Parental factors predicting social deviance and psychological outcomes in offspring: Evidence from the Avon Longitudinal Study of Parents and Children (ALSPAC).

Objective: The objective of the present study was to examine whether exposure to prenatal psychoactive substances is associated with psychological outcomes and deviant behaviour. Methods: This was a secondary analysis of 7,769 mother-child dyads in the Avon Longitudinal Study of Parents and Children (ALSPAC) who were followed until the children were aged approximately 12 years. Parental characteristics and maternal use of various substances were collected in pregnancy and entered as predictors of psychological outcomes in childhood and deviant behaviours in early adolescence. The psychological outcomes were IQ, social cognition, working memory and inhibition, while the deviant behaviours were threatening others, truancy and cruelty to animals. Weighted logistic regression models were used to predict deviant behaviours and weighted linear regression for the psychological outcomes. Results: High prenatal alcohol exposure predicted truancy and cruelty to animals. Tobacco exposure predicted lower IQ, a greater social communication deficit, lower working memory, truancy and threatening others. Illicit drugs predicted a higher social communication deficit and truancy. All prenatal substance exposures remained significant after adjustment for peer influences and covariate imbalance. Conclusion: Alcohol, tobacco and illicit drugs were associated with deviant behaviours in early adolescence and these behaviours were preceded by psychological deficits in childhood. The present study supports the guideline that no amount of alcohol is safe to consume in pregnancy and that tobacco and illicit drugs should be avoided.

Screening and identification of fetal alcohol spectrum disorder in criminal legal settings: A realist review.

BACKGROUND: Screening for fetal alcohol spectrum disorder (FASD) has been identified as a promising approach to improve recognition, understanding and effective response to the unique needs of those with FASD in criminal legal settings. However, to date, there has been limited synthesis of relevant screening tools, indicators, or implementation considerations in this context. AIMS: The present review aimed to synthesise evidence and develop a conceptual framework for understanding how, when, why, for whom and by whom FASD screening tools, items and/or indicators and characteristics serve to accurately identify people with FASD in criminal legal contexts, with consideration of individual and system needs relevant to effective implementation and response. METHODS: A preregistered search was conducted using a modified realist review framework for both peer-reviewed articles and grey literature. Included sources were available in English, which focused on individuals with prenatal alcohol exposure and/or FASD with criminal legal involvement and offered new empirical evidence. Sources were reviewed using the Quality Control Tool for Screening Titles and Abstracts by Second Reviewer framework, extracted using a structured coding form and narratively synthesised. RESULTS: The search yielded 52 sources, 11 FASD screening tools designed for or applied in criminal legal settings and 38 potential FASD indicators or characteristics relevant to identifying people who may have FASD in criminal legal settings, organised into six conceptually related domains. There was limited evidence supporting the psychometric properties of screening tools across populations or settings, though growing evidence highlights the promise of some instruments. Although few studies characterised potential considerations to be made when implementing a screening tool or approach, both system and individual level needs related to recognising and effectively responding to FASD in criminal legal contexts were identified, and findings revealed strong support among legal and clinical professionals regarding the need for FASD screening in these settings. CONCLUSIONS: Findings of this review can be used to inform the development, selection, implementation and evaluation of FASD screening tools in criminal legal settings and underscore a continued need for enhanced resources, policy and cross-sectoral response to better support the needs of people with FASD in the criminal legal contexts.

Unleashing compassionate care: canine-assisted intervention as a promising harm reduction approach to prisonization in Canada and its relevance to forensic psychiatry.

In recent years, there has been a global advancement in the offering of canine-assisted interventions (CAI) in prisons. However, these programs have focused primarily on the benefits to the dogs involved and not on the impact on the participants. The authors of this perspective study have been running a CAI program with therapy dogs, called PAWSitive Support, in a Canadian federal prison since 2016. Thoughts from the program facilitators and interviews with prison staff indicate that the program, and specifically the therapy dogs, provides a unique and integrated source of comfort, support, and love for participants. These benefits are consistent with those seen in CAI programs outside of prisons. Unique to the prison setting appears to be an improvement in participant-staff relations. The therapy dogs have helped participants to experience comfort and consequently express their emotions. This seems to contribute to their recognition of support within the prison system and specifically developing trust with staff. Additionally, the dogs have helped to create an experience of the feeling of love within the prison, interpreted as the feeling of being cared for, which is rare for this population. The authors suggest that the integration of a therapy dog intervention in prison could be a novel harm reduction strategy to address issues related to prisonization and associated mental health concerns, including substance use. This consideration can offer unique insight into the field of forensic psychiatry about providing compassionate care to patients.

Childhood trauma as a mediator between attachment and recidivism risk: A study of Canadian offenders with mental disorders.

The current study aimed to explore the relationships between attachment and childhood trauma on recidivism risk in a sample of Canadian offenders with mental disorder (OMDs). N = 56 OMDs completed the Adverse Childhood Experiences (ACE) questionnaire, a measure of adult attachment (Experiences in Close Relationships Scale), and interview to determine recidivism risk (Level of Service/Case Management Inventory; LS/CMI). The variables of interest had small to moderate correlations. Multivariable regression analysis found that ACE scores but not attachment insecurity were associated with LS/CMI scores. Mediation analyses demonstrated that ACE scores fully mediated the association between attachment anxiety and attachment avoidance and recidivism risk. Results demonstrate that as exposure to diverse ACEs increased so did the risk to recidivate and this exposure mediated the relationship between attachment insecurity and recidivism risk. This study highlights the necessity of addressing both attachment insecurity and the experience of ACE when providing psychiatric services to OMDs.

The influence of a Learning to Forgive Program on institutional offending and recidivism among offenders with mental disorder.

Previous researchers have demonstrated that learning to forgive may reduce the likelihood of offending/reoffending. Forgiveness therapy may be useful for rehabilitation by assisting traumatized individuals to release revengeful emotions. The current study is a follow up to a previous study that examined the effects of a 6-week forgiveness psychoeducational intervention for offenders with mental disorders. The aim of the current study was to determine any differences for participants who received a forgiveness intervention versus a control group for rates of recidivism (likelihood of reoffending and length of time to reoffend) and type of institutional offense. Recidivism data was collected through the Canadian Police Information Center. Both the control and treatment group in this study were selected from offenders with mental disorder at the Regional Psychiatric Centre, a multilevel forensic psychiatry hospital in Saskatoon, Canada. Results indicated that participants who received the forgiveness intervention took significantly longer than the control group to both commit non-violent offenses, and to be convicted of any offense. Results suggest that forgiveness therapy for offender populations may improve behavior and reduce recidivism.

Substance Use Disorders and Antisocial Personality Disorder among a Sample of Incarcerated Individuals with Inadequate Health Care: Implications for Correctional Mental-Behavioural Health and Addiction Services.

Epidemiological estimates of substance use disorders (SUD) are critical for the planning of evidence-informed intervention and services. In this study, 250 incarcerated individuals in Nigeria were interviewed with the Mini International Neuropsychiatric Inventory (MINI) to diagnose SUD and antisocial personality disorder (ASPD). Most of the participants were males (97.6%), and the mean age was 35.4 (SD=13.5) years. Substance use disorder and ASPD were prevalent in 57.6% and 11.2% of the participants, respectively. Of those diagnosed with SUD, 35.2% and 22.4% had poly-SUD and mono-SUD respectively. Psychotic and dependence syndromes involving cannabis misuse were the most prevalent poly-SUD, and mono-SUD was characterized by alcohol, nicotine, and opioid dependence syndromes. Substance use disorder was more likely in participants charged with robbery and convicted, while ASPD was associated with prior and long-term imprisonment. There is a need for effective integration of treatment for ASPD/SUD into correctional mental health services in settings with inadequate health care using an appropriate model and a viable strategy.

Caregivers' experiences and perceptions of suicidality among their children and youth with fetal alcohol spectrum disorder.

Individuals with Fetal Alcohol Spectrum Disorder (FASD) experience a range of biopsychosocial vulnerabilities that can increase the possibility of adverse life outcomes, including a heightened risk of suicidality. In this study, we explored the lived experiences of caregivers of children and youth with FASD and suicidality, including their perceptions of their child and youth's suicidal experiences. Between March and June 2021, six comprehensive, semi-structured interviews were conducted with five caregivers of children and youth with FASD (Mage = 14.5 years, range 11-22) who were currently experiencing suicidality or had a history of suicidality. Data were analyzed using interpretative phenomenological analysis and then developed into a composite vignette informed and organized by the social-ecological suicide prevention model (SESPM). The composite vignette revealed the narratives of families living with and caring for children and youth with FASD who experience suicidality in relation to the complex and intersectional individual, relational, community, and societal level contextual and protective factors. Findings from this study highlight the critical need for comprehensive FASD-informed suicide prevention and intervention approaches to promote the mental health and wellbeing of children and youth with FASD and their caregivers.

Aggressive behaviour and violence in children and adolescents with FASD: A synthesizing review.

Interpretation and response to behaviour is predicated on understanding. However, our present understanding of aggressive behaviour, especially for complex and vulnerable populations is limited. The purpose of this review is to enhance our understanding of aggressive behaviour by providing a comprehensive outline of the conditions and underlying mechanisms that drive aggressive behaviour for children and adolescents with neurodevelopmental disorders (NDDs), focusing on Fetal Alcohol Spectrum Disorder (FASD). This review will: (1) Synthesize the present literature regarding aggressive behaviour, via the cognitive, environmental, and emotional factors that drive it, for children and adolescents with NDDs; (2) Identify and integrate information specific to the elevated vulnerability for aggressive behaviour that FASD poses; and (3) Utilize the information derived from the review to propose frameworks, in the form of two corresponding models, for recognizing and responding to aggressive behaviour. The advantages of such neurodevelopmentally guided, comprehensive, and integrative framework are to clarify predisposing and perpetuating mechanisms, inform appropriate caregiver and caseworker support, and inform clinicians' preliminary intervention. These ultimately should improve the ability to respond and promote healthy outcomes for these vulnerable youngsters.

Rates and implications of fetal alcohol spectrum disorder among released offenders with mental disorder in Canada.

Fetal alcohol spectrum disorder (FASD) is prevalent among individuals involved in the justice system. However, many of the characteristics of justice-involved individuals with FASD remain unknown. We assessed patients in a forensic mental health hospital (n = 26) for FASD before their release. The two objectives were to establish the prevalence of FASD in this unique environment and to describe the mental health and neurocognitive characteristics of individuals with FASD compared to patients with complex needs and those without FASD. The prevalence of FASD was 46%. We found the FASD group to have more than six impaired brain domains, greater than the other groups, and a higher prevalence of ADHD. Given the high prevalence of FASD reported in this study, along with the complexities and adversities associated with FASD and criminal justice involvement, this is a population that requires screening, assessment, and intervention.

The neurocognitive profiles of justice involved people with foetal alcohol spectrum disorder: A systematic review.

Foetal alcohol spectrum disorder (FASD) is highly prevalent in criminal justice settings. Despite increased awareness of the neurocognitive deficits among justice-involved individuals with FASD, no systematic evaluation of the literature in the field has been conducted to date. We aimed to conduct a systematic review of the literature on the neurocognitive profiles of justice-involved individuals with FASD, by searching five key electronic databases, dissertations database, and Google scholar, up to January 2021. The findings indicate that when contrasted with comparison groups, justice-involved individuals with FASD display significant impairment in a greater number of neurocognitive domains including intellectual capacity, executive function, language, academic achievements, motor skills, and adaptive living skills. The relatively small number of the studies included in the review, along with the confounding effects of comorbidities among study participants, precludes drawing firm conclusions about the true extent and implications of neurocognitive deficits in this population. To advance the field further, there is an urgent need to conduct robust studies involving larger samples of justice-involved individuals with FASD and suitable comparison groups. Advancing knowledge in the field can have important implications for understanding of the antecedents of offending behaviour in this population, and informing strategies for early identification and intervention.

Suicidality and Associated Factors Among Individuals Assessed for Fetal Alcohol Spectrum Disorder Across the Lifespan in Canada.

OBJECTIVE: Individuals with fetal alcohol spectrum disorder (FASD) experience a range of complex neurodevelopmental, psychological, and socioenvironmental vulnerabilities. There is growing evidence that suicidal ideation, attempts, and death by suicide are significant concerns within this population. In this study, we (1) determined the rate of suicidal ideation/attempts in a large group of individuals with prenatal alcohol exposure (PAE) who were assessed for FASD in Canada and (2) investigated the associations between suicidal ideation/attempts and select demographic and biopsychosocial factors in this group. METHOD: A secondary analysis of data from Canada's National FASD Database, a national repository of clinical information gathered through FASD assessment and diagnostic clinics across the country, was conducted. Descriptive analyses, chi-square/Fisher's exact tests, and binary logistic regression were used to examine demographic and biopsychosocial variables and their associations with suicidality. RESULTS: In our sample of 796 participants (Mage = 17.7 years, range = 6-59; 57.6% male) assessed for FASD, 25.9% were reported to experience suicidal ideation/attempts. Numerous demographic and biopsychosocial factors were found to be significantly associated with suicidal ideation/attempts. The strongest associations with suicidal ideation/attempts were substance use, history of trauma/abuse, and impaired affect regulation. CONCLUSIONS: With this study, we contribute to the emerging evidence of elevated risk of suicidality among individuals with PAE/FASD and improve our understanding of factors that may exacerbate this risk. Findings have relevance for improving screening, prevention, and proactive treatment approaches for individuals with PAE and FASD, their families, and wider support systems.

Utilization of psychotropic medications in children with FASD: a retrospective review.

BACKGROUND: Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental condition resulting from pre-natal alcohol exposure. In Canada, an estimated 1.4-4% of newborns are affected by FASD. FASD is often associated with behavioural comorbidities and many individuals require psychotropic medication. However, to date there are no FASD specific guidelines for prescribing medication. Recently, Mela and colleagues described four behavioural symptom clusters commonly seen in FASD with suggested pharmacologic treatment for each cluster within an algorithm. The primary objective was to compare the proposed treatment algorithm retrospectively to actual treatment in a real-world FASD pediatric practice. The secondary objective was to refine the description of symptom clusters which will be targeted with treatment. METHODS: We collected the diagnostic and medication history from all patient visits of a Regina Developmental Pediatrician who specializes in FASD diagnosis and medication treatment. Three hundred fifty-four FASD patients were identified between 2005 to 2020. The medications that would be predicted from the algorithm were compared to the real-world historical data. A positive case was defined as all algorithm-predicted medications matching the historical data; a negative case had one or more medications failing to match. RESULTS: Of the 354 patients, 36 were removed for insufficient information. Of the remaining 318 cases, 172 (54.1%) were positive compared to 146 (45.9%) negatives. In single prescription cases (n=147), the incidence of positives was 67.3%; in multi-prescriptions (n=72) it was 27.8%; and in cases where no prescription was needed (n=99), the positive incidence was 53.5%. CONCLUSIONS: The prescription algorithm is promising but requires further refinement to accommodate the range of presentations in children with FASD. With respect to unclassified symptoms, we propose the following: sleep onset difficulty as hyperarousal; gender dysphoria and obsessive compulsive disorder as cognitive inflexibility; grief as emotional regulation; and autism spectrum disorder as hyperactive/neurocognitive.

Psychiatric Morbidity among Incarcerated Individuals in an Underserved Region of Nigeria: Revisiting the Unmet Mental Health Needs in Correction Services.

While epidemiological description of psychiatric morbidity can promote evidenceinformed mental health services, there is a paucity of such evidence among incarcerated individuals in prisons with underserved healthcare. We evaluated 250 incarcerated individuals detained in an underserved prison in north-western Nigeria with the Mini International Neuropsychiatric Inventory (MINI). Predominantly, study participants were men (97.6%) and the mean age was 35.4 (SD=13.5) years. The majority of the incarcerated individuals (81.2%) were awaiting trial, the most common crime was armed robbery (38.8%), and 16.4% of participants were recidivists. The prevalence of psychiatric morbidity was 47.4%, with major depression being the most common diagnosis (23.2%). The majority (92.8%) had no prior contact with psychiatric treatment. Being single, employed, and lacking prior psychiatric treatment were independently associated with psychiatric morbidity (R2=0.27). These findings underscore the need for better investment in correctional mental health services. Multi-pronged efforts with multisectoral collaboration between the government and other stakeholders to develop scalable interventions are advocated.

Responding to the Unique Complexities of Fetal Alcohol Spectrum Disorder.

Fetal alcohol spectrum disorder (FASD) is a multifaceted disability, characterized not only by brain- and body-based challenges, but also high rates of environmental adversity, lifelong difficulties with daily living, and distinct sociocultural considerations. FASD is one of the most common neurodevelopmental disabilities in the Western world and associated with significant social and economic costs. It is important to understand the complexities of FASD and the ways in which FASD requires unique consideration in research, practice, and policy. In this article, we discuss our perspectives on factors that distinguish FASD from other disabilities in terms of complexity, co-occurrence, and magnitude. We provide an overview of select literature related to FASD as a socially rooted disability with intergenerational impacts and multiple layers of stigma. These social issues are intertwined with notable experiences of adversity across the lifespan and high rates of co-occurring health concerns for individuals with FASD, all of which present unique challenges for individuals, caregivers, families, service providers, and policy makers. Understanding these factors is the first step in developing and implementing specialized initiatives in support of positive outcomes for individuals with FASD and their families. Future directions are proposed for advancing research, practice, and policy, and responding to the unique complexities of FASD.

A Systematic Review of Interventions to Improve Mental Health and Substance Use Outcomes for Individuals with Prenatal Alcohol Exposure and Fetal Alcohol Spectrum Disorder.

Individuals with fetal alcohol spectrum disorder (FASD) experience remarkably high rates of mental health and substance use challenges, beginning early in life and extending throughout adulthood. Proactive intervention can help to mitigate some of these negative experiences. Although the literature on FASD intervention is growing, there is currently a lack of consolidated evidence on interventions that may improve mental health and substance use outcomes in this population. Informed by a life course perspective, we undertook a systematic review of the literature to identify interventions that improve mental wellness through all developmental stages for people with prenatal alcohol exposure (PAE) and FASD. A total of 33 articles were identified, most of which were focused on building skills or strategies that underlie the well-being of children with PAE and FASD and their families. Other interventions were geared toward supporting child and family wellness and responding to risk or reducing harm. There was a notable lack of interventions that directly targeted mental health and substance use challenges, and a major gap was also noted in terms of interventions for adolescents and adults. Combined, these studies provide preliminary and emerging evidence for a range of intervention approaches that may support positive outcomes for individuals with FASD across the life course.

Treatment algorithm for the use of psychopharmacological agents in individuals prenatally exposed to alcohol and/or with diagnosis of fetal alcohol spectrum disorder (FASD).

Psychotropic medication treatment of individuals who have experienced prenatal alcohol exposure (PAE) has lagged behind psychosocial interventions. Multiple psychotropic medications are often prescribed for those diagnosed with a range of neurodevelopmental disabilities and impairments of PAE (neurodevelopmental disorder associated with prenatal alcohol exposure and/or fetal alcohol spectrum disorder [ND-PAE/FASD]). Despite the diverse comorbid mental disorders, there are no specific guidelines for psychotropic medications for individuals with ND-PAE/FASD. When prescribed, concerned family members and caregivers of individuals with ND-PAE/FASD reported that polypharmacy, which was typical and adverse effects render the psychotropic medications ineffective. The objective of this work was to generate a treatment algorithm for the use of psychopharmacological agents specifically for individuals with ND-PAE/FASD. The development of decision tree for use to prescribe psychotropic medications incorporated findings from previous research and the collective clinical experience of a multidisciplinary and international panel of experts who work with individuals with ND-PAE/FASD, including an algorithm specialist. After multiple meetings and discussions, the experts reached consensus on how best to streamline prescribing along neurodevelopmental clusters. These were subdivided into four ligand-specific, receptor-acting medication targets (hyperarousal, emotional dysregulation, hyperactive/neurocognitive, and cognitive inflexibility). Each cluster is represented by a list of common symptoms. The experts recommended that prescribers first ensure adequate psychosocial and environmental, including sufficient dietary, exercise, and sleep support before prescribing psychotropic medications. Treatment then progresses through three steps of psychotropic medications for each cluster. To support established treatment goals, the most function impairing clusters are targeted first.

Neurocognitive Function and Fetal Alcohol Spectrum Disorder in Offenders with Mental Disorders.

Individuals with a history of offending behavior show high rates of mental disorder as well as fetal alcohol spectrum disorder (FASD). Neurocognitive impairments are common in both mental disorders and FASD and may interface with offending behavior. Understanding these impairments could effectively inform clinical considerations among this population. The purpose of this study was to characterize the life experiences and examine the neurocognitive profile of a group of adult forensic psychiatric outpatients. We also investigated potential differences between offenders with FASD and the rest of the sample. Data were collected on 45 subjects on numerous variables, including demographics, background information, offending histories, and comorbidities. Subjects also completed extensive neurocognitive testing. The sample was primarily male (82.2%) with a mean age of 42 years. There was a high prevalence of lifetime adversity and varied offense histories. Subjects showed the most significant neurocognitive impairment in executive function, visual memory (immediate and delayed recall), and full-scale IQ. The FASD group (n = 12) did not differ significantly from the No-FASD group (n = 33) on any background variables. The FASD group showed significantly lower neurocognitive scores in the areas of verbal IQ, full-scale IQ, working memory, processing speed, and expressive vocabulary.

Mental Health and Affect Regulation Impairment in Fetal Alcohol Spectrum Disorder (FASD): Results from the Canadian National FASD Database.

AIMS: Individuals with fetal alcohol spectrum disorder (FASD) frequently have challenges with regulating emotional arousal, or affect regulation (AR), and experience high rates of mental health disorders. This study examined children and adults with FASD to investigate the relationship between AR impairment and several mental health problems and diagnoses. METHODS: Data from the Canadian national FASD database was used for analysis. Seven mental health diagnoses, including attention-deficit/hyperactivity disorder, post-traumatic stress disorder, conduct disorder, attachment disorder, intellectual disability, and language disorder were examined. A history of suicidality was also examined. The prevalence of these mental health problems in individuals with and without AR impairment was compared. RESULTS: Individuals with FASD and AR impairment were significantly more likely to be diagnosed with conduct disorder (OR 4.8), attachment disorder (OR 6.1), or post-traumatic stress disorder (OR 8.1) when compared to those without AR impairment. They were also more likely to have a history of suicidality (OR 8.6). AR impairment was most commonly found in those with greater overall neurodevelopmental impairment. Having AR impairment was associated with receiving a diagnosis of FASD at a later age, but was not related to gender, intellectual disability, or language disorder. CONCLUSION: AR impairment is strongly related to several mental health diagnoses in those with FASD and presents some promising possibilities for targeted early intervention.

Recent advances in fetal alcohol spectrum disorder for mental health professionals.

PURPOSE OF REVIEW: Understanding the pathophysiologic, diagnostic, and treatment implications of the interface between mental disorder and the consequences of Prenatal Alcohol Exposure (PAE) is important for mental health professionals (MHP) seeking to provide the most effective care. This review was written to highlight the importance of identifying and intervening with regards to the unique mental health and medical needs of individual with PAE. RECENT FINDINGS: Over the last year, research has identified differences in the diagnostic criteria for Neurodevelopmental Disorder Associated with PAE (ND-PAE)/Fetal Alcohol Spectrum Disorder (FASD) and called for standardization, given that diagnosis is the main route to appropriate support. Care will improve with advances in epigenetic, neuroimaging, and electrophysiological discoveries regarding the consequences of PAE. For example, recent progressions allow for improved detection of alterations in DNA methylation and functional connectivity between cortical and deep grey matter. Therapeutic innovations targeting specific neurocognitive impairment and ligand-specific symptom clusters, as well as lifelong multidisciplinary interventions to support patients, were reported as producing effective outcomes. SUMMARY: Developments in genetics, epigenetics, imaging, and interventions are relevant to the current knowledge of FASD. MHP are encouraged to recognize the importance of understanding unique considerations for this population, including forensic implications and the whole-body impacts of FASD, which could assist in reducing stigma and improving quality of care.