Exploring fitness to participate in court proceedings among defendants with Fetal Alcohol Spectrum Disorder: A systematic scoping review

Exploring fitness to participate in court proceedings among defendants with Fetal Alcohol Spectrum Disorder: A systematic scoping review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring fitness to participate in court proceedings among defendants with Fetal Alcohol Spectrum Disorder: A systematic scoping review Tania L H Goddard, Clare S Allely, Raja A S Mukherjee, Alan D Price This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7235748/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Fetal Alcohol Spectrum Disorder (FASD) is a lifelong neurodevelopmental condition resulting from prenatal alcohol exposure, affecting both cognitive and behavioural functioning. Within the legal system, determining whether an individual can effectively participate in court proceedings is essential to ensuring a fair trial. Legal professionals, psychiatrists and psychologists must carefully assess the abilities and limitations of accused individuals, particularly those with FASD, whose cognitive impairments can significantly impact their legal fitness to participate. This scoping review examines empirical studies investigating FASD in relation to fitness to plead or equivalent legal constructs. A systematic search across six databases, following PRISMA guidelines, identified nine empirical studies. The findings highlight key challenges, including the invisibility of FASD within fitness assessments, immaturity-related barriers, the need for adaptive and executive functioning evaluations, limited judicial awareness, insufficient community resources, and the need for specialised legal frameworks such as alternative courts. To ensure fair legal proceedings, there is a pressing need for early recognition of FASD and diversion strategies, particularly within the UK, where research remains limited. This review discusses the legal implications, recommendations, and future research directions necessary to improve fitness to participate assessments and promote equitable access to justice for individuals with FASD. Fetal Alcohol Spectrum Disorder FASD fitness to plead fitness to stand trial Competency Criminal justice system. Figures Figure 1 1 Introduction Fetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental condition resulting from prenatal alcohol exposure, affecting both cognitive and behavioural functioning (Webster et al., 2023 ). While individuals with FASD often demonstrate strengths in creative and artistic domains, and can thrive with appropriate support (Flannigan et al., 2021 ), the condition presents lifelong challenges that may significantly impact their ability to navigate legal proceedings. Without sufficient intervention, individuals with FASD are estimated to be nineteen times more likely to become involved in the Criminal Justice System (CJS) compared to those without FASD (Popova et al., 2011 ). The prevalence of FASD is notably high, with estimates ranging from 1.8–3.6% in the UK, 2–5% in Europe, 1.1–5.0%, in four communities using a conservative approach in the US, 2 to 3% in Canada, and 2.91–4.41% in Australia (McCarthy et al., 2021 ; Wozniak et al., 2019 ; May et al., 2018 ; Popova et al., 2019 ; Tsang et al., 2025 ). Over time, researchers have sought to understand the specific vulnerabilities individuals with FASD face in legal contexts, including suggestibility, confabulation, and the absence of structured screening measures (Gilbert et al., 2023 ; Flannigan et al., 2018 ; Flannigan et al., 2025 ). Additionally, the need to include executive and adaptive functioning in testing has been widely discussed (Brown et al., 2017 ; Pei et al., 2016 ; Mela, 2022 ), further deficits including planning, organizing, impulse control, and social comprehension have also been raised. All of these challenges have the potential to affect an individual’s ability to participate meaningfully in legal proceedings (Meltzer, 2007; Allely & Gebbia, 2016 ). In several Western countries, legal frameworks recognize that if a defendant cannot comprehend or respond to charges, a conventional trial should not proceed. In England and Wales the courts rely on the Pritchard Criteria, established in the case of R v Pritchard in1836, to assess a defendants fitness to plead. The Pritchard Criteria, as confirmed in the case of R v M (John) 2003 states that to be fit to plead the defendant must be able to: understand the charges; decide whether to plead guilty or not; exercise the right to challenge jurors; instruct solicitor or counsel; follow the course of proceeding and be able to give evidence in their own defence. While jurisdictions such as the United States of America (USA), Canada, New Zealand, and Australia initially adopted a similar doctrine, legal precedents and statutory developments have led to divergent fitness standards (Blake et al., 2022 ). In Australia, comprehension and communication are emphasised with cognitive disorders being the primary indicator of incompetency. In contrast the USA prioritizes rationality, making psychosis the primary predictor of incompetency (White et al., 2012 ; Blake & Ogloff, 2020). In addition to the Pritchard Criteria the Convention of the Rights of Persons with Disabilities (United Nations, 2006 ), and Article 6 of the European Convention of Human Rights (Council of Europe/European Court of Human Rights, 1950) assert that defendants must be able to understand and effectively participate in criminal proceedings. Effective participation presupposes that the defendant has a broad understanding of the nature of the trial process, what is at stake, and the significance of any penalty which may be imposed. The most comprehensive definition having been provided in the case of SC v UK ( 2005 ) (Owusu-Bempah, 2018 ). Lawyers face many challenges in identifying FASD as a contributing factor to fitness determinations. Research has highlighted that most legal professionals know relatively little about FASD and therefore it is important that any assessments are performed by specialists with some expertise in FASD (Gordorn & Madore, 2021; Freckelton, 2016 ). A further challenge for legal professionals and expert witnesses involves the role of stigma. Stigma may cause individuals and families to carefully choose what they want to disclose to their representative (Dunbar Winsor, 2021 ). Expert witness testimony plays a pivotal role in determining fitness to participate, with most jurisdictions requiring multiple psychiatric, forensic, clinical, or neuropsychological evaluations (Freckelton, 2016 ). Courts rely heavily on expert assessments, with near-perfect concordance between expert recommendations and judicial determinations (Zapf et al., 2004 ). A comprehensive medical-legal report can assist both the lawyers and judges involved with defendants living with FASD. Within any reports psychological assessments and social histories are important. Further, due to the difficulties in comprehension and recall it is critical that psychiatrists do not solely rely on the informants responses. It is also crucial that previous reports are not taken at face value without verification (Fast & Conry, 2009 ). Despite the increasing recognition of FASD within some legal systems, no systematic reviews have specifically investigated fitness to participate in relation to FASD, underscoring a critical gap in research. The discordant evolution of fitness standards across Western jurisdictions and the hidden nature of FASD within fitness to participate assessments highlights an urgent need for empirical investigations into how FASD influences fitness determinations. A recent systematic review recognised that fitness to participate is an emerging field of study (Flannigan et al., 2025 ). To our knowledge, this is the first review to systematically identify empirical studies on FASD related fitness to participate determinations. To ensure clarity, this article adopts the term “fitness to participate”, to encompass the variations in terminology such as fitness to plead, fitness to stand trial, effective participation and competency. 1.1 Objective The objective of this scoping review was to identify empirical studies which have investigated FASD in relation to fitness to participate. 2 Materials and methods 2.1 Eligibility criteria Studies were included in this review if they involved a human study population and investigated fitness to participate and FASD and associated words. Studies were excluded if they were outside the scope of fitness to participate proceedings. Papers not published in English, dissertations, book chapters, systematic reviews, literature reviews, discussion papers (also considered review papers) and case law reviews were also excluded. The reference sections of relevant systematic/literature reviews; editorials; commentary papers; dissertations were carefully screened for any potentially relevant articles. 2.2 Information sources and search strategy The guidelines described by the Preferred Reporting Items for Systematic Scoping Reviews and Meta-Analyses (PRISMA) were followed (Page et al., 2021 ). The extension for Scoping Reviews 22 item checklist was used to improve transparency PRISMA-ScR (Trico et al, 2018). The flowchart shown in Fig. 1 outlines the process of identifying relevant articles following PRISMA guidelines. Several articles identified in the scoping review did not meet the inclusion criteria due to their methodological approach. Case law reviews, which summarise and analyse judicial decisions, were excluded as they do not present original empirical data and are typically classified as secondary legal analyses. However, given their relevance to court decisions and broader judicial trends, key insights from these reviews are integrated into the results section. Similarly, systematic reviews, opinion pieces, and editorial discussions that did not meet inclusion criteria were assessed for critical perspectives and are incorporated into the broader legal discussion. 2.3 Databases searched Searches were carried out on 29th August 2024 on six databases including; the Web of Science; MEDLINE; CINAHL; PsycINFO; PubMed; and Taylor and Francis legal database. Covidence software platform was used to manage and streamline the systematic review ( www.covidence.org ). Duplicates were automatically removed Covidence. 2.4 Search terms Search terms included words relating to FASD and the equivalent of fitness to participate. "fetal alcohol" OR "foetal alcohol" OR "alcohol related neuro-developmental disorder" OR "alcohol-related neurodevelopmental disorder" OR "alcohol related neurodevelopmental disorder" OR "FAS" OR "FASD" OR "prenatal alcohol" OR "PAE" "Fetal Alcohol Syndrome" OR "Foetal alcohol syndrome" OR "Partial Foetal Alcohol Syndrome" OR "Partial Fetal Alcohol Syndrome" OR "PFAS" OR "NDPAE" OR "Neurobehavioral disorder associated with prenatal alcohol exposure" OR "Static Encephalopathy alcohol exposed" AND "criminal justice" OR "fitness to plead" OR "fit to enter plea" OR "unfit to plead" OR "not fit to plead" OR "unfit to be tried" OR "fit to stand trial" OR "unfit to stand trial" OR "fitness to be tried" OR "fitness to stand trial" OR "criminal elements" OR "Special measures" OR "reasonable adjustment*" OR "vulnerable defendants" OR "common law capacity" OR "Pritchard criteria" OR "effective participation" OR "ability to participate" OR "fair hearing" OR "mental capacity" OR "capacity to participate" OR "cognitive impairment" OR "trial" OR "defence" OR "defense" OR "mitigation" OR "sentencing" OR "expert witness" OR "witness" OR "Court proceeding" OR "court" OR "insanity" OR "NGRI" OR "Not guilty by reason of insanity" OR "criminal court" OR "legal process" OR "legal proceeding*" OR "intermediaries" OR "practitioner knowledge" OR "knowledge of FASD" OR "criminal responsibility" OR "legal process" OR "culpability" OR "mens rea" OR "criminal conduct" OR "diminished responsibility" OR "mitigating" OR "criminal liability" OR "courtroom process" OR "legal decisions" OR "actus reus" OR "requisite intent to harm" OR "criminal justice process" OR "legally responsible" OR "Juror" OR "judge" OR "lawyer" OR "solicitor" OR "barrister" OR "legal representation" OR "prosecution" OR "jury" OR "competency to stand trial" OR "death penalty" 2.5 Screening In addition to the database searches, citations included in the articles identified were checked for relevance. Numerous permutations of FASD and fitness to participate were also entered into Google Scholar and a thorough search for articles, not identified in the databases search, was made. A further search on Google Scholar took place on the 21th October 2024 with a final search being made on the 25th February 2025. Alerts were also put in place on ‘Google Scholar’ and ‘Research Gate’ to tag any new research. The papers were reviewed independently by CA and AP. 2.6 The risk of bias To assess the quality and rigour of the studies extracted quality assessment tools, in the form of JBI checklists, were completed to assess the quality of the variety of study designs (Munn et al., 2020 ). Joanna Briggs Institute (JBI) is a global organisation promoting and supporting evidence-based decisions that improve health and health and service delivery. Table 2 identifies the type of checklist completed to ensure quality and rigour. The checklist scores, the strengths and limitations of the studies as well the relevance, reliability, validity and applicability of the studies. Table 1 JBI checklist for quality and rigour Author (s) and year Critical Appraisal Checklist Quality Checklist Score Strengths Limitations Relevance Reliability Validity Applicability McLachlan et al., ( 2014 ). Analytical cross sectional studies (Moola et al., 2020) 7/8 87.5% This study employs validated individualised forensic assessment tools. It added jurisdictional specific content to Grisso's instruments to increase validity. It used a comparative design with participants from a real world criminal justice setting to ensure applicability to actual legal contexts. The study has a modest sample. The assessments were completed under ideal conditions and are likely to reflect an underrepresentation of deficits in the population. The underlying causes of impaired psycho-legal abilities were not explicitly assessed and raters were not blinded to the participants diagnostic status. This is the first study that has attempted to empirically evaluate the psychol-egal abilities of young offenders with FASD. It highlights the need for specialised forensic assessments raises issues of remediation and the consideration of legal protections. The study follows rigorous ethical guidelines, including informed consent and institutional review board approval. Procedures for data collection, scoring, and statistical analysis are clearly documented, ensuring replicability. This study fills a critical research gap in forensic psychology and legal studies by providing empirical evidence on the psycho-legal abilities of young offenders with FASD. This study specifically highlights the challenges youth with FASD face in understanding their legal rights. The assessments align with the legal criteria for determining fitness to plead. Pei et al., (2016) Qualitative research checklist (Lockwood et al., 2015 ) 6/8 75% This study provides important information about the experiences of individuals living with FASD within the CJS. It had clear objectives, methodology and analysis. The authors acknowledge that this study provides emerging and preliminary information. The study has a small sample in a limited jurisdiction. There is no explicit philosophical framework guiding the research and limited discussion of researcher bias and positionality. This study provides valuable evidence of the systematic challenges that individuals with FASD face in the CJS. The use of semi structured interviews allowed for in depth exploration of the participant's experiences. The study uses thematic coding ensuring a structured approach and had a team of multiple coders to enhance trustworthiness and reduce bias. The study demonstrates strong validity it had clearly defined objectives used appropriate data collection methods, had ethical integrity, used a structured coding process and used direct quotes. This study is highly applicable as it provides first hand insights into the barriers individuals with FASD face in the CJS. McLachlan et al. ( 2019 ) Reporting Prevalence Data (Munn et al., 2015 ) 8/9 88%% The sample size was adequate for estimating prevalence of FASD in a correctional population using active case assessment. It included power calculations, effect size, confidence intervals, comparability. It included a detailed descriptions of study subjects and setting. It followed Canadian FASD Diagnostic Guidelines. The team received training, supervision and consultation with clinicians and held case conferences to discuss findings and reach clinical consensus. The study acknowledges the estimates may be limited by a conservative sample size and voluntary participation. The challenge of confirming PAE in the non-clinically referred adult sample. The over representation of Indigenous Canadians recovering from colonist policies. This study provides important information for clinicians, administrators and policy makers in understanding the relevance of FASD across both the health and legal contexts. More diagnosed participants had significant impairment in the executive functioning domain. It raises the lack of training and awareness among clinicians, limited diagnostic capacity, evidence based screening tools and the relative 'invisibility' of FASD. The study measured the FASD in a standard and reliable way for all participants ensuring high consistency. Best practices for analysing forensic mental health data ensured the findings were systematic and unbiased. Measures were taken to ensure systematic and unbiased participant inclusion, reinforcing the study's validity The study provides quantitative evidence on the prevalence and cognitive impairments of individuals with FASD in correctional settings and the need for mental health professionals to consider FASD related impairments, mandatory screening protocols to ensure fair legal proceedings. Douglas et al., (2012) Analytical cross sectional studies (Moola et al., 2020) 7/8 87.5% The study employs a validated survey methodology, uses comparative legal analysis to contextualise findings, collects demographic information which strengthens validity. The method section is comprehensive outlines the research design, participant selection and ethical considerations. The study acknowledges the low response rates could introduce bias and that those who participated may have knowledge or an interest in FASD. The study employed self-reported responses that maybe subject to potential bias. Highlights awareness of FASD limited to Queensland in contrast to the USA and Canada where courts often consider FASD in fitness to plead assessments. The unique difficulties FASD presents directly impacts their ability to participate in their defence. Current legal frame works do not adequately account for FASD. A Greater need for training to identify signs of cognitive impairment and adjust legal proceedings. The standardised survey methodology ensured consistency in data collection. The use of self-report is a common and accepted method for assessing professional knowledge and attitudes. The study employed appropriate statistical analysis methods to ensure the validity and reliability of its findings. The study builds on existing studies highlighting gaps in judicial awareness and legal protections for individuals with FASD. It suggests that in light of the Extraordinary challenges FASD presents the criminal justice system should try things differently. Blagg et al., ( 2017 ) Qualitative research checklist (Lockwood et al., 2015 ) 9/10 90% The authors explicitly acknowledge their theoretical and cultural positioning. The aims align with the research question exploring justice interventions and alternatives for vulnerable defendants with FASD. The study integrates place-based interviews and focus groups ensuring indigenous voices shape the interpretation of results. Using a postcolonial perspective although acknowledged may influence the interpretation of findings. Although the article does not explicitly state the formal institutional ethics approval process (such as approval from a university ethics committee), it does emphasize community-based ethical approval and adherence to Indigenous research protocols. Highlights legislation that enables a person who is found unfit to be indefinitely detained. Raises issue of legal advisors being put in a precarious position. FASD amplifying the chances of involvement in the CJS. Diversion is needed and alternative system. Highlights that Indigenous youth, with FASD and other cognitive impairments, maturation does not bring with it desistance from offending, The study employs a qualitative action research approach, which aligns with the thematic analysis used to interpret findings. The study’s postcolonial framework ensures that results are analysed within the broader context of colonial dispossession, rather than in isolation. The research process itself evolves through community dialogue, reinforcing the mutual impact between the researchers and the study participants. By embedding the research within Indigenous-owned agencies, the methodology ensures that results are interpreted through culturally secure lenses, rather than imposing Western legal perspectives. This congruity strengthens the study’s ability to propose meaningful reforms and highlight the systemic failures affecting Indigenous youth with FASD. Young et al., ( 2018 ) Checklist for Case Series (Munn et al., 2020 ) 9/10 90% The high methodological rigor, clear reporting and practical implications highlighted by this study make it a reliable and impactful research study. The study acknowledges that the small cohort should be considered when interpreting the results. The results are representative of one jurisdiction in Australia It was not established whether there was pretrial management of comorbid psychotic disorders and the potential contribution of close informants reports on court determinations were not assessed. The judicial determinations were not clear. This study indicates that the severity of cognitive impairment can be associated with unfitness. The pivotal role psychiatrists play in Mental Health Court (MHC) determinations for people with cognitive disabilities is highlighted. The need for training at every level of the justice The study followed structured psychiatric and cognitive evaluations conducted by psychiatrists ensuring consistency across all cases. The study ensured that all eligible cases within the timeframe were included to prevent selection bias. The identification of cognitive impairment was systematic and unbiased. The study provides quantitative evidence that the severity of cognitive impairment can be associated with unfitness. Psychiatrists play a pivotal role in MHC determinations for people with cognitive disabilities Tan et al., ( 2018 ) Checklist for Case Series (Munn et al., 2020 ) 5/8 62.5% This study had a comprehensive data collection over a five year period. It combines forensic evaluation with Youth Court outcomes providing a holistic view of fitness determinations. The study provides statistical rigor in its use of logistic regression to analyse predictors of fitness determinations. The authors acknowledge that the data was captured from one youth forensic service in New Zealand limiting generalisation. That individual report writers could differ in their approach to evaluating fitness. As a retrospective study the standardisation of interviews did not occur. The Ministry of Justice data was limited reducing the sample size and could be biased. The IQ scores of 32 defendants were not recorded in the reports reviewed. This study provides empirical insights into how age, immaturity and diagnosis influence fitness determinations in New Zealand Youth Courts. It raises the issue of whether developmental immaturity and neurodisability like FASD should be explicitly considered in fitness assessments. It highlights the need for more screening and accommodations for individuals with FASD to ensure a fair proceedings. This study provides a robust methodology using clear legal statutory criteria used logical regression and methods that ensure reliable associations between variables. The finding of 75% agreement rate between forensic evaluators and court determinations reinforce interrater reliability. A structured data set was provided and records demographic, clinical and legal variables ensuring methodological transparency. However, there is no discussion of model assumptions which affects internal validity. This study provides specific evidence on whether youth with neurodisabilities like FASD should be explicitly considered in fitness assessments. 4% had FASD. Immaturity was considered. No association between diagnosis and court findings of unfitness. Wakefield et al., (2024) Checklist for Case Series (Munn et al., 2020 ) 7/10 70% This study had a clearly defined study design, comprehensive case inclusion, detailed data collection and reporting and has a large data set. The authors acknowledge incomplete data on the outcomes and the small number of unfit defendants. The reasons the assessors opined whether a defendant was fit or unfit was not analysed. Most reports did not use standardised fitness assessment instruments. The study has a regional focus and there is limited detail with regard to the statistical analysis of the data. This study provides empirical evidence on the increasing number of court ordered fitness assessments in New Zealand. It is relevant to forensic psychiatry resources, legal policy and human rights. The fact that few cases of FASD were highlighted raises concerns over underdiagnosis in forensic settings. The retrospective audit provides consistent data extraction over a eight year period. In 97% of cases the assessors reached agreement. The validity is affected by the limited transparency in statistical methods. The study uses established legal and forensic criteria and provides comprehensive data collection and consistent expert assessments. However, the legal disposition of 29 out of 105 unfit defendants was unknown creating gaps in the long term legal outcomes. This study has strong applicability in forensic psychiatry, legal policy and the challenges in providing sufficient provision of mental health services. Brown et al., ( 2016 ) Analytical cross sectional studies (Moola et al., 2020) 6/8 75% This study uses a mixed method approach to highlight gaps in the District Attorney knowledge and training of FASD in the United States of America (USA). It uses a valid web based survey. It is noted that the open ended questions provide strong alignment with the research goals, ethical approval is acknowledged and there is meaningful interpretation of qualitative responses. The study relies on self-reported data which may introduce bias and has no standardised tool for measuring knowledge levels. The study has limited control over confounding factors. The authors acknowledge the modest response rate and the fact that it was limited to prosecutors. They consider the study exploratory. The qualitative response provides limited discussion in relation to researcher bias. There is also limited qualitative analysis on the findings. This study provides empirical evidence that US prosecutors are not trained to recognise the unique difficulties individuals with FASD face which could lead to inappropriate prosecutions for those who lack capacity to participate in proceedings. The survey design, standardised questions and reproducibility of the findings demonstrates strong reliability. The modest response rate and self-reported data means there are some limitations with this study. The study demonstrates strong validity in its methodology and reasonable accuracy in its findings. This study highlights significant gaps among US prosecutors regarding FASD related impairments that could affect a defendants ability to participate effectively in criminal proceedings. Table 2 Study Characteristics Author (s) and year Country Sample/Population Characteristics Aims of the article Study Design and Method(s) Main Findings McLachlan et al., ( 2014 ). Canada Two groups of young offenders 50 with FASD and 50 without prenatal alcohol exposure completed To raise issues surrounding the law and justice intervention and non-intervention. To emphasise FASD cannot be uncoupled from the history of colonial settlement. To highlight the need for a fresh diversionary paradigm. To map out a reform agenda based on a decolonizing alternative to the mainstream justice process.. Qualitative research undertaken in three indigenous communities. Interviews and roundtables. Western Australian legislation enables a person who is found unfit to be indefinitely detained. Legal advisors are put in a precarious position. Diversion or an alternative system is needed. Diversion for indigenous populations into indigenous owned therapeutic alternatives. In the context of many Indigenous youth, particularly those with FASD and other cognitive impairments, maturation does not bring with it desistance from offending. Judicial discretion should be used whilst reform takes place as it already exists in legislation and common law. Pei et al., (2016) Canada 9 individuals with an FASD (5 males, 4 females; mean age of 34.1 years, age range of 24–59 years) 12 professionals working in the criminal justice system (3 males, 9 females). To explore the experiences of individuals in the criminal justice system with a Fetal alcohol spectrum disorder (FASD) in order to identify possible ways to reduce the likelihood of re-entry into the criminal justice system. Qualitative research methods used to interview individuals with FASD and professionals who work with clients with FASD. Part of a larger program of research. Once individuals with an FASD entered the criminal justice system, there were multiple factors that continued to place these individuals at a disadvantage. In particular: (1) biological factors, (2) psychological and social issues, and (3) factors that trapped individuals with FASD in the system and hindered their ability to fully understand and act in their best interest within the justice system McLachlan et al. ( 2019 ) Canada A sample of 80 justice-involved adults (ages 18–40, 85% male) over an 18-month period from 2013 to 2015. Prevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections The participants completed interdisciplinary clinical assessments comprising medical and psychological evaluations to estimate the prevalence of FASD in Northern Canada A high rate of FASD was found which could have been as high as 31.2% with confirmation of prenatal alcohol exposure. Most participants in this study presented with significant neurodevelopmental and cognitive deficits in at least two domains of functioning, irrespective of diagnosis, It was noted that neurocognitive deficits could have an impact on fitness to plead. Douglas et al., (2012) Australia 37 magistrates, nine District Judges and two supreme Court judges To report the results of a survey of members of the Queensland judiciary about their understanding of FASD and how they deal with FASD in their judicial role Survey by post and online. Questions about personal background, awareness of FASD, impact of FASD on practice and training, and information needs. 80% of the judiciary had not heard of FASD. There are questions of fitness to plead in Canada and USA. The rushed environment of the lower courts and the pressure to plead guilty are not conducive to ensuring clear communication and understanding of the process for a person with FASD. Blagg et al., ( 2017 ) Australia 60 people interviewed from legal and mental health services, 15 workers from partner organisations, 35 court and police personnel at a round table event. To raise issues surrounding the law and justice intervention and non-intervention. To emphasise FASD cannot be uncoupled from the history of colonial settlement. To highlight the need for a fresh diversionary paradigm. To map out a reform agenda based on a decolonizing alternative to the mainstream justice process. Qualitative research undertaken in three indigenous communities. Interviews and roundtables. Western Australian legislation enables a person who is found unfit to be indefinitely detained. Legal advisors are put in a precarious position. Diversion or an alternative system is needed. Diversion for indigenous populations into indigenous owned therapeutic alternatives. In the context of many Indigenous youth, particularly those with FASD and other cognitive impairments, maturation does not bring with it desistance from offending. Judicial discretion should be used whilst reform takes place as it already exists in legislation and common law. Young et al., ( 2018 ) Australia Extracted case file data of 92 individuals who had a criminal case referred to the Queensland Mental Health Court (MHC). To (1) describe the severity of impairment in people with cognitive disability referred to the Queensland Mental Health Court; (2) estimate the association between severity of impairment and a determination of unsoundness or unfitness by the MHC; and (3) assess the socio-demographic, clinical and legal factors that predict being deemed unsound or unfit to stand trial by Court in Australia. MHC record review Over half the individuals referred to the MHC had moderate to severe cognitive impairment with a 1.5 increased likelihood of being found unfit to stand trial compared to mild/borderline cognitive impairment. This study suggests that the clinical level of cognitive impairment is key in applying moral, social and legal criteria. Almost two in three individuals with mild or borderline cognitive disability were found unfit to stand trial by the MHC. Psychiatrists play a pivotal role in MHC determinations for people with cognitive disability. Disability-specific training for clinicians and justice professionals at every level of the justice and MHC process is needed. The study infers that Fetal alcohol spectrum disorder, and acquired brain injury may not result in significant cognitive impairment. Tan et al., ( 2018 ) New Zealand A retrospective review fitness to stand trial reports for o 79 youth consecutively referred to the Region Regional Youth Forensic Service from 2010 to 2015 To better understand how juvenile fitness to stand trial is approached in New Zealand, particularly with respect to the notion of immaturity and its effect on fitness to stand trial determinations in light of international research. A cross-sectional observational study involving retrospective review of forensic evaluation reports and court outcomes. More than half (58%, n = 46) of youth in the sample were opined to be mentally impaired. Intellectual disability was the most common diagnosis. Other diagnoses used by evaluators to demonstrate mental impairment included attention deficit hyperactivity disorder (ADHD, 17%), psychosis (4%), autistic spectrum disorder (ASD, 4%) and foetal alcohol syndrome disorder (FASD, 4%), No statistically significant association was found between these diagnoses and court findings of youth being unfit to stand trial. Wakefield et al., (2024) New Zealand A retrospective audit of 415 defendants Court ordered health assessor reports. To audit defendants assessed by a New Zealand forensic psychiatry service An audit of fitness to stand trial assessments made by psychiatrists between 2014 and 2022. Primary diagnoses were psychotic disorders (37%), intellectual disability (13%) and acquired neurocognitive disorders (15%). Few people with foetal alcohol spectrum disorder were identified suggesting FASD is overlooked by court assessors. The increase in fitness to stand trial reports has implications for the forensic mental health services. Brown et al., ( 2016 ) USA 216 USA District Attorneys 166 men and 50 women To investigate the knowledge and legal experiences of District Attorneys concerning FASD, and to compare these across sexes, legal experience levels, as well as geographical The survey was distributed electronically to all US District Attorneys following the Dillman Total Design Method. The need for forensic screening instruments. District attorneys were found to vary in their ability to accurately identify signs and symptoms of FASD, underestimated the prevalence of criminal justice involvement among individuals diagnosed with FASD. Not routinely aware of unique psycho-legal impairments of this population. 3 Results The titles and abstracts of 1722 studies were screened. Seven further empirical studies were identified from the citation search and the update searches. After the removal of duplicates and further screening 1051 studies were found to be irrelevant. Sixty-five studies were extracted and assessed for eligibility. A further 56 studies were excluded using the eligibility criteria leaving nine studies that provided empirical evidence from the database searches. A total of nine empirical studies were identified in this scoping review investigating some aspect of FASD and fitness to participate within the CJS. Table 2 provides the study characteristics stating the author and year, country, sample/population, aim of the study, the study design and methods and main findings. [Table 2 Study characteristics about here] 3.1 Articles extracted This review includes nine studies from four countries: Canada (3), Australia (3), New Zealand (2), and the United States (1). The extent to which these studies address fitness to participate in legal proceedings and FASD varies considerably, warranting an examination of the notable trends across the jurisdictions. 3.2 Notable Trends Across Jurisdictions 3.2.1 Canada The scope and variety of studies within Canada provide a leading example of empirical Inquiry. In Canada, individuals with FASD have been recognized as a vulnerable population since the passing of resolutions by the Canadian Bar Association in 2011. The resolution underscored the increasing attention on FASD in North American justice policy (McLachlan et al., 2014 ). A landmark study by McLachlan and colleagues ( 2014 ) was the first in-depth investigation into the cognitive impairments affecting legal fitness among individuals with FASD. This study highlights the challenges faced by youth in comprehending their legal rights and court proceedings. It specifically considered the issues surrounding fitness to participate and the abilities needed to participate effectively. Building on these findings, a 2016 qualitative study explored the lived experiences of individuals with FASD navigating the criminal justice system (Pei et al., 2016 ). This study provided direct evidence of the barriers faced by individuals living with FASD and their ability to understand court proceedings, marking it as the only study offering first-hand insights into legal competency concerns. A further advancement in empirical inquiry is evidenced by McLachlan and colleagues 2019 quantitative study. The prevalence study examined the prevalence of FASD within correctional populations, utilizing active case assessments. The findings emphasized the urgent need for mental health professionals to incorporate FASD specific screenings in forensic evaluations (McLachlan et al., 2019 ) 3.2.2 Australia Australia has provided an emerging awareness of FASD and the issues surrounding fitness to participate and the institutional gaps (Tulich, 2020; Chisholm et at., 2017). Early discourse on FASD in Australian legal settings began with a 2012 study surveying the Queensland judiciary members on their knowledge of FASD (Douglas et al., 2012 ). The study revealed systemic barriers, including the pressures to plead guilty in fast paced lower court environments, which pose additional challenges for individuals with FASD in understanding legal procedures. At the time, Canada and the USA were conducting routine FASD fitness to participate assessments, whereas the authors acknowledge that Australia and New Zealand had limited testing protocols. By 2017, research was expanded to include a discussion around fitness to participate with qualitative research addressing the fitness to plead assessments, the vulnerabilities of Indigenous youth, and the need for alternative solutions incorporating community participation (Blagg et al., 2017 ). Further research in 2018, examined case file data from the Queensland Mental Health Court (MHC). The authors of the 2018 study found notable associations between cognitive impairments and unfitness determinations (Young et al., 2018 ). While the study suggested that FASD may not necessarily lead to severe cognitive impairment, it highlighted that two in three individuals with mild to borderline cognitive disabilities were deemed unfit to stand trial by the MHC. 3.2.3 New Zealand Research from New Zealand has shown an increased awareness of the issue surrounding fitness to participate and the empirical studies have concentrated on forensic assessment and judicial recognition. In 2018 a retrospective study examined 79 cases in the Youth Court, evaluating how fitness assessments influenced judicial outcomes (Tan et al., 2018 ). This study revealed a strong association between intellectual disability and unfit to participate determinations, though FASD diagnoses (4%) did not show statistical significance in judicial findings. In contrast, a recent 2024 forensic psychiatry audit assessed fitness to participate evaluations within adult criminal proceedings (Wakefield et al., 2024). Despite FASD’s known prevalence within the CJS, only a small number of cases were formally identified, indicating gaps in screening and recognition. This lack of identification was noted despite disability advocacy groups supporting the courts in relation to neurodivergent cases. The study reinforced the growing demand for forensic mental health services. 3.2.4 USA In the USA empirical evidence on fitness to participate and the issues surrounding fitness remains limited. In 2016 a web-based survey assessed prosecuting District Attorneys' awareness and experience with FASD related legal issues (Brown et al., 2016 ). While the study offered limited insights into fitness to participate concerns, it highlighted significant gaps in prosecutorial knowledge underscoring the need for improved training, screening protocols, and research into legal comprehension issues. 3.3 Comparative Findings Across the jurisdictions identified, Canada leads in empirical research, conducting comprehensive investigations into cognitive impairments, legal fitness, prevalence, and lived experiences. Australia’s framework is evolving, with growing judicial awareness and the emergence of mental health courts to assess fitness to participate concerns. New Zealand is increasingly incorporating forensic assessments into legal proceedings and has an awareness of the challenges individuals with FASD face, although formal identification of FASD remains inconsistent. The United States has explored prosecutorial awareness, but systemic knowledge gaps persist, affecting the application of FASD related fitness to participate assessments in court. 3.4 Case Law Reviews and Judicial Interpretation The empirical studies identified in this scoping review provide evidence that recognition of FASD within judicial proceedings remains inconsistent. This is also evidenced by the limited discussion of FASD within fitness to participate appeal cases reviewed from the court decisions. In 2023 a systematic review of 350 Canadian cases found that only two appeal cases referenced FASD in fitness to participate considerations and the FASD evidence ‘ did not have great relevance in either of the two cases ’ (Mullally et al., 2023 :425). In the USA, federal case law reviews indicate broader fitness to participate concerns. A 2022 survey by Brown et al. explored FASD-related suggestibility and wrongful convictions, but none appeared to directly examine fitness to participate (Brown et al., 2022 ). Similarly, a 2013 study by Douds and colleagues found that courts refused to hold competency hearings based solely on prenatal toxic exposure (Douds et al., 2013 ). While fitness to participate determinations remain underexplored, these reviews underscore ongoing legal challenges. The Judges appear to recognise the implications of FASD, but the application within fitness to participate hearings remains inconsistent, highlighting the urgent need for improved screening, legal education, and standardized protocols in fitness to participate assessments. 4 Discussion The empirical studies reviewed in this research underscore the vulnerabilities of both youth and adults with FASD in legal proceedings, particularly regarding fitness to participate. Despite the variations in study methodologies, there is growing international recognition of the need to address critical issues when individuals with FASD face the justice system (Flannigan et al., 2025 ). This section examines the broader legal and theoretical concerns raised in the identified empirical studies, along with insights from discussion articles and the case law reviews. Key themes include judicial inconsistencies in recognizing FASD related impairments, barriers to fitness to participate assessments, and the challenges of ensuring fair trial participation. By integrating these perspectives, this discussion highlights the need for enhanced legal frameworks, improved assessments, and greater awareness of the impact of FASD on legal processes. 4.1 Judicial Awareness and Training Deficiencies FASD has been described as an invisible disability due to the variability in cognitive functioning. Where expressive language abilities may remain intact, an illusion of competence, despite significant underlying impairments (such as comprehension) being present (Chudley, 2008 ). The first challenge for legal professionals is to be able to recognise the possibility of FASD and the impact it is likely to have on defendants ability to be fit to participate in proceedings (Passmore et al., 2018 ). There also remains a significant challenge in relation to diagnosis, with FASD frequently being missed or misdiagnosed as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders (ASD), or conduct disorders. This challenge leads to inaccurate prevalence estimates and missed opportunities for early intervention (Chasnoff et al., 2015 ; McLachlan et al., 2019 ). Current research indicates that a Legal professionals' ability to identify and accommodate FASD in court proceedings varies. In Canada, Gagnier et al. ( 2011 ) emphasise the importance of legal counsel introducing the possibility of FASD, noting that expert assessments and testimony can significantly aid judicial decision-making. However, they caution that the justice system should not become a substitute for social services. This contrasts with Johansen-Hill ( 2019 ), who argues that deficiencies in community resources often force the criminal justice system to compensate, making its role in supporting individuals with FASD a necessity. Butcher ( 2020 ) further underscores this concern in New Zealand, emphasising that individuals with FASD frequently face cycles of addiction and poverty. Butcher considers that because FASD cannot be cured, the quality of life for affected individuals is highly dependent on legal and societal support, making criminal law a vital institution for ensuring fair treatment. Due to complex nature of FASD, and the need for multidisciplinary assessments, medical-legal reports often fail to fully consider the cognitive impairments associated with FASD. McLachlan et al. ( 2014 ) noted that psycho-legal deficits in defendants with FASD receive less attention than severe psychopathology, likely due to their cooperative demeanour. Additionally, Roach & Bailey suggested that the fast-paced environment of lower courts exacerbated these challenges, pressuring defendants to plead guilty prematurely and limiting their ability to communicate effectively (Roach & Bailey, 2009 ). Finally, there remains a significant gap in training for legal professionals, medical practitioners, and the judiciary regarding FASD, its manifestations, and its impact on competency assessments (Mela, 2022 ; Allely & Gebbia, 2016 ; Brown et al., 2024 ; Allely & Mukherjee, 2019 ). An illustrative example comes from Wakefield et al. (2024), who found that among 415 fitness to stand trial reports in New Zealand, few suspected FASD cases were identified despite the presence of disability advocacy groups within the courts. This suggests systemic oversight in recognizing FASD, reinforcing the urgent need for enhanced judicial training and standardised evaluation protocols. 4.2 Systematic Barriers in Legal Processes One of the most pressing concerns in the fitness to participate determinations is the role of immaturity, particularly in young defendants with FASD facing criminal proceedings. FASD can result in young adults functioning cognitively at the level of a child. Within the legal system developmental immaturity is rarely anticipated or addressed (Fast & Conry, 2009 ). Three empirical studies in this review highlight the overrepresentation of Indigenous youth within the CJS in Western Australian, New Zealand and Canadian courts. Tan et al. ( 2018 ) found that immaturity did not significantly influence mental health evaluators' assessments of fitness, suggesting that New Zealand evaluators apply a higher threshold for fitness compared to the Youth Court standard. In contrast, USA judges explicitly factor age into fitness determinations, demonstrating jurisdictional differences in the role of developmental maturity in legal decisions. Studies have indicated that there are broader implications regarding immaturity in fitness to participate determinations with a need for further discussion in relation to the implications in criminal proceedings (Blagg et al., 2017 ; McLachlan et al., 2019 ; Tan et al., 2018 ). Beyond youth-related immaturity, lifelong fitness concerns for individuals with FASD further complicate judicial proceedings. McLachlan et al. ( 2014 ) emphasise that defendants found unfit are not restorable to fitness may face indefinite detention, imprisonment, or supervision with conditions they cannot realistically follow (Roach & Bailey, 2009 ). In serious cases, charges are rarely discharged, creating long-term barriers for affected individuals. To address these gaps, researchers advocate for alternative court models that accommodate individuals with FASD and psycho-legal impairments. Blagg et al. ( 2017 ), Chisholm et al. ( 2017 ), and Bush ( 2017 ) propose a needs-based approach for unfit Aboriginal persons with FASD, ensuring culturally responsive legal interventions. Perlin & Cucolo (2022) position FASD as both a due process issue and a human rights concern, advocating for therapeutic jurisprudence as a key legal framework. Further discussions on specialized courts reinforce the necessity for legal environments to be tailored to neurodevelopmental disabilities. Wartnik & Carlson ( 2011 ) examined case studies from Therapeutic Drug Courts, while Brown et al. ( 2024 ) called for greater judicial intervention through specialized FASD courts. Douglas et al. ( 2012 ) explored problem-solving courts, highlighting Brisbane’s Special Circumstances Court as a model that supports defendants with homelessness, impaired decision-making capacity, and minor criminal charges through rehabilitation and treatment-oriented strategies. These discussions underscore the urgent need for systemic reforms, particularly in fitness to participate determinations for individuals with FASD. Specialised legal frameworks, enhanced judicial awareness, and improved access to alternative court models are essential to addressing the persistent barriers faced by vulnerable defendants. 4.3 Standardizing Fitness Assessments and Screening The need for standardised screening and assessment protocols for FASD has been widely discussed across the empirical and review studies (Passmore et al., 2016; Brown et al., 2024 ; Allely & Mukherjee, 2019 ). While recognizing the challenges in developing effective screening tools due to FASD’s complex presentation, researchers emphasize that such instruments could enhance identification, evaluation, and competency determinations (Brown, 2024). The only UK discussion paper identified in this scoping review reinforces this need. While primarily focused on suggestibility, false confessions, and competency concerns within an American context, it raises significant recommendations, including an urgent need for further empirical research into the psycho-legal impact of FASD, specialised training for medical and legal professionals, and the implementation of formal screening protocols to address gaps in structured assessment measures (Allely & Mukherjee, 2019 ). 4.4 Rethinking Traditional Fitness to Participate Assessments The use of traditional fitness to participate assessments remains inconsistent, hindered by the absence of standardised screening protocols. Existing fitness determinations frequently overlook key factors such as developmental immaturity and co-morbid conditions with a reliance on IQ based metrics. Mela in 2022 criticised the use of traditional competency frameworks, arguing that legal professionals fail to account for the functional realities of FASD when applying models designed for neurotypical individuals. Studies have suggested that assessments should align with adaptive and executive functioning capacities, a recommendation echoed in Brookbanks et al. (2021) and Butcher ( 2020 ), who advocate for screening beyond IQ and facial dysmorphology to determine a defendants legal participation capability. The lack of judicial awareness of FASD and the need to incorporate a holistic approach to assessments was discussed by Luckasson & Schalock in 2015. The authors stressed the importance of disability-specific training for professionals, advocating for culturally validated standardised diagnostic and screening tools. They emphasised a need to incorporate collateral information from individuals close to the defendant rather than relying solely on clinical assessments. These findings reinforce the urgent need to modernize legal fitness to participate assessments, moving beyond outdated methodologies toward individualised, evidence-based screening protocols tailored to FASD and other cognitive disabilities. 4.5 Limitations Although extensive search terms were used in this review it is possible that the search failed to capture all of the relevant research in this field. To minimise the risk of missing any relevant articles additional searches on ‘Google Scholar’ were made using the search criteria previously mentioned (see Table 1 ). All of the studies extracted had limitations when checked for quality and rigour either due to modest or limited samples, incomplete data of self-reported data (see Table 2 ). However, many of the limitations had been acknowledged by the authors with suggestions made for future research. 4.6 Future research This review highlights several critical gaps requiring further investigation to improve fairness and access to justice for individuals with FASD in relation to the ability of being fit to participate. Key priorities include enhancing judicial awareness through targeted training, particularly its influence on fitness to participate assessments and legal outcomes. Research should also explore how developmental immaturity and co-occurring conditions impact assessment validity. Standardisation is essential in developing structured screening tools, specifically for FASD. Research is also required to evaluate the reliability of assessments with a view to including adaptive and executive functioning in all assessments. Ultimately there is a need make further inquiry into therapeutic courts and specialised legal responses to support equitable trial participation. Broader systemic reform should also consider alternative legal frameworks that better accommodate neurodevelopmental impairments. Conclusion This scoping review sought to identify empirical studies examining FASD in relation to fitness to participate or comparable legal constructs internationally. The findings reveal that while Canada, the USA, Australia, and New Zealand have begun addressing this issue within legal frameworks, research remains extremely limited in the UK, exposing a significant gap in judicial understanding and implementation. Further research is required to examine cross-national approaches, ensuring legal frameworks are both comprehensive and adaptable to the unique needs of individuals with FASD. By prioritizing these research and policy advancements, legal systems can progress toward more informed, consistent, and fair competency determinations, ensuring that individuals with FASD receive the recognition, accommodations, and protections necessary for meaningful participation in legal proceedings. Declarations Ethical Approval Not applicable Funding No funding was received Availability of data and materials This study is a systematic scoping review and did not involve the collection of original empirical data. All data extracted from the included studies during the review process are available within the article. The screening and selection process was conducted using Covidence software. Author Contribution Author 1 wrote the main manuscript text and author 2-4 reviewed the manuscript. References Allely, C. S., & Gebbia, P. (2016). Studies investigating fetal alcohol spectrum disorders in the criminal justice system: a systematic PRISMA review. SOJ Psychology , 3 (1). https://doi.org/10.15226/2374-6874/3/1/00123 Allely, C. S., & Mukherjee, R. (2019). Suggestibility, false confessions and competency to stand trial in individuals with fetal alcohol spectrum disorders: Current concerns and recommendations. Journal of Criminal Psychology , 9 (4), 166–172. https://doi-org.salford.idm.oclc .org/10.1108/JCP-11-2019-050 Blagg, H., Tulich, T., & Bush, Z. (2017). Indefinite detention meets colonial dispossession: Indigenous youths with foetal alcohol spectrum disorders in a white settler justice system. Social & Legal Studies , 26 (3), 333–358. https://doi-org.salford.idm .oclc.org/10.1177/0964663916676650 Blake, G.A., Ogloff, J., & Fullam, R. (2022). Knowledge and Opinions of Fitness to Stand Trial Elements in Australia. International Journal of Forensic Mental Health , 21 (3), 241–255. https://doi.org/10.1080/14999013.2021.1966140 Blake, G. A., Ogloff, J. R., & Antolak-Saper, N. (2023). Interpreting R v Presser: a clinician’s guide to contemporary Australian fitness to stand trial case law. Psychiatry, Psychology and Law , 30 (6), 836–862. https://doi-org.salford.idm. oclc.org/10.1080/13218719.2022.2136278 Brookbanks, W., McGinn, V., & Chu, J. T. W. (2022). Unfitness to stand trial and fetal alcohol spectrum disorder: Understanding and responding to FASD within the criminal justice system in New Zealand. Behavioral Sciences & the Law , 40 (1), 159–169. https://doi.org/10.1002/bsl.2555 Brown, J., Helmstetter, D., Harr, D., & Singh, J. (2016). Perceptions of FASD by United States district attorneys. Journal of Intellectual Disabilities and Offending Behaviour , 7 (4), 195–201. https://doi.org/10.1108/JIDOB-04-2016-0005 . Brown, J. M., Haun, J., Zapf, P. A., & Brown, N. N. (2017). Fetal Alcohol Spectrum Disorders (FASD) and competency to stand trial (CST): Suggestions for a ‘best practices’ approach to forensic evaluation. International Journal of Law and Psychiatry , 52 , 19–27. https://doi.org/10.1016/j.ijlp.2017.04.002 Brown, J., Madore, E., Carter, M. N., Spiller, V., & Jozan, A. (2022). Fetal alcohol spectrum disorder (FASD) and suggestibility: A survey of united states federal case law. International Journal of Law and Psychiatry , 80 , 101763. doi: https://doi-org.salford.idm.oclc .org/10.1016/j.ijlp.2021.101763 Brown, J., Lewis, D. S., Kivisalu, T., Wartnik, A. P., Carter, M. N., Harr, D., Jozan, A., & Gilbert, D. J. (2024). Fetal alcohol spectrum disorder (FASD) and the criminal justice system: A guide for legal professionals. International Journal of Law and Psychiatry , 97 , Article 102029. https://doi.org/10.1016/j.ijlp.2024.102029 Bush, Z. (2017). Healing colonial binaries: a “needs-based” approach to Aboriginal persons found unfit to stand trial on the basis of FASD. Griffith Law Review , 26 (3), 401–429. https://doi.org/10.1080/10383441.2017.1436373 Butcher, J. (2020). The revolving door: Are we sentencing people with FASD to a life trapped in the criminal justice system? Auckland University Law Review , 26 , 150–177. Chasnoff, I. J., Wells, A. M., & King, L. (2015). Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure. Pediatrics , 135 (2), 264–270. https://doi.org/10.1542/peds.2014-2171 Chisholm, R., Tulich, T., & Blagg, H. (2017). Indigenous young people with foetal alcohol spectrum disorders: The convention on the rights of persons with disabilities and reform to the law governing fitness to stand trial in Western Australia. Law in Context , 35 (2), 85–107. Chudley, A. E. (2008). Fetal alcohol spectrum disorder: counting the invisible – mission impossible? Archives of Disease in Childhood , 93 (9), 721–722. https://doi.org/10.1136/adc.2008.137109 Council of Europe & European Court of Human Rights. (1950). European Convention on Human Rights (Article 6). https://www.echr.coe.int/documents/convention_ Douds, A. S., Stevens, H. R., & Sumner, W. E. (2013). Sword or Shield? A Systematic Review of the Roles FASD Evidence Plays in Judicial Proceedings. Criminal Justice Policy Review , 24 (4), 492–509. https://doi.org/10.1177/0887403412447809 Douglas, H., Hammill, J., Hall, W., & Russell, E. (2012). Judicial views of foetal alcohol spectrum disorder in Queensland's criminal justice system. Journal of Judicial Administration , 21 (3), 178–188. Dunbar Winsor, K. (2021). An invisible problem: stigma and FASD diagnosis in the health and justice professions. Advances in Dual Diagnosis , 14 (1), 8–19. https://doi.org/10.1108/ADD-07-2020-0014 Fast, D. K., & Conry, J. (2009). Fetal alcohol spectrum disorders and the criminal justice system. Developmental Disabilities Research Reviews , 15 (3), 250–257. https://doi-org.salford.idm.oclc .org/10.1002/ddrr.66 Flannigan, K., Pei, J., Stewart, M., & Johnson, A. (2018). Fetal Alcohol Spectrum Disorder and the criminal justice system: A systematic literature review. International Journal of Law and Psychiatry , 57 , 42–52. https://doi.org/10.1016/j.ijlp.2017.12.008 Flannigan, K., Wrath, A., Ritter, C., McLachlan, K., Harding, K. D., Campbell, A., Reid, D., & Pei, J. (2021). Balancing the story of fetal alcohol spectrum disorder: A narrative review of the literature on strengths. Alcoholism, Clinical and Experimental Research , 45 (12), 2448–2464. https://doi.org/10.1111/acer.14733 Flannigan, K., Pun, J. W., Buttinger, P., McLachlan, K., Holmstrom, K., Tremblay, M., Mela, M., & Pei, J. (2025). An updated systematic review of the literature on fetal alcohol spectrum disorder and the criminal legal system. International Journal of Law and Psychiatry , 100 , Article 102073. https://doi.org/10.1016/j.ijlp.2025.102073 Freckelton, I. (2016). Expert evidence in fetal alcohol spectrum disorder cases. Ethics, Medicine, and Public Health , 2 (1), 59–73. https://doi.org/10.1016/j.jemep.2016.01.006 Gagnier, K. R., Moore, T. E., & Green, J. M. (2011). A need for closer examination of FASD by the criminal justice system: Has the call been answered? Journal of Population Therapeutics and Clinical Pharmacology , 18 (3), e426–e439 Gilbert, D. J., Allely, C. S., Hickman, N., Mukherjee, R. A. S., & Cook, P. A. (2023). ‘I inevitably get in trouble … in one way or another’: Qualitative exploration of the vulnerabilities and experiences of justice system encountered individuals with fetal alcohol spectrum disorder. Forensic Science International. Mind and Law , 4 , Article 100124. https://doi.org/10.1016/j.fsiml.2023.100124 Gordon, F., Madore, E., & Novick Brown, N. (2021). Prosecutorial Decision-Making and Practice: Victims and Witnesses with Fetal Alcohol Spectrum Disorders. In Evaluating Fetal Alcohol Spectrum Disorders in the Forensic Context (pp. 443–464). Springer International Publishing. https://doi.org/10.1007/978-3-030-73628-6_17 Johansen-Hill, Z. (2019). Proportionate justice: An examination of fetal alcohol spectrum disorders and the principles of sentencing in Saskatchewan. Saskatchewan Law Review , 82 ( 1 ), 75–95. Luckasson, R., & Schalock, R. L. (2015) Standards to guide the use of clinical judgment in the field of intellectual disability. Intellectual and Developmental Disabilities 53 , 240–51. https://doi.org/10.1352/1934-9556-53.3.240 . McCarthy, R., Mukherjee, R. A. S., Fleming, K. M., Green, J., Clayton-Smith, J., Price, A. D., Allely, C. S., & Cook, P. A. (2021). Prevalence of fetal alcohol spectrum disorder in Greater Manchester, UK: An active case ascertainment study. Alcoholism, Clinical and Experimental Research , 45 (11), 2271–2281. https://doi.org/10.1111/acer.14705 McLachlan, K., Roesch, R., Viljoen, J. L., & Douglas, K. S. (2014). Evaluating the Psycholegal Abilities of Young Offenders With Fetal Alcohol Spectrum Disorder. Law and Human Behavior , 38 (1), 10–22. https://doi.org/10.1037/lhb0000037 McLachlan, K., McNeil, A., Pei, J., Brain, U., Andrew, G., & Oberlander, T. F. (2019). Prevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections: a Canadian case ascertainment study. BMC Public Health , 19 (1), Article 43. https://doi.org/10.1186/s12889-018-6292-x May, P. A., Chambers, C. D., Kalberg, W. O., Zellner, J., Feldman, H., Buckley, D., Kopald, D., Hasken, J. M., Xu, R., Honerkamp-Smith, G., Taras, H., Manning, M. A., Robinson, L. K., Adam, M. P., Abdul-Rahman, O., Vaux, K., Jewett, T., Elliott, A. J., Kable, J. A., … Hoyme, H. E. (2018). Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. JAMA: The Journal of the American Medical Association , 319 (5), 474–482. https://doi.org/10.1001/jama.2017.21896 Mela, M. (2022). The Blind Spot of Medico-Legal Implications of Prenatal Alcohol Exposure. The Journal of the American Academy of Psychiatry and the Law , 50 (4), 509–516. Meltzer, L. J., Pollica, L., Barzillai, M., & Meltzer, L. (2007). Executive function in the classroom: Embedding strategy instruction into daily teaching practices. Executive function in education . New York: Guildford , 165–193. Mullally, K., McLachlan, K., Jewell, E., Viljoen, J., & Rudin, J. (2023). Fetal Alcohol Spectrum Disorder Evidence in Canadian Criminal Cases: A Case Law Review. Psychology, Public Policy, and Law , 29 (4), 417–434. https://doi.org/10.1037/law0000391 Munn, Z., Moola, S., Lisy, K., Riitano, D., & Tufanaru, C. (2015). Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. JBI Evidence Implementation , 13 (3), 147–153. Munn, Z., Barker, T. H., Moola, S., Tufanaru, C., Stern, C., McArthur, A., … Aromataris, E. (2020). Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI evidence synthesis , 18 (10), 2127–2133. DOI: 10.1097/XEB.0000000000000054 Owusu-Bempah, A. (2018). The interpretation and application of the right to effective participation. The International Journal of Evidence & Proof , 22 (4), 321–341. https://doi.org/10.1177/1365712718780800 Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ (Online) , 372 , n71–n71. https://doi.org/10.1136/bmj.n71 Passmore, H. M., Mutch, R. C., Burns, S., Watkins, R., Carapetis, J., Hall, G., & Bower, C. (2018). Fetal Alcohol Spectrum Disorder (FASD): Knowledge, attitudes, experiences and practices of the Western Australian youth custodial workforce. International Journal of Law and Psychiatry , 59 , 44–52. https://doi.org/10.1016/j.ijlp.2018.05.008 . Pei, J., Leung, W. S. W., Jampolsky, F., & Alsbury, B. (2016). Experiences in the Canadian Criminal Justice System for Individuals with Fetal Alcohol Spectrum Disorders: Double Jeopardy? Canadian Journal of Criminology and Criminal Justice , 58 (1), 56–86. https://doi.org/10.3138/cjccj.2014.E25 Perlin, M. L., & Cucolo, H. E. (2023). “Take the Motherless Children off the Street”: Fetal Alcohol Syndrome and the Criminal Justice System. University of Miami Law Review , 77 (3), 561–612. Popova, S., Lange, S., Bekmuradov, D., Mihic, A., & Rehm, J. (2011). Fetal Alcohol Spectrum Disorder Prevalence Estimates in Correctional Systems: A Systematic Literature Review. Canadian Journal of Public Health , 102 (5), 336–340. https://doi.org/10.1007/BF03404172 Popova, S., Lange, S., Poznyak, V., Chudley, A. E., Shield, K. D., Reynolds, J. N., Murray, M., & Rehm, J. (2019). Population-based prevalence of fetal alcohol spectrum disorder in Canada. BMC Public Health , 19 (1), Article 845. https://doi.org/10.1186/s12889-019-7213-3 Roach, K, & Bailey, A. (2009). The relevance of fetal alcohol spectrum disorder in Canadian criminal law from investigation to sentencing. Boston College Law Review , 42 , 1. Tan, D., Friedman, S. H., Armstrong, C., Fitzgerald, J. T., & Neumann, C. (2018). New Zealand youth fitness to stand trial: The impact of age, immaturity and diagnosis on evaluator opinions and court determinations. Psychiatry, Psychology and Law , 25 (3), 374–385. https://doi.org/10.1080/13218719.2017.1396867 . Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., … Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR):Checklist and Explanation . https://doi.org/10.7326/M18-0850 Tsang, T. W., Rosenblatt, D. H., Parta, I., & Elliott, E. J. (2025). Estimating the Prevalence of Fetal Alcohol Spectrum Disorder in Australia. Drug and Alcohol Review , 44 (5), 1522–1525. https://doi.org/10.1111/dar.14082 Tulich, T. (2021). FASD in the courts: Fitness to stand trial. In Decolonising Justice for Aboriginal Youth with Fetal Alcohol Spectrum Disorders (1st ed., pp. 78–96). Routledge. https://doi.org/10.4324/9780429325526-4 United Nations. (2006). Convention on the Rights of Persons with Disabilities . https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf Wakefield, A., Every-Palmer, S., & Foulds, J. A. (2025). Fitness to stand trial: 415 consecutive defendants assessed by a New Zealand forensic psychiatry service. Australasian Psychiatry: Bulletin of the Royal Australian and New Zealand College of Psychiatrists , 33 (1), 51–56. https://doi.org/10.1177/10398562241290027 Wartnik, A. P., & Carlson, S. S. (2011). A Judicial Perspective on Issues Impacting the Trial Courts Related to Fetal Alcohol Spectrum Disorders. Journal of Psychiatry & Law , 39 (1), 73–119. https://doi.org/10.1177/009318531103900104 Webster, B. M., Carlisle, A. C. S., Livesey, A. C., Deeprose, L. R., Cook, P. A., & Mukherjee, R. A. S. (2023). Evaluating the Difference in Neuropsychological Profiles of Individuals with FASD Based on the Number of Sentinel Facial Features: A Service Evaluation of the FASD UK National Clinic Database. Children (Basel) , 10 (2), 266. https://doi.org/10.3390/children10020266 White, A. J., Batchelor, J., Pulman, S., & Howard, D. (2012). The Role of Cognitive Assessment in Determining Fitness to Stand Trial. International Journal of Forensic Mental Health , 11 (2), 102–109. https://doi.org/10.1080/14999013.2012.688091 Wozniak, J. R., Riley, E. P., & Charness, M. E. (2019). Clinical presentation, diagnosis, and management of fetal alcohol spectrum disorder. Lancet Neurology , 18 (8), 760–770. https://doi.org/10.1016/S1474-4422(19)30150-4 Young, J. T., Davis, F. J., Wardale, S., Vassos, M., Dooren, K., Nankervis, K., & Lennox, N. G. (2018). Severity of cognitive disability and mental health court determinations about fitness to stand trial. Journal of Intellectual Disability Research , 62 (2), 126–139. https://doi.org/10.1111/jir.12468 Zapf, P. A., Hubbard K. L., Cooper, V. G., Wheeles M. C., & Ronan K. A. (2004) Have the courts abdicated their responsibility for determination of competency to stand trial to clinicians? Journal of Forensic Psychology Practice , 4 , 27–44. https://doi.org/10.1300/J158v04n01_02 . Cases Pora v R [2015] UKPC 9; 1 Cr App R 3 R v M (John) [2003] EWCA Crime 3452 R v Pritchard (1836) 7 C&P 303 SC v UK (2005) 40 EHRR 10 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7235748","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497388222,"identity":"66485769-c3ee-464f-8f4e-e44dca0ae1e6","order_by":0,"name":"Tania L H Goddard","email":"data:image/png;base64,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","orcid":"","institution":"University of Salford","correspondingAuthor":true,"prefix":"","firstName":"Tania","middleName":"L H","lastName":"Goddard","suffix":""},{"id":497388223,"identity":"6d6205ba-7ace-4954-9352-488f97694f4c","order_by":1,"name":"Clare S Allely","email":"","orcid":"","institution":"University of Salford","correspondingAuthor":false,"prefix":"","firstName":"Clare","middleName":"S","lastName":"Allely","suffix":""},{"id":497388224,"identity":"22ad9740-68f7-49eb-853f-0e089c0b655b","order_by":2,"name":"Raja A S Mukherjee","email":"","orcid":"","institution":"University of Salford","correspondingAuthor":false,"prefix":"","firstName":"Raja","middleName":"A S","lastName":"Mukherjee","suffix":""},{"id":497388225,"identity":"83b7beb5-0001-47dc-9b99-c7002ee1704a","order_by":3,"name":"Alan D Price","email":"","orcid":"","institution":"University of Salford","correspondingAuthor":false,"prefix":"","firstName":"Alan","middleName":"D","lastName":"Price","suffix":""}],"badges":[],"createdAt":"2025-07-28 16:09:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7235748/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7235748/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":88899215,"identity":"651fe7be-681c-4583-b3e4-1d0e0bc0003d","added_by":"auto","created_at":"2025-08-12 13:26:19","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":117600,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA Flow Chart\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7235748/v1/75e60c0ef67dff652053b1ac.png"},{"id":88902860,"identity":"0ff2cf81-72ec-4cc4-aa9c-d3bed72c4273","added_by":"auto","created_at":"2025-08-12 13:58:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1273698,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7235748/v1/2128e283-77b0-4c4c-8519-263904f000b1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring fitness to participate in court proceedings among defendants with Fetal Alcohol Spectrum Disorder: A systematic scoping review","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eFetal Alcohol Spectrum Disorder (FASD) is a neurodevelopmental condition resulting from prenatal alcohol exposure, affecting both cognitive and behavioural functioning (Webster et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). While individuals with FASD often demonstrate strengths in creative and artistic domains, and can thrive with appropriate support (Flannigan et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), the condition presents lifelong challenges that may significantly impact their ability to navigate legal proceedings. Without sufficient intervention, individuals with FASD are estimated to be nineteen times more likely to become involved in the Criminal Justice System (CJS) compared to those without FASD (Popova et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2011\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe prevalence of FASD is notably high, with estimates ranging from 1.8\u0026ndash;3.6% in the UK, 2\u0026ndash;5% in Europe, 1.1\u0026ndash;5.0%, in four communities using a conservative approach in the US, 2 to 3% in Canada, and 2.91\u0026ndash;4.41% in Australia (McCarthy et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wozniak et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; May et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Popova et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Tsang et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Over time, researchers have sought to understand the specific vulnerabilities individuals with FASD face in legal contexts, including suggestibility, confabulation, and the absence of structured screening measures (Gilbert et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Flannigan et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Flannigan et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Additionally, the need to include executive and adaptive functioning in testing has been widely discussed (Brown et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; Pei et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Mela, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e), further deficits including planning, organizing, impulse control, and social comprehension have also been raised. All of these challenges have the potential to affect an individual\u0026rsquo;s ability to participate meaningfully in legal proceedings (Meltzer, 2007; Allely \u0026amp; Gebbia, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn several Western countries, legal frameworks recognize that if a defendant cannot comprehend or respond to charges, a conventional trial should not proceed. In England and Wales the courts rely on the Pritchard Criteria, established in the case of \u003cem\u003eR v Pritchard\u003c/em\u003e in1836, to assess a defendants fitness to plead. The Pritchard Criteria, as confirmed in the case of \u003cem\u003eR v M (John)\u003c/em\u003e 2003 states that to be fit to plead the defendant must be able to: understand the charges; decide whether to plead guilty or not; exercise the right to challenge jurors; instruct solicitor or counsel; follow the course of proceeding and be able to give evidence in their own defence. While jurisdictions such as the United States of America (USA), Canada, New Zealand, and Australia initially adopted a similar doctrine, legal precedents and statutory developments have led to divergent fitness standards (Blake et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Australia, comprehension and communication are emphasised with cognitive disorders being the primary indicator of incompetency. In contrast the USA prioritizes rationality, making psychosis the primary predictor of incompetency (White et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Blake \u0026amp; Ogloff, 2020).\u003c/p\u003e\u003cp\u003eIn addition to the Pritchard Criteria the Convention of the Rights of Persons with Disabilities (United Nations, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2006\u003c/span\u003e), and Article 6 of the European Convention of Human Rights (Council of Europe/European Court of Human Rights, 1950) assert that defendants must be able to understand and effectively participate in criminal proceedings. Effective participation presupposes that the defendant has a broad understanding of the nature of the trial process, what is at stake, and the significance of any penalty which may be imposed. The most comprehensive definition having been provided in the case of SC v UK (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e2005\u003c/span\u003e) (Owusu-Bempah, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLawyers face many challenges in identifying FASD as a contributing factor to fitness determinations. Research has highlighted that most legal professionals know relatively little about FASD and therefore it is important that any assessments are performed by specialists with some expertise in FASD (Gordorn \u0026amp; Madore, 2021; Freckelton, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). A further challenge for legal professionals and expert witnesses involves the role of stigma. Stigma may cause individuals and families to carefully choose what they want to disclose to their representative (Dunbar Winsor, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eExpert witness testimony plays a pivotal role in determining fitness to participate, with most jurisdictions requiring multiple psychiatric, forensic, clinical, or neuropsychological evaluations (Freckelton, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Courts rely heavily on expert assessments, with near-perfect concordance between expert recommendations and judicial determinations (Zapf et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2004\u003c/span\u003e). A comprehensive medical-legal report can assist both the lawyers and judges involved with defendants living with FASD. Within any reports psychological assessments and social histories are important. Further, due to the difficulties in comprehension and recall it is critical that psychiatrists do not solely rely on the informants responses. It is also crucial that previous reports are not taken at face value without verification (Fast \u0026amp; Conry, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eDespite the increasing recognition of FASD within some legal systems, no systematic reviews have specifically investigated fitness to participate in relation to FASD, underscoring a critical gap in research. The discordant evolution of fitness standards across Western jurisdictions and the hidden nature of FASD within fitness to participate assessments highlights an urgent need for empirical investigations into how FASD influences fitness determinations. A recent systematic review recognised that fitness to participate is an emerging field of study (Flannigan et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). To our knowledge, this is the first review to systematically identify empirical studies on FASD related fitness to participate determinations.\u003c/p\u003e\u003cp\u003eTo ensure clarity, this article adopts the term \u0026ldquo;fitness to participate\u0026rdquo;, to encompass the variations in terminology such as fitness to plead, fitness to stand trial, effective participation and competency.\u003c/p\u003e\u003cdiv id=\"Sec2\" class=\"Section2\"\u003e\u003ch2\u003e1.1 Objective\u003c/h2\u003e\u003cp\u003eThe objective of this scoping review was to identify empirical studies which have investigated FASD in relation to fitness to participate.\u003c/p\u003e\u003c/div\u003e"},{"header":"2 Materials and methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1 Eligibility criteria\u003c/h2\u003e\n\u003cp\u003eStudies were included in this review if they involved a human study population and investigated fitness to participate and FASD and associated words.\u003c/p\u003e\n\u003cp\u003eStudies were excluded if they were outside the scope of fitness to participate proceedings. Papers not published in English, dissertations, book chapters, systematic reviews, literature reviews, discussion papers (also considered review papers) and case law reviews were also excluded.\u003c/p\u003e\n\u003cp\u003eThe reference sections of relevant systematic/literature reviews; editorials; commentary papers; dissertations were carefully screened for any potentially relevant articles.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2 Information sources and search strategy\u003c/h2\u003e\n\u003cp\u003eThe guidelines described by the Preferred Reporting Items for Systematic Scoping Reviews and Meta-Analyses (PRISMA) were followed (Page et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). The extension for Scoping Reviews 22 item checklist was used to improve transparency PRISMA-ScR (Trico et al, 2018). The flowchart shown in Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the process of identifying relevant articles following PRISMA guidelines.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSeveral articles identified in the scoping review did not meet the inclusion criteria due to their methodological approach. Case law reviews, which summarise and analyse judicial decisions, were excluded as they do not present original empirical data and are typically classified as secondary legal analyses. However, given their relevance to court decisions and broader judicial trends, key insights from these reviews are integrated into the results section. Similarly, systematic reviews, opinion pieces, and editorial discussions that did not meet inclusion criteria were assessed for critical perspectives and are incorporated into the broader legal discussion.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003e2.3 Databases searched\u003c/h2\u003e\n\u003cp\u003eSearches were carried out on 29th August 2024 on six databases including; the Web of Science; MEDLINE; CINAHL; PsycINFO; PubMed; and Taylor and Francis legal database. Covidence software platform was used to manage and streamline the systematic review (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ewww.covidence.org\u003c/span\u003e\u003c/span\u003e). Duplicates were automatically removed Covidence.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003e\u003cem\u003e2.4 Search terms\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eSearch terms included words relating to FASD and the equivalent of fitness to participate.\u003c/p\u003e\n\u003cp\u003e\"fetal alcohol\" OR \"foetal alcohol\" OR \"alcohol related neuro-developmental disorder\" OR \"alcohol-related neurodevelopmental disorder\" OR \"alcohol related neurodevelopmental disorder\" OR \"FAS\" OR \"FASD\" OR \"prenatal alcohol\" OR \"PAE\" \"Fetal Alcohol Syndrome\" OR \"Foetal alcohol syndrome\" OR \"Partial Foetal Alcohol Syndrome\" OR \"Partial Fetal Alcohol Syndrome\" OR \"PFAS\" OR \"NDPAE\" OR \"Neurobehavioral disorder associated with prenatal alcohol exposure\" OR \"Static Encephalopathy alcohol exposed\"\u003c/p\u003e\n\u003cp\u003eAND\u003c/p\u003e\n\u003cp\u003e\"criminal justice\" OR \"fitness to plead\" OR \"fit to enter plea\" OR \"unfit to plead\" OR \"not fit to plead\" OR \"unfit to be tried\" OR \"fit to stand trial\" OR \"unfit to stand trial\" OR \"fitness to be tried\" OR \"fitness to stand trial\" OR \"criminal elements\" OR \"Special measures\" OR \"reasonable adjustment*\" OR \"vulnerable defendants\" OR \"common law capacity\" OR \"Pritchard criteria\" OR \"effective participation\" OR \"ability to participate\" OR \"fair hearing\" OR \"mental capacity\" OR \"capacity to participate\" OR \"cognitive impairment\" OR \"trial\" OR \"defence\" OR \"defense\" OR \"mitigation\" OR \"sentencing\" OR \"expert witness\" OR \"witness\" OR \"Court proceeding\" OR \"court\" OR \"insanity\" OR \"NGRI\" OR \"Not guilty by reason of insanity\" OR \"criminal court\" OR \"legal process\" OR \"legal proceeding*\" OR \"intermediaries\" OR \"practitioner knowledge\" OR \"knowledge of FASD\" OR \"criminal responsibility\" OR \"legal process\" OR \"culpability\" OR \"mens rea\" OR \"criminal conduct\" OR \"diminished responsibility\" OR \"mitigating\" OR \"criminal liability\" OR \"courtroom process\" OR \"legal decisions\" OR \"actus reus\" OR \"requisite intent to harm\" OR \"criminal justice process\" OR \"legally responsible\" OR \"Juror\" OR \"judge\" OR \"lawyer\" OR \"solicitor\" OR \"barrister\" OR \"legal representation\" OR \"prosecution\" OR \"jury\" OR \"competency to stand trial\" OR \"death penalty\"\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n\u003ch2\u003e2.5 Screening\u003c/h2\u003e\n\u003cp\u003eIn addition to the database searches, citations included in the articles identified were checked for relevance. Numerous permutations of FASD and fitness to participate were also entered into Google Scholar and a thorough search for articles, not identified in the databases search, was made. A further search on Google Scholar took place on the 21th October 2024 with a final search being made on the 25th February 2025. Alerts were also put in place on \u0026lsquo;Google Scholar\u0026rsquo; and \u0026lsquo;Research Gate\u0026rsquo; to tag any new research.\u003c/p\u003e\n\u003cp\u003eThe papers were reviewed independently by CA and AP.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003e2.6 The risk of bias\u003c/h2\u003e\n\u003cp\u003eTo assess the quality and rigour of the studies extracted quality assessment tools, in the form of JBI checklists, were completed to assess the quality of the variety of study designs (Munn et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e). Joanna Briggs Institute (JBI) is a global organisation promoting and supporting evidence-based decisions that improve health and health and service delivery. Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e identifies the type of checklist completed to ensure quality and rigour. The checklist scores, the strengths and limitations of the studies as well the relevance, reliability, validity and applicability of the studies.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eJBI checklist for quality and rigour\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAuthor (s) and year\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCritical Appraisal Checklist\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eQuality Checklist Score\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStrengths\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLimitations\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRelevance\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eReliability\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eValidity\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eApplicability\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMcLachlan et al., (\u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnalytical cross sectional studies (Moola et al., 2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7/8 87.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study employs validated individualised forensic assessment tools. It added jurisdictional specific content to Grisso's instruments to increase validity. It used a comparative design with participants from a real world criminal justice setting to ensure applicability to actual legal contexts.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study has a modest sample. The assessments were completed under ideal conditions and are likely to reflect an underrepresentation of deficits in the population. The underlying causes of impaired psycho-legal abilities were not explicitly assessed and raters were not blinded to the participants diagnostic status.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis is the first study that has attempted to empirically evaluate the psychol-egal abilities of young offenders with FASD. It highlights the need for specialised forensic assessments raises issues of remediation and the consideration of legal protections.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study follows rigorous ethical guidelines, including informed consent and institutional review board approval. Procedures for data collection, scoring, and statistical analysis are clearly documented, ensuring replicability.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study fills a critical research gap in forensic psychology and legal studies by providing empirical evidence on the psycho-legal abilities of young offenders with FASD.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study specifically highlights the challenges youth with FASD face in understanding their legal rights. The assessments align with the legal criteria for determining fitness to plead.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePei et al., (2016)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative research checklist\u003c/p\u003e\n\u003cp\u003e(Lockwood et al., 2015 )\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6/8 75%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides important information about the experiences of individuals living with FASD within the CJS. It had clear objectives, methodology and analysis.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe authors acknowledge that this study provides emerging and preliminary information. The study has a small sample in a limited jurisdiction. There is no explicit philosophical framework guiding the research and limited discussion of researcher bias and positionality.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides valuable evidence of the systematic challenges that individuals with FASD face in the CJS.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe use of semi structured interviews allowed for in depth exploration of the participant's experiences. The study uses thematic coding ensuring a structured approach and had a team of multiple coders to enhance trustworthiness and reduce bias.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study demonstrates strong validity it had clearly defined objectives used appropriate data collection methods, had ethical integrity, used a structured coding process and used direct quotes.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study is highly applicable as it provides first hand insights into the barriers individuals with FASD face in the CJS.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMcLachlan et al. (\u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eReporting Prevalence Data (Munn et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8/9 88%%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe sample size was adequate for estimating prevalence of FASD in a correctional population using active case assessment. It included power calculations, effect size, confidence intervals, comparability. It included a detailed descriptions of study subjects and setting. It followed Canadian FASD Diagnostic Guidelines. The team received training, supervision and consultation with clinicians and held case conferences to discuss findings and reach clinical consensus.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study acknowledges the estimates may be limited by a conservative sample size and voluntary participation. The challenge of confirming PAE in the non-clinically referred adult sample. The over representation of Indigenous Canadians recovering from colonist policies.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides important information for clinicians, administrators and policy makers in understanding the relevance of FASD across both the health and legal contexts. More diagnosed participants had significant impairment in the executive functioning domain. It raises the lack of training and awareness among clinicians, limited diagnostic capacity, evidence based screening tools and the relative 'invisibility' of FASD.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study measured the FASD in a standard and reliable way for all participants ensuring high consistency. Best practices for analysing forensic mental health data ensured the findings were systematic and unbiased.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMeasures were taken to ensure systematic and unbiased participant inclusion, reinforcing the study's validity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study provides quantitative evidence on the prevalence and cognitive impairments of individuals with FASD in correctional settings and the need for mental health professionals to consider FASD related impairments, mandatory screening protocols to ensure fair legal proceedings.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDouglas et al., (2012)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnalytical cross sectional studies (Moola et al., 2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7/8 87.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study employs a validated survey methodology, uses comparative legal analysis to contextualise findings, collects demographic information which strengthens validity. The method section is comprehensive outlines the research design, participant selection and ethical considerations.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study acknowledges the low response rates could introduce bias and that those who participated may have knowledge or an interest in FASD. The study employed self-reported responses that maybe subject to potential bias.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHighlights awareness of FASD limited to Queensland in contrast to the USA and Canada where courts often consider FASD in fitness to plead assessments. The unique difficulties FASD presents directly impacts their ability to participate in their defence. Current legal frame works do not adequately account for FASD. A Greater need for training to identify signs of cognitive impairment and adjust legal proceedings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe standardised survey methodology ensured consistency in data collection. The use of self-report is a common and accepted method for assessing professional knowledge and attitudes.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study employed appropriate statistical analysis methods to ensure the validity and reliability of its findings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study builds on existing studies highlighting gaps in judicial awareness and legal protections for individuals with FASD. It suggests that in light of the Extraordinary challenges FASD presents the criminal justice system should try things differently.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlagg et al., (\u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative research checklist (Lockwood et al., 2015 )\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9/10 90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe authors explicitly acknowledge their theoretical and cultural positioning. The aims align with the research question exploring justice interventions and alternatives for vulnerable defendants with FASD. The study integrates place-based interviews and focus groups ensuring indigenous voices shape the interpretation of results.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUsing a postcolonial perspective although acknowledged may influence the interpretation of findings. Although the article does not explicitly state the formal institutional ethics approval process (such as approval from a university ethics committee), it does emphasize community-based ethical approval and adherence to Indigenous research protocols.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHighlights legislation that enables a person who is found unfit to be indefinitely detained. Raises issue of legal advisors being put in a precarious position. FASD amplifying the chances of involvement in the CJS. Diversion is needed and alternative system. Highlights that Indigenous youth, with FASD and other cognitive impairments, maturation does not bring with it desistance from offending,\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study employs a qualitative action research approach, which aligns with the thematic analysis used to interpret findings. The study\u0026rsquo;s postcolonial framework ensures that results are analysed within the broader context of colonial dispossession, rather than in isolation.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe research process itself evolves through community dialogue, reinforcing the mutual impact between the researchers and the study participants.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBy embedding the research within Indigenous-owned agencies, the methodology ensures that results are interpreted through culturally secure lenses, rather than imposing Western legal perspectives. This congruity strengthens the study\u0026rsquo;s ability to propose meaningful reforms and highlight the systemic failures affecting Indigenous youth with FASD.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYoung et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChecklist for Case Series (Munn et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9/10 90%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe high methodological rigor, clear reporting and practical implications highlighted by this study make it a reliable and impactful research study.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study acknowledges that the small cohort should be considered when interpreting the results. The results are representative of one jurisdiction in Australia It was not established whether there was pretrial management of comorbid psychotic disorders and the potential contribution of close informants reports on court determinations were not assessed. The judicial determinations were not clear.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study indicates that the severity of cognitive impairment can be associated with unfitness. The pivotal role psychiatrists play in Mental Health Court (MHC) determinations for people with cognitive disabilities is highlighted. The need for training at every level of the justice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study followed structured psychiatric and cognitive evaluations conducted by psychiatrists ensuring consistency across all cases.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study ensured that all eligible cases within the timeframe were included to prevent selection bias. The identification of cognitive impairment was systematic and unbiased.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study provides quantitative evidence that the severity of cognitive impairment can be associated with unfitness. Psychiatrists play a pivotal role in MHC determinations for people with cognitive disabilities\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTan et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChecklist for Case Series (Munn et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5/8 62.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study had a comprehensive data collection over a five year period. It combines forensic evaluation with Youth Court outcomes providing a holistic view of fitness determinations. The study provides statistical rigor in its use of logistic regression to analyse predictors of fitness determinations.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe authors acknowledge that the data was captured from one youth forensic service in New Zealand limiting generalisation. That individual report writers could differ in their approach to evaluating fitness. As a retrospective study the standardisation of interviews did not occur. The Ministry of Justice data was limited reducing the sample size and could be biased. The IQ scores of 32 defendants were not recorded in the reports reviewed.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides empirical insights into how age, immaturity and diagnosis influence fitness determinations in New Zealand Youth Courts. It raises the issue of whether developmental immaturity and neurodisability like FASD should be explicitly considered in fitness assessments. It highlights the need for more screening and accommodations for individuals with FASD to ensure a fair proceedings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides a robust methodology using clear legal statutory criteria used logical regression and methods that ensure reliable associations between variables. The finding of 75% agreement rate between forensic evaluators and court determinations reinforce interrater reliability.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA structured data set was provided and records demographic, clinical and legal variables ensuring methodological transparency. However, there is no discussion of model assumptions which affects internal validity.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides specific evidence on whether youth with neurodisabilities like FASD should be explicitly considered in fitness assessments. 4% had FASD. Immaturity was considered. No association between diagnosis and court findings of unfitness.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWakefield et al., (2024)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChecklist for Case Series (Munn et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7/10 70%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study had a clearly defined study design, comprehensive case inclusion, detailed data collection and reporting and has a large data set.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe authors acknowledge incomplete data on the outcomes and the small number of unfit defendants. The reasons the assessors opined whether a defendant was fit or unfit was not analysed. Most reports did not use standardised fitness assessment instruments. The study has a regional focus and there is limited detail with regard to the statistical analysis of the data.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides empirical evidence on the increasing number of court ordered fitness assessments in New Zealand. It is relevant to forensic psychiatry resources, legal policy and human rights. The fact that few cases of FASD were highlighted raises concerns over underdiagnosis in forensic settings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe retrospective audit provides consistent data extraction over a eight year period. In 97% of cases the assessors reached agreement. The validity is affected by the limited transparency in statistical methods.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study uses established legal and forensic criteria and provides comprehensive data collection and consistent expert assessments. However, the legal disposition of 29 out of 105 unfit defendants was unknown creating gaps in the long term legal outcomes.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study has strong applicability in forensic psychiatry, legal policy and the challenges in providing sufficient provision of mental health services.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBrown et al., (\u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnalytical cross sectional studies (Moola et al., 2020)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6/8 75%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study uses a mixed method approach to highlight gaps in the District Attorney knowledge and training of FASD in the United States of America (USA). It uses a valid web based survey. It is noted that the open ended questions provide strong alignment with the research goals, ethical approval is acknowledged and there is meaningful interpretation of qualitative responses.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study relies on self-reported data which may introduce bias and has no standardised tool for measuring knowledge levels. The study has limited control over confounding factors. The authors acknowledge the modest response rate and the fact that it was limited to prosecutors. They consider the study exploratory. The qualitative response provides limited discussion in relation to researcher bias. There is also limited qualitative analysis on the findings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study provides empirical evidence that US prosecutors are not trained to recognise the unique difficulties individuals with FASD face which could lead to inappropriate prosecutions for those who lack capacity to participate in proceedings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe survey design, standardised questions and reproducibility of the findings demonstrates strong reliability. The modest response rate and self-reported data means there are some limitations with this study.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe study demonstrates strong validity in its methodology and reasonable accuracy in its findings.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThis study highlights significant gaps among US prosecutors regarding FASD related impairments that could affect a defendants ability to participate effectively in criminal proceedings.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eStudy Characteristics\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAuthor (s) and year\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eCountry\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSample/Population Characteristics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAims of the article\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eStudy Design and Method(s)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMain Findings\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMcLachlan et al., (\u003cspan class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTwo groups of young offenders 50 with FASD and 50 without prenatal alcohol exposure completed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo raise issues surrounding the law and justice intervention and non-intervention. To emphasise FASD cannot be uncoupled from the history of colonial settlement. To highlight the need for a fresh diversionary paradigm. To map out a reform agenda based on a decolonizing alternative to the mainstream justice process..\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative research undertaken in three indigenous communities. Interviews and roundtables.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWestern Australian legislation enables a person who is found unfit to be indefinitely detained. Legal advisors are put in a precarious position. Diversion or an alternative system is needed. Diversion for indigenous populations into indigenous owned therapeutic alternatives. In the context of many Indigenous youth, particularly those with FASD and other cognitive impairments, maturation does not bring with it desistance from offending. Judicial discretion should be used whilst reform takes place as it already exists in legislation and common law.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePei et al., (2016)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 individuals with an FASD (5 males, 4 females; mean age of 34.1 years, age range of 24\u0026ndash;59 years) 12 professionals working in the criminal justice system (3 males, 9 females).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo explore the experiences of individuals in the criminal justice system with a Fetal alcohol spectrum disorder (FASD) in order to identify possible ways to reduce the likelihood of re-entry into the criminal justice system.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative research methods used to interview individuals with FASD and professionals who work with clients with FASD. Part of a larger program of research.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOnce individuals with an FASD entered the criminal justice system, there were multiple factors that continued to place these individuals at a disadvantage. In particular: (1) biological factors, (2) psychological and social issues, and (3) factors that trapped individuals with FASD in the system and hindered their ability to fully understand and act in their best interest within the justice system\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMcLachlan et al. (\u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCanada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA sample of 80 justice-involved adults (ages 18\u0026ndash;40, 85% male) over an 18-month period from 2013 to 2015.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe participants completed interdisciplinary clinical assessments comprising medical and psychological evaluations to estimate the prevalence of FASD in Northern Canada\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA high rate of FASD was found which could have been as high as 31.2% with confirmation of prenatal alcohol exposure. Most participants in this study presented with significant neurodevelopmental and cognitive deficits in at least two domains of functioning, irrespective of diagnosis, It was noted that neurocognitive deficits could have an impact on fitness to plead.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDouglas et al., (2012)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAustralia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 magistrates, nine District Judges and two supreme Court judges\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo report the results of a survey of members of the Queensland judiciary about their understanding of FASD and how they deal with FASD in their judicial role\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSurvey by post and online. Questions about personal background, awareness of FASD, impact of FASD on practice and training, and information needs.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e80% of the judiciary had not heard of FASD. There are questions of fitness to plead in Canada and USA. The rushed environment of the lower courts and the pressure to plead guilty are not conducive to ensuring clear communication and understanding of the process for a person with FASD.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBlagg et al., (\u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAustralia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e60 people interviewed from legal and mental health services, 15 workers from partner organisations, 35 court and police personnel at a round table event.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo raise issues surrounding the law and justice intervention and non-intervention. To emphasise FASD cannot be uncoupled from the history of colonial settlement. To highlight the need for a fresh diversionary paradigm. To map out a reform agenda based on a decolonizing alternative to the mainstream justice process.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eQualitative research undertaken in three indigenous communities. Interviews and roundtables.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWestern Australian legislation enables a person who is found unfit to be indefinitely detained. Legal advisors are put in a precarious position. Diversion or an alternative system is needed. Diversion for indigenous populations into indigenous owned therapeutic alternatives. In the context of many Indigenous youth, particularly those with FASD and other cognitive impairments, maturation does not bring with it desistance from offending. Judicial discretion should be used whilst reform takes place as it already exists in legislation and common law.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYoung et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAustralia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eExtracted case file data of 92 individuals who had a criminal case referred to the Queensland Mental Health Court (MHC).\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo (1) describe the severity of impairment in\u003c/p\u003e\n\u003cp\u003epeople with cognitive disability referred to the\u003c/p\u003e\n\u003cp\u003eQueensland Mental Health Court; (2) estimate the association between severity of impairment and a determination of unsoundness or unfitness by the MHC; and (3) assess the socio-demographic, clinical and legal factors that predict being deemed unsound or unfit to stand trial by Court in Australia.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMHC record review\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOver half the individuals referred to the MHC had moderate to severe cognitive impairment with a 1.5 increased likelihood of being found unfit to stand trial compared to mild/borderline cognitive impairment. This study suggests that the clinical level of cognitive impairment is key in applying moral, social and legal criteria. Almost two in three individuals with mild or borderline cognitive disability were found unfit to stand trial by the MHC. Psychiatrists play a pivotal role in MHC determinations for people with cognitive disability. Disability-specific training for clinicians and justice professionals at every level of the justice and MHC process is needed. The study infers that Fetal alcohol spectrum disorder, and acquired brain injury may not result in significant cognitive impairment.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTan et al., (\u003cspan class=\"CitationRef\"\u003e2018\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNew Zealand\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA retrospective review fitness to stand trial reports for o 79 youth consecutively referred to the Region Regional Youth Forensic Service from 2010 to 2015\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo better understand how juvenile fitness to stand trial is approached in New Zealand, particularly with respect to the notion of immaturity and its effect on fitness to stand trial determinations in light of international research.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA cross-sectional observational study involving retrospective review of forensic evaluation reports and court outcomes.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMore than half (58%,\u0026nbsp;n\u0026nbsp;= 46) of youth in the sample were opined to be mentally impaired. Intellectual disability was the most common diagnosis. Other diagnoses used by evaluators to demonstrate mental impairment included attention deficit hyperactivity disorder (ADHD, 17%), psychosis (4%), autistic spectrum disorder (ASD, 4%) and foetal alcohol syndrome disorder (FASD, 4%),\u0026nbsp;No statistically significant association was found between these diagnoses and court findings of youth being unfit to stand trial.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWakefield et al., (2024)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNew Zealand\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eA retrospective audit of 415 defendants Court ordered health assessor reports.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo audit defendants assessed by a New Zealand forensic psychiatry service\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAn audit of fitness to stand trial assessments made by psychiatrists between 2014 and 2022.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary diagnoses were psychotic disorders (37%), intellectual disability (13%) and acquired neurocognitive disorders (15%). Few people with foetal alcohol spectrum disorder were identified suggesting FASD is overlooked by court assessors. The increase in fitness to stand trial reports has implications for the forensic mental health services.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBrown et al., (\u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e216 USA District Attorneys 166 men and 50 women\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTo investigate the knowledge and legal experiences of District Attorneys concerning FASD, and to compare these across sexes, legal experience levels, as well as geographical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe survey was distributed electronically to all US District Attorneys following the Dillman Total Design Method.\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThe need for forensic screening instruments. District attorneys were found to vary in their ability to accurately identify signs and symptoms of FASD, underestimated the prevalence of criminal justice involvement among individuals diagnosed with FASD. Not routinely aware of unique psycho-legal impairments of this population.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eThe titles and abstracts of 1722 studies were screened. Seven further empirical studies were identified from the citation search and the update searches. After the removal of duplicates and further screening 1051 studies were found to be irrelevant. Sixty-five studies were extracted and assessed for eligibility. A further 56 studies were excluded using the eligibility criteria leaving nine studies that provided empirical evidence from the database searches.\u003c/p\u003e\u003cp\u003eA total of nine empirical studies were identified in this scoping review investigating some aspect of FASD and fitness to participate within the CJS. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides the study characteristics stating the author and year, country, sample/population, aim of the study, the study design and methods and main findings.\u003c/p\u003e\u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e Study characteristics about here]\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Articles extracted\u003c/h2\u003e\u003cp\u003eThis review includes nine studies from four countries: Canada (3), Australia (3), New Zealand (2), and the United States (1). The extent to which these studies address fitness to participate in legal proceedings and FASD varies considerably, warranting an examination of the notable trends across the jurisdictions.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Notable Trends Across Jurisdictions\u003c/h2\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1 Canada\u003c/h2\u003e\u003cp\u003eThe scope and variety of studies within Canada provide a leading example of empirical Inquiry. In Canada, individuals with FASD have been recognized as a vulnerable population since the passing of resolutions by the Canadian Bar Association in 2011. The resolution underscored the increasing attention on FASD in North American justice policy (McLachlan et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). A landmark study by McLachlan and colleagues (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) was the first in-depth investigation into the cognitive impairments affecting legal fitness among individuals with FASD. This study highlights the challenges faced by youth in comprehending their legal rights and court proceedings. It specifically considered the issues surrounding fitness to participate and the abilities needed to participate effectively. Building on these findings, a 2016 qualitative study explored the lived experiences of individuals with FASD navigating the criminal justice system (Pei et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). This study provided direct evidence of the barriers faced by individuals living with FASD and their ability to understand court proceedings, marking it as the only study offering first-hand insights into legal competency concerns. A further advancement in empirical inquiry is evidenced by McLachlan and colleagues \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e quantitative study. The prevalence study examined the prevalence of FASD within correctional populations, utilizing active case assessments. The findings emphasized the urgent need for mental health professionals to incorporate FASD specific screenings in forensic evaluations (McLachlan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2 Australia\u003c/h2\u003e\u003cp\u003eAustralia has provided an emerging awareness of FASD and the issues surrounding fitness to participate and the institutional gaps (Tulich, 2020; Chisholm et at., 2017). Early discourse on FASD in Australian legal settings began with a 2012 study surveying the Queensland judiciary members on their knowledge of FASD (Douglas et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The study revealed systemic barriers, including the pressures to plead guilty in fast paced lower court environments, which pose additional challenges for individuals with FASD in understanding legal procedures. At the time, Canada and the USA were conducting routine FASD fitness to participate assessments, whereas the authors acknowledge that Australia and New Zealand had limited testing protocols. By 2017, research was expanded to include a discussion around fitness to participate with qualitative research addressing the fitness to plead assessments, the vulnerabilities of Indigenous youth, and the need for alternative solutions incorporating community participation (Blagg et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Further research in 2018, examined case file data from the Queensland Mental Health Court (MHC). The authors of the 2018 study found notable associations between cognitive impairments and unfitness determinations (Young et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). While the study suggested that FASD may not necessarily lead to severe cognitive impairment, it highlighted that two in three individuals with mild to borderline cognitive disabilities were deemed unfit to stand trial by the MHC.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3 New Zealand\u003c/h2\u003e\u003cp\u003eResearch from New Zealand has shown an increased awareness of the issue surrounding fitness to participate and the empirical studies have concentrated on forensic assessment and judicial recognition. In 2018 a retrospective study examined 79 cases in the Youth Court, evaluating how fitness assessments influenced judicial outcomes (Tan et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). This study revealed a strong association between intellectual disability and unfit to participate determinations, though FASD diagnoses (4%) did not show statistical significance in judicial findings. In contrast, a recent 2024 forensic psychiatry audit assessed fitness to participate evaluations within adult criminal proceedings (Wakefield et al., 2024). Despite FASD\u0026rsquo;s known prevalence within the CJS, only a small number of cases were formally identified, indicating gaps in screening and recognition. This lack of identification was noted despite disability advocacy groups supporting the courts in relation to neurodivergent cases. The study reinforced the growing demand for forensic mental health services.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.2.4 USA\u003c/h2\u003e\u003cp\u003eIn the USA empirical evidence on fitness to participate and the issues surrounding fitness remains limited. In 2016 a web-based survey assessed prosecuting District Attorneys' awareness and experience with FASD related legal issues (Brown et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). While the study offered limited insights into fitness to participate concerns, it highlighted significant gaps in prosecutorial knowledge underscoring the need for improved training, screening protocols, and research into legal comprehension issues.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Comparative Findings\u003c/h2\u003e\u003cp\u003eAcross the jurisdictions identified, Canada leads in empirical research, conducting comprehensive investigations into cognitive impairments, legal fitness, prevalence, and lived experiences. Australia\u0026rsquo;s framework is evolving, with growing judicial awareness and the emergence of mental health courts to assess fitness to participate concerns. New Zealand is increasingly incorporating forensic assessments into legal proceedings and has an awareness of the challenges individuals with FASD face, although formal identification of FASD remains inconsistent. The United States has explored prosecutorial awareness, but systemic knowledge gaps persist, affecting the application of FASD related fitness to participate assessments in court.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Case Law Reviews and Judicial Interpretation\u003c/h2\u003e\u003cp\u003eThe empirical studies identified in this scoping review provide evidence that recognition of FASD within judicial proceedings remains inconsistent. This is also evidenced by the limited discussion of FASD within fitness to participate appeal cases reviewed from the court decisions. In 2023 a systematic review of 350 Canadian cases found that only two appeal cases referenced FASD in fitness to participate considerations and the FASD evidence \u0026lsquo;\u003cem\u003edid not have great relevance in either of the two cases\u003c/em\u003e\u0026rsquo; (Mullally et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2023\u003c/span\u003e:425).\u003c/p\u003e\u003cp\u003eIn the USA, federal case law reviews indicate broader fitness to participate concerns. A 2022 survey by Brown et al. explored FASD-related suggestibility and wrongful convictions, but none appeared to directly examine fitness to participate (Brown et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Similarly, a 2013 study by Douds and colleagues found that courts refused to hold competency hearings based solely on prenatal toxic exposure (Douds et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile fitness to participate determinations remain underexplored, these reviews underscore ongoing legal challenges. The Judges appear to recognise the implications of FASD, but the application within fitness to participate hearings remains inconsistent, highlighting the urgent need for improved screening, legal education, and standardized protocols in fitness to participate assessments.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThe empirical studies reviewed in this research underscore the vulnerabilities of both youth and adults with FASD in legal proceedings, particularly regarding fitness to participate. Despite the variations in study methodologies, there is growing international recognition of the need to address critical issues when individuals with FASD face the justice system (Flannigan et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis section examines the broader legal and theoretical concerns raised in the identified empirical studies, along with insights from discussion articles and the case law reviews. Key themes include judicial inconsistencies in recognizing FASD related impairments, barriers to fitness to participate assessments, and the challenges of ensuring fair trial participation. By integrating these perspectives, this discussion highlights the need for enhanced legal frameworks, improved assessments, and greater awareness of the impact of FASD on legal processes.\u003c/p\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Judicial Awareness and Training Deficiencies\u003c/h2\u003e\u003cp\u003eFASD has been described as an invisible disability due to the variability in cognitive functioning. Where expressive language abilities may remain intact, an illusion of competence, despite significant underlying impairments (such as comprehension) being present (Chudley, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). The first challenge for legal professionals is to be able to recognise the possibility of FASD and the impact it is likely to have on defendants ability to be fit to participate in proceedings (Passmore et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). There also remains a significant challenge in relation to diagnosis, with FASD frequently being missed or misdiagnosed as Attention Deficit Hyperactivity Disorder (ADHD), Autism Spectrum Disorders (ASD), or conduct disorders. This challenge leads to inaccurate prevalence estimates and missed opportunities for early intervention (Chasnoff et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; McLachlan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eCurrent research indicates that a Legal professionals' ability to identify and accommodate FASD in court proceedings varies. In Canada, Gagnier et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) emphasise the importance of legal counsel introducing the possibility of FASD, noting that expert assessments and testimony can significantly aid judicial decision-making. However, they caution that the justice system should not become a substitute for social services. This contrasts with Johansen-Hill (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who argues that deficiencies in community resources often force the criminal justice system to compensate, making its role in supporting individuals with FASD a necessity. Butcher (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) further underscores this concern in New Zealand, emphasising that individuals with FASD frequently face cycles of addiction and poverty. Butcher considers that because FASD cannot be cured, the quality of life for affected individuals is highly dependent on legal and societal support, making criminal law a vital institution for ensuring fair treatment.\u003c/p\u003e\u003cp\u003eDue to complex nature of FASD, and the need for multidisciplinary assessments, medical-legal reports often fail to fully consider the cognitive impairments associated with FASD. McLachlan et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) noted that psycho-legal deficits in defendants with FASD receive less attention than severe psychopathology, likely due to their cooperative demeanour. Additionally, Roach \u0026amp; Bailey suggested that the fast-paced environment of lower courts exacerbated these challenges, pressuring defendants to plead guilty prematurely and limiting their ability to communicate effectively (Roach \u0026amp; Bailey, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2009\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFinally, there remains a significant gap in training for legal professionals, medical practitioners, and the judiciary regarding FASD, its manifestations, and its impact on competency assessments (Mela, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Allely \u0026amp; Gebbia, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Brown et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Allely \u0026amp; Mukherjee, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). An illustrative example comes from Wakefield et al. (2024), who found that among 415 fitness to stand trial reports in New Zealand, few suspected FASD cases were identified despite the presence of disability advocacy groups within the courts. This suggests systemic oversight in recognizing FASD, reinforcing the urgent need for enhanced judicial training and standardised evaluation protocols.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Systematic Barriers in Legal Processes\u003c/h2\u003e\u003cp\u003eOne of the most pressing concerns in the fitness to participate determinations is the role of immaturity, particularly in young defendants with FASD facing criminal proceedings. FASD can result in young adults functioning cognitively at the level of a child. Within the legal system developmental immaturity is rarely anticipated or addressed (Fast \u0026amp; Conry, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Three empirical studies in this review highlight the overrepresentation of Indigenous youth within the CJS in Western Australian, New Zealand and Canadian courts. Tan et al. (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) found that immaturity did not significantly influence mental health evaluators' assessments of fitness, suggesting that New Zealand evaluators apply a higher threshold for fitness compared to the Youth Court standard. In contrast, USA judges explicitly factor age into fitness determinations, demonstrating jurisdictional differences in the role of developmental maturity in legal decisions. Studies have indicated that there are broader implications regarding immaturity in fitness to participate determinations with a need for further discussion in relation to the implications in criminal proceedings (Blagg et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e; McLachlan et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Tan et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBeyond youth-related immaturity, lifelong fitness concerns for individuals with FASD further complicate judicial proceedings. McLachlan et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) emphasise that defendants found unfit are not restorable to fitness may face indefinite detention, imprisonment, or supervision with conditions they cannot realistically follow (Roach \u0026amp; Bailey, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). In serious cases, charges are rarely discharged, creating long-term barriers for affected individuals. To address these gaps, researchers advocate for alternative court models that accommodate individuals with FASD and psycho-legal impairments. Blagg et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), Chisholm et al. (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2017\u003c/span\u003e), and Bush (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2017\u003c/span\u003e) propose a needs-based approach for unfit Aboriginal persons with FASD, ensuring culturally responsive legal interventions. Perlin \u0026amp; Cucolo (2022) position FASD as both a due process issue and a human rights concern, advocating for therapeutic jurisprudence as a key legal framework.\u003c/p\u003e\u003cp\u003eFurther discussions on specialized courts reinforce the necessity for legal environments to be tailored to neurodevelopmental disabilities. Wartnik \u0026amp; Carlson (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) examined case studies from Therapeutic Drug Courts, while Brown et al. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) called for greater judicial intervention through specialized FASD courts. Douglas et al. (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) explored problem-solving courts, highlighting Brisbane\u0026rsquo;s Special Circumstances Court as a model that supports defendants with homelessness, impaired decision-making capacity, and minor criminal charges through rehabilitation and treatment-oriented strategies.\u003c/p\u003e\u003cp\u003eThese discussions underscore the urgent need for systemic reforms, particularly in fitness to participate determinations for individuals with FASD. Specialised legal frameworks, enhanced judicial awareness, and improved access to alternative court models are essential to addressing the persistent barriers faced by vulnerable defendants.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Standardizing Fitness Assessments and Screening\u003c/h2\u003e\u003cp\u003eThe need for standardised screening and assessment protocols for FASD has been widely discussed across the empirical and review studies (Passmore et al., 2016; Brown et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Allely \u0026amp; Mukherjee, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). While recognizing the challenges in developing effective screening tools due to FASD\u0026rsquo;s complex presentation, researchers emphasize that such instruments could enhance identification, evaluation, and competency determinations (Brown, 2024).\u003c/p\u003e\u003cp\u003eThe only UK discussion paper identified in this scoping review reinforces this need. While primarily focused on suggestibility, false confessions, and competency concerns within an American context, it raises significant recommendations, including an urgent need for further empirical research into the psycho-legal impact of FASD, specialised training for medical and legal professionals, and the implementation of formal screening protocols to address gaps in structured assessment measures (Allely \u0026amp; Mukherjee, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec23\" class=\"Section2\"\u003e\u003ch2\u003e4.4 Rethinking Traditional Fitness to Participate Assessments\u003c/h2\u003e\u003cp\u003eThe use of traditional fitness to participate assessments remains inconsistent, hindered by the absence of standardised screening protocols. Existing fitness determinations frequently overlook key factors such as developmental immaturity and co-morbid conditions with a reliance on IQ based metrics. Mela in 2022 criticised the use of traditional competency frameworks, arguing that legal professionals fail to account for the functional realities of FASD when applying models designed for neurotypical individuals. Studies have suggested that assessments should align with adaptive and executive functioning capacities, a recommendation echoed in Brookbanks et al. (2021) and Butcher (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), who advocate for screening beyond IQ and facial dysmorphology to determine a defendants legal participation capability.\u003c/p\u003e\u003cp\u003eThe lack of judicial awareness of FASD and the need to incorporate a holistic approach to assessments was discussed by Luckasson \u0026amp; Schalock in 2015. The authors stressed the importance of disability-specific training for professionals, advocating for culturally validated standardised diagnostic and screening tools. They emphasised a need to incorporate collateral information from individuals close to the defendant rather than relying solely on clinical assessments.\u003c/p\u003e\u003cp\u003eThese findings reinforce the urgent need to modernize legal fitness to participate assessments, moving beyond outdated methodologies toward individualised, evidence-based screening protocols tailored to FASD and other cognitive disabilities.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Limitations\u003c/h2\u003e\u003cp\u003eAlthough extensive search terms were used in this review it is possible that the search failed to capture all of the relevant research in this field. To minimise the risk of missing any relevant articles additional searches on \u0026lsquo;Google Scholar\u0026rsquo; were made using the search criteria previously mentioned (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAll of the studies extracted had limitations when checked for quality and rigour either due to modest or limited samples, incomplete data of self-reported data (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e2\u003c/span\u003e). However, many of the limitations had been acknowledged by the authors with suggestions made for future research.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Future research\u003c/h2\u003e\u003cp\u003eThis review highlights several critical gaps requiring further investigation to improve fairness and access to justice for individuals with FASD in relation to the ability of being fit to participate. Key priorities include enhancing judicial awareness through targeted training, particularly its influence on fitness to participate assessments and legal outcomes. Research should also explore how developmental immaturity and co-occurring conditions impact assessment validity. Standardisation is essential in developing structured screening tools, specifically for FASD. Research is also required to evaluate the reliability of assessments with a view to including adaptive and executive functioning in all assessments. Ultimately there is a need make further inquiry into therapeutic courts and specialised legal responses to support equitable trial participation. Broader systemic reform should also consider alternative legal frameworks that better accommodate neurodevelopmental impairments.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review sought to identify empirical studies examining FASD in relation to fitness to participate or comparable legal constructs internationally. The findings reveal that while Canada, the USA, Australia, and New Zealand have begun addressing this issue within legal frameworks, research remains extremely limited in the UK, exposing a significant gap in judicial understanding and implementation.\u003c/p\u003e\u003cp\u003eFurther research is required to examine cross-national approaches, ensuring legal frameworks are both comprehensive and adaptable to the unique needs of individuals with FASD. By prioritizing these research and policy advancements, legal systems can progress toward more informed, consistent, and fair competency determinations, ensuring that individuals with FASD receive the recognition, accommodations, and protections necessary for meaningful participation in legal proceedings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo funding was received\u003c/p\u003e\u003cp\u003eAvailability of data and materials\u003c/p\u003e\u003cp\u003eThis study is a systematic scoping review and did not involve the collection of original empirical data. All data extracted from the included studies during the review process are available within the article. The screening and selection process was conducted using Covidence software.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor 1 wrote the main manuscript text and author 2-4 reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAllely, C. S., \u0026amp; Gebbia, P. (2016). Studies investigating fetal alcohol spectrum disorders in the criminal justice system: a systematic PRISMA review. \u003cem\u003eSOJ Psychology\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15226/2374-6874/3/1/00123\u003c/span\u003e\u003cspan address=\"10.15226/2374-6874/3/1/00123\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAllely, C. S., \u0026amp; Mukherjee, R. (2019). Suggestibility, false confessions and competency to stand trial in individuals with fetal alcohol spectrum disorders: Current concerns and recommendations. \u003cem\u003eJournal of Criminal Psychology\u003c/em\u003e, \u003cem\u003e9\u003c/em\u003e(4), 166\u0026ndash;172. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi-org.salford.idm.oclc\u003c/span\u003e\u003cspan address=\"https://doi-org.salford.idm.oclc\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.org/10.1108/JCP-11-2019-050\u003c/span\u003e\u003cspan address=\".10.1108/JCP-11-2019-050\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlagg, H., Tulich, T., \u0026amp; Bush, Z. (2017). Indefinite detention meets colonial dispossession: Indigenous youths with foetal alcohol spectrum disorders in a white settler justice system. \u003cem\u003eSocial \u0026amp; Legal Studies\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(3), 333\u0026ndash;358. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi-org.salford.idm\u003c/span\u003e\u003cspan address=\"https://doi-org.salford.idm\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.oclc.org/10.1177/0964663916676650\u003c/span\u003e\u003cspan address=\".oclc.10.1177/0964663916676650\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlake, G.A., Ogloff, J., \u0026amp; Fullam, R. (2022). Knowledge and Opinions of Fitness to Stand Trial Elements in Australia. \u003cem\u003eInternational Journal of Forensic Mental Health\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(3), 241\u0026ndash;255. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/14999013.2021.1966140\u003c/span\u003e\u003cspan address=\"10.1080/14999013.2021.1966140\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBlake, G. A., Ogloff, J. R., \u0026amp; Antolak-Saper, N. (2023). Interpreting R v Presser: a clinician\u0026rsquo;s guide to contemporary Australian fitness to stand trial case law. \u003cem\u003ePsychiatry, Psychology and Law\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(6), 836\u0026ndash;862. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi-org.salford.idm.\u003c/span\u003e\u003cspan address=\"https://doi-org.salford.idm.\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eoclc.org/10.1080/13218719.2022.2136278\u003c/span\u003e\u003cspan address=\"oclc.10.1080/13218719.2022.2136278\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrookbanks, W., McGinn, V., \u0026amp; Chu, J. T. W. (2022). Unfitness to stand trial and fetal alcohol spectrum disorder: Understanding and responding to FASD within the criminal justice system in New Zealand. \u003cem\u003eBehavioral Sciences \u0026amp; the Law\u003c/em\u003e, \u003cem\u003e40\u003c/em\u003e(1), 159\u0026ndash;169. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/bsl.2555\u003c/span\u003e\u003cspan address=\"10.1002/bsl.2555\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown, J., Helmstetter, D., Harr, D., \u0026amp; Singh, J. (2016). Perceptions of FASD by United States district attorneys. \u003cem\u003eJournal of Intellectual Disabilities and Offending Behaviour\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(4), 195\u0026ndash;201. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/JIDOB-04-2016-0005\u003c/span\u003e\u003cspan address=\"10.1108/JIDOB-04-2016-0005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown, J. M., Haun, J., Zapf, P. A., \u0026amp; Brown, N. N. (2017). Fetal Alcohol Spectrum Disorders (FASD) and competency to stand trial (CST): Suggestions for a \u0026lsquo;best practices\u0026rsquo; approach to forensic evaluation. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e52\u003c/em\u003e, 19\u0026ndash;27. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijlp.2017.04.002\u003c/span\u003e\u003cspan address=\"10.1016/j.ijlp.2017.04.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown, J., Madore, E., Carter, M. N., Spiller, V., \u0026amp; Jozan, A. (2022). Fetal alcohol spectrum disorder (FASD) and suggestibility: A survey of united states federal case law. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e80\u003c/em\u003e, 101763. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi-org.salford.idm.oclc\u003c/span\u003e\u003cspan address=\"https://doi-org.salford.idm.oclc\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.org/10.1016/j.ijlp.2021.101763\u003c/span\u003e\u003cspan address=\".10.1016/j.ijlp.2021.101763\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBrown, J., Lewis, D. S., Kivisalu, T., Wartnik, A. P., Carter, M. N., Harr, D., Jozan, A., \u0026amp; Gilbert, D. J. (2024). Fetal alcohol spectrum disorder (FASD) and the criminal justice system: A guide for legal professionals. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e97\u003c/em\u003e, Article 102029. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijlp.2024.102029\u003c/span\u003e\u003cspan address=\"10.1016/j.ijlp.2024.102029\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBush, Z. (2017). Healing colonial binaries: a \u0026ldquo;needs-based\u0026rdquo; approach to Aboriginal persons found unfit to stand trial on the basis of FASD. \u003cem\u003eGriffith Law Review\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e(3), 401\u0026ndash;429. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/10383441.2017.1436373\u003c/span\u003e\u003cspan address=\"10.1080/10383441.2017.1436373\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eButcher, J. (2020). The revolving door: Are we sentencing people with FASD to a life trapped in the criminal justice system? \u003cem\u003eAuckland University Law Review\u003c/em\u003e, \u003cem\u003e26\u003c/em\u003e, 150\u0026ndash;177.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChasnoff, I. J., Wells, A. M., \u0026amp; King, L. (2015). Misdiagnosis and missed diagnoses in foster and adopted children with prenatal alcohol exposure. \u003cem\u003ePediatrics\u003c/em\u003e, \u003cem\u003e135\u003c/em\u003e(2), 264\u0026ndash;270. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1542/peds.2014-2171\u003c/span\u003e\u003cspan address=\"10.1542/peds.2014-2171\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChisholm, R., Tulich, T., \u0026amp; Blagg, H. (2017). Indigenous young people with foetal alcohol spectrum disorders: The convention on the rights of persons with disabilities and reform to the law governing fitness to stand trial in Western Australia. \u003cem\u003eLaw in Context\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(2), 85\u0026ndash;107.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChudley, A. E. (2008). Fetal alcohol spectrum disorder: counting the invisible \u0026ndash; mission impossible? \u003cem\u003eArchives of Disease in Childhood\u003c/em\u003e, \u003cem\u003e93\u003c/em\u003e(9), 721\u0026ndash;722. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/adc.2008.137109\u003c/span\u003e\u003cspan address=\"10.1136/adc.2008.137109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCouncil of Europe \u0026amp; European Court of Human Rights. (1950). \u003cem\u003eEuropean Convention on Human Rights\u003c/em\u003e (Article 6). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.echr.coe.int/documents/convention_\u003c/span\u003e\u003cspan address=\"https://www.echr.coe.int/documents/convention_\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDouds, A. S., Stevens, H. R., \u0026amp; Sumner, W. E. (2013). Sword or Shield? A Systematic Review of the Roles FASD Evidence Plays in Judicial Proceedings. \u003cem\u003eCriminal Justice Policy Review\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(4), 492\u0026ndash;509. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/0887403412447809\u003c/span\u003e\u003cspan address=\"10.1177/0887403412447809\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDouglas, H., Hammill, J., Hall, W., \u0026amp; Russell, E. (2012). Judicial views of foetal alcohol spectrum disorder in Queensland's criminal justice system. \u003cem\u003eJournal of Judicial Administration\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(3), 178\u0026ndash;188.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDunbar Winsor, K. (2021). An invisible problem: stigma and FASD diagnosis in the health and justice professions. \u003cem\u003eAdvances in Dual Diagnosis\u003c/em\u003e, \u003cem\u003e14\u003c/em\u003e(1), 8\u0026ndash;19. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1108/ADD-07-2020-0014\u003c/span\u003e\u003cspan address=\"10.1108/ADD-07-2020-0014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFast, D. K., \u0026amp; Conry, J. (2009). Fetal alcohol spectrum disorders and the criminal justice system. \u003cem\u003eDevelopmental Disabilities Research Reviews\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(3), 250\u0026ndash;257. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi-org.salford.idm.oclc\u003c/span\u003e\u003cspan address=\"https://doi-org.salford.idm.oclc\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e.org/10.1002/ddrr.66\u003c/span\u003e\u003cspan address=\".10.1002/ddrr.66\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlannigan, K., Pei, J., Stewart, M., \u0026amp; Johnson, A. (2018). Fetal Alcohol Spectrum Disorder and the criminal justice system: A systematic literature review. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e, 42\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijlp.2017.12.008\u003c/span\u003e\u003cspan address=\"10.1016/j.ijlp.2017.12.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlannigan, K., Wrath, A., Ritter, C., McLachlan, K., Harding, K. D., Campbell, A., Reid, D., \u0026amp; Pei, J. (2021). Balancing the story of fetal alcohol spectrum disorder: A narrative review of the literature on strengths. \u003cem\u003eAlcoholism, Clinical and Experimental Research\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(12), 2448\u0026ndash;2464. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/acer.14733\u003c/span\u003e\u003cspan address=\"10.1111/acer.14733\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFlannigan, K., Pun, J. W., Buttinger, P., McLachlan, K., Holmstrom, K., Tremblay, M., Mela, M., \u0026amp; Pei, J. (2025). An updated systematic review of the literature on fetal alcohol spectrum disorder and the criminal legal system. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e100\u003c/em\u003e, Article 102073. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijlp.2025.102073\u003c/span\u003e\u003cspan address=\"10.1016/j.ijlp.2025.102073\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreckelton, I. (2016). Expert evidence in fetal alcohol spectrum disorder cases. \u003cem\u003eEthics, Medicine, and Public Health\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(1), 59\u0026ndash;73. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jemep.2016.01.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jemep.2016.01.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGagnier, K. R., Moore, T. E., \u0026amp; Green, J. M. (2011). A need for closer examination of FASD by the criminal justice system: Has the call been answered? \u003cem\u003eJournal of Population Therapeutics and Clinical Pharmacology\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(3), e426\u0026ndash;e439\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGilbert, D. J., Allely, C. S., Hickman, N., Mukherjee, R. A. S., \u0026amp; Cook, P. A. (2023). \u0026lsquo;I inevitably get in trouble \u0026hellip; in one way or another\u0026rsquo;: Qualitative exploration of the vulnerabilities and experiences of justice system encountered individuals with fetal alcohol spectrum disorder. \u003cem\u003eForensic Science International. Mind and Law\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e, Article 100124. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.fsiml.2023.100124\u003c/span\u003e\u003cspan address=\"10.1016/j.fsiml.2023.100124\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGordon, F., Madore, E., \u0026amp; Novick Brown, N. (2021). Prosecutorial Decision-Making and Practice: Victims and Witnesses with Fetal Alcohol Spectrum Disorders. In \u003cem\u003eEvaluating Fetal Alcohol Spectrum Disorders in the Forensic Context\u003c/em\u003e (pp. 443\u0026ndash;464). Springer International Publishing. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/978-3-030-73628-6_17\u003c/span\u003e\u003cspan address=\"10.1007/978-3-030-73628-6_17\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJohansen-Hill, Z. (2019). Proportionate justice: An examination of fetal alcohol spectrum disorders and the principles of sentencing in Saskatchewan. \u003cem\u003eSaskatchewan Law Review\u003c/em\u003e, \u003cem\u003e82\u003c/em\u003e(\u003cem\u003e1\u003c/em\u003e), 75\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuckasson, R., \u0026amp; Schalock, R. L. (2015) Standards to guide the use of clinical judgment in the field of intellectual disability. \u003cem\u003eIntellectual and Developmental Disabilities 53\u003c/em\u003e, 240\u0026ndash;51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1352/1934-9556-53.3.240\u003c/span\u003e\u003cspan address=\"10.1352/1934-9556-53.3.240\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcCarthy, R., Mukherjee, R. A. S., Fleming, K. M., Green, J., Clayton-Smith, J., Price, A. D., Allely, C. S., \u0026amp; Cook, P. A. (2021). Prevalence of fetal alcohol spectrum disorder in Greater Manchester, UK: An active case ascertainment study. \u003cem\u003eAlcoholism, Clinical and Experimental Research\u003c/em\u003e, \u003cem\u003e45\u003c/em\u003e(11), 2271\u0026ndash;2281. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/acer.14705\u003c/span\u003e\u003cspan address=\"10.1111/acer.14705\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcLachlan, K., Roesch, R., Viljoen, J. L., \u0026amp; Douglas, K. S. (2014). Evaluating the Psycholegal Abilities of Young Offenders With Fetal Alcohol Spectrum Disorder. \u003cem\u003eLaw and Human Behavior\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e(1), 10\u0026ndash;22. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/lhb0000037\u003c/span\u003e\u003cspan address=\"10.1037/lhb0000037\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcLachlan, K., McNeil, A., Pei, J., Brain, U., Andrew, G., \u0026amp; Oberlander, T. F. (2019). Prevalence and characteristics of adults with fetal alcohol spectrum disorder in corrections: a Canadian case ascertainment study. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), Article 43. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-018-6292-x\u003c/span\u003e\u003cspan address=\"10.1186/s12889-018-6292-x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMay, P. A., Chambers, C. D., Kalberg, W. O., Zellner, J., Feldman, H., Buckley, D., Kopald, D., Hasken, J. M., Xu, R., Honerkamp-Smith, G., Taras, H., Manning, M. A., Robinson, L. K., Adam, M. P., Abdul-Rahman, O., Vaux, K., Jewett, T., Elliott, A. J., Kable, J. A., \u0026hellip; Hoyme, H. E. (2018). Prevalence of Fetal Alcohol Spectrum Disorders in 4 US Communities. \u003cem\u003eJAMA: The Journal of the American Medical Association\u003c/em\u003e, \u003cem\u003e319\u003c/em\u003e(5), 474\u0026ndash;482. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1001/jama.2017.21896\u003c/span\u003e\u003cspan address=\"10.1001/jama.2017.21896\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMela, M. (2022). The Blind Spot of Medico-Legal Implications of Prenatal Alcohol Exposure. \u003cem\u003eThe Journal of the American Academy of Psychiatry and the Law\u003c/em\u003e, \u003cem\u003e50\u003c/em\u003e(4), 509\u0026ndash;516.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMeltzer, L. J., Pollica, L., Barzillai, M., \u0026amp; Meltzer, L. (2007). Executive function in the classroom: Embedding strategy instruction into daily teaching practices. \u003cem\u003eExecutive function in education\u003c/em\u003e. \u003cem\u003eNew York: Guildford\u003c/em\u003e, 165\u0026ndash;193.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMullally, K., McLachlan, K., Jewell, E., Viljoen, J., \u0026amp; Rudin, J. (2023). Fetal Alcohol Spectrum Disorder Evidence in Canadian Criminal Cases: A Case Law Review. \u003cem\u003ePsychology, Public Policy, and Law\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(4), 417\u0026ndash;434. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1037/law0000391\u003c/span\u003e\u003cspan address=\"10.1037/law0000391\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunn, Z., Moola, S., Lisy, K., Riitano, D., \u0026amp; Tufanaru, C. (2015). Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. \u003cem\u003eJBI Evidence Implementation\u003c/em\u003e, \u003cem\u003e13\u003c/em\u003e(3), 147\u0026ndash;153.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMunn, Z., Barker, T. H., Moola, S., Tufanaru, C., Stern, C., McArthur, A., \u0026hellip; Aromataris, E. (2020). Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. \u003cem\u003eJBI evidence synthesis\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(10), 2127\u0026ndash;2133. \u003cem\u003eDOI: 10.1097/XEB.0000000000000054\u003c/em\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOwusu-Bempah, A. (2018). The interpretation and application of the right to effective participation. \u003cem\u003eThe International Journal of Evidence \u0026amp; Proof\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(4), 321\u0026ndash;341. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/1365712718780800\u003c/span\u003e\u003cspan address=\"10.1177/1365712718780800\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePage, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hr\u0026oacute;bjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., \u0026hellip; Moher, D. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. \u003cem\u003eBMJ (Online)\u003c/em\u003e, \u003cem\u003e372\u003c/em\u003e, n71\u0026ndash;n71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1136/bmj.n71\u003c/span\u003e\u003cspan address=\"10.1136/bmj.n71\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePassmore, H. M., Mutch, R. C., Burns, S., Watkins, R., Carapetis, J., Hall, G., \u0026amp; Bower, C. (2018). Fetal Alcohol Spectrum Disorder (FASD): Knowledge, attitudes, experiences and practices of the Western Australian youth custodial workforce. \u003cem\u003eInternational Journal of Law and Psychiatry\u003c/em\u003e, \u003cem\u003e59\u003c/em\u003e, 44\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.ijlp.2018.05.008\u003c/span\u003e\u003cspan address=\"10.1016/j.ijlp.2018.05.008\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePei, J., Leung, W. S. W., Jampolsky, F., \u0026amp; Alsbury, B. (2016). Experiences in the Canadian Criminal Justice System for Individuals with Fetal Alcohol Spectrum Disorders: Double Jeopardy? \u003cem\u003eCanadian Journal of Criminology and Criminal Justice\u003c/em\u003e, \u003cem\u003e58\u003c/em\u003e(1), 56\u0026ndash;86. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3138/cjccj.2014.E25\u003c/span\u003e\u003cspan address=\"10.3138/cjccj.2014.E25\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePerlin, M. L., \u0026amp; Cucolo, H. E. (2023). \u0026ldquo;Take the Motherless Children off the Street\u0026rdquo;: Fetal Alcohol Syndrome and the Criminal Justice System. \u003cem\u003eUniversity of Miami Law Review\u003c/em\u003e, \u003cem\u003e77\u003c/em\u003e(3), 561\u0026ndash;612.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePopova, S., Lange, S., Bekmuradov, D., Mihic, A., \u0026amp; Rehm, J. (2011). Fetal Alcohol Spectrum Disorder Prevalence Estimates in Correctional Systems: A Systematic Literature Review. \u003cem\u003eCanadian Journal of Public Health\u003c/em\u003e, \u003cem\u003e102\u003c/em\u003e(5), 336\u0026ndash;340. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF03404172\u003c/span\u003e\u003cspan address=\"10.1007/BF03404172\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePopova, S., Lange, S., Poznyak, V., Chudley, A. E., Shield, K. D., Reynolds, J. N., Murray, M., \u0026amp; Rehm, J. (2019). Population-based prevalence of fetal alcohol spectrum disorder in Canada. \u003cem\u003eBMC Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(1), Article 845. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12889-019-7213-3\u003c/span\u003e\u003cspan address=\"10.1186/s12889-019-7213-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoach, K, \u0026amp; Bailey, A. (2009). The relevance of fetal alcohol spectrum disorder in Canadian criminal law from investigation to sentencing. \u003cem\u003eBoston College Law Review\u003c/em\u003e, \u003cem\u003e42\u003c/em\u003e, 1.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTan, D., Friedman, S. H., Armstrong, C., Fitzgerald, J. T., \u0026amp; Neumann, C. (2018). New Zealand youth fitness to stand trial: The impact of age, immaturity and diagnosis on evaluator opinions and court determinations. \u003cem\u003ePsychiatry, Psychology and Law\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 374\u0026ndash;385. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/13218719.2017.1396867\u003c/span\u003e\u003cspan address=\"10.1080/13218719.2017.1396867\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTricco, A. C., Lillie, E., Zarin, W., O\u0026rsquo;Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., \u0026hellip; Straus, S. E. (2018). \u003cem\u003ePRISMA Extension for Scoping Reviews (PRISMA-ScR):Checklist and Explanation\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.7326/M18-0850\u003c/span\u003e\u003cspan address=\"10.7326/M18-0850\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTsang, T. W., Rosenblatt, D. H., Parta, I., \u0026amp; Elliott, E. J. (2025). Estimating the Prevalence of Fetal Alcohol Spectrum Disorder in Australia. \u003cem\u003eDrug and Alcohol Review\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(5), 1522\u0026ndash;1525. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/dar.14082\u003c/span\u003e\u003cspan address=\"10.1111/dar.14082\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTulich, T. (2021). FASD in the courts: Fitness to stand trial. In \u003cem\u003eDecolonising Justice for Aboriginal Youth with Fetal Alcohol Spectrum Disorders\u003c/em\u003e (1st ed., pp. 78\u0026ndash;96). Routledge. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.4324/9780429325526-4\u003c/span\u003e\u003cspan address=\"10.4324/9780429325526-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnited Nations. (2006). \u003cem\u003eConvention on the Rights of Persons with Disabilities\u003c/em\u003e. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.un.org/disabilities/documents/convention/convoptprot-e.pdf\u003c/span\u003e\u003cspan address=\"https://www.un.org/disabilities/documents/convention/convoptprot-e.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWakefield, A., Every-Palmer, S., \u0026amp; Foulds, J. A. (2025). Fitness to stand trial: 415 consecutive defendants assessed by a New Zealand forensic psychiatry service. \u003cem\u003eAustralasian Psychiatry: Bulletin of the Royal Australian and New Zealand College of Psychiatrists\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e(1), 51\u0026ndash;56. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/10398562241290027\u003c/span\u003e\u003cspan address=\"10.1177/10398562241290027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWartnik, A. P., \u0026amp; Carlson, S. S. (2011). A Judicial Perspective on Issues Impacting the Trial Courts Related to Fetal Alcohol Spectrum Disorders. \u003cem\u003eJournal of Psychiatry \u0026amp; Law\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(1), 73\u0026ndash;119. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/009318531103900104\u003c/span\u003e\u003cspan address=\"10.1177/009318531103900104\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWebster, B. M., Carlisle, A. C. S., Livesey, A. C., Deeprose, L. R., Cook, P. A., \u0026amp; Mukherjee, R. A. S. (2023). Evaluating the Difference in Neuropsychological Profiles of Individuals with FASD Based on the Number of Sentinel Facial Features: A Service Evaluation of the FASD UK National Clinic Database. \u003cem\u003eChildren (Basel)\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e(2), 266. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.3390/children10020266\u003c/span\u003e\u003cspan address=\"10.3390/children10020266\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWhite, A. J., Batchelor, J., Pulman, S., \u0026amp; Howard, D. (2012). The Role of Cognitive Assessment in Determining Fitness to Stand Trial. \u003cem\u003eInternational Journal of Forensic Mental Health\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(2), 102\u0026ndash;109. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1080/14999013.2012.688091\u003c/span\u003e\u003cspan address=\"10.1080/14999013.2012.688091\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWozniak, J. R., Riley, E. P., \u0026amp; Charness, M. E. (2019). Clinical presentation, diagnosis, and management of fetal alcohol spectrum disorder. \u003cem\u003eLancet Neurology\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(8), 760\u0026ndash;770. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/S1474-4422(19)30150-4\u003c/span\u003e\u003cspan address=\"10.1016/S1474-4422(19)30150-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoung, J. T., Davis, F. J., Wardale, S., Vassos, M., Dooren, K., Nankervis, K., \u0026amp; Lennox, N. G. (2018). Severity of cognitive disability and mental health court determinations about fitness to stand trial. \u003cem\u003eJournal of Intellectual Disability Research\u003c/em\u003e, \u003cem\u003e62\u003c/em\u003e(2), 126\u0026ndash;139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jir.12468\u003c/span\u003e\u003cspan address=\"10.1111/jir.12468\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZapf, P. A., Hubbard K. L., Cooper, V. G., Wheeles M. C., \u0026amp; Ronan K. A. (2004) Have the courts abdicated their responsibility for determination of competency to stand trial to clinicians? \u003cem\u003eJournal of Forensic Psychology Practice\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e, 27\u0026ndash;44. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1300/J158v04n01_02\u003c/span\u003e\u003cspan address=\"10.1300/J158v04n01_02\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCases\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003ePora v R\u003c/em\u003e [2015] UKPC 9; 1 Cr App R 3\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eR v M (John) [2003] EWCA Crime 3452\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eR v Pritchard\u003c/em\u003e (1836) 7 C\u0026amp;P 303\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u003cem\u003eSC v UK\u003c/em\u003e (2005) 40 EHRR 10\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fetal Alcohol Spectrum Disorder, FASD, fitness to plead, fitness to stand trial, Competency, Criminal justice system.","lastPublishedDoi":"10.21203/rs.3.rs-7235748/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7235748/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eFetal Alcohol Spectrum Disorder (FASD) is a lifelong neurodevelopmental condition resulting from prenatal alcohol exposure, affecting both cognitive and behavioural functioning. Within the legal system, determining whether an individual can effectively participate in court proceedings is essential to ensuring a fair trial. Legal professionals, psychiatrists and psychologists must carefully assess the abilities and limitations of accused individuals, particularly those with FASD, whose cognitive impairments can significantly impact their legal fitness to participate. This scoping review examines empirical studies investigating FASD in relation to fitness to plead or equivalent legal constructs. A systematic search across six databases, following PRISMA guidelines, identified nine empirical studies. The findings highlight key challenges, including the invisibility of FASD within fitness assessments, immaturity-related barriers, the need for adaptive and executive functioning evaluations, limited judicial awareness, insufficient community resources, and the need for specialised legal frameworks such as alternative courts. To ensure fair legal proceedings, there is a pressing need for early recognition of FASD and diversion strategies, particularly within the UK, where research remains limited. This review discusses the legal implications, recommendations, and future research directions necessary to improve fitness to participate assessments and promote equitable access to justice for individuals with FASD.\u003c/p\u003e","manuscriptTitle":"Exploring fitness to participate in court proceedings among defendants with Fetal Alcohol Spectrum Disorder: A systematic scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-12 13:26:15","doi":"10.21203/rs.3.rs-7235748/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e6f004c9-478b-482d-8f8f-1f8a5a905dd5","owner":[],"postedDate":"August 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-09T20:08:57+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-12 13:26:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7235748","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7235748","identity":"rs-7235748","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}