Transcript Fetal Alcohol Spectrum Disorder in the Legal System: A

(A10)
FASD in the Legal System:
A Multidisciplinary Assessment
Model for Adults & Adolescents
Presented by FASDExperts.com
Judge Anthony Wartnik, JD – Legal Director
Natalie Novick Brown, PhD – Program Director
Paul Connor, PhD – Neuropsychology Director
Richard Adler, MD – Medical Director
3rd International Conference on
Fetal Alcohol Spectrum Disorder
Victoria, BC, Canada
March 11, 2009
Hon. Anthony P. Wartnik,
J.D., Judge (Retired)
Legal Director
Natalie Novick Brown, Ph.D.
Program Director
FASD Experts:
Multidisciplinary Forensic
Assessment Team
• Unique multi-stage/multi-disciplinary approach to
FASD assessment within the forensic context
• Broad forensic applicability:
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Criminal
Civil
Trial
Post-conviction
Defense
Prosecution (i.e. victims with FASD)
• International scope
Take Home Messages
• Multidisciplinary FASD assessment is an
important advance
• Best practice = multidisciplinary
model
• Best practice = structured protocol
• What we’ve learned from current case
law
• What we’ve learned from our own
history
• Spreading the word
Related Workshops at This Conference
• Services to FASD Youth in Criminal Justice
System
(Manitoba Youth Justice Program)
• Cognitive Profiles/Social Risk Factors for Youth
Justice Clients
(BC’s Asante Center for FAS)
• Educating Justice Professionals
(DOJ Canada & Public Health Agency of
Canada)
• Changing Public Policy in the Legal System
(FASD Experts, UW FADU, Los Angeles Mental
Health Court DPD)
Typical FASD-like Behaviors in the
Criminal Context:
• Easily led by more sophisticated peers
• Multiple low-grade offenses in adolescent
years, often with others / frequently
arrested
• Offenses don’t “make sense” (e.g.,
stealing something of little value;
engaging in crime when likelihood of being
detected is high)
• Impulsive, opportunistic crimes
• Failure to change strategy when
something goes wrong
(perseveration)
Typical FASD-like Behaviors in the
Criminal Context:
• No exit strategy for crimes resulting in
“fight-or-flight” behavior in chaotic
high-stress situations
• Rights against self-incrimination waived
immediately upon arrest
• Guileless confessions (occasionally to
offenses subject hasn’t committed)
• No apparent guilt or remorse
• Unable to appreciate magnitude of
crime (nonchalance, inappropriate
smiling)
State of the Art in
Forensic Assessment of FASD
• Pre-2007: “Hit or Miss”
• Post-2007: FASD Experts 
– First systematic, structured approach
to forensic assessment of FASD
Relevance of FASD
in the Legal Arena
Pretrial Stage:
• Plea negotiation
• Competency
– Waiving Miranda/Right against selfincrimination
– Consent to search,
– Competency to proceed to trial
Relevance of FASD
in the Legal Arena
Trial/Guilt Phase
• Diminished capacity/guilt: mental
state “beyond a reasonable doubt” /
“mens rea”
• False confession
• Testimonial capacity (e.g., as
defendant, as witness, as victim)
• Vulnerable victim
Relevance of FASD
in the Legal Arena
Trial/Sentencing
• Mitigation (circumstances affecting
capacity to appreciate the
wrongfulness of the conduct or to
conform conduct to the requirements
of the law)
• Sentencing options (e.g., DDD)
• Treatment planning
Relevance of FASD
in the Legal Arena
Post-conviction Stage
• Appeal (e.g., was waiver voluntary
and knowing? did trial court err?)
• Ineffective assistance of counsel
Role of the Forensic Mental Health
Professional:
“Expert Witness”
• Expert witnesses: individuals considered to
have special knowledge of the subject by virtue
of education, training, and experience such that
others may legally and officially rely on their
opinions
vs
• Fact witnesses: can only testify about the
“facts” in a case and cannot give their opinions
Expert Witnesses in the
Mental Health Arena:
THE GOOD:
Review and provide information re: psychiatric conditions
that might cause problems with intellectual functioning,
memory and other relevant issues:
Prenatal:
• Genetic conditions
• FASDs
Postnatal:
• Traumatic brain damage caused by head injury (TBI)
• Degenerative brain diseases
• Chronic alcohol and drug abuse
• Secondary to general medical conditions
Expert Witnesses in the
Mental Health Arena:
THE BAD AND THE UGLY:
• Adversarial: expert witnesses are
subject to cross examination and
attacks on their reputation,
credibility, and opinions
How is Forensic Assessment
Different from Clinical
Assessment?
A forensic assessment often involves an
individual who has been charged with a
crime (usually a violent crime) to establish
whether there were any physical or mental
factors that:
1) affected criminal conduct,
2) affect ability to make competent legal
decisions,
3) affect risk of future violent offences
PREVALENCE
Why Is FASD Relevant in a Forensic Context?
Secondary Disabilities
100
Ages 6 - 51
Ages 21 - 51
90
80
70
%
60
50
40
30
20
10
Mental Health
Problems
Trouble
Inappropriate
Dependent
With the
Sexual Behavior
Living
Law
Alcohol &
Problems with
Disrupted School
Confinement
Drug Problems
Employment
Experience
Ages 6-51 (n=408-415)
Ages 21-51 (n=89-90)
Why is FASD
Relevant in Court?
• FASD = brain damage that may
affect executive functioning 
• Executive functioning = judgment,
decision making, impulse control 
• Judgment, decision making, impulse
control impact all aspects of
behavior in the legal context
History of FASD
In Court:
• Over 100 court decisions regarding
FASD reflect general recognition that
FASD affects behavior in ways that are
relevant to the justice system
• However, decisions reflect an
imperfect understanding of the
diagnostic process, symptoms, and
behavioral consequences of FASD
History of FASD
In Court:
There is a world of difference between evidence of
past behavioral problems and evidence that a
defendant has organic brain damage from FASD
that caused such behavior.
A critical question in law is whether a defendant is
fully responsible for his criminal actions.
Absent a link between the brain damage and the
criminal conduct (“the nexus”), a history of
behavior problems may only convince the jury that
the defendant is a “bad actor.”
FASD is a Potential Mitigating Factor
• It is organic in nature rather than the
result of a bad disposition;
• It arises from circumstances entirely
beyond the individual’s control (unlike,
for example, alcohol or drug abuse);
and
• It affects the defendant’s ability to
understand society’s norms and/or to
conduct his behavior within those
norms.
U.S. Criminal Case Law Review
(UW/FADU Legal Issues Web Site)
Pre-Trial Phase
• Miranda Waiver (right against self-incrimination): 0
cases
• Competency to Stand Trial: 5 cases
• Juvenile Remand: 0 cases (*)
Trial/Sentencing Phase
• Diminished Capacity/Guilt: 5 cases
• Sentencing Mitigation: 35 cases
Post-Conviction Phase
• Ineffective Assistance of Counsel: 29 cases
U.S. Criminal Case Law Review
(UW/FADU Legal Issues Web Site)
Other
• Sexual Offenses: 12 cases
• Police Practices: 2 cases
• Testimony by Individuals with
FAS/FAE: 5 cases
• Vulnerable Victim: 8 cases
• Waiver of Rights: 5 cases
• General: 6 cases
What does analysis of
over 100 legal cases tell
us about the problems
with FASD in the
courtroom?
Assumption Errors in FASD Cases:
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Average IQ precludes FASD diagnosis
Good verbal skills preclude FASD dx
MRI/EEG tests are definitive
Structured/organized reasoning
precludes FASD dx
Omission Errors in FASD
Cases:
• Failing to obtain specific FASD diagnosis
• Failing to address if low IQ may be due to
FASD
• Failing to consider competency and mental
state issues
• Failing to select appropriate experts (i.e.,
assuming a generic expert “can do
everything”)
• Failing to supply experts w/ sufficient
information (“cherry picking”)
• Failing to adequately investigate mom’s
drinking
More errors…
• Failure of legal team to educate
themselves about FASD
• Shotgun approach to mitigation
• Discarding FASD defense if there is no
evidence of maternal drinking
• Stopping FASD investigation if mom
denies drinking during pregnancy
• Inadequate records search (e.g., school
records)
Still more errors…
• Failing to address “the nexus”
• Assuming that previous criminal problems =
antisocial personality disorder
• Assuming psychiatric conditions/personality
disorders/acute substance intoxication explain
“all” of the problem
• Failing to ensure general consistency among
defense experts
• Assuming a non-M.D. or generic M.D. can
“diagnose” FASD
• Opting for “local” M.D. expert with “some”
FASD experience (“seat of the pants” diagnosis)
to reduce cost
Inherent Problem in FASD Defense:
Complicated Diagnosis
• Physical, as well as psychological,
assessment (i.e., need at least 2
experts), which is more difficult in
adolescents and adults
• Complex diagnostic criteria that are
addressed in 2 separate government
documents but not addressed in the
DSM-IV-TR
FASD Diagnosis Requires
Explanation for Erroneous
Stereotypes & Assumptions:
• Average IQ
• Good verbal skills
• Careful “planning” or “premeditation” of
offense behavior
• Lack of evidence/mom denies drinking
during pregnancy
• Failure to meet criteria for a full FAS
diagnosis
How is Forensic FASD Diagnosis
Similar To Clinical Diagnosis?
Best practice:
• standardized diagnostic criteria
• structured diagnostic protocol
• multidisciplinary assessment and
reliance on multiple sources of data
How is Forensic FASD
Diagnosis Different Than
Clinical Diagnosis?
1)
Clinical diagnosis typically involves
children and does not contemplate legal
challenge,
2)
Forensic diagnosis typically involves
adolescents or adults and contemplates a
significant legal challenge,
3)
Forensic diagnosis requires detailed and
understandable links from prenatal exposure
to the instant offense behavior or to
civil/clinical impairment
Forensic Assessment Must
Address The Nexus
(i.e. Link FASD to Offense Conduct):
prenatal exposure
↓
brain damage in fetus
↓
lifelong cognitive-behavioral deficits
↓
specific deficits in judgment, decision-making,
cause-and-effect awareness, and impulse
control
↓
instant offense behavior
Inherent Problem in FASD
Case Law: Confusion
While the body of case law reflects a
widespread recognition that FASD
affects behavior in ways that might be
relevant to the legal system, it also
reflects an imperfect understanding of
symptoms, methods of diagnosing, and
behavioral consequences of FASD.
FASD Diagnostic Criteria
• Institute of Medicine (1996)
• 4-Digit Diagnostic Code (2000)
• Centers for Disease Control (2004)
ICD-10: Q86.0, “Fetal Alcohol Syndrome “
DSM-IV-TR: Cognitive Disorder NOS due
to a general medical condition
Quick Reminder
of Diagnostic Criteria:
5 possible diagnoses per IOM under FASD
umbrella: FAS (with and without confirmed
exposure), Partial FAS, ARND, ARBD
4 diagnostic criteria per CDC for FAS:
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prenatal alcohol exposure
growth deficit
facial abnormalities
CNS abnormalities
3 CNS abnormalities:
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Structural
Neurological
Functional
Why Use A Multidisciplinary
Team Assessment In The
Forensic Context?
CDC (2004) guidelines:
“FAS Diagnosis (is) confirmed using
dysmorphic and anthropometric
assessment procedures along with
appropriate neurodevelopmental
data” (p. 8).
Impetus for FASD Experts:
Case #1
• Post-Conviction Appeal (ineffective assistance
of counsel) - New Jersey, 2005
• Trial Date: 1995
• IQ: VIQ=96, PIQ=82, FSIQ=88
• Referral question: Was there sufficient
information in the 1995 trial record to support
an FASD diagnosis in 35-year-old man
convicted of Murder 1?
• Defense experts:
Dr. Fred Bookstein (MRI analysis)
Dr. Natalie Brown (FASD diagnostic record
review)
Case #1:
• Case Outcome: upon petition, New
Jersey Court of Appeals agreed to hear
motion, but appeal was rendered moot
when shortly thereafter state abolished
the death penalty
• Lessons Learned:
1) face-to-face interview should
accompany even a “document review”
2) We need an MD to diagnose
Case #2:
• Post-Conviction Appeal (ineffective assistance of
counsel) – South Carolina, 2006
• Trial Date: 2002
• IQ: VIQ = 94, PIQ = 106, FSIQ = 99
• Referral Question: Was there sufficient
information in the 2002 trial record to support an
FASD diagnosis in 32-year-old man convicted of
Murder 1?
• Defense experts:
Dr. Fred Bookstein, PhD (MRI analysis)
Dr. Richard Adler, MD (diagnosis)
Dr. Natalie Brown, PhD (lifelong functional
assessment, maternal drinking, nexus)
Case #2:
• Case Outcome: PCR hearing on hold
pending ruling from South Carolina
Supreme Court on another matter
• Lessons Learned:
1) We need a neuropsychologist to
test for current, standardized
evidence of neurological impairment!
Case #3:
• Sentencing Phase- California, 2007
• Referral Question: Was 20-year-old defendant’s
offense conduct affected by an FASD in this Murder 1
case (victim was a policeman shot in line of duty)?
• IQ: VIQ = 100, PIQ = 92, FSIQ = 97
• Defense experts:
Dr. Fred Bookstein, PhD (MRI analysis)
Dr. Paul Connor, PhD (neuropsychological
testing)
Dr. Richard Adler, MD (diagnosis)
Dr. Natalie Brown, PhD (lifelong functional
assessment and nexus*)
Case #3:
• Case Outcome: convicted of Murder 1 / death sentence
• Lessons Learned:
1) We need to form a STRUCTURED diagnostic process
that provides complete functional assessment to the
diagnostician (an M.D.) prior to his assessment (in
this case example, the diagnosis occurred prior to the
lifelong functional assessment)
2) ALL members of team (ideally) should testify about
respective findings in order to adequately explain &
maintain integrity of complex assessment process
3) Nexus MUST be addressed in testimony
4) MRI and Admissibility Issues (i.e. Frye/Daubert)
5) MRI/corpus callosum analysis unnecessary (but
sometimes helpful) for diagnosis
Outcome: FASD Experts
Psychologist Neuropsychologist
Psychiatrist
Judicial/
Legal
Consultant
Lifelong
functional
assessment,
maternal
drinking
Current
functional
assessment
Conduct
physical, photo
analyses &
review
functional
assessments 
diagnosis
Legal guidance
re: forensic
issues & legal
strategy
DIFFERENTIAL
DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
REPORT
REPORT
REPORT
TESTIMONY
TESTIMONY
TESTIMONY
Consult w/
Defense Team
Psychologist’s Role
(FASD Experts)
Element
Criterion
Maternal
Confirmed vs.
Drinking
Unconfirmed
deficits: 2
CNS Functional Cognitive
s.d.’s below mean on IQ
test
Deficits
Neurodevelopmental
deficits: 1 s.d. below
mean in > 3 domains
CNS Functional Domains
per CDC (2004)
Domain
Criterion
Cognition (IQ)
< 2nd percentile (2 s.d. below mean)
Learning deficits
< 16th percentile (1 s.d. below mean)
Motor skills
< 16th percentile (1 s.d. below mean)
Attention
< 16th percentile (1 s.d. below mean)
Executive functioning
< 16th percentile (1 s.d. below mean)
Social skills
< 16th percentile (1 s.d. below mean)
Memory
< 16th percentile (1 s.d. below mean)
Pragmatic language
< 16th percentile (1 s.d. below mean)
Other
< 16th percentile (1 s.d. below mean)
School Record Review
•
•
•
•
Standardized IQ testing
Standardized achievement tests
Standardized behavioral assessment
Documented evidence of substandard performance compared to
IQ-based expectations
Psychological Testing
Subject:
• Gudjonsson Suggestibility Scale
• Competency Assessment
• Personality Testing (differential dx)
• SCL-90-R (differential dx)
• Malingering Assessment
Collateral informants:
• Behavioral Rating Inventory of Executive
Functions-Adult (executive functioning)
• Fetal Alcohol Behaviors Scale (FABS)
Psychological Assessment:
Differential Diagnosis
• Environmental trauma/neglect  PTSD
• Substance abuse (comorbidity ~ 30%)
• Mental illness including ADD/ADHD
(comorbidity > 90% of individuals with
FASD)
• Oppositional/Defiant Disorder, Conduct
Disorder  Personality Disorder
• Malingering
Neuropsychologist’s Role
(FASD Experts)
Element
Functional
Criterion
Cognitive deficits: 2
s.d.’s below mean on IQ
test
Neurodevelopmental
deficits: 1 s.d. below
mean in > 3 domains
Medical Doctor’s Role
(FASD Experts)
Element
Structural
Criterion
Face / Growth
Head circumference
< 10th percentile
Abnormal brain on
CT/MRI
Neurological
Motor problems,
seizures not due to
postnatal insult, soft
signs
Legal Director’s Role
(FASD Experts)
Consultation with FASD Experts team re:
forensic issues pertinent to each case
Consultation with Defense Team re: legal issues
FASD Experts’ Protocol:
Forensic Application of The
Scientific Method
Procedural Integrity
1)
2)
3)
4)
5)
6)
7)
8)
9)
Structured case initiation: Program Director
Explicit written retainer agreements with each Team member
Consultation from FASD Experts’ Legal Advisor Judge Wartnik
Standardized (yet flexible) assessment process
Clear division of labor/unique contributions from each Team
member
Reliance on external experts for structural/neurological deficits
Standardized tests with published norms and known
reliability/validity
Reliance in record review on observable behavior
Group consultation (including legal expertise) and consensus
FASD Experts Protocol
Empirically-based Criteria
•
•
CDC, 2004
IOM, 1996
Reliability Enhancement
•
•
•
malingering assessment
informant selection criteria
differential diagnosis
Evidentiary Compliance
•
•
relevance
reliability (testable, peer-reviewed/published, known error rate,
generally accepted in scientific community)
•
•
Frye: evidence must have general acceptance in relevant scientific
community
Daubert: 2-pronged test of evidence admissibility
Why do we go to all this
trouble?
• Adversarial context
• “Heinous Crimes” / unsympathetic to a trier
of fact
• FASD isn’t “intuitively obvious” to trier of
fact
• Lack of extensive forensic history with FASD
• Difficulty of relating scientific information to
judges/lay juries
• Absence of FASD in DSM-IV-TR Axis I
• FASD Experts is unique  no prior
established assessment procedure for adults
FASD Experts: Preliminary
Success
Reverse Waiver: 15 y/o remanded back to juvenile court in
Murder -2 case (WA; 2008)  PRECEDENT SETTING
Probation Violation: originally sentenced to an “indeterminate
sentence,” judge eliminated requirement that def complete
SSOSA sex offender treatment and permitted him to enroll in
DDD community protection program (WA; 2008)
Felony Harassment: prosecutor agreed to reduce charges to
misdemeanor harassment (WA; 2008)
Arson 2: FAS/MR diagnosis resulted in juvenile being found
incompetent to stand trial (WA; 2008)  PRECEDENT
SETTING
Arson 1: downward departure from standard range (WA; 2008)
Attempted Child Enticement/Molest: jury found def w/ FAS
had a “mental defect” but convicted anyway (WI; 2008)
Sexual Assault: low end of range on prison sentence
Post-conviction habeas: judge granted habeas petition for
death row inmate (NJ; 2006)
Vehicular Homicide: Extraordinary sentence down (WA; 2008)
Problems We’ve Encountered
Problems We’ve Encountered
• “Divide and Conquer” approach from
defense team
Problems We’ve Encountered
• “Divide and Conquer” approach from
defense team
• Ignoring the nexus
Problems We’ve Encountered
• “Divide and Conquer” approach from
defense team
• Ignoring the nexus
• Defendant resistance to “mental
health” defense
Problems We’ve Encountered
• “Divide and Conquer” approach from
defense team
• Ignoring the nexus
• Defendant resistance to “mental
health” defense
• “Doing it on the cheap” approach
from defense team
Problems We’ve Encountered
• “Divide and Conquer” approach from
defense team
• Ignoring the nexus
• Defendant resistance to “mental
health” defense
• “Doing it on the cheap” approach
from defense team
• “Reluctant warriors”
Summary:
Forensic FASD Assessment =
Benefits Beyond Justice
• Proactive, knowledgeable judges who
understand the profound effects on
executive functioning
• Knowledgeable attorneys who
recognize the red flags and take
initiative
• Interventions: not just a diagnosis
but a solution
In Conclusion
• Forensic assessment of FASD has
produced success in multiple legal
arenas
• The word is spreading slowly
• It’s lonely out here - join us!
Paul Connor, Ph.D.
Neuropsychological Director
Role of Neuropsychology
in the Diagnosis of FASD
• Identify pattern of current strengths and weaknesses
of the client
• Determine consistency with research on FASD
• Determine the timeline of cognitive deficits
• Identify competing etiologies
• Determine if evidence of cognitive difficulties
prior to competing etiologies
• Render an opinion of meeting criteria for FASD based
on CDC Guidelines
• Refer information on to Dr. Adler for final medical
diagnosis
CDC Guidelines
•
Confirmed prenatal alcohol exposure
• Facial Dysmorphology
• Smooth Philtrum
• Thin upper lip
• Small palpebral fissures
• Growth Deficits
• Confirmed height, weight or both below 10th
percentile at one point in time
• CNS Abnormalities
• Structural
• Head circumference below 10th percentile
• Evidence of brain abnormalities in imaging
• Neurological impairments
• And /or…
CDC Guidelines
• Functional Deficits
– IQ 2 SD below average
– Deficits 1 SD below average in at least 3
domains
•
•
•
•
•
•
Cognitive or developmental deficits
Executive functioning deficits
Motor functioning delays
Problems with attention or hyperactivity
Social skills
Other, such as sensory problems, pragmatic
language problems, memory deficits, etc.
Neuropsychological
Outcomes of FAS/FAE
• Intelligence
• Achievement
• Motor Skill
• Attention
• Learning/Memory
• Adaptive Functioning
• Executive Function
• -Problem Solving
• -Concept Formation
• -Fluency
• -Working Memory
FAS/FAE Attentional Problems
Auditory vs. Visual
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
77
77
Nonpatient
FAE
FAS
85
85

85
85

90
90
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 92
92
Visual
Problems
(1st PC)
107
107
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117
117 
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138
138 128
128
100
100
113  
107
113
107
113
112
112 106
106
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Auditory Problems
(1st PC)

85
85

75
75

88
88
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113
113
88
88
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84
84

Standard Deviation of Reaction Time: CPT Tone
6-Minute Record
0.8
0.4
Control J—FSIQ=90
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Reaction
Time 0.8
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Patient N, FAS—FSIQ=84
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Correct Response
Error of Omission
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A Run of Corrects
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Executive Functions Are
A Group of Cognitive Abilities
•
•
•
•
•
•
Self-Regulation of Behaviors
Sequencing of Behaviors
Cognitive Flexibility
Response Inhibition
Planning
Organization of Behavior
A “Future-Oriented” Process
• Goal Directed
• Delayed Gratification
An Integrative Process
•
•
•
•
•
Perception
Attention
Memory
Motor
General Intelligence
Studies in Children and Adolescents with FASD
Kodituakku and colleagues (ACER, 1995)
•
•
•
•
10 subjects with FAS/FAE, 10 controls mean age 13
Fewer categories and more perseverative errors (WCST)
Generated fewer words (COWAT)
Difficulty with complex planning problems (PPT)
Mattson and colleagues (ACER, 1999)
• 10 subjects with FAS, 8 PEA, 10 controls mean age 11
• D-KEFS (Trails, Stroop, Tower, Word Context)
• Deficits in:
• Planning
• Response Inhibition
• Abstract Thinking
• Flexibility
• Deficits not related to Diagnosis
Studies in Children and Adolescents with FASD
Coles and colleagues (ACER, 1997)
• Children with FAS, ADHD, controls
• WCST
• FAS had fewer categories completed
than either controls or ADHD
Carmichael Olson and colleagues (ACER, 1998)
•
•
•
•
•
9 children with FAS, 52 IQ similar controls, age 14-16
Higher percentage of errors
Fewer categories completed
Non rule based errors
Perseverative
Kopera-Frye and colleagues (Neuropsychologia, 1996)
• Adolescent and Adults with FAS/FAE
• Cognitive Estimation Test
• More bizarre responses
Overlap Between
Executive Functions and
Intelligence
In 1996 Martha Denckla described a complex overlap
between EF and IQ
• Performance IQ with Fluid Intelligence and Timed Tasks
• Verbal IQ with Crystallized Intelligence
However, very few studies of EF have considered IQ
effects
This study addressed IQ involvement with EF in the
presence of prenatal alcohol damage
• Direct Effects of Prenatal Alcohol on EF tasks
• Indirect Effects of Prenatal Alcohol as Mediated by IQ
Executive Function Measures
•Wisconsin Card Sorting Test (WCST)
•Cognitive Estimation (CE)
•Controlled Oral Word Association Test (COWAT)
•Ruff’s Figural Fluency (RFF)
•Trail Making Test (Trails)
•Stroop Color-Word Test (Stroop)
•Consonant Trigrams Test (CTT)
•Digit Span (DS)
•California Verbal Learning Test (CVLT)
(Clustering, Intrusions, Perseverations)
Motor Coordination Battery
•Denckla Motor Coordination Test (DNCT)
•5 Tasks of finger, hand, and foot coordination, manually
administered
•Finger Sequencing Test (FS)
•3 tasks of finger coordination, computer administered
•Hand Steadiness Test (HST)
•A task measuring tremor by inserting a stylus into a hole
and attempting to not touch the sides
•Dynamic Balance (DB)
•Requires the subject to maintain balance on a free moving
“teeter-totter” board
Neurobehavioral Battery
•Attention/Memory Tests
•Continuous Performance Test
(CPT)
•Talland Letter Cancellation Test
(LCT)
•Attention Process Training
(APT)
•Stepping Stone Maze (SSM)
•California Verbal Learning Test
(CVLT)
•Executive Functioning
•Wisconsin Card Sorting Test
WCST
•Stroop Color-Word Test
(STROOP)
•Consonant Trigrams Test (CTT)
•Controlled Oral Word
Association Test (COWAT)
•Ruff’s Figural Fluency Test
(RFF)
•Cognitive Estimation (CE)
•Information Processing
•Wechsler Adult Intelligence
Scale – Revised (WAIS-R)
•Wide Range Achievement Test –
Revised (WRAT-R) Arithmetic
•Word Attack (WA)
•Spatial-Visual Reasoning Task
(SVRT)
•General Brain Damage
•Trail Making Test (TRAILS)
•Rey-Osterreith Complex Figure
Test (RCFT)
“Pathognomonic” Indicators
From Adult Neurobehavioral
Study
Controls
(n=30)
FAE
FAS
(n=30) (n=30)
Stepping Stone Maze (SSM)
Could not reach criteria
Tried to move off maze board more
than once
Wisconsin Card Sorting Test (WCST)
Could not complete all 6 categories
Failed to maintain set more than once
0
0
4
6
7
11
1
4
9
9
14
7
Writes with Left Hand
1
4
9
Full Neurobehavioral Battery
•Attention/Memory Tests
•Continuous Performance Test (CPT)
•Talland Letter Cancellation Test
(LCT)
•Attention Process Training (APT)
•Stepping Stone Maze (SSM)
•California Verbal Learning Test
(CVLT)
•Executive Functioning
•Wisconsin Card Sorting Test WCST
•Stroop Color-Word Test (STROOP)
•Consonant Trigrams Test (CTT)
•Controlled Oral Word Association
Test (COWAT)
•Ruff’s Figural Fluency Test (RFF)
•Cognitive Estimation (CE)
•Information Processing
•Wechsler Adult Intelligence Scale –
Revised (WAIS-R)
•Wide Range Achievement Test –
Revised (WRAT-R) Arithmetic
•Word Attack (WA)
•Spatial-Visual Reasoning Task
(SVRT)
•General Brain Damage
•Trail Making Test (TRAILS)
•Rey-Osterreith Complex Figure Test
(RCFT)
•Motor Coordination
•Denckla Motor Coordination Test
(DNCT)
•Finger Sequencing Test (FS)
•Hand Steadiness Test (HST)
•Dynamic Balance (DB)
However
• Financially not possible to conduct all
of this testing
• Several tests are experimental
– Need to have normative samples to
compare with
So
• Created a battery that incorporated many
of the most salient clinical tests based on
30+ years of research experience
–
–
–
–
–
–
–
–
IQ
Achievement
Learning and Memory (verbal and visual)
Attention
Motor Coordination
Executive Functions
Psychiatric Symptoms
Adaptive behaviors
IQ and Academic Tests
• Wechsler Adult Intelligence Scale –
3rd Edition (WAIS-III) (Now WAIS-IV)
– Generalized IQ
• Woodcock Johnson – 3rd Edition (WJIII)
– Variety of academic tasks (reading,
spelling, arithmetic, passage
comprehension, academic knowledge)
Memory and Attention
• California Verbal Learning Test (CVLT)
– List learning task with repeated trials and
delayed recall/recognition
• Rey Complex Figure Test (RCFT)
– Nonverbal spatial memory task
• Green’s Word Memory Test (WMT)
– Assessment of effort or “malingering”
• Conner’s Continuous Performance Test
(CPT)
– Sustained attention and impulsivity
Motor Coordination
• Grooved Pegboard (GP)
– Speeded eye-hand coordination
• Finger Tapping (FT)
– Speeded finger movements
• Grip Strength (GS)
– Strength
Executive Functioning
• Trail Making Test (TMT)
– Visual scanning and tracking
• Controlled Oral Word Association Test
(COWAT)
– Generation of verbal information
• Ruff’s Figural Fluency Test (RFF)
– Generation of nonverbal information
• Stroop Test
– Inhibition of responses
Executive Functions (cont.)
• Consonant Trigrams Test (CTT)
– Working memory and multitasking
• Wisconsin Card Sorting Test (WCST)
– Planning, hypothesis generation,
learning from past mistakes, shifting of
hypotheses
• Tower of London (TOL)/DKEFS Tower
– Planning
Mental Health and Adaptive
Functioning
• Brief Symptom Inventory/Symptom
Checklist 90
– Brief screening for mental health concerns
– Not to diagnose individual disorders
• Vineland Adaptive Behavior Scale
(VABS)
– Daily living assessment
– Communication, daily living skills,
socialization
Expected Findings
• Alcohol nonspecific teratogen
– Effects depend on timing and dose
– Similar effects with drinking at different
times
• Rarely see IQ below 70
• “Patchy” presentation rather than
global or focal deficits
• Academic deficits especially in
arithmetic
• Social/Adaptive functioning deficits
• Executive function deficits
• Increased variability in performance
CDC Guidelines
• Functional Deficits
– IQ 2 SD below average
– Deficits 1 SD below average in at least 3
domains
•
•
•
•
•
•
Cognitive or developmental deficits
Executive functioning deficits
Motor functioning delays
Problems with attention or hyperactivity
Social skills
Other, such as sensory problems, pragmatic
language problems, memory deficits, etc.
The Case of Patient O
The Case of Patient O
• Areas of Deficit
– Variability of functioning (eg. CVLT vs
RCFT )
– Non verbal memory
– Academics
– Executive Functions
– Adaptive functioning (not shown)
• Meets criteria for functional deficits
based on CDC
Richard Adler, M.D.
Medical Director
FASD IS A MEDICAL
DIAGNOSIS
• Axis III (General Medical
Conditions) in DSM-IV-TR
• ICD- 9, ICD - 10
• Diagnostic criteria
–FAS – CDC 2004
–“FASD” – IOM 1996*
ELEMENTS IN MAKING THE
DIAGNOSIS WHICH UNIQUELY
REQUIRE M.D. INVOLVEMENT
• Medical chart review
ELEMENTS IN MAKING THE
DIAGNOSIS WHICH UNIQUELY
REQUIRE M.D. INVOLVEMENT
• Medical chart review
• Physical examination (general
and specialized)
ELEMENTS IN MAKING THE
DIAGNOSIS WHICH UNIQUELY
REQUIRE M.D. INVOLVEMENT
• Facial Photographic Analysis
(current and historical)
• Ancillary testing (ordering de
novo, review of prior)
– MRI/DTI
– EEG
– Other
Model-guided Segmentation of Corpus Callosum in MR Images
Arvid Lundervold1, Nicolae Duta2, Torfinn Taxt1 & Anil K. Jain2 - 1999
DIAGNOSTIC FINE POINTS
• Comorbidity/concurrent conditions - high in
FASD :
• ADHD
• Head trauma
• Substance abuse
• FAS is “diagnosis of exclusion”
– Must address why the picture is not better
accounted for by other elements
– Not “paint by numbers” – requires a
diagnostic synthesis
Pediatricians' Knowledge, Training, and
Experience in the Care of Children With
Fetal Alcohol Syndrome
“Whereas 62% felt prepared to identify and
50% felt prepared to diagnose, only 34% felt
prepared to manage and coordinate the
treatment of children with fetal alcohol
spectrum disorders.”
Sheila Gahagan, MD, MPH, Tanya Telfair Sharpe, PhD,
Michael Brimacombe, PhD, et al. PEDIATRICS, Vol. 118
No. 3, September 2006, pp. e657-e668
FAMILIARITY WITH
FORENSIC NUANCES
• General forensic background (familiarity
with procedural issues, terminology,
report standards)
– Standard for “reasonable medical certainty”
– Distinction between forensic and clinical roles
– Licensing requirement in venue
• Admissability/evidentiary issues of data
relied upon:
• Frye
• Daubert
• Standard unique to the venue
DIFFERENTIAL DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
PHYSICAL EXAMINATION:
PRACTICAL ISSUES
• Reasonably private room/use of
infirmary/clinic (examination table)
• Examinee not in handcuffs, ankle cuffs
• Ability to turn down lights
• Gown
• Access to scale (height, weight)
• Clearance to bring diagnostic tools
• Approval for use of digital camera
• Arranging for examinee to be clean-shaven
ROLE OF M.D. IN THE FORENSIC
PROCESS
• Testimony: benefit of repetition, different
“teaching” styles, strengths
• Opportunity to have M.D. generate
diagnosis independently versus
collaboratively
• Ability to incorporate, testify to
neuropsychological or other findings.
• Potential to circumscribe role to clinical
diagnosis
• Ability to jettison a “bruised” witness
• Liaison with other medical professionals
WILL ANYONE
WITH AN M.D. DO?
Hon. Anthony P. Wartnik,
J.D., Judge (Retired)
Legal Director
THE STARTING POINT
1. “The treatment of criminal
offenders as rational, autonomous
and choosing agents is a
fundamental organizing principle of
our criminal law.”
G.Ferguson, “A Critique of Proposals to Reform the
Insanity Defence” (1989) 14 Queen’s L.J. 135, at p. 140
2.
-“This is a fundamental condition upon which
criminal responsibility reposes. Individuals
have the capacity to reason right from wrong,
and thus choose between right and wrong.
It is these dual capacities – reason and choice –
which give the moral justification to imposing
criminal responsibility and punishment on
offenders.
- If a person can reason right from wrong and
has the ability to choose right from wrong, then
attribution of responsibility and punishment is
morally justified or deserved when that person
consciously chooses wrong.”
R v. Ruzic, 153 C.C.C. 1, Supreme Court of Canada.
3. Getting rid of the blame game:
“Evidence concerning certain alcohol-related conditions has
long been admissible during the guilt phase of criminal
proceedings to show lack of specific intent . . . . (I)f
evidence of a self-induced condition such as voluntary
intoxication is admissible, then so too should be evidence
of other commonly understood conditions that are beyond
one’s control, such as epilepsy. . . . Just as the harmful
effect of alcohol on the mature brain of an adult imbiber is
a matter within the common understanding, so too is the
detrimental effect of this intoxicant on the delicate,
evolving brain of a fetus held in utero. As with ‘epilepsy,
infancy or senility,’ . . . . we can envision few things more
certainly beyond one’s control than the drinking habits of a
parent prior to one’s birth. We perceive no significant legal
distinction between the condition of epilepsy . . . And that
of alcohol-related brain damage in issue here—both are
specific, commonly recognized conditions that are beyond
one’ control.”
Dillbeck v. State, 643 So. 2nd 1027 (Fla.)
GETTING RID OF MYTHS
1. FASD is a temporary condition,
2. FASD is a diagnosis or condition lacking
in objective findings,
3. FASD is a condition lacking in scientific
support,
4. FASD is a diagnosis conceived of by
lawyers and or mental health care providers
to excuse criminal behavior,
5. FASD cannot be diagnosed without direct
evidence that the mother drank during
pregnancy.
FACTS
1. FASD is a condition involving
behavioral problems rooted in organic
brain damage, permanent organic brain
damage,
2. FASD is supported by over 30 years of
scientific study and research with
indisputable objective findings,
3. FASD is a condition, which if not
diagnosed and treated at the earliest
possible stages of child development, will
likely lead to costly and devastating
secondary disabilities,
FACTS
4. Some offenders with FASD will not be held
responsible for their criminal actions due to
incompetency or insanity,
5. Some offenders with FASD will be held
responsible for their criminal actions but will
receive consideration due to diminished
capacity,
6. Some offenders with FASD will be held
responsible for their criminal actions and will
receive long term incarceration due to the
need for community safety and the inability
to successfully treat the offender in the
community (e.g.), crimes of violence and or
chronic recidivistic behavior,
FACTS
Modern diagnostic standards do not require
confirmed prenatal exposure to alcohol in all cases to
make a diagnosis of FAS.
7.
Circumstantial evidence to support a finding of FAS
may include
*
mother’s abuse of alcohol prior to conception
*
the birth of other children alive around the time
the subject was born but who died either shortly
before or shortly after birth
*
a brain condition that is consistent with the
subject having suffered from alcohol exposure in
utero.
THE PROBLEM
People afflicted with FASD often are
not:
- Rational
- Autonomous
- Choosing agents
- Able to reason right from wrong
- Able to choose right from wrong
THE RIGHT TO DIAGNOSIS BY
AN EXPERT
1.
Castro v. Oklahoma, 71 F.3rd 1502 (10th Cir. 1995), p.
10
Castro was convicted of murder and sentenced to
death
The court held:
* Castro was entitled to a court appointed and paid
for expert to help develop evidence regarding five
different problems, including FAS and FAE
* A criminal defendant was entitled to such experts
provide that he made a substantial showing that his
mental state was in dispute and was relevant to the
outcome of the case, to either the guilt determination
or the sentence
2. Dillbeck v. State, 643 So. 2d 1027 (Fla.),
p. 28
The court held:
*
Evidence of FAE should be
admitted at the guilt phase of a trial if
offered to show that defendant lacked
the mental state (here premeditation)
that is part of the crime
3.
Lambert v. Blodgett, 248 F.Supp. 2d 988 (E.D. Wa.
2003) p. 59
Juvenile was charged with murder and the case was
transferred to adult court where he pled guilty and
was sentenced to life in prison without possibility of
parole
Held:
*
Defendant was denied effective assistance
of counsel because counsel hired a psychologist
and did not provide sufficient information as to
permit a meaningful evaluation including the
possibility that the client was FAS which might
provide a diminished capacity defense or provide
counsel with a realization that there was a need to
explain in greater detail the legal issues to the client
4.
Silva v. Woodford, 279 F.3rd 825 (9th Cir. 2002),
p. 98
Defendant was tried and sentenced to death
while co-defendants received 11 years and life
with the possibility of parole
Held:
*
Defendant was denied effective
assistance of counsel due to failure to
investigate the possibility of FAS for mitigation,
counsel didn’t investigate client’s background,
including family, criminal history, substance
abuse and mental health history
5.
State v. Brett, 126 Wn.2d 868 (2001), p. 108
Following conviction for aggravated murder 1st
degree, counsel requested a one month delay
of the punishment trial in order to obtain a
diagnosis regarding FAS/FAE which was denied
by the trial court
Held:
*
Defendant was denied effective
assistance of counsel due to failure to attempt
to obtain such a diagnosis before the guilt
phase trial. The court overturned the death
penalty sentence.
6. Landrigan v. Schriro, 441 F.3rd 638 (9th Cir. 2006)
• Landrigan sought the appointment of a medical expert
to assist in establishing mitigating evidence regarding the
effects drug and alcohol use on a developing fetus, and
also sought an evidentiary hearing on his claim of
ineffective assistance of counsel
• The state court denied both motions
• The federal court found that counsel’s knowledge of drug
and alcohol use by client’s mother, his attempt to
introduce such facts as testimony together with counsel’s
failure to look into the results of substance abuse during
pregnancy and its effect on the child required an
evidentiary hearing on the ineffective assistance of
counsel claim
7.
Rompilla v. Beard, 545 U.S. 374 (2005)
Rompilla was convicted of murder and sentenced to death. He
claimed ineffective assistance of counsel at the penalty phase for
failure to develop evidence of FAS. He claimed that had counsel
obtained school, medical, court and prison records, they would
have revealed significant mitigating evidence about his childhood,
mental capacity and health, and alcoholism
Two psychologist examined him after sentencing and reviewed the
records that the attorney had failed to obtain and concluded that
Rompilla’s problems relate back to his childhood and were likely
caused by FAS and that his capacity to appreciate the criminality of
his condut or to conform his conduct to the law was substantially
impaired at the time of the offense, Id. at 244
* The Supreme Court held that the facts constituted ineffective
assistance of counsel since counsel knew that the prosecution
would be relying on the very same records as evidence of
aggravation and because review of the records would have
uncovered “a range of mitigation leads that no other source had
opened up.” (5 – 4 decision)
YOU MUST TIMELY SEEK
DIAGNOSIS
People v. W, 564 N.W.2d 903 (Mich. C/A 1997), p. 85
The trial judge sentenced the defendant and later
granted a motion to modify the sentence based on
psychological reports that had not been submitted
prior to the original sentencing, reducing the sentence
based on these reports
Held:
* Once sentencing takes place, the trial court loses
jurisdiction to modify or alter the sentence
*
The law is the same in the State of Washington
WHY THE TEAM DIAGNOSTICS
APPROACH?
There is power in numbers -multi-disciplinary
approach:
* Medical diagnosis alone only yields an answer
as whether the client has FASD
* The other team members, the psychologist
and neuropsychologist can provide important
information regarding the client’s volitional
control and cognitive functioning limitations, comorbidities, etc.
* The combined forensic team testimony
leaves very few important questions unanswered
* It is the best vehicle for the necessary
ongoing refinement of the protocols.
CLIENT MUST BE SEEN BY THE
MEDICAL EVALUATOR
Trial court and appellate court judges
are resistant to accepting the expert
opinion of a doctor who has only
examined the client’s medical
records and social history and has
not physically examined the client
JUDICIAL RESISTANCE
1. Hicks v. Schofield, 599 S.E.2d 156 (Ga. 2004)
Hicks was convicted of murder and sentenced to death. His
application for certificate of probable cause to appeal and
stay of execution was denied by the state Supreme Court
* Per the Chief Justice’s dissent, the majority ignored a
substantial and credible claim of mental retardation based
in part on Hicks’ FAS diagnosis
* A doctor retained by the defense reviewed Hicks’
records but was unable to give a definitive diagnosis of
mental retardation without interviewing Hicks due to the
fact the state denied the doctor access to Hicks in jail
* The dissent found this to be a constitutional violation
2. U.S. v. Nelson, 419 F.Supp.2d 891 (E.D. La. 2006)
After a pre-trial evidentiary hearing the judge ruled that Nelson
was ineligible for the death penalty due to his being mentally
retarded. The court relied upon the Atkins v. Virginia,536 U.S.
304 (2002), definition (a combination of the American Psychiatric
Association standard and the standard contained in the
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
Text Revision) that defines mental retardation as (1) having an
IQ of approximately 70 or below or two standard deviations
below the mean (ii) concurrent deficits of impairments in
adaptive functioning in at least two of the following areas:
communication, self-care, home living, social/interpersonal skills,
use of community resources, self-direction, functional academic
skills, work, leisure, health and safety; and (iii) the onset of such
symptoms before age 18.
In a pre-trial hearing, the court ruled that Nelson was ineligible
for the death penalty.
2. U.S. v. Nelson (Cont.)
Testimony had been presented by three
psychiatrists who had each administered tests to
Nelson. Each concluded that he met each of the
Criteria. On doctor testified that her diagnosis
was partly attributable to the fetal alcohol
exposure that Nelson suffered, as children
exposed to alcohol in utero have a higher
instance of mental retardation and learning
disabilities. Id. At 897
Stankewitz v. Woodford, 365 F.3rd 706 (9th Cir. 2004)
Stankewitz was convicted of murder and sentenced to death.
Three experts all agreed that Stankewitz had brain damage and
would have testified had his lawyer requested. One expert
testified that he appeared “not to be fully able to appreciate the
flow of events or full implications of his actions.” Another
medical expert opined that he “is borderline retarded, with an IQ
of 79, and suffers from significant brain dysfunction, perhaps
attributable to FAS and childhood abuse.” The third expert
stated that his brain damage “would produce problems with
emotional control, tendencies to be impulsive and unpredictable,
and to be unable to exercise adequate judgment or to
understand the consequencesof his behavior.”
* The court found that the mitigating facts alleged by
Stankewitz – which included “organic brain damage”
(presumably a reference to FAS)– constitute “the kind of
troubled history (the Supreme Court has) declared relevant to
assessing a defendant’s moral culpability.” 365 F.2d at 723
FASD AND MENTAL HEALTH
Mental health problems are common
among those with FASD
* 94% may have at least one comorbid diagnosis in adulthood
* (52% depression, 43% suicide
threats, 33% panic attacks,29%
psychosis, 23% suicide attempts,
40% ADHD
TROUBLE WITH THE LAW
* Approximately 60% of all
individuals with FASD get in trouble
with the law and about 40% end up
incarcerated or hospitalized
* Because FASD impairs ability to
function in society, the impact of
contact with the criminal justice
system has great potential to either
aggravate or ameliorate their
impairments
TROUBLE WITH THE LAW
(Cont.)
* The organic brain deficits caused
by fetal alcohol exposure result in
difficulty associating cause and
effect, learning from experience,
generalizing to new situations, and
internalizing principles of behavior
- This results in inconsistent and
erratic behavior, and affects the
ability to explain and justify their
actions
FASD AND SPECIAL
ATTENTION BY THE COURT
* Some people committed crimes they
don’t understand
* Some people are accused of crimes
they didn’t do
* Some people have been convicted of
crimes that never happened
* Some people have been convicted of
crimes and are doomed to getting caught
in the criminal justice system’s revolving
door unless you recommend or do things
differently
DO THE FACTS JUSTIFY AN
FASD ASSESSMENT?
* Ask questions to determine mom’s
alcohol use during pregnancy
* Determine the defendant’s behavior
from birth to the present
* Identify the criminal history and the
type(s) of crime
* Determine cognitive and functional
abilities and limitations
* When appropriate, seek/order an
evaluation by experts who are able and
skilled in the diagnosis of FASD, ADHD,
ADD, and other prevalent mental
conditions and disorders
BEYOND FASD DIAGNOSIS:
SO WHAT?
The fact that a person has FASD may bear on the prosecution
and or sentencing in the following ways:
*
It may result in a finding of incompetency to commit the
crime or it may result in a finding of incompetency to knowingly
and intelligently waive the right against self-incrimination
*
It may reduce culpability of the criminal conduct
*
It will require different measures to reduce the chances of
recidivism, future criminal behavior
*
It usually means significant difficulties functioning in adult
society, problems which a sentencing may aggravate or alleviate
*
It means that your diagnostic team needs to be skilled both
as a clinicians and in forensics as their testimony will likely make
a difference in the outcome
WHO ARE THE PLAYERS?
The following are the individuals to whom
diagnosis is important in addition to the
diagnostic
team:
• The client
• The defense counsel
• The prosecuting Attorney
• The trial judge
• The probation and parole officers
• Persons in a position to mentor, advise
and or advise the client
TEN SENTENCING PRINCIPLES
FOR PEOPLE WITH FASD
1. Consider whether the disability involves
reduced culpability and thus warrants a
less severe sentence
2. Avoid lengthy (or any) incarceration
3. Seek or impose milder but targeted
sanctions
4. Seek or impose a longer term of
supervision
5. Use the judge’s position of authority
(stature) with the offender
TEN SENTENCING PRINCIPLES
FOR PEOPLE WITH FASD
(Cont.)
6. Get a sponsor or advocate for
guidance and assistance
7. Create structure in the offender’s life
8. Write out, simplify and repeat rules
and conditions of supervision
9. Make sure the probation officer
understands FASD
10.Don’t overreact to probation violations
– particularly status offenses
FASD Experts: Future
Directions
• Increasing capacity:
Training/consultation with other
forensic groups
• Continuous refinement of our protocol
(e.g., a priori hypotheses re: potential
findings)
• Adding additional consulting specialists
as needed (e.g., radiologist)
• Research: Suggestibility, FABS
FASD EXPERTS – CONTACT
INFO
FASD Experts – www.fasdexperts.com
a.
Dr. Natalie Novick Brown, Ph.D, Program Director
Licensed Psychologist
12535 – 15th Ave. NE, Suite 201
Seattle, WA 98125
Office – 206.441.7652
Cell – 425.275.1238
Fax – 888.807.5991
Email – [email protected]
Web – www.Dr.NatalieBrown.net
Assistant – Ms. Christine Simmons
FASD EXPERTS – CONTACT
INFO (Cont.)
b.
Dr. Paul Connor, Ph.D., Neuropsychological
Director
Licensed Psychologist & Clinical
Neuropsychologist
22517 – 7th Ave. South
Des Moines, WA 98198 – 6820
Phone – 206.940.1106
Fax – 206.870.9081
Email – [email protected]
Web – www.ConnorNeuropsychology.com
FASD Experts – Contact Info
(Cont.)
c.
Richard S. Adler, MD, Medical Director
Forensic and Clinical Psychiatry
1700 Seventh Avenue, Suite 210
Seattle, WA 98101
Office – 206.624.3800
Cell – 206.793.1453
Fax – 206.624.3801
Email – [email protected]
Web – www.RichardAdlerMD.com
Assistant – Ms. Ann Lippman-Cepeda
Email - [email protected]
FASD Experts – Contact Info
(Cont.)
d.
Hon. Anthony P. Wartnik, J.D., Judge (Retired),
Legal Director
8811 SE 55th Pl.
Mercer Island, WA 98040
Office – 206.232.2970
Cell – 206.290.0451
Fax – 206.232.2970
Email – [email protected]