FETAL ALCOHOL SPECTRUM DISORDERS
AND YOUTH JUSTICE IN NEW ZEALAND:
A BRIEF OVERVIEW
Dr Craig Immelman
Child, Adolescent & General Psychiatrist
Private Practice, Auckland
Acknowledgments
 
Dr Valerie McGinn, Neuropsychologist, Auckland
 
Principal Youth Court Judge Andrew Becroft
 
Youth Court Judges Tony Fitzgerald and Stephen O’Driscoll
Dr Kwadwo Asante and staff, Asante Centre for Fetal Alcohol
Syndrome, Maple Ridge British Columbia
 
Professor Ann Streissguth, FADU, University of Washington
 
 
Judge Tony Wartnick, Dr Rich Adler, Dr Paul Conner, Assistant
Professor Natalie Novick Brown, Seattle
Professor Ab Chudley, Canada
Christine Rogan, Alcohol Healthwatch Trust
 
Dr Tina Page, Addiction Psychiatrist, Auckland
 
 
Agenda
How I came to be involved in FASD
  What is FASD?
  The NZ experience
  Questions, comments, suggestions
 
My background
Trained in adult forensic psychiatry in the early
1990s
  Went on to train in child & adolescent psychiatry
  First locally trained child & adolescent psychiatrist
to work at the Auckland Regional Youth Forensic
Service
  Attended a presentation on FASD in 2008 in
Auckland
  Invited to look at services in Canada & the US, and
to train in how to diagnosis FASD
 
Seattle FAS Experts &
Federal Habeas Corpus Appeals
c.3000 prisoners on Death Row at present
  c.40 executed every year
 
Prisoners under sentence of death in
the United States
Executions in the US
Federal Habeas Corpus Appeals
Executions can be unconstitutional
th
  8 Amendment (“cruel & unusual”)
  Atkins v Virginia 2002 – mental impairment
  Roper v Simmons 2005 - juveniles
 
Seattle-based experts
Retired Federal Judge
  C&A and General Psychiatrist
  Two Neuropsychologists
  Conducting multidisciplinary FASD assessments
  Including Death Row cases
 
Criminal Justice System: Basic Premises
Offenders have the ability:
  to
learn from the consequences of their antisocial
behaviour;
  and to be deterred by sentences imposed on other
offenders.
But…
What if someone with brain damage (that is not
always obvious) has problems with:
  Understanding
cause and effect;
  Understanding social norms of behaviour
  Learning
Judicial interest…
Judge O’Driscoll – NZLJ May 2011
 
Judges wonder why some offenders:
  don’t
seem to learn from their previous appearances in
Court;
  seem unable to complete community work sentences;
  have little appreciation of risk of harm to themselves;
  have little appreciation of harm caused to their victims.
 
One explanation (for a some offenders) may be
brain damage due to prenatal alcohol exposure
(Fetal Alcohol Spectrum Disorder)
Overseas FASD prevalence studies
23% youth in a Canadian inpatient forensic
psychiatric unit (Conry 1997)
  10% (confirmed), 18% (possible) FASD in a
Canadian adult prison (MacPherson 2007)
 
Trajectory of those with FASD
60% have had contact with the law (Streissguth
2004)
  Thus there is a disproportionate representation of
those with FASD in Justice system in Canada and the
US
 
Prevalence of FASD
US/Canada: estimated at 2 – 5% of general
population (May 2009)
  Over-representation of FASD in Justice Sector in
North America
  NZ: no epidemiological data at this point
  Small non-representative NZ study of 11 individuals
(many Court-referred) showed 8 had FASD
 
What is FASD?
Brain damage as a result of in utero alcohol exposure
Alcohol is a neurotoxin and teratogen
FASD can be likened to a head injury (i.e. brain
damage) of the developing foetus
  Where the brain is damaged depends on what
stage of development it is exposed to alcohol
  How much of the brain is damaged depends on
exposure (dose) and vulnerability
 
Ethanol crosses the placenta freely Alcohol Chicks Fail Detour Learning Test
Animal Models - mouse
Only present in about 30% (early first trimester exposure)
Tend to be less distinguishable from puberty
Major Effects of Ethanol by Trimester of Pregnancy Diagnosis
Multidisciplinary (trained medical doctor & trained
clinical psychologist at a minimum)
  Not in DSM-4TR
  Canadian & University of Washington guidelines
 
Making a diagnosis of a FASD
 
Assesses four domains:
  Maternal
alcohol exposure;
  Growth deficiency;
  CNS (brain) damage;
  FAS facial features.
Prenatal Alcohol Exposure
Growth
Face: philtrum, lip, PFL
Differential diagnosis of facial dysmorphology
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Fetal anticonvulsant embryopathy
Maternal PKU embryopathy
Dubowitz syndrome
Aarskog syndrome
Noonan syndrome
Williams syndrome
Kabuki syndrome
Ritcher-Schinzel syndromes
Cornelia de Lange syndrome
22q.11.2 del and other Chromosomal disorders
And others…
Acknowledgments: Ab Chudley
CNS effects
The field of a trained neuropsychologist
  Need to demonstrate impairment in more than 2 domains
  A number of instruments are used including measures of
adaptive function
  FSIQ is often >70 but with marked functional & frontal
deficits
 
Making a diagnosis of a FASD
 
Assesses four domains:
  Maternal
alcohol exposure;
  Growth deficiency;
  CNS (brain) damage;
  FAS facial features.
4 Digit Diagnostic Code
Precedent
Court of Appeal: R v Lucas-Edmonds [2009] 3 NZLR
493
  High Court: Komene v Police HC Auckland
CRI-2009-404-242, 7 Nov 2009 per Lang J
 
Judicial Interest
Completed project, mostly s.333 reports, sponsored
by the Principal Youth Court Judge Andrew Becroft
  Approached about developing a screening project
for FASD in the Auckland Youth Court
  A number of cases presenting with FASD, a few of
whom with fitness to stand trial and intellectual
disability issues
  Wide range of offending, including a couple of
murder, arson and sexual offending trials (public
safety)
 
Conclusion
FASD is a serious & debilitating disorder, and has
received little recognition in the YJ and criminal
justice sector in NZ
  International research shows that with early
diagnosis secondary disability can begin to be
addressed
  This may confer significant advantage not just to the
offender but also the community in general
  Knowledge of FASD is growing…NZ must ensure it
keeps up to date
Source: Judge O’Driscoll
 
Questions, comments, suggestions