Written by Stephen Lee-Cheong, a member of the 2023 CanFASD Trainee Program

Hi, everybody! I’m Dr. Stephen Lee-Cheong, a second-year psychiatry resident at the University of Saskatchewan in Regina. I received my medical degree from the National University of Ireland, Galway, and my Master’s in public health with specialization in mental health from King’s College London in the UK. I have a broad research interest including addictions, forensics, public health, and fetal alcohol spectrum disorder (FASD), and am part of the CanFASD Trainee Program.

I’d like to share a bit about a project I have been conducting alongside Dr. Mansfield Mela and Ms. Monique Reboe-Benjamin, which integrates the fields of FASD and forensics.

FASD and the Criminal Justice System

When unsupported, people with FASD have disproportionately high rates of involvement with the child welfare system, childhood abuse, school disruption, and difficulty maintaining independent living and employment. These factors put them at increased risk for criminal justice system involvement. An estimated 60% of adolescents and adults with FASD report contact with the justice system, compared to the North American general population estimate of 2-5%.

In spite of overrepresentation, people with FASD often go undetected in legal settings, as they may not show obvious physical characteristics and their impairments in mental functioning, while substantial, may be somewhat hidden. Unfortunately, this failure to detect FASD may result in poor treatment outcomes, increased risk of reoffending, and overall poorer health.

Dangerous Offenders

Dangerous offenders (DOs) are those who continue to pose a tremendous future risk to public safety and for whom management in the community is not possible. Using information from multiple sources, judges are able to make this designation. The DO designation often requires the offender to be in prison for life.

DOs share certain clinical features that often overlap with what is seen in FASD that may contribute to their risk of reoffending and potential dangerousness, including: substance use, personality and mental illness, borderline cognitive functioning, and biological factors. Despite the closeness of the behavioural patterns of repeated offending among DOs and those with FASD, there has been limited research on the link between the two. We hypothesize that FASD is prevalent in DOs, considering the overlap in clinical features.

What Are We Going To Do?

Out study will examine clinical variables among those declared DOs in the provinces of Alberta and Ontario from 2002-2022 and compare those with screening features of two FASD screening tools. This approach will help us understand how many people who were declared dangerous offenders would also be screened positively for FASD on screening tools.

From our data, just within Alberta, 8/35 (22.86%) offenders screened positive on the FASD Screening and Referral Form for Youth Probation Officers to be referred to a youth justice FASD program. 3/35 (8.57%) offenders screened positive on the Life History Screen to be referred to an FASD diagnostic clinic. 2 out of the 3 offenders that screened positive in the Life History Screen also screened positive on the FASD Screening and Referral Form for Youth Probation Officers. Overall, there were 9/35 (25.71%) unique offenders that screened positive on either screening tool.

This project is ongoing and currently we are screening the Ontario cases.

What We Propose

Forty-five percent of DOs have 15 or more prior convictions as an adult, consistent with the repetitive pattern of antisocial behaviour required to receive a DO designation. Considering this information, we propose that providing appropriate management to offenders with FASD early on in their life can help prevent reoffending and any eventual DO designation, thereby preventing harm to society and the offenders themselves.

The National Flagging System was announced in 1995 and was designed to track high-risk, violent offenders. This system has been shown to be effective in identifying offenders who have higher rates of violent/sexual reoffending compared to the typical Canadian male federal offender population. Therefore, we propose that FASD screening tools be applied to those identified through the National Flagging System in order to help facilitate timely diagnostic clarification and subsequent appropriate management relating to FASD.

Screening of FASD among such a vulnerable population with a high risk of being designated dangerous may be the only avenue to identify and intervene beforehand. It is often quite complex to diagnose FASD, considering the constellation of information required, and so beginning the process early on in an offender’s life can ensure that sufficient information is acquired in order to make a diagnosis of FASD. With insufficient diagnostic capacity, we believe legal practitioners should advocate for screening as a minimum standard for those identified by the National Flagging system. We believe this approach will help to more quickly and effectively identify those with FASD in corrections systems and improve outcomes for offenders with FASD who are overrepresented in a system that is not designed to support their unique needs.

Dr. Stephen Lee-Cheong MB BCh BAO PgCPain MSc is a second year psychiatry resident at the University of Saskatchewan in Regina. He received his medical degree from the National University of Ireland, Galway, and his Master’s in public health with specialism in mental health from King’s College London in the UK. He has a broad research interest including addictions, forensics, public health, and FASD.