Study protocol for screening and diagnosis of fetal alcohol spectrum disorders (FASD) among young people sentenced to detention in Western Australia

It takes a village: Influencing policy and practice to prevent alcohol use in pregnancy and promote better outcomes for individuals living with Fetal Alcohol Spectrum Disorder

Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental disorder caused by exposure to alcohol in utero. It has pervasive, lifelong impacts and is recognised as a major public health concern in many countries where alcohol is used. The FASD Research Australia Centre of Research Excellence (CRE) was funded by the National Health and Medical Research Council to generate and translate evidence to address prevention, diagnosis, and management of FASD in Australia. The current paper describes the approach to policy and practice impact taken by our CRE, including our stakeholder engagement processes and the key principles that underlie our approach. We provide examples of policy and practice influence in FASD prevention, diagnosis and management that have been achieved over the past five years and discuss challenges that are routinely faced in the translation of our work.

Fetal alcohol spectrum disorders (FASD) and youth firesetting: A call on criminal justice, emergency responder, and fire prevention specialists to become informed

Central nervous system damage resulting from prenatal exposure to alcohol, often referred to as fetal alcohol spectrum disorders (FASD), commonly manifests as lacking cognitive functioning, problem solving, impulsivity, memory, executive functioning, and social skill deficits. For individuals with FASD, these brain-based deficits translate into impulsive behaviors and poorly thought-out decision-making, coupled with an inability to anticipate and recognize the sometimes very severe consequences of their behaviors. Not unexpectedly, individuals with FASD frequently find themselves disproportionately involved in the criminal justice system and mental health services. For some individuals with FASD, these behaviors can also include firesetting. First responders, like other health and legal professionals, are often unable to recognize the behavioral indicators of FASD, primarily due to a lack of training. As a result, firesetting behaviors are often attributed to deliberate, willful acts of delinquency, a desire to damage property, thrill seeking, or as attempts for personal gain, rather than being viewed as maladaptive attempts to solve problems by individuals who lack the tools to do this in more appropriate ways. These same skill deficits also present when individuals with FASD are interviewed about their involvement in such behaviors, sometimes resulting in confabulation, suggestibility, and false confessions. Further education and training in FASD are vital for first responders if they are to better support individuals with FASD and minimize their chances of becoming involved in firesetting behaviors. Furthermore, this training and education will help ensure that first responders can intervene in more appropriately when crisis situations do occur. This article will outline key behavioral symptoms of FASD as well as provide first responders with suggestions as to how to best support individuals when FASD is suspected. The brief quote that follows highlights some of the key challenges facing individuals with FASD and how poor decision-making and impulsiveness can result in severe consequences for the individual and those around them.

A Validation Study of the Alcohol Related Neurodevelopmental Disorders Behavioral Checklist

BACKGROUND

The initial confirmatory factor analysis of the Alcohol Related Neurodevelopmental Disorder Behavioral Checklist (ABC) utilized a population of 203 children. The analysis identified 10 independent measures (executive functioning, attention and concentration, cognition, memory, confabulation, gullibility, communication skills, academic skills, living/social skills, and juvenile justice). The 10 measures differentiated children with FASD from non-FASD controls. In this study, we present a validity study of the ABC using a different population of children with FASD and non-FASD controls.

METHODS

A chart review identified 224 children with ABC checklist scores who had been evaluated for FASD. From this sample, we implemented a case-control study of 76 children diagnosed with FASD and 76 non-FASD controls who were matched by gender and closest age in years (mean age was 8.5 years).

RESULTS

The averages of the total score and individual domain scores were compared between the 2 data sets and then between children with FASD and non-FASD controls. Children with FASD had significantly higher scores on all 10 measures than the non-FASD controls. There were very high sensitivity and specificity scores for the total score cutoff and for all 10 of the individual measures.

CONCLUSIONS

In an independent sample, we found minimal differences between the previous data and the current validation study on measures of average total score cutoffs, scores for the 10 measures and correlations. Combining the 2 samples yielded robust differences in scores between children with FASD and non-FASD controls. The sensitivity, specificity and accuracy estimates were also very high. The ABC Screen appears to have acceptable epidemiologic performance data to support its use as a screening tool and as an initial step in differentiating children with FASD from those who do not have FASD.

The oral and written narrative language skills of adolescent students in youth detention and the impact of language disorder

BACKGROUND

Unmet language and literacy needs are common among young people who are involved with youth justice systems. However, there is limited research regarding the functional text-level language skills of this population with regard to narrative macrostructure (story grammar) and microstructure (semantics and syntax) elements.

METHODS

In this study, we examined macrostructure and microstructure elements in the oral and written narrative texts of 24 adolescent students of a youth detention centre. The students, who were aged 14- to 17- years, were all speakers of Standard Australian English, and 11 (46%) students met criteria for language disorder (LD).

FINDINGS

When we compared the narratives according to modality of language, the students demonstrated stronger narrative language skills in the written modality compared to the oral. However, when we compared the narratives according to language ability, we found that the impact of LD on inclusion of macrostructure elements was greater in the oral modality, and for microstructure elements, was greater in the written modality. Errors in written conventions were common among both students with and without LD.

CONCLUSIONS

Our results indicate that both the modality of language as well as the presence of LD should be considered when young people are required to participate in forensic contexts including programs that address educational and rehabilitation needs. Our results indicate a need for consistent text-level language assessment to better identify and respond to functional difficulties within language and literacy. There is potential for speech-language pathology services to enhance comprehensive assessment as well as inform educational and rehabilitation programs for young people who are involved with youth justice systems.

Navigating complexity to support justice-involved youth with FASD and other neurodevelopmental disabilities: needs and challenges of a regional workforce

BACKGROUND

Young people with Fetal Alcohol Spectrum Disorder (FASD) can face significant challenges in their lives, including overrepresentation in the justice system from a young age. Police questioning and court proceedings can be difficult for these young people to navigate. Practice and policy responses are necessary to identify these individuals, provide appropriate support/rehabilitation, and upskill the justice workforce. The aim of this research was to determine the unmet workforce development needs of a regional workforce providing care and support to youth involved with the justice system. Interviews were conducted with 29 participants from 14 organisations to understand the support provided to youth, existence and uptake of referral pathways, and unmet needs.

RESULTS

Results revealed a workforce that wants to see improvements to outcomes for young people with FASD and other neurodevelopmental disabilities who enter the youth justice system. However more support is required through training, ongoing funding, and assistance to develop FASD informed work practices.

CONCLUSIONS

The workforce supporting youth to navigate the justice system requires practical interventions to achieve best practice so that young people with FASD and other neurodevelopmental disabilities receive the support that they need. Following the interviews a model of care tool was developed and piloted in the sector. The tool includes current pathways through the justice system and provides resources to assist staff in achieving best practice care for young people with FASD and other neurodevelopmental disabilities.

Reframe the Behaviour: Evaluation of a training intervention to increase capacity in managing detained youth with fetal alcohol spectrum disorder and neurodevelopmental impairments

The first study to investigate the prevalence of fetal alcohol spectrum disorder (FASD) within an Australian juvenile detention centre has identified the highest known prevalence of FASD among a justice-involved population worldwide. However, there has been limited investigation into the capacity of the custodial workforce to identify and manage young people in Australian detention centres with FASD or other neurodevelopmental impairment (NDI), and no published interventions aiming to develop environments appropriate for those with FASD in justice settings. Using the Template for Intervention Description and Replication checklist, this study describes the conception, implementation and evaluation of a training intervention aiming to upskill the custodial workforce in the management of youth with FASD and NDI; 117 staff participated in the intervention, and 109 completed pre- and post-intervention surveys. Improvements were seen across almost all knowledge and attitude items, and the intervention was considered highly necessary, appropriate and valuable by the workforce.

Disability "In-Justice": The Benefits and Challenges of "Yarning" With Young People Undergoing Diagnostic Assessment for Fetal Alcohol Spectrum Disorder in a Youth Detention Center

Undertaking research with young people presents an array of methodological challenges. We report the findings from a qualitative study that took place alongside a fetal alcohol spectrum disorder (FASD) prevalence study among detainees in Australia. Of 38 participants, 27 were Aboriginal youth. Interviews were conducted using "social yarning" and "research topic yarning," an Indigenous research method which allows for data collection in an exploratory, culturally safe way. A complex interplay emerged between social yarning and research topic yarning which provided a space to explore responsively with participants their experiences of FASD assessments. Flexibility, including language adaptation and visual descriptions about assessments, was utilized to assist participants recall and retell their experiences. There were, however, challenges in gathering data on the assessment experiences of some participants. We describe how employing a "yarning" method for collecting data could benefit children and young people undergoing neurodevelopmental assessments in the future.

Challenges in Accurately Assessing Prenatal Alcohol Exposure in a Study of Fetal Alcohol Spectrum Disorder in a Youth Detention Center

BACKGROUND

Prenatal alcohol exposure (PAE) can result in permanent disability, including physical, neurodevelopmental, and cognitive impairments, known as fetal alcohol spectrum disorder (FASD). Individuals with FASD are more likely to engage with the law, including being placed in detention, than individuals without FASD. Young people who were sentenced to detention participated in a FASD prevalence study in Western Australia. The diagnosis of FASD requires a multidisciplinary assessment and confirmation of maternal alcohol consumption during pregnancy. Obtaining accurate assessment of PAE for young people participating in the study was challenging.

METHODS

An interview with the birth mother or other responsible adult for young people sentenced to detention in Western Australia was conducted as part of the FASD assessment. The Alcohol Use Disorders Identification Test consumption subset (AUDIT-C), other relevant questions, and documentary evidence were used to assess PAE. PAE was categorized according to the Australian Guide to the Diagnosis of FASD: no PAE reported, confirmed or confirmed high-risk, or unknown.

RESULTS

Among the 101 participants, information on PAE was unable to be obtained for 13 (13%) young people. Of the remaining 88 participants with information of PAE, 41 reported no PAE and 47 had confirmed PAE.

CONCLUSIONS

Accurately assessing prenatal alcohol consumption is challenging in any setting, but it is exceptionally challenging when assessed 13 to 17 years retrospectively as part of a FASD assessment for a young person sentenced to detention. Recording and recoding detailed qualitative responses was required to provide an accurate assessment of PAE using the AUDIT-C. Standardized recording of PAE in antenatal and birth records would facilitate later assessments for FASD and provide opportunities for advice and support for women who continue to drink during pregnancy.

Fetal alcohol spectrum disorder in Australia: What is the current state of affairs?

The term fetal alcohol spectrum disorder (FASD) is used to describe a wide range of difficulties that individuals who are exposed to alcohol prenatally can face. FASD is a significant public health concern that is currently under-recognised and consequently, under-diagnosed in Australia. A new Commonwealth FASD Strategy (2018-2028) is being developed and the Australian Government has announced significant funding for the expansion of FASD prevention, diagnostic and intervention services around Australia. Therefore, it is timely to consider what the current state of affairs regarding FASD in Australia is and describe areas for future research and service delivery.

Fetal Alcohol Spectrum Disorder (FASD): Knowledge, attitudes, experiences and practices of the Western Australian youth custodial workforce

BACKGROUND

Fetal Alcohol Spectrum Disorder (FASD) is a condition caused by prenatal alcohol exposure and characterised by lifelong physical, behavioural and cognitive abnormalities. Primary disabilities, such as impairment in memory, attention, cognition, language, executive function, and adaptive function, can lead to young people with FASD becoming engaged with the justice system. Little is known about the extent of FASD in youth detention in Australia, or of the capacity custodial staff have to manage and support young people with FASD. In tandem with a study assessing the prevalence of FASD among youth in detention in Western Australia (WA), this study aims to establish the current knowledge, attitudes, experiences and practices regarding FASD and other neurodevelopmental impairments among youth custodial officers in order to develop training resources for this workforce.

METHODS

We invited youth custodial officers in the only youth detention centre in WA to participate in an online or hardcopy survey. The survey was developed following extensive consultation with the workforce and investigated their knowledge, attitudes, experiences and practices relating to FASD and other neurodevelopmental impairments. This included experience working with young people with FASD and other impairments, and attitudes towards relevant training.

RESULTS

112 youth custodial officers (51% of the youth custodial workforce) completed the survey. While many respondents had heard of FASD (77%) and understood it is relevant to the justice system (74%), limited in-depth FASD knowledge existed. Many respondents were unsure or unaware that FASD is permanent brain damage (53%) and cannot be outgrown (57%). Respondents were infrequently informed if a young person in detention had a diagnosis of FASD. Almost all custodial officers indicated motivation to complete training to further understand FASD (92%) and other neurodevelopmental impairments (94%), with particular interest in the application of management strategies appropriate for affected young people.

CONCLUSIONS

A lack of specific knowledge, inadequate training to recognise and manage young people with neurodevelopmental impairments, and inconsistent information-sharing processes reduce the ability of the custodial workforce to care for young people with FASD and other neurodevelopmental impairments. These findings have supported the development and evaluation of training resources targeting the specific needs and requests of the WA youth custodial workforce, and this is now underway.

Fetal alcohol spectrum disorder and youth justice: a prevalence study among young people sentenced to detention in Western Australia

OBJECTIVES

To estimate the prevalence of fetal alcohol spectrum disorder (FASD) among young people in youth detention in Australia. Neurodevelopmental impairments due to FASD can predispose young people to engagement with the law. Canadian studies identified FASD in 11%-23% of young people in corrective services, but there are no data for Australia.

DESIGN

Multidisciplinary assessment of all young people aged 10-17 years 11 months and sentenced to detention in the only youth detention centre in Western Australia, from May 2015 to December 2016. FASD was diagnosed according to the Australian Guide to the Diagnosis of FASD.

PARTICIPANTS

99 young people completed a full assessment (88% of those consented; 60% of the 166 approached to participate); 93% were male and 74% were Aboriginal.

FINDINGS

88 young people (89%) had at least one domain of severe neurodevelopmental impairment, and 36 were diagnosed with FASD, a prevalence of 36% (95% CI 27% to 46%).

CONCLUSIONS

This study, in a representative sample of young people in detention in Western Australia, has documented a high prevalence of FASD and severe neurodevelopmental impairment, the majority of which had not been previously identified. These findings highlight the vulnerability of young people, particularly Aboriginal youth, within the justice system and their significant need for improved diagnosis to identify their strengths and difficulties, and to guide and improve their rehabilitation.