Understanding the Similarities and Differences between Fetal Alcohol Spectrum Disorder and Mental Health Disorders

4. Similarities and Differences between FASD and Mental Disorders

The literature reviewed above shows that there is an overlap between the group of individuals with FASD and the group of individuals with mental health disorders. There is a risk that the rights of either group will be jeopardized in aspects of the legal process if both factors are not considered.

For the person with FASD, it is important to consider the brain damage from prenatal alcohol exposure in addition to a likely mental health disorder in terms of their accountability, response to treatment, and response to legal corrections. The person with FASD may present as competent, but the ability to participate in the legal process is based on cognitive functioning and reasoning abilities that may not be present in someone with FASD. With current diagnostic tools, the effects on the brain of prenatal alcohol exposure cannot always be distinguished from the effects of a mental illness, and the individual needs to be considered as a whole. Individuals who are assessed for FASD should also be seen for possible mental health disorders.

For example, a person whose primary mental health disorder is ADHD has trouble paying attention, is impulsive, and may be hyperactive. A person with FASD can have similar symptoms. If either of these individuals has a substance use disorder, there is an increased risk of trouble with the law. It can be very difficult to determine whether the behaviours are because of the FASD, the ADHD, the substance use disorder, or the combination. However, the outcome for a person with FASD where the underlying problem is brain damage is likely to be more problematic than that of the person whose primary problem is ADHD. It may be possible to manage the symptoms of ADHD and reduce impulsive behaviours, but for the person with FASD who also has underlying deficits in reasoning, connecting cause and effect, and anticipating the consequences of their actions managing the ADHD alone is not sufficient to prevent conflict in the legal system.

A person with many types of mental illness and no FASD might be expected to understand the legal process and consequences. Someone who has a severe mental health disorder, such as a severe psychotic disorder, needs special consideration and probable life-long support. However, many mental health disorders can be managed with medication and supportive therapy.

There is no treatment for the primary disability of FASD, which is a permanent, life-long brain injury. However, people with FASD with or without a mental illness can be helped before, during, and after incarceration through environmental changes, behavioural support, and medication. The brain of an individual with FASD appears to be more sensitive and more vulnerable than that of the typical person, and may react to pharmacological treatment in different and unexpected ways. Thus, people with FASD may need closer supervision than others when being treated with medication. Psychotherapeutic treatment can be more challenging with people who have FASD because of their language and memory deficits and poor insight; as a result, standard therapeutic approaches are often less effective than they would be for a person with a normal brain (Conry and Fast 2010). The concern is that the lack of response to therapy by the person with FASD could be interpreted as manipulative and willful, when the underlying reason is actually the brain dysfunction.

For both individuals with FASD and those whose primary disability is a mental health disorder, a review of their past histories may reveal incidents involving accidents and assaults that further compromise their functioning. However, people who have experienced a traumatic brain injury once had a normally functioning brain and have residual function. Some areas of the brain may have been damaged by the traumatic event and some areas may have been spared; there is usually a possibility of recovery to a degree. On the other hand, individuals who have brain damage due to prenatal alcohol exposure never had a fully functioning brain and have fewer mental reserves to draw on.

Although beyond the scope of this review, it is important to mention the emergence, since 1998, of mental health courts (Canadian Institute for Health Information 2008). Their purpose is to direct people with a mental illness away from the CJS and to treatment. The programs take a variety of forms and criteria for participation, but the offender is required to adhere to an individualized program and certain requirements. It is not known how many individuals who have mental health issues and FASD may be in such programs. The person with FASD may be set up for failure and further jail time due to inability to comply with requirements.

The language and actions of people with FASD may be misinterpreted, especially if the possibility of an FASD is overlooked and the focus is only on the mental disorder(s). The possibility of FASD should be considered in those for whom the primary concern is mental health. Endicott (1991 p.4) noted that “inmates who have intellectual disabilities are at serious risk of harm due to their special susceptibility in the correctional system to abuse, exploitation, manipulation, misunderstanding of what is expected to them, and inability to benefit from most existing rehabilitative programs”. People with FASD have similar risks whether or not they have intellectual disabilities or mental health disorders.

Current programs in correctional institutions may not be effective for people with FASD with or without a mental illness, and could be detrimental to these individuals when they return to their communities. The prison environment is linked to stress-inducing factors, such as risk of violence, danger to personal safety, and separation from social support networks (Canadian Institute for Health Information 2008). Existing mental health disorders could also be exacerbated by this stress and the person’s poor coping ability. For inmates with FASD, because of their neurobiological vulnerability to stress, these effects can be compounded.

5. Summary and Conclusions

Studies of people with FASD indicate that they are at increased risk for maladaptive behaviours that may lead to criminal activity and victimization. These behaviours are often interpreted as willful, premeditated, and manipulative, but it is the underlying brain disabilities, including cognitive and mental health disorders, that contribute to their dysfunction. The effects of prenatal alcohol exposure on the brain are permanent, and this means that a person with an FASD will need life-long support and supervision to mitigate the secondary disabilities associated with prenatal alcohol exposure. Similar to offenders whose primarily disability is a mental health disorder and without FASD, the mental illness will need to be addressed and treated. However, people with FASD who have mental health disorders may respond differently to treatment than individuals without FASD who also have mental health disorders. Their disabilities in areas such as cognition, reasoning, and memory may reduce the effectiveness of standard psychotherapies. If the system only looks at the mental health disorders, treatments may be ineffective and planning for release will be inappropriate.

Involvement with the legal system may be the final common pathway for many individuals with FASD who also have mental health, social-emotional, and cognitive disabilities. Offenders with FASD should not return to their communities worse off than when they left, due to misunderstanding, victimization, and mismanagement of their disabilities, including mental health disorders. Determining the accountability of people with FASD, with or without a mental disorder, is a significant challenge for the legal system in developing promising practices to support and help these individuals and reduce recidivism.

Through its Institutional Mental Health Initiative, the CSC continues to focus on addressing the diverse mental health needs of offenders for the duration of their sentence and to ensure a successful transition back to the community. Concurrently, there also has been more education of correctional staff and mental health workers to better manage individuals with FASD in the CJS with the recognition that their disabilities go beyond mental health needs.

In the past decade, individuals are more likely to be diagnosed with FASD. There is greater understanding of the disabilities associated with FASD and the understanding that people without full FAS can be severely affected by the brain damage from prenatal alcohol exposure. There is also recognition that individuals with FASD can respond impulsively and erratically to expectations in court, correctional facilities, probation, and the community. Those with FASD have unique vulnerabilities that warrant special consideration in the CJS. Supporting people with FASD in managing their mental health disorders, cognitive disabilities, and social deficits may lead to better outcomes for the individuals with FASD and for society.

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