Elsevier

Ethics, Medicine and Public Health

Volume 2, Issue 1, January–March 2016, Pages 59-73
Ethics, Medicine and Public Health

Dossier “Forensic ethics”
Studies
Expert evidence in fetal alcohol spectrum disorder casesPreuve d’expertise dans les troubles du spectre de l’alcoolisation fœtale

https://doi.org/10.1016/j.jemep.2016.01.006Get rights and content

Summary

Fetal Alcohol Spectrum Disorder (FASD) is an umbrella term relating to a set of disorders, including Fetal Alcohol Syndrome (FAS), partial Fetal Alcohol Syndrome (pFAS), Alcohol Related Developmental Disorder (ARND) and Alcohol Related Birth Defects (ARBD). Each disorder is pervasive and life-long, resulting from prenatal exposure to alcohol (PEA). While the incidence of FASDs remains debatable, it may well be in the region of 1% of the population in countries such as Canada, New Zealand and Australia. They have been disproportionately identified in persons from an indigenous background in a number of countries. In addition, FASDs are present in significant numbers amongst persons who are charged with criminal offences and who are sentenced to imprisonment, especially young offenders. Understandably, as FASDs continue to be attended by a level of diagnostic uncertainty, they have been significantly under-diagnosed. They can easily be mistaken for other disorders, especially in the context of comorbidities. However, their relevance in the forensic context in terms of reduced culpability for criminal offending and problematic capacity to respond to interviewing by persons in authority, such as police, is significant but in many instances subtle. In addition, the potential for FASDs to be misinterpreted on the basis of persons with FASDs appearing ‘normal’ is significant. Thus, mental health professionals who assess persons charged with criminal offenders have an important role in identifying FASD symptomatology and, where necessary, referring such offenders for specialist assessment. Those who provide FASD assessments to the courts need not only to educate judicial officers about the phenomenology of FASDs but about how in the particular scenario a FASD may have forensic relevance, in the sense of having played a role in the offender's criminal offending and in relation to how the offender is likely to fare in a custodial environment. As there are different forms of FASDs and as their symptomatology varies significantly in nature and severity, it is incumbent upon assessors to provide offender-specific assistance to courts, sometimes incorporating counter-intuitive information. Judicial officers are increasingly receiving submissions about FASDs in many countries, especially in respect of offenders from First Nations. The quality of such evidence has been variable and there have been occasions when courts have not received the assistance they have required. Some have become experts in the area; others have little knowledge about the issues. However, international case law, based upon expert assessments from psychiatrists and psychologists, has evolved substantially since 2000. There is now a significant body of sentencing law, in particular, upon which advocates can draw and judicial officers can rely, based upon expert opinions provided by mental health assessors, when imposing sentences upon offenders with FASDs. This article reviews important and illustrative examples of such law from Canada, England, New Zealand and Australia. It argues that this corpus of legal authority now provides constructive guidance for FASD cases, and that it should be utilized to enhance forensic FASD assessments and judicial decision-making about offenders with FASDs.

Résumé

Les Troubles du Spectre de l’Alcoolisation Fétale (TSAF) sont un terme générique recouvrant toute une série de troubles, dont le Syndrome Alcoolique du Fœtus (SAF), le Syndrome Alcoolique partiel du Fœtus (SApF), les Troubles du Développement Liés à l’Alcool (TDLA) et les Défauts de Naissance Liés à l’Alcool (DNLA). Chacun de ces troubles constitue un problème prépondérant, qui se manifeste à vie, résultant de l’exposition prénatale à l’alcool (EPA). Alors que l’étendue des TSAF reste sujet à débat, elle pourrait se situer autour de 1 % de pays tels que le Canada, la Nouvelle-Zélande et l’Australie. Les troubles ont été identifiés de manière disproportionnée chez des personnes issues des populations indigènes dans de nombreux pays. De plus, les TSAF sont présents en nombre significatif parmi les personnes inculpées pour des offenses criminelles et qui sont condamnées à l’emprisonnement, particulièrement les jeunes délinquants. Comme on peut le comprendre, puisque les TSAF souffrent d’un certain niveau d’incertitude diagnostique, ils ont été sous-diagnostiqués de manière significative. On peut aisément les confondre avec d’autres troubles, particulièrement dans le contexte de comorbidité. Cependant, leur pertinence dans le contexte de médecine légale en termes de culpabilité réduite pour les offenses criminelles et de capacité problématique à répondre à des interrogations par des personnes représentant l’autorité, comme la police, est significative mais très subtile dans beaucoup de cas. De plus, le potentiel pour que les TSAF soient mal interprétés sur la base de personnes souffrant de TSAF mais apparaissant “normales” est significatif. Ainsi, les professionnels de la santé mentale qui évaluent les personnes inculpées d’offenses criminelles ont un rôle important à jouer pour identifier la symptomatologie des TSAF et, quand cela s’avère nécessaire, pour proposer une évaluation spécialisée pour des criminels ayant ce profil. Ceux qui conduisent les évaluations des TSAF pour les cours de justice doivent non seulement éduquer les officiers judiciaires sur la phénoménologie des TSAF mais aussi sur la question de savoir comment, dans un scénario donné, des TSAF peuvent avoir une pertinence dans le domaine de la médecine légale, dans la mesure où les troubles ont joué un rôle dans l’offense criminelle du prévenu, et en relation avec la façon dont le prévenu risque de se comporter dans un environnement carcéral. De même qu’il existe différentes formes de TSAF et que leur symptomatologie varie significativement en nature et en gravité, il incombe aux évaluateurs de fournir aux cours de justice une assistance personnalisée du point de vue des criminels, qui comporte parfois des informations pouvant paraître surprenantes. Les officiers judiciaires reçoivent de plus en plus de contributions sur les TSAF dans beaucoup de pays, particulièrement concernant les criminels issus des Premières Nations. La qualité de ces témoignages a été variable et il y a eu des occasions au cours desquelles les cours de justice n’ont pas reçu l’assistance qu’elles avaient demandée. Certaines cours sont devenues expertes dans le domaine; d’autres connaissent mal ces questions. Quoi qu’il en soit, le droit international, basé sur des évaluations d’experts conduites par des psychiatres et des psychologues, a évolué de façon substantielle depuis 2000. Il existe désormais un corpus significatif de loi pénale, en particulier, que les avocats peuvent utiliser et sur lequel les officiers judicaires peuvent s’appuyer, basé sur des opinions d’experts fournies par des évaluateurs dans le domaine de la santé mentale, dans le cas où l’on applique une sentence à un criminel souffrant de TSAF. Cet article examine des exemples importants et qui illustrent bien la question, tirés du droit du Canada, d’Angleterre, de Nouvelle-Zélande et d’Australie. Il soutient que ce corpus d’autorité légale fournit désormais un guide constructif pour les cas de TSAF, et qu’il devrait être utilisé pour améliorer les évaluations de médecine légale concernant les TSAF ainsi que les prises de décisions judiciaires concernant les criminels souffrant de TSAF.

Introduction

Fetal Alcohol Spectrum Disorders (FASDs) are a suite of conditions that have the potential to impact upon both suspected persons’ capacity to participate reliably in police interviews and upon evaluations of criminal responsibility and culpability by expert assessors and criminal courts alike. Therefore, important issues arise in respect of the conduct of expert assessments for forensic purposes of persons who may have FASDs and in respect of the needs of the courts for information about the characteristics of FASDs and their impact upon accused persons so that suitably informed decisions can be made.

This article identifies the clinical evidence for the forensic relevance of FASDs, explores their repercussions for legal practitioners and mental health professionals, and reflects on issues that are emerging for the role of expert witnesses in respect of identification of the sequelae of the harm caused by prenatal exposure to alcohol (PEA). It does so on the basis of the clinical literature and decisions by courts which have been called upon to deal with accused persons who have been diagnosed with FASDs. It argues for the need for increased awareness of the symptomatology of FASDs on the part of forensic mental health assessors, judicial officers and legal representatives. It argues that there is a need for state funding of specialist assessments to assist courts where the incidence of FASDs is particularly high.

Section snippets

Diagnosis of FASDs

FASD is an umbrella term relating to a set of disorders, including Fetal Alcohol Syndrome (FAS), partial Fetal Alcohol Syndrome (pFAS), Alcohol-Related Neurodevelopmental Disorder (ARND) and Alcohol-Related Birth Defects (ARBD). Each disorder results from PEA and is pervasive and life-long [1]. Each can result in different ways and to different extents in learning difficulties; a reduced capacity to remember tasks from day to day; impaired appreciation of the ramifications of conduct; limited

Phenomenology of FASD

The contemporary incidence of FASDs is unknown but it is of significant dimensions [1]. The Public Health Agency of Canada in 2005 estimated that about 1% of Canadians had a FASD. [29] In 2014, its estimate continued to be that FASD occurs at a rate of 1 out of every 100 live births and that its prevalence is between 2% and 5% [30].

Recent studies in a Rocky Mountains region city (1.1–2.5%) [31], a midwestern United States community (2.4-4.4%) [32]; Arizona, Colorado and New York (between 0.3

Forensic relevance of FASDs

The available evidence is compelling that a disproportionately high percentage of persons with FASDs become involved in the criminal justice system – in particular as offenders, prisoners and victims. [59] This means that forensic mental health practitioners, the courts and correctional facilities have significant contact with offenders with FASD. Imprisonment rates of persons with FASD were found to be 19 times greater than those without FASD in a 2011 Canadian study [60]. Prevalence rates of

Interviewee suggestibility: a case example

FASDs have a significant potential to be relevant to the voluntariness of interviews undertaken by persons in authority such as police [63] with those with FASDs and may impact upon the capacity of persons who are suspected of committing offences to understand their right not to answer questions [64]. This may be relevant to the admissibility of the evidence of such admissions but, more broadly, also to the risk of miscarriages of justice.

The circumstances which attended the landmark 2015 Privy

Criminal responsibility and culpability

Based on Canadian data, researchers have estimated that young people with FASD are 19 times more likely to be incarcerated than other young people in a given year [68]. One of the study's authors told a Canadian Parliamentary Committee in 2014 that the prevalence of FASD among incarcerated youth ranged from 11% to 23% [30]. Whether or not this is an accurate figure or can be extrapolated to other jurisdictions, it is apparent that the issue is of significant dimensions for the capacity of

Sentencing of offenders with FASDs

The imposition of a sentence for an offender with FASD presents particular difficulties [86], [87]. A consequence of this is arguably that sentencers should focus upon protection of the community by separation of the offender (by imprisonment) as a means of providing the community with necessary protection and also upon rehabilitation. [88] Thus, factors such as denunciation, punishment and deterrence become less significant. [77] However, a collateral consideration is that while those with

Challenges for Mental Health Assessors, Lawyers and Judicial Officers

While the diagnostic criteria for FASDs remain to be resolved authoritatively and FASDs have not been absorbed unequivocally into the American Psychiatric Association's 2013 DSM-5 [18], [97], it is apparent that FASDs have a significant incidence, in particular in Indigenous populations where there is a high level of maternal consumption of alcohol during pregnancy. They have been seriously under-diagnosed and therefore under-treated [98]. As Australian reports have identified, they can be

Disclosure of interest

The author declares that he has no competing interest.

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