenting

Positive social support

Cultural & spiritual practice

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I am my environment

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Ability to predict what will happen next is compromised.SLBK

Conscience is what you show me.Action is what you script for me.

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Seeming inability to learn from mistakes

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Difficulty generalizing information

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Concrete Processing

“This is not my street.”

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Behavior is communication

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Extremely socialCuddly

Clinging

Credulous

Confused

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Brain-based behavior… …is not willful defiance…is not a “behavior

problem”

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Failure is not a teacher.

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Identify & reinforce what is working

…concretely mappingthe positive actions

…scripting for socialskill development

…creating CollaborativeCircles of Care

…integrating systemswith service delivery

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…providing frequency and duration of services that are understood to be essential to building and sustaining skills. Use CHWs, CEWs, natural

community helpers, mentoring and volunteer resources.

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• FASD produces a spectrum of impacts, expressing itself differently in each person. • faces are not predictors of behavior. • social cues are read through face and body language.

Remember…

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❖ Some Steps for Justice Personnel

• Refer for assessment and diagnosis

• Assist arrested individuals in understanding court procedures

• Adapt interview process • Train courts and judges and

assist with appropriate sentencing guidelines

• Train corrections staff and probation officers in implications of F.A.S.D.

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❖Using existing training tools in concert with the Forensic Screening Tool

❖ Offense Conduct• Illogical actions with high detection risk

• “Simple” plan (focus is only on the objective)• No real exit strategy• Impulsive and aggressive over-reaction to

unforeseen events (“fight or flight”)

• More sophisticated/experienced co-defendants

Forensic Assessment of FASD

❖ Arrest Conduct• Immediately or easily waives rights• Over-confesses (suggestible)• Brags about prowess or takes full responsibility if

co-defendants• Emotionally detached from crime (shows little remorse or guilt)• Behavioral regression (breaks down in tears, infantile behavior)

❖ Prior Legal History• Easily led by more sophisticated peers• Multiple low-grade offenses in teen years, often

with co-defendants• Lots of stealing• Illogical offenses (e.g., stealing something with

little value)• Oblivious to risk• Impulsive, opportunistic crimes• Probation violations

❖ Life History• Mom abuses alcohol/drugs• Involvement with child welfare• Adoption/foster or relative placements/juvenile

commitment• Special Education/learning disabilities in school• Multiple diagnoses in childhood (especially ADD/ADHD)• Rule-breaking behaviors (lies, cheats, steals, fights)• Disrupted education• Substance abuse• Unstable adult lifestyle (improves with structure)

❖ Interview with Client• Short stature (not always)• Unstable lifestyle• Immature and naïve• Eager to please or stubbornly resists the obvious• Can’t provide coherent, detailed narrative• Can’t concentrate• Doesn’t add much• Doesn’t seem to remember what you tell him/her from appointment to appointment

FASDForensic assessment of Fetal Alcohol Spectrum Disorder

Richard Adler, MD, Medical DirectorNatalie Novick Brown, PhD, Program DirectorPaul Connor, PhD, Neuropsychological DirectorRetired Judge Anthony Wartnik, Legal Director

❖ Remember:• Average age of an individual with an FASD who is in trouble with the law

is 12.8 years• Youth with an FASD are safer and more successful placed in juvenile

systems rather than in adult prisons• Fifty percent of individuals with an FASD have a history of jail, prison

or placement within psychiatric institutions• People with an FASD are more likely to engage in confabulation and

make false confessions• Attorneys may be successful in presenting FASD as a mitigating factor

for creating alternative and diversionary sentencing and utilizing community placements as methodologies for concrete “making of amends” and accountability

• Court ordered diagnosis and treatment that is cognitively aligned with and reflective of that diagnosis are appropriate interventions creating the most positive and successful outcomes

❖ Create Protocols inclusive of…• Court-ordered assessment, using diagnostic tools as soon as possible. Implement full functional assessments in concert with diagnosis for suspected offenders prior to sentencing, and if possible, immediately post-arrest/interview process.

• Cognitive retailoring of interview protocols and language. Understand that behavioral training in not effective.

• Adapting policies of risk assessment to more appropriate evaluative tools that do not focus on past history to predict future behavior.

• Focusing on future pro-social behavior rather than past negative behaviors, looking for what individuals can do, rather than what they can’t do. Adapt language of the probation order to what they should do, rather than what they should not do.

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• Assessing and determining appropriate use of NCR defense for clients with an F.A.S.D.

• Guidelines for use of conditional and alternative sentencing which include interventions with emotional regulatory approaches rather than cognitive behavioral training.

• Development of multidisciplinary team-generated client probation orders and work plans of integrated services from a strengths-based, culturally appropriate collaborative model that utilizes Natural Helpers, family and community assets to provide the frequency and duration of contact necessary for success.

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Thank you❖ For recognizing and knowing the signs of FASD as they

are expressed through:

•Poor judgement• Impulsiveness• Inability to link or predict cause and effect• Inability to identify dangerous situations or people• Inability to anticipate/understand consequences (multiple arrests for similar crimes)•Much better expressive than receptive language•Literal/concrete thinking•Behavioral echolalia•Sensorial reactiveness

“Thank you so much for…Caring, committing and considering

the implications of FASD…”