Understanding the Relationship between Fetal Alcohol Spectrum Disorder (FASD) and Criminal Justice: A Systematic Review

Prenatal alcohol exposure is considered one of the main causes of preventable birth disorders; however, it represents the main form of developmental delay in the world. Among the so-called secondary disabilities related to fetal alcohol spectrum disorder (FASD), there is a close connection with criminal behavior. This systematic review aims to provide up-to-date information about the relationship between FASD subjects and criminal justice analyzing different aspects. In light of the results of this review, a further goal is to provide several suggestions in order to reduce the public cost impact of FASD. A systematic review of the literature was conducted according to the PRISMA guidelines, producing 20 articles that met the inclusion criteria. Based on the results published in the selected studies, fetal alcohol syndrome (FAS) is a leading cause of preventable birth disorders and developmental disabilities in newborns. Moreover, these subjects seem to be more inclined to criminal acts compared to others. In conclusion, it should be pointed out that FASD entails high public health costs, both regarding the support measures provided to the affected individual and to their family, as well as the cost and social impact of any criminal offenses committed.


Introduction
Fetal alcohol spectrum disorder (FASD) is an umbrella term which includes a wide range of neurological and behavioral problems that can affect a person who was born to a woman who had abused alcohol during pregnancy [1].
The prevalence of FASD in different countries correlates with the percentage of women who drink alcohol during pregnancy. Globally, the prevalence of fetal alcohol syndrome (FAS) in the general population has been estimated at 14.6 per 10,000 [2]. Based on a recent study conducted by Popova et al. [2] the prevalence of FAS in the United States is 14.8 per 10,000, while in Canada it is 10. In Europe, the prevalence is higher in Eastern European countries that are known for their high alcohol consumption: FAS is 46.6 in Belarus, 36

Inclusion and Exclusion Criteria
All articles that matched the study keywords "FASD and criminal justice" were evaluated: all articles that analyzed data about subjects affected by FASD involved in criminal behavior were included. Moreover, the selection of studies was performed evaluating the characteristics of the published paper. Based on older international guidelines [4,5], during the revision process, we have included the articles that have used following acronyms: FASD; Fetal alcohol syndrome (FAS); Partial FAS (pFAS) [17]; Alcohol-Related Neurodevelopmental Disorder (ARND [18]; and Alcohol-Related Birth Defects (ARBD) [19]. Retrospective and interviewed-based studies were included. The following exclusion criteria were used: (1) review, (2) articles not in English, (3) editorial, (4) book chapter and (5) communications at conferences. The inclusion criteria were as follows: (1) original article, (2) case report, (3) articles in English, (4) in vivo studies.

Quality Assessment and Data Extraction
F.S initially evaluated all the articles, evaluating the title, the abstract and the whole text. M.S. then reanalyzed the articles chosen independently. In order to evaluate the degree of agreement between the studies, Kappa's statistical test was applied [20] showing a high value κ = 0.85. Disagreements concerning eligibility were resolved by a consensus process with the supervision of C.P.

Risk of Bias
Different strengths are present in this systematic review, these include the amount and breadth of the studies, which span the globe, the search technique and a flowchart that describes in detail the study selection process. Moreover, the agreement between studies gave a high value for Kappa's statistical test. The bias risks are related to the relative keywords that may have influenced the search strategy.

Characteristics of Eligible Studies
A total of 161 articles were selected. Of these, 36 duplicates were removed and 15 studies were excluded because they did not match the study aims. Thirty-two papers were removed because they did not meet the inclusion criteria. From a total of 78 articles, 58 studies were further excluded after a careful evaluation. At the end of the review processes, 20 studies were included in the present systematic review ( Figure 1).

Results
All selected articles are summarized in Table 1. Analyzing the data obtained, 12 studies were performed in Canada, 3 in Australia, 2 in the USA, and 1 study each in New Zealand, Brazil and Sweden.

Results
All selected articles are summarized in Table 1. Analyzing the data obtained, 12 studies were performed in Canada, 3 in Australia, 2 in the USA, and 1 study each in New Zealand, Brazil and Sweden.  In the sample analyzed, the authors identified about 17% of the subjects with FASD; moreover, about 31% of subjects had been exposed to alcohol in the prenatal period. Data from the present study confirm that subjects with FASD are more likely to have adverse childhood events (ACEs) than the control group. Increased ACEs were associated with higher rates of neurodevelopmental disorders for subjects with FASD. The results of this study showed that subjects in the FASD group committed fewer total offenses than those in the No-FASD group, although no statistically significant differences were reported. However, significant cognitive impairment was found in the FASD group compared to the control group. Cognitive impairment may be considered an important risk factor in order to commit a crime, particularly in the cases of sexual violence.

FASD Subjects and Brain Impairment
Based on the results published in the selected studies, FAE represents a leading cause of preventable birth defects and developmental disability in newborns. As reported by Streissguth et al. [21], subjects with FAS or FAE showed arithmetic disability and specific problems with adaptive behavior. Similar results were reported by McLachlan et al. [26] who described an impairment in at least one psycholegal ability and brain impairment in FASD subjects. Banerji and Shah [27] in an FASD group reported learning disabilities and behavioral problems, developmental delay, attention deficit hyperactivity disorder (ADHD), alcohol abuse and problems with the justice system. Kambeitz et al. [35] reported that subjects with FASD were more likely to have adverse childhood events (ACEs). Increased ACEs were associated with increased rates of neurodevelopmental disorders for subjects with FASD.
Although Mela et al. [36] described the FASD group as showing clinically significant impairments in visual memory (delayed and immediate recall), with additional pronounced deficits in full-scale IQ, verbal IQ, working memory and processing speed, they reported contradictory results concerning FASD and crime involvement. It was reported that subjects in the FASD group committed fewer total crimes than those in the No-FASD group, although no statistical differences were reported. All other studies confirmed the theory that subjects exposed to alcohol in the prenatal period are more inclined to criminal activities compared to others with no FASD. Analyzing FAS subjects, Salmon and Buetow [24] reported mental health problems from alcohol and recreational drug usage: this situation is strictly related with their physical status, with a sufferance of anxiety relief, boredom, addiction and impulsivity. They described that only a few participants became involved with the justice and/or the legal system. A deficit in IQ was reported by Mullay et al., who described IQ values <70 in the FASD group [37]. These data were confirmed by Brownell et al. [34]. Finally, Tait et al. [28] reported highlighted the importance the importance of support programs to guarantee the long-term stability for individuals living with FASD.

FASD Subjects in Indigenous Group
Two studies reported differences in FASD exposure analyzing the data about indigenous subjects compared to non-indigenous subjects: in both studies, it emerged that indigenous subjects have a greater exposure to FAS compared to the non-indigenous group. Rojas and Gretton [23] analyzed the Canadian situation, concluding that aboriginal youth were more likely to have background histories of FASD, substance abuse, childhood victimization, academic difficulties and instability in their living environment than non-aboriginal youth. The risk of having a history of FASD in the aboriginal population is related to their social context: particularly, from a historical point of view, they have been subjected to cultural oppression, social marginalization and governmental control (living in reservations, integrating in schools and as a result of federal legislation) [40][41][42]. The importance of socio-economic factors in FASD risks was highlighted by Rangmar et al. [11] and Brownell et al. [34]: subjects in the FAS group had a lower income than those in the comparison group.

FASD Subjects and Justice System
A direct link between FASD subjects and problems with the justice system was described by Bower et al. [29], who confirmed a high prevalence of FASD and severe neurodevelopmental impairment in a representative sample of young subjects in detention. Similar results were obtained in two studies performed in Canada: both research groups confirmed that FASD should be considered a risk factor for problems with the justice system [31,32]. Brownell et al. [34] reported that, although FASD subjects had similar health service use to non-FASD subjects, they were more likely to be charged with a crime. Hashmi et al. [39] confirmed these data analyzing legal databases: they reported that 36% of cases dealt with offenders who had a confirmed comorbid diagnosis of FASD and the crime that was more frequently found was sexual offense. Contrariwise, Momino et al. [25] concluded that criminal behavior is determined by complex interactions between environmental and social issues, including prenatal alcohol exposure. Controversial results were obtained by Rangmar et al. [11]: this group reported a higher percentage of offenders in the FASD group; these findings were not found if the analysis was limited to subjects who had been in state care as children.
Another important aspect that may be related to FASD is imputability. In Italy, the penal code (art. 85) establishes that a person cannot be punished for a crime if when he/she committed the fact, he/she was not responsible, that is, he/she was not able to understand what he/she was doing: as in the case of FASD. Given the variations across legal jurisdictions, this issue warrants analysis at both national and international levels. Cockram [22] reported that offenders with an intellectual disability were given a custodial sentence 11.3% of the time, while those offenders without an intellectual disability received custodial sentences 8.9% of the time. Flannigan et al. [33] described young offenders with FASD displaying a profile of neurocognitive functioning more severely impaired than young offenders without FASD, analyzing numerous tasks. In this way, FASD status should be taken into consideration during trials. This important theme is remarked by Hamilton et al. 2020 [38], who underlined the importance of FASD diagnosis in subjects in prison in order to have a right process. Moreover, as reported by McLachlan et al. [30], several interventions, such as Structured Assessment of Violence Risk in Youth (SAVRY) and the Youth Level of Service/Case Management Inventory (YLS/CMI), could be useful in predicting recidivism in youths with FASD having problems with the justice system. Despite these findings, the presence of FASD is usually completely ignored by the police, as described by Salmon and Buetow [24].

Discussion
Analyzing data worldwide, as summarized in Table 1, Canada is the country that has applied great effort towards analyzing the FAS problem. Indeed, several important studies have been performed that have increased our knowledge about this important health concern. As described above, FAS is diffused in different European countries, while only Sweden has published a scientific paper on this theme. It is very strange that different countries such as Ireland, Denmark, United Kingdom and Italy have not published studies on this theme: in our opinion, in the near future, it will be important to perform new studies in order to evaluate the European situation, country by country, suggesting possible supporting actions. As recently described by Brown et al. [43], the most common consequences detected in subjects with FASD were impulse control problems, executive function deficits, learning disabilities, adaptive functioning deficits, social skill deficits and poor judgment. Based on previous studies, an early diagnosis of FASD is associated with more positive outcomes including a reduced amount of contact with the criminal justice system (CJS) [44]. Moreover, it is important to highlight that FASD may be related to cases of sudden cardiac death in infants [45].
From a forensic point of view, there are two main questions: the legal responsibility of the mother in FASD cases after alcohol consumption during pregnancy and the imputability of an FASD subject. Brown et al. [46] suggested that when rationality is impaired by FASD, acts driven by strong emotion and urges can occur, suggesting that the obvious implications regarding criminal responsibility should be reduced.
In this context, considering the responsibility of the mother, the identification of new molecular biomarkers to demonstrate prenatal exposure remains challenging for the scientific community [47][48][49][50][51]: in different countries, there is a legal responsibility for the mother if her newborn tests positive for abused substances [52]. The considerations about the mother's responsibility are strictly related to each country. In some parts of the USA, the mother may be criminalized for drinking in pregnancy as a form of child abuse. This leads to the mother being incarcerated and the child removed from the mother's care upon birth [53]. Contrariwise, there are also some countries (such as Canada) that do not legally determine the fetus as a human for purposes of law until birth [54]. Moreover, different initiatives should be put in place to prevent alcohol consumption during pregnancy. In Canada, Rasmussen et al. [55] described the use of the First Steps program (modeled after the Parent-Child Assistance Program) demonstrating an improvement in outcomes among women at risk for giving birth to a child with FASD. In Australia, several initiatives have been adopted, such as the presence of a court empowered to order that the mother be taken into care pending birth, or otherwise impose conditions upon conduct, with the purpose to take care of the life and health of unborn children [56]. Furthermore, as recently remarked, health institutions should organize programs to facilitate health counselling on alcohol consumption during pregnancy, particularly when providing care to women with low levels of education [57].
FASD is relevant across the legal spectrum from offensive behavior and arrest through the entire adjudication process to incarceration. For example, brain damage in FASD may be relevant, reducing the individual's self-control and ability to recognize when his/her conduct is subjecting others to harm. The diagnosis of FASD could be very important in order to establish the sentence: after arrest, cognitive impairments may affect competency to proceed to trial by causing significant misunderstanding about the implications of waiving rights to silence and legal counsel before and during police questioning [58]. As reported by McMurtrie [59], it is important to note that subjects with FASD are treated differently by the criminal justice system in sex offense prosecutions, in relation to their role in the crime, if they are victims or perpetrators. The primary and secondary disabilities associated with FASD are usually taken into consideration when assessing the capacity of a victim to consent to sexual activity, but generally not considered in determining whether a defendant had the mens rea to engage in criminal sexual conduct. A comprehensive medico-legal report, prepared by professionals experienced with FASD, can help courts and attorneys to understand the complex interactions between brain injury, genetics and the environment. Corrections and probation officers should comprehend the significance of FASD and how it impacts the offender's ability to understand and follow probation rules and orders [60].
Considering the data obtained through this literature review, the absence of a timely diagnosis of FASD may lead to serious consequences by denying these subjects the appropriate support: in this way, they cannot reduce their difficulties in carrying out daily activities; thus, there is the possibility of misbehavior. In order to reduce the adverse effects of FASD, it would be desirable to carry out timely neurodevelopmental assessments, giving appropriate support for FASD subjects. This phenomenon should be urgently analyzed jointly by national health and justice systems: undoubtedly, a timely intervention supporting FASD subjects may guarantee a lower economic burden for both the public health and juridical systems [14,61,62].
As stated above, FASD status may be considered as a risk factor for committing a criminal act, it is important to implement support measures both to prevent and to avoid recidivism by these subjects. In a recent paper, it was reported that support of health professionals is very important in order to reduce alcohol consumption during pregnancy: informing pregnant women about the harmful effects of alcohol consumption is a very important countermeasure to prevent FASD [63]. Finally, it is important to guarantee juridical support for all subjects with FASD involved in a crime. It cannot be ignored that these subjects may experience inequalities at all stages of the justice system, for example, the inability to fully understand the situation at hand.
In light of these considerations, the following activities should be adopted by each country, particularly in the case of the presence of a high rate of FASD subjects.
In our opinion, it is necessary: to adopt specific training for police, courts staff, lawyers and other stakeholders in order to illustrate the complex FASD phenomenon; -to constitute a multidisciplinary group to promptly identify subjects with FASD to conduct a fair trial; -to carry out research studies both to better define the possible incidence of FASD in the prison population and to establish targeted support interventions in prison to prevent recidivism; -to activate a follow-up for all prisoners diagnosed with FASD.

Conclusions
As previously discussed, young subjects with FASD are at risk of poor health, education and social outcomes, having greater than normal problems with the justice system. This review stresses the usefulness of appropriate interventions to support children with FASD. Another important aspect related to FASD is the economic burden: although the data are scarce and the existing estimates likely underestimate the full economic impact of this disorder on the affected subjects, their caregivers and society, it seems to be demonstrated that FASD is a serious public health problem associated with tremendous economic burden. A reduction in the societal costs of FAS, both preventive and targeted interventions for children with FAS, should be prioritized. For example, different countermeasures should be applied by governments, providing services to educate and train subjects with FASD, their family members, teachers and social service workers to prevent victimization and report victimization when it occurs. Moreover, in the same manner, the justice system and law enforcement should develop systems to protect the rights of subjects with FASD who are victimized, especially when they appear as witnesses.
Part of changing the landscape of FASD is to modify the way the community perceives and reacts to FASD. A multidisciplinary approach to addressing this problem is increasingly necessary. Rather than a purely psychological or medical approach, the integration of FASD subjects is the most important measure that can be taken to prevent the risk of criminal behavior. This becomes a way to change the conversation around FASD from the current sense of certain failure to one of possibility of success.
Finally, well-designed studies should be performed, country by country, to provide an up-to-date status, allowing each government to adopt new and useful interventions.