Forensic Aspects of Autism Spectrum Disorders

1. Forensic Aspects of Autism Spectrum Disorders Dr Kiriakos Xenitidis Adult ASD & ADHD Service, The Maudsley Hospital, SLAM Dept of Forensic and Neurodevelopmental Science, Institute of Psychiatry

2. Wing 1981: ASD Triad of impairment • Qualitative impairments in reciprocal social interaction • Abnormalities in verbal and non-verbal communication • Restricted and repetitive range of behaviours, interests and activities

3. Asperger’s Syndrome • Among individuals with ‘high-functioning autism’, the term ‘Asperger syndrome’ is reserved for people for whom the social interaction and restricted patterns of behaviour occur in the context of • normal early language development • no cognitive impairment

4. Hans Asperger (1944) Some children with AS mischievous and malicious without regard for the consequences for other people.

5. Prevalence of autistic disorders in children. • Ehlers & Gillberg (1993, Gothenburg): 71 per 10,000 children for Asperger’s (36) descriptions and other autistic conditions (35) [320,000 people in the UK). • Baird, Simonoff et al (2006): 116·1 per 10 000 incl prevalence of childhood autism was (38·9) and other ASD (77·2) Ratio male: female 4:1 - 15:1. • Unclear whether the increase is true or due to better ascertainment, broader diagn. criteria.

6. ASD in Adulthood • Brugha et al (2011) Community prevalance 0.9% • Nylander, Gillberg (2013): ADHD or ASD diagnoses entified in an adult psychiatry register (N=56,462) • ADHD was diagnosed in up to 2.7% and ASD in 1.3% of the patients. • Diagnostic delay 2-10 years • Comorbidity: in 60%. Affective disorders in ADHD; Psychoses and intellectual disability in ASD

7. ASD and offending • Siponmaa, Gillberg (2001) PDD: 15% of young offenders referred for psych assess • Ghaziuddin et al. (1991):Review from 1944 to 1990: no clear link between Asperger syndrome (AS) and violent crime. • Mouridsen (2012). Review: ‘still no body of evidence to suppose that people with ASD are more prone to commit offences…However, a small number of serious crimes can be linked to the core features or comorbidity

8. RCPsych publication • Advances in Psychiatric Treatment 2010 (16: 37-43) • K Dein, M Woodbury-Smith • No clear association between criminal behaviour and ASD

9. Rates in high security: Broadmoor Hospital • Screened male population (N = 392) for Asperger’s Syndrome. • 6 clear cases identified and 3 equivocal cases. Prevalence of 1.5 - 4.3%. • 0.36% community prevalence using same criteria (Allen 2007). • Interests commonly involving poisons and weapons. • Average length of stay 6y, PDD length of stay 8.5y • Two of six had prior diagnosis. • ‘Unique challenges in terms of management’ Scragg & Shah (1994)

10. Broadmoor, Rampton and Moss Side All 1305 residents screened for ASD. 93.5% male 6.5% female. • 31 definite ASD; 31 “information insufficient for diagnosis”. • Prevalence between 2.4% and 5.3% • Mean length of stay = 11y • Circumscribed interests commonly morbid; violence, weapons, Nazism. Similar offending patterns; markedly less sexual offending. Hare et al (1999)

11. Women in High security • 10% women in high secure had PDD (Crocombe et al 2006)

12. Prison • ASD prevalence in prisons not known. • Fazel, Xenitidis Powell (2008) meta analysis of 12000 prisoners: 0.5-1.5% had intellectual disability • Myers (2004) A study asking staff in the Scottish Prison Service how many cases they were aware of yielded 19 people with an established diagnosis of learning disability and/or ASDs across 16 prisons

13. Problems with studies ... • PDD, ASD, AS, or HfA! • How is diagnosis defined ? ICD-10/DSM-IV or, ADI, ADOS etc. • Ever changing rates in general population make comparisons to forensic populations problematic. • The literature generally refers to individuals with higher functioning autism spectrum disorders. • Administrative bias, e.g.: Reluctance to link mental disorder with criminality. Tolerance of disturbed behaviour in people with disability An unwillingness to prosecute where conviction unlikely (Berney, 2004).

14. Conclusions on rates • PDD over represented compared to baseline in high secure; possibly greater in women • Greater lengths of stay • Prison rates unknown (may be ‘model prisoners’ and unknown to prison and probation services) • No clear evidence of increase in rates of convictions or offending • May suggest: • Relative absence of disposal/placement options • Difficulty assessing risk • Refractory to treatment

15. All Party Parliamentary Group on Autism • Autism and the Criminal Justice System April 2002. • Very little known about the number of people involved with the criminal justice system, either as perpetrators or victims. • No figures for people with autism in the prison system. • No rates of offending for people with autism. - Only figures available are for those in the special hospitals.

16. Pattern of offending Case studies++. Most offence types represented. Fire setting. Group studies: • 25% of community sample (Woodbury-Smith 2005) • 63% of community sample (Siponmaa 2001) • 16 v 10% in Special Hospital study (Hare 1999). • Case control study: only offence type to reach statistical significance (Mouridsen 2008)

17. Pattern of offending • Sexual offending: Low in Special Hospitals Rates of sexual offending generally low, esp child sex offences (computer related crime?) • Violent offending: Offenders with PDD more likely to have prior convictions for assault (Elvish 2007). Contradictory findings in Special Hospitals (Hare 1999, Murphy 2003)

18. Factors mediating offending in AS:bottom-up 1 General factors Poor educational achievement Truancy Social exclusion 2 Factors associated with the diagnostic triad 3 ‘Core’ deficits: (a) Empathy: I ToM II Face recognition (b) Executive dysfunction 4 Comorbidity 5 Late diagnosis

19. Factors in offending in ASD NAS view on PDD and offending 1. Social naivety, being duped as unwitting accomplices in theft and robbery. 2. Difficulty managing unexpected changes leading to aggression. • Inappropriate social advances being being interpreted as sexual advances. • Obsessional interests involving dangerous topics, such as poisons or explosions.

20. NAS: offending and ASD • Offences relating to social naivety (unwitting accomplices of criminals) • Offences of an aggressive nature: related to routine change (eg delay in public transport). • Misunderstanding of social cues (e.g. prolonged eye contact misinterpreted as unwanted sexual advances). • Rigid adherence to rules (damage cars that are parked illegally). People with ASD often do not understand the implications of their behaviour and due to their difficulties with social imagination they often do not learn from past experience. They may repeatedly offend if not offered the correct support and intervention. • In addition, the methods used by the police may exacerbate a situation for someone with ASD. For example, the use of handcuffs and restraint may be extremely frightening for someone with ASD who does not understand what is happening and may not be able to communicate their fears in an appropriate way. This, coupled with the use of loud sirens, may cause an individual to experience sensory overload and try to escape a situation by running away or, in extreme circumstances, hitting out at people, including the police. The very presence of the police may cause great anxiety to a law-abiding person with ASD who has no comprehension of the crime they may have committed.

21. Possibly indicative of undiagnosed ASD (Berney, 2004) • Inexplicable violence • Computer crime • Offences arising out of misjudged social relationships • Obsessive harassment (stalking) Mullen et al (1995): 5 types of ‘stalker’. ‘Incompetent suitor’ characterised by: Isolated Lonely Socially inept. Typically male, underemployed, average intelligence.

22. Triad of impairments Impairments in reciprocal social interaction Lack of social understanding (Howlin 1997) Social naivety and lack of common sense (Wing 1997) • Misinterpretation of intentions of others as malicious/hostile. • Poor understanding of the consequences of actions on others. • Misuse/deliberate exploitation by others (Howlin 1997)

23. Triad of impairments Communication Difficulties expressing emotional states/needs may lead to frustration and inappropriate attempts to communicate Literal interpretation of language Stereotyped behaviours and restricted interests Obsessional tendencies or morbid interests Aggressive behaviour, often as a result of disruption to routine Rigid interpretation of rules

24. Empathy (Blair 2005) • Cognitive Empathy (Theory of Mind) • Normal in psychopaths, abnormal in ASD • Emotional Empathy • Affective response to social-emotional signals of others • Selective deficits in psychopaths (fear and sadness) • OFC lesions (anger – ‘social response reversal’) • Motor Empathy • Tendency to automatically mimic and synchronise social-emotional signals and movements with those of another person (clinically present in PDD).

25. PDD and psychopathy PDD at Broadmoor: None of PDD patients greater than cut off on PCL-R But higher scores on lack of remorse, guilt, lack of empathy Comparable mean PCL-R scores. PDD in Sweden: Unemotionality and behavioural dyscontrol correlate with autistic traits Interpersonal factors: no correlation; possibly core psychopathic features. Possible overlap in offenders between some cognitive deficits in ASD, psychopathy (and ADHD). Most people with PDD do not share these characteristics (even with ASPD)!

26. Specific co-morbidities in PDD • ADHD (30-45 %) • Intellectual Disability (30-80%) • Depression (4-38%) • Anxiety Disorders (11-76%) • Obsessive-Compulsive Disorder (25-50 %) • Schizophreniform Disorders (7-35%) • Bipolar Affective Disorder (3-9%) • Catatonia/Movement disorders (4.5-20%) • Specific Reading/Writing difficulties

27. ADHD and offending Court records Youths 4 – 5x more likely arrested Multiple arrests and convictions Prison studies (USA, Sweden, Norway, Canada, Germany) 22 – 67% inmates hx childhood ADHD Up to 30% have symptoms in adulthood 16% in partial remission Rates much higher in YOI(Young, S in Fitzgerald et al, 2007, Handbook of ADHD) Surprising given PDD/ADHD comorbidity that rates of offending as low as they are! ‘Core’ PDD features protective?

28. Late Diagnosis Probably more common where IQ high May be more difficult because: Leads to: Absence of childhood informants Failure of education Confounds of comorbidity Decreased socialisation Skills acquisition Maladpative coping skills Where diagnosis difficult, management dictated by current need (logistic and administratively difficult) (Dein 2010) Need for: Psychiatric education re diagnosis Use of screening instruments in forensic settings

29. Autism and the CJS PDD may affect: Fitness Capacity Mitigation People with PDD not more suggestible, but may be more compliant(North et al, 2008)

30. Autism: a guide for criminal justice professionals Provides background information about autistic spectrum disorders. It aims to assist all professionals working in the Criminal Justice System, particularly police officers, solicitors, barristers, magistrates, justices of the peace, the judiciary and the courts. Autism and the CJS

31. Forensic treatment environments Minimal specialist NHS provision: private sector Varies from area to area (e.g. LD v forensic v general adult) A low number of a heterogeneous group of patients. Causes of variation: • Type and severity of social understanding, restricted interests, impulse control • Co-morbid mental health symptoms, challenging behaviours, forensic presentations • Medical conditions (e.g. epilepsy syndromes) • IQ variation (‘borderline’ to very high) Usually insufficient nos for local units, so units within units, or out of area.

32. Aspects of assessment Assess:cognitive profile/theory of mind special interests/interaction/communication interpersonal history/history of bullying preferred routines anger comorbidity (especially ADHD) Functional analytic model (eg Sturmey 1996): Antecedents, setting factors, consequences Note potential for reinforcement of offending by stress reducing consequences

33. Aspects of treatment No established reason why not treatment as usual, though groups difficult. Co-morbid mental illness:treatment can produce dramatic reductions in risk Adaptations to talking therapies (CBT) Greater use of visual materials Affective education More directive approach Social skills training (groups) Medication… Visual idiographic risk monitoring tools Self-generated risk monitoring likely to be difficult. Carer support usually necessary. Risk reductionvia high levels of supervision, structure, and support; graduated transitions.

34. Case study • 40 year old male • ‘borderline‘ ID • Charged with assault • Detained under S 3 then S37 • Treatment • Non drug • Atypical antispychotics

35. Service implications • Prisoners with ASD (+/_ ID) are a vulnerable population • Suicide risk (Shaw, Appleby, & Baker, 2003 found 3%-double the rate of non ID prisoners) • increased risk of mental illness and victimisation (Glaser & Deane, 1999; Noble & Conley, 1992).

36. Service implications • Health service providers should take note of the increased rates and consider • development of specific treatment programmes • training of prison staff • and promotion of links between criminal justice, forensic mental health and intellectual disabilities services.

37. Journal of Intellectual Disabilities and Offending Behaviour • Special Issue 2013: Autism and Offending Behaviour

38. ARC SCOTLAND • Supporting Offenders with learning disabilities 2010 • james.fletcher@arcuk.org.uk • 0131 663 4444