Neuropsychiatry and Forensics: FASD , ASD , and AD HD

• Author: David Nussbaum, Melanie Dawn Douglass, and Stephanie Daoud
• Pages: 447-464

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CHAPTER 22

Neuropsychiatry and Forensics:

FASD, ASD, and ADHD

David Nussbaum, Melanie Dawn Douglass, and Stephanie Daoud

I. INTRODUCTION

According to the International Neuropsychiatric Association, neuropsychiatry is dened as “a eld

of scientic medicine that concerns itself with complex relationship between human behaviours and

brain function, and endeavours to understand behavioural disorders on the basis of an interaction of

neurobiological and psychological-social factors” (INA Mission Statement, 1998). e major premise of

neuropsychiatry is that “mental disorders are disorders of the brain” (Berrios & Markova, 2002). By dint

of its precise and validated measurement of cognition and other relevant behaviours, neuropsychology

continues to make salient contributions to neuropsychiatry (Sachdev, 2002) in terms of assessment

and research. Pragmatically, a neuropsychiatric approach seeks to understand specic symptomatol-

ogy within a broad range of disorders common to psychiatry rather than dening specic disorders as

“neuropsychiatric” as opposed to “psychiatric” or “neurological.”

In line with the purpose of this handbook to provide useful guidelines for identication of problems

and methods of management within forensic contexts, this chapter will focus on three diagnoses for

which a neuropsychiatric perspective may be especially helpful. ese include fetal alcohol syndrome/

eects (FAS/FAE), autistic spectrum disorders (ASD) focusing primarily on its association with aggres-

sion, and attention-decit/hyperactivity disorder (ADHD). ese have been chosen respectively because

a) FAS/FAE aects many people incarcerated, especially in Western Canada, b) the incidence of diag-

nosed ASD is increasing dramatically and there are psycholegal implications for the courts, and c) ADHD

is very prevalent in both the forensic and criminal justice systems, oen comorbid with antisocial per-

sonality disorder (APD), and psychopathy. All three conditions can impact tness to stand trial, crimina l

responsibility, recommendations for sentencing, and patient management.

II. FETAL ALCOHOL SYNDROME

It has now been over a quarter of a century since Jones and Smith (1973) rst identied fetal alcohol

syndrome (FAS), noting that maternal alcohol ingestion during pregnancy could induce a unique set of

morphological and behavioural anomalies. Fetal alcohol spectrum disorders (FASD) are a collection of

disorders that are the direct result of exposure to alcohol prenatally. FAS is the most severe of this group,

and the more subtle version is typically labeled as fetal alcohol eects (FAE) (Chudley et al., 2005) or

partial FAS (Stratton et al.,1996). Unfortunately, a number of the impairments that result from prenatal

exposure to alcohol make some individuals who suer from these conditions vulnerable to antisocial

behaviours, given the overrepresentation of individuals with FAS/FAE in correctional facilities in

Canada (see below).

David Nussbaum, Melanie Dawn Douglass, and Stephanie Daoud

A. Diagnostic Criteria

e Diagnostic and Statistical Manual Fourth Edition Text Revision (DS M- I V-T R) (APA, 2000) does not

provide a diagnostic classication for FAS or FASD, but criteria have been developed by dierent as-

sociations to identify both children and adults who suer from these conditions. In 1996, the Institute

of Medicine assigned a committee to address the issue of FASD and this committee developed specic

criteria for the diagnosis of four dierent categories of disorders that result from prenatal exposure to

alcohol (Stratton et al., 1996).

e rst three categories fall under the general heading of FAS (Stratton et al., 1996). e rst is FAS

with conrmed maternal alcohol exposure (Stratton et al., 1996). Besides actual evidence that the mother

drank while pregnant, this category requires that the individual t hat was exposed demonstrate common

characteristics of FAS, including short palpebral ssures and an abnormal premaxillary zone (i.e., a at

upper lip, midface, or philtrum; Stratton et al., 1996). Further, the exposed individual must have a low

birth weight for their gestational age, weight loss over time that is not related to nutrition, or an improper

height-to-weight ratio (Stratton et al., 1996). Lastly, the exposed individual must have central nervous

system (CNS) neurodevelopmental abnormalities, which must be demonstrated by either smaller cranial

size when born, abnormal brain structures, or other neurological signs such as impaired hand-eye co-

ordination and poor ne motor skills (Stratton et al., 1996).

e second category is FAS without conrmed maternal alcohol exposure, which requires the same

criteria as above, but there is no conrmed evidence that the mother drank while pregnant (Stratton et

al., 1996). e third category, partial FAS with conrmed maternal alcohol exposure, is very similar to the

rst category, but involves a less severe pattern of symptomatology. Specically, only some facial abnor-

malities must be present, and the exposed individual should show either an abnormal growth pattern,

CNS neurodevelopmental abnormality, or some other complex pattern of impairments in cognition and

behavioural abnormalities that cannot be attributed to some other factor, such as familial background or

environment (Stratton et al., 1996).

Moving from FAS related categories a further two categories were identied by the committee. e

rst of these last categories identies alcohol-related birth defects (ARBD) aecting the cardiac, skeletal,

renal, ocular, auditory, as well as other systems (Stratton et al., 1996). e nal category of these criteria

is alcohol-related neurodevelopmental disorder (ARND; Stratton et al., 1996). is section requires the

evidence of the same CNS neurodevelopmental abnormalities mentioned in the FAS with conrmed

maternal alcohol exposure category, and/or the cognitive impairments and behavioural abnormalities of

the partial FAS category (Stratton et al., 1996).

ese diagnostic criteria are quite useful in providing detailed descriptions of the abnormalities that

are expected with the dierent levels of impairment severity within FASD. It is important to note that

the committee has also made a distinction between individuals who do and do not have a conrmed

history of prenatal exposure to alcohol (Stratton et al., 1996). Without this conrmation, it is not entirely

possible to conclude the developmental impairments that the individual is exhibiting are due to prenatal

alcohol exposure.

Astley and Clarren (1999; 2000; as reported in Chudley et al., 2005) developed a dierent system of

diagnosing FAS that consists of 4-Digit Diagnostic Code. is method uses a 4-point Likert scale (from

1 = not present, to 4 = extreme expression) to document the severity of four key characteristics of FAS:

“growth deciency; the FAS facial phenotype; central nervous system damage or dysfunction; [and] ges-

tational exposure to alcohol” (Chudley et al., 2005, p. 53).

In 2005, Chudley and colleagues published Canadian guidelines for the diagnosis of FASD. In this

paper, they take an approach that is an amalgamation of the specic diagnostic criteria put forth by

Stratton et al. (1996) and the 4-Digit Diagnostic Code. Specically, these guidelines incorporated the