WILLIAM J. EDWARDS, DEPUTY PUBLIC DEFENDER OFFICE OF THE PUBLIC DEFENDER

1. REPRESENTING CLIENTSWITH FASD IN THECRIMINAL JUSTICE SYSTEM:Changing Court AttitudesRaising FASD at all stages WILLIAM J. EDWARDS, DEPUTY PUBLIC DEFENDER OFFICE OF THE PUBLIC DEFENDER LOS ANGELES COUNTY, CALIFORNIA

2. Fetal Alcohol Syndrome (FAS) FAS is a neuropsychiatric developmental disorder that is a common public health issue according to the U.S. Surgeon General’s 2005 Report. A set of mental, physical and neurobehavioral birth defects caused by exposure to alcohol during pregnancy.

3. Today, I’ll cover 4 essentials 1. What people with FAS & FASD look like at different ages 2. How their unusual behaviors are related to brain damage from prenatal alcohol exposure and possibly enhanced by bad environments 3. How can you establish that the mother drank alcohol during her pregnancy with this child 4. And which experts can make your case. (I’ll also tell you about mistakes I’ve made)

4. FAS May Include: • Confirmed prenatal alcohol exposure • Evidence of a characteristic pattern of facial anomalies that includes features such as an indistinct philtrum, thin upper lip & small eyes. • Evidence of growth retardation in at least one of the following areas: • Low Birth Weight - babies born with FAS are usually below the third to tenth percentile in their birth weight. • Decelerating weight over time not due to nutrition. • Failure To Thrive. • Disproportional low weight to height

6. FAS Cont. • Evidence of central nervous system dysfunction. • In many cases the child or adult will have a lower IQ sometimes within the range of intellectual disability (mental retardation). • Structural brain damage.

8. Fetal AlcoholSpectrum Disorders (FASD) FASD is an umbrella term used to describe the many different disabling effects of prenatal alcohol exposure. FASD includes FAS and other alcohol-related diagnostic categories such as ALCOHOL RELATED NEURODEVELOPMENTAL DISORDER (ARND), formerly known as Fetal Alcohol Effects (FAE).

9. FASD is a developmental disorder because of the obstructions and delays from normal growth patterns and resulting deficits including:

10. Developmental Deficits • ADHD and ADD • Mental Retardation • Learning Disabilities • Mental Illness including Bi-polar disorder, Oppositional Defiant Disorder, Antisocial Personality Disorder, Borderline Personality Disorder and Depression • Poor memory and recall • Poor planning

11. PRIMARY DISABILITIES ASSOCIATED WITH FASD General intelligence, mastery of academics and general level of adaptive functioning are measures of “primary disabilities.”

12. Cognitive • Lower IQ (may be normal or even gifted) • Difficulties with: • Memory • Poor math skills-problems handling money • Self awareness, reflection • Abstract concepts

13. Medical/Neuromotor Difficulties with: • Balance, coordination • Seizures • Growth “FAILURE TO THRIVE” • Hyperactivity (present is about 85% of the children with FAS) • Middle ear infections • Eye problems, e.g. severe nearsightedness • Orthopedic problems • Cardiac anomalies, e.g. heart murmurs, patent ductus arteriosus, ventricular septal defect

14. Executive Functioning Difficulties with: • Planning • Judgment • Delayed gratification • Impulse Control • Organization skills • Attention, focus, concentration

15. Emotional • Little ability to recognize feelings • Little ability to articulate feelings • Mood disorders • Anger/Rage disorders • Vulnerability to mental illness

16. Speech/Language • Parroting of others-speech patterns • Delay in communication • Talkativeness • Confabulation

17. Interpersonal Skills • Inability to read social clues • Inability to empathize • Excessive demand for attention • Externalization of blame • Arrested social development

18. Difficulties In Early Childhood • Poor visual focus - “severe nearsightedness” • Sleep & feeding difficulties • Seizures • Poor motor coordination - appear to be clumsy • Developmental Delays

19. Early Childhood Cont. • Distractibility and hyperactivity- “unable to pay attention or sit still” • Difficulty adapting to change • Difficulty following directions • Born into a dysfunctional family, the infant is commonly abandoned in the hospital, or put up for adoption by the mother, or removed by Child Protective Services.

21. Difficulties in Mid-Childhood • Difficulty understanding / predicting consequences • Emerging discrepancy between expressive language and comprehension • Hyperactivity - memory deficits - impulsivity • Poor comprehension of social rules

22. Mid-Childhood Cont. • ADHD symptoms – “child might get up and walk out of the classroom” • Academic failure • Special Education • Concrete thinking may frustrate relationships • Gullibility

23. Difficulty in Adolescence • Lying – stealing - truancy • Failing to understand consequences of actions • Inappropriate sexual behavior • Low self esteem • Mental health issues • Poor choice of companions

24. Adolescence Cont. • They may reach an average academic level of fourth grade reading, third grade spelling and only second grade math • Adaptive skills in the areas of living, communication and socialization skills are significantly delayed • Unable to grasp such essential concepts as “cause and effect,” or the “relevance of time”

25. Difficulties in Adulthood • Behavior problems • Depression - Anxiety • Alcohol/Drug Addiction • Suicidal • Psychotic behavior • Secondary disabilities may become dominant

26. SECONDARY DISABILITIES Secondary disabilities are those that the client is not born with, and that could presumably be ameliorated (either fully or partially) through better understanding and appropriate interventions.

27. In a 1996 study conducted by Dr. Ann Streissguth from the University of Washington School of Medicine, the prevalence of Secondary Disabilities was measured in 473 people with FAS/FASD from ages 6 to 51.

28. Secondary Disabilities • Mental Health Problems 90% • Disrupted school experience 41% • Trouble with the law 40% • Confinement (Jail, Juv. or Prison) 30% • Inappropriate sexual behavior 45% • Alcohol and Drug Problems 20% • Dependent Living 80% • Problems with Employment 79%

29. DEVELOPING A SOCIAL HISTORY THROUGH INTERVIEWS AND RECORDS Problems Substantiating FAS/FASD

30. HISTORY

31. MATERNAL HISTORY

32. Mother’s History • Keep in mind that the mother may have been involved with other toxic substances such as glue sniffing, drugs and may not have considered alcohol her “drug of choice.” Her medical records may reflect drug use but not the concomitant alcohol use which is usually present. • Some women may not realize there is no safe kind of alcohol, for example, thinking wine/wine coolers don’t count.

33. Mother’s History Cont. • Or they may not realize there is no safe time to drink during pregnancy, from conception (just before they found out they were pregnant) to birth. For example, they may say no because they quit when they found out they were pregnant. • NOTE: Alcohol exposure to the fetus during the first trimester poses the greatest risk for physical changes to brain, body and organ development. i.e. birth defects. The central nervous system (brain) is sensitive to damage throughout pregnancy.

34. Mother’s History Cont. • Important to tell the birth mother why this diagnoses is important: • Services. • Treatment. • Intervention. • Placement in school. • Prevent next generation affected. • Prevent subsequent FASD births (77%).

35. Assessing Maternal Alcohol Usethrough interview of the Mother • When there are signs that the mother drank there must be an investigation that reaches 3 generations. Counsel will have to look at the history of drinking by the mother and the grandmother. • Counsel must also review all family medical conditions and vulnerability to cultural, environmental, nutritional and psychological issues including poverty.

36. When asking about use of any substances, frame the question by asking “How many…” rather than “Did you…” • Asking “How many…” gives the mother permission to acknowledge that she did drink during pregnancy. • This manner is more effective when interviewing others also (spouse, siblings, etc).

37. Assess substance use separately for the time periods: • prior to pregnancy. • prior to pregnancy recognition. • post pregnancy recognition. Women are more likely to acknowledge alcohol use prior to pregnancy than after pregnancy recognition. Drinking PATTERNS from time periods prior to pregnancy are predictive of outcomes.

38. Assess pattern of use. • Ask about both typical and maximum consumption: “Before you knew you were pregnant what was the most number of drinks you drank on any one occasion. • Ask “What type of alcohol beverage do you prefer?” to better allow mother to estimate alcohol use. • Ask the size of the drinking container, keeping in mind that malt liquors have a higher concentration of alcohol.

39. Good positively stated question to ask: In the 30 days BEFORE you found out you were pregnant, how many drinks did you have?

40. Mother’s Medical Issues • Diabetes – associated with heightened rates of birth defects, including central nervous damage. Maternal diabetes can be argued to greatly increase the risk of fetal alcohol exposure. (Reproductive Toxicology 24: 31-41 (2007)) • Was the mother Zinc deficient during pregnancy?

41. Medical & Psychological History Records to show a maternal history of alcohol use by the mother • Mother’s hospitalizations (medical or psychiatric) • Mental and physical injuries (neurological and psychological records) • records showing alcohol and drug use (arrest records showing DUI or public intoxication or even domestic violence records)

42. Medical & Psychological History cont. • Prenatal care records and postnatal follow up • Birth records showing any birth trauma • Social service records (dependency records if the client and siblings were taken away from the mother) • Death certificate of the mother

43. CLIENT HISTORY

44. Client’s History • Previous Diagnosis May Have Been Incorrect or Incomplete. • Antisocial personality disorder. • ADHD/ADD - placed on Ritalin. • Speech and language handicaps. • Learning disabilities. • Behavioral problems, ODD, RAD, Conduct Disorder.

45. Birth Records • Look at the weight, height (length) and head circumference of the child. • In one case my client was born with cocaine in his system and a social worker was called to interview the mother. • In another case my client was hospitalized because he had lost so much weight at birth-”Failure To Thrive.” • But remember, most people with FASD do not have physical and or cognitive disabilities and still have serious brain based neurobehavioral disabilities.

46. Client’s Educational Records • All academic and attendance records • Special education records including eligibility and placement reports (many kids qualify for more than one category) • All IEP reports (goals and accommodations) • (Investigate the parent’s failure to follow up with the IEP meetings to request the required services for the client) • Was there any IQ testing completed.

47. Juvenile Court/Juvenile Delinquency Records • Get all juvenile delinquency records • All social services reports, psychological records. • If the client was incarcerated you will need to get all educational records, social histories.

48. USE OF EXPERTS

49. Experts List • Social worker • Neurologist • Dysmorphologist and/or Geneticist • Pediatric Doctor • Dr. Fred Bookstein, University of Washington, Seattle (Formats an MRI to look at brain damage caused by alcohol)

50. Experts List Cont. • Neuropsychologist • Adaptive behavioral testing • Executive functioning testing • Social/Emotional testing • Worthwhile to repeat IQ testing, if not recent or from reliable source.