Adapting Risk Assessment and Treatment to meet the needs of Offenders on the ASD Spectrum

1
Adapting Risk Assessment and Treatment to meet
the needs of Offenders on the ASD Spectrum

• By
• Dr David Murphy
• Consultant Clinical Psychologist
• Broadmoor Hospital
• Sam Cooper-Evans
• Consultant Clinical Psychologist
• St Andrews Healthcare

2
Aims of the session

• To share considerations about what to include
  when compiling a risk assessment involving a
  person with ASD in terms of
• Assessments
• Considering ongoing management and treatment in
  secure settings
• Application to a clinical case by Dr Murphy
• Questions

3
Adapting SPJ tools for ASD offenders

• The impact of ASD requires consideration within
  offence formulation both in static (historical)
  and dynamic factors
• Historical
• How did the ASD contribute to the offending
  behaviour?
• Dynamic
• How is ASD impacting on current functioning
• what ASD specific considerations will need to be
  made with regard to treatment and risk management?

4
Triad of impairments refresher

• http//www.autism.org.uk/living-with-autism/educat
  ion/transition-issues-in-education/breaking-down-b
  arriers-to-learning/asperger-syndrome-the-triad-of
  -impairments.aspx

RISK
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Risk Assessment Process
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Risk Assessment ctd
Current environmental influences
Past environmental influences
Future environmental influences
Risk Formulation predicted scenarios
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Reporting ASD in a risk assessment

• Current structured risk assessment (SPJ) tools
  discuss the presence and relevance of a risk
  factor over time
• For example, the HCR-20 considers
• Historical factors
• Current clinical factors
• Future risk management factors
• ASD specific considerations need to be made and
  these can be included as other factors
• For example, having a diagnosis of ASD is not
  necessarily an indicator of risk but the triad
  can help inform the risk factors.
• Risk scenarios and formulation help to draw all
  the factors together to predict likely risk
  situations.

8
Reporting ASD in a risk assessment Historical
Items

• Presence
• - when was the diagnosis made?
• - how did it impact their social-emotional
  functioning development, particularly with
  their understanding of social rules as well as
  behaviour and how this relates to the
  offending/risk behaviour
• were sensory issues relevant in their offence
  e.g. tactile over/under-stimulation
  sensory-seeking (e.g. arsonists)
• Relevance
• ASD is pervasive disorder therefore will remain
  relevant in terms of ongoing and future risk
  management in terms of this person's specific
  presentation
• Neuropsychological presentation is important in
  terms of treatment and management

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Reporting ASD in a risk assessment Clinical
Items

• Presence
• how is the ASD impacting on current functioning
  in current environment
• What is their level of motivation, insight and
  awareness into their ASD and how this relates to
  their offending?
• Relevance
• How well are they able to respond to available
  treatment i.t.o. abilities and motivation/insight
• Based on neuropsychological assessment and
  observation, how can treatment be shaped to
  optimise their ability to learn and benefit?

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Reporting ASD in a risk assessment Risk
Management Items

• Presence
• Impact of changes in environment
• Ability to make use of available support
• Consider protective factors e.g. coping/strengths
• Relevance
• Pervasive diagnosis therefore requires expertise
  in management i.e. specialist services
• What services are available? What ASD specific
  considerations will need to be taken into account
  to optimise outcome?

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Practical ideas for enhancing engagement in
assessment and treatment

• a) Managing anxieties about the unknown
• - Clear explanation about the process (preferably
  supported by visual aids either written or
  pictorial) and how this may benefit them
• Eg. Social Story Handouts what is a structured
  risk assessment?
• E.g. Following a written list of questions that
  client has choice over
• b) Supporting central cohesion
• visual aids (use of timelines/family trees)
• Repetition (checking retention and comprehension)

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Practical ideas for enhancing engagement in
assessment and treatment (2)

• Sensory needs to support emotional regulation
• Sensory rooms
• Sensory profiling and care planning
• More general strategies
• Encouraging active participation
• Direct feedback about progress
• Consistency in approach

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Management Considerations for Clients

• ASD specific knowledge preferable within team
  particularly regarding sensory issues
• Explicit and consistent rules/expectations
• Clearly communicated processes that are rigidly
  adhered to e.g. smoke times, how to get
  unescorted leave, what happens in ward round?
• Advanced warning about potential changes and a
  clearly communicated plan about how this will be
  implemented before changes occur
• Structure and routine environmental issues
• All of the above contribute to ability to cope
  and manage risks safely

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Management Considerations for Teams

• ASD specific knowledge is essential
• Essential to agree and adhere to the rules
• where are what decisions made?e.g. what happens
  in ward round
• Who makes what decisions?
• Being mindful of the impact of changes on
  presentation of clients (e.g. new
  admissions/discharges) and how this may escalate
  risks
• Being robust enough to take ASC honesty!!! e.g.
  my clumpy mascara

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Can offenders with ASD be treated and managed
safely? A few thoughts for consideration..

• Pros

• Cons

• Most can manage well with clarity and structure
  once they are able to predict the rules
• Many can learn skills to recognise and manage
  their emotions in specific settings
• Many do see the need for treatment and do want
  help to develop social skills
• Many learn to communicate their feelings and use
  available support once they have established its
  consistency.

• Co-morbity those with more deviant pathology can
  take advantage of such clearly communicated
  processes and of other patients.
• Can these skills be generalised?
• Some, despite significant support will not shift
  their views about treatment
• Some, may never show overt signs of aggression
  (due to ASC) or choose to communicate it

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Extreme violence in a man with an autistic
spectrum disorderAssessment and treatment
within high security psychiatric care
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Violence ASD

• No formal evidence to suggest that adults with
  ASD receive more convictions for violent offences
  than rest of population
• Prevalence studies of high security psychiatric
  care (HSPC) misleading (highly specific patient
  group, not all violent)
• Groups studies suggest ASD patients may have
  lower violence ratings for index offence
  unlikely to have a history of violence in
  comparison to other patient groups (e.g. Murphy,
  2003)
• Several case studies describing highly unusual
  violent offending among some individuals with AS
  (e.g. Murrie et al., 2002)
• Very few case studies of homicide in ASD
• 1999 survey found homicide offences occurred at
  rate consistent with base rate for HSPC patients
• Most case studies highlight role of cognitive
  difficulties in contributing to occurrence of
  violence, but with less emphasis on how these
  interact with development of dysfunctional coping
  
• Rage may be a problem for some (an extreme
  reaction completely out of proportion to any
  provocation) / Intermittent Explosive Disorder
  (IED)

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• Admitted to high security psychiatric care for
  assessment, following killing ofco-worker
  (supervisor)
• Plea of manslaughter on the grounds of diminished
  responsibility
• Detained under Section 45A of MHA (1983)
  classification MI

SHE GOT ME FIRED SHE HAD TO DIE.. Cold-blooded
words of McDonald's killer The Mirror
Sacked burger man killed manager McDonalds
worker stabbed his boss during a childrens
party The Times
19
Background

• No pregnancy or birth complications
• Minor problem with healing of umbilical cord
• Born with small abnormality in outer ear
• Described as a quiet baby reached milestones
  with acceptable limits
• Speech slow to develop (in comparison to older
  sister) did not talk very much
• Described as being different from an early age
  (preferred being alone did not engage in
  imaginative play)
• Very picky about foods dislike of some tastes
  (ginger toothpaste)
• Dislike of certain noises (e.g. vacuum cleaner,
  lawnmower telephone)
• A detached manner (uninterested in immediate
  environment)
• No history of alcohol or illicit substance abuse
• No previous forensic history

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Background contd

• Family live in an isolated rural area
• Helped with basic tasks, avoided contact with
  public
• Maternal uncle described as odd (ASD?)
• Early problem incidents at school (a wish to stab
  a girl at school who had been taunting him of
  losing it with a teacher)
• Some descriptions of a history of self harm
  sudden rages

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Developmental history key points

• Delayed speech development
• Reading writing difficulties
• Referred to an educational psychologist during
  childhood (but not followed up)
• Significant difficulties within school
  (difficult behaviour dealt with by removing him
  from classroom allowing him to complete work in
  corridor)
• Appeared to benefit from a more structured
  consistent teaching approach
• No friends (reports having friends, but unable to
  describe any details did not spend any time
  with others outside of school)
• A dislike of being touched of any physical
  affection
• Left school at 16 years old with 7 GCSEs, with
  grades ranging from B to E

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Interests

• Electronics
• Buying shares
• Used to collect plastic bottles (liked the
  patterns colours)

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Background to offence

• Working as a part time cleaner (approximately one
  year prior to arrival of victim)
• Reported job as okay (money a free meal), but
  disliked contact with public complaints
• Wished to move into kitchens (to be away from
  public victim of offence / supervisor more
  money)
• Felt under some pressure from parents to find
  another job (told to apply for two a week)
• Did not socialise with other work colleagues

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Context of index offence

• Assaulted a teenage girl approximately one week
  prior to index offence (punched her in the face
  following her throwing free food around
  taunting him)
• Anxious about break being moved forward
  inspectors visiting on same day (had to work a
  longer shift than usual)
• Victim was his supervisor (has never accepted
  this)
• Felt she was always complaining about him being
  unreasonable
• Assault incident witnessed by supervisor
  reported to management
• Dismissed as a result
• Following dismissal, left restaurant, bought a
  knife, returning to stab the victim numerous
  times in front of public
• Expressed view that the victim was responsible
  for losing his job to blame (for breaking
  company rules giving out free food)

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Diagnostic process
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Autistic Quotient comparison
AB Broadmoor pts (n100) ASD (n58) Controls(n174) Students(n840) Olympiads(n16)
Total 32 21.8 (7.2) 35.8 (6.5) 16.4 (6.3) 17.6 (6.4) 24.5 (5.7)
Communication 5 3.5 (1.8) 7.2 (2.0) 2.4 (1.9) 2.9 (2.0) 3.0 (2.3)
Social 9 4.3 (2.4) 7.5 (1.9) 2.6 (2.3) 2.3 (2.2) 5.1 (3.2)
Imagination 7 4.3 (2.1) 6.4 (2.1) 2.3 (1.7) 2.5 (1.9) 4.9 (2.5)
Attentionswitching 9 5.2 (2.2) 6.7 (2.3) 5.3 (2.3) 5.3 (2.2) 6.6 (2.3)
Local details 2 4.6 (2.4) 8.0 (1.8) 3.9 (1.9) 4.5 (2.0) 4.9 (1.9)
Baron Cohen et al. (2001), Murphy (submitted)
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Neurophysiology

• EEG examination
• Posterior temporal slow waves (PTSW)
• an immature profile
• MRI scan
• Overall conservative view normal, but possible
  developmental disturbance / pathology
• Possible asymmetry
• Possible cyst in caudate nucleus of right
  hemisphere

With thanks to Dr John Lumsden, Head of
Neurophysiology, Broadmoor hospital
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EEG
29
MRI scan
30
Neuropsychological functioning
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Qualitative impressions

• Inappropriate eye contact (tendency to stare)
• Receptive expressive communication difficulties
• Speech lacked prosody monotone
• No spontaneous information
• Lack of reference ( displayed confusion) to
  feelings mental states (own others) / poor
  perspective taking
• Motor tics (facial grimaces, scratching his hands
  head)
• Odd gait
• Extremely concrete, literal rigid in thinking
  understanding
• Lack of central cohesion (focus on irrelevant
  details rather than overall context of situation
  / circumstances)
• Easily irritated when asked about subjects that
  relate to his responsibility in his offence
  (difficulty in accepting personal responsibility
  being counter challenged)

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WAIS III profile
Scale Sum of SS IQ score Qualitative description
Verbal 57 96 Average
Performance 45 92 Average
Full scale 102 95 Average
Sum of SS Index score
Verbal comprehension 32 103
Perceptual organisation 33 105
Working memory 21 82
Processing speed 12 79
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WAIS III profile
Verbal subtests Raw score Age SS
Vocabulary 30 9
Similarities 23 10
Arithmetic 8 6
Digit Span 14 8
Information 21 13
Comprehension 20 11
Letter Number Sequencing 8 7
Performance subtests Raw score Age SS
Picture Completion 18 8
Digit Symbol coding 51 8
Block Design 54 13
Matrix Reasoning 20 12
Picture Arrangement 11 7
Symbol Search 26 7
Object Assembly 36 10
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WMS III abbreviated
Raw score Scaled score Scaled score
Logical memory one 39 9 -
Family pictures one 34 6 -
Logical memory two 24 - 10
Family pictures two 40 - 7
Sums of scaled scores Sums of scaled scores 15 17
Sums of scaled scores Sums of scaled scores Immediate memory Delayed memory
Total memory Total memory 32 32
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Literacy

• Speed Capacity of Language Processing test
  (SCOLP)
• Spot the word
• Scaled score 3
• 1st percentile
• Speed of comprehension test
• Scaled score 5
• 5th percentile

36
Visual spatial organisation/planning (Rey CFT)
Raw score Percentile T score
Copy 33 11th 16th -
Immediate recall 16.5 2nd 29
Delayed recall 15.5 1st 26
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CFT
38
Executive functioning

• Poor performance in Verbal fluency, Stroop test,
  Trail Making Test, WCST, Hayling Sentence
  Completion, Brixton Spatial Anticipation test
  Iowa gambing task
• Poor verbal organisation
• Poor cognitive flexibility
• Poor rule attainment
• Slow speed of information processing
• Impaired working memory
• Cautious response style

39
Suggestibility

• Performance in the Gudjonsson Suggestibility
  Scale (GSS) suggested some vulnerability to
  suggestibility, i.e. changing responses to some
  leading questions specifically a shift in some
  responses
• Consistent with qualitative observations
• May question capacity at police interview

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Theory of mind
Revised eyes task ABsPerformance ASgroup Schizophreniagroup Personalitydisorder group Normal males
( correct) 58.3 60.8 58.4 (13.7) 65.1 (17.2) 82.6 (7.6)
from Baron-Cohen et al. (2001) adults with AS,
n15. Male patients (aged between 20 to 40
years) detained in high secure psychiatric care,
n 30 (Murphy, 2006).
ABs Performance Schizophreniagroup Personalitydisorder group Normal males
First order ToM 100 70.8 (33.6) 91.6 (19.5) 100 (0)
First order memoryperformance 100 85.4 (23.8) 98.8 (6.2) 100 (0)
Second order ToM 66.6 38.9 (33.4) 58.3 (30.9) 100 (0)
Second order memoryperformance 66.6 67.7 (30.4) 78.1 (25.6) 100 (0)
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The revised eyes task
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Personality anger assessment
43
Millon Clinical Multiaxial Inventory III(MCMI
III)

• A 175 self report item true / false measure of 14
  personality patterns 10 clinical syndromes for
  use with adults (18 years above) being
  evaluated in mental health settings
• One of the most frequently used instruments in
  the examination of personality disorders major
  clinical syndromes
• Consists of a validity index, modifying indices
  (disclosure, desirability debasement), clinical
  personality pattern scales, severe personality
  pathology scales, clinical syndrome scales (axis
  I symptom scales) severe syndrome scales
• No ASD comparative data as yet

44
ABs MCMI III profile

• A valid profile
• Modifying indices acceptable, suggesting AB
  answered questions honestly did not attempt to
  hide difficulties, portray a positive image or
  fake bad
• Within clinical personality patterns, AB produced
  clinically significant scores within the
  schizoid dependent personality traits
  (primary problems)
• Schizoid traits associated with severe
  relationship difficulties restricted emotional
  expression. Individuals appear aloof,
  introverted, emotionally bland detached, with
  flat affect low need for social contact
• No clinically significant scores within any
  severe personality pathology dimensions (i.e.
  schizotypal, borderline or paranoid)
• Within clinical syndromes, anxiety significant
  (high level of generalised anxiety)
• No clinically significant scores within any of
  the severe clinical syndromes (i.e. thought
  disorder, major depression or delusional disorder)

45
ABs MCMI III profile
46
Psychopathy
AB Broadmoor ASpatients (n13) British offenders(percentile T score)
PCL-R total score 9 15 (3.7) 17.1 39
Factor 1 (interpersonal / affective) 7 7.9 (2.2) 68 53
Factor 2 (social deviance) 2 7.0 (2.2) 7.4 34
Facet 1 (interpersonal) 0 1.2 (1.6) 18.2 38
Facet 2 (affective) 7 6.8 (1.2) 96.7 66
Facet 3 (lifestyle) 1 4.2 (1.2) 7.7 33
Facet 4 (anti-social) 1 3.2 (1.9) 19.1 37
Murphy (2007), Hare 2003 (N1117)
47
STAXI II profile

• State Trait Anger Expression Inventory II
• Designed to evaluate experience, expression
  control of anger
• A 57 item self report measure comprised of 6
  scales, 5 subscales an anger expression index
  (providing an overall measure of the expression
  control of anger)
• State anger (S Ang)
• Feeling angry (S Ang / F
• Feel like expressing anger verbally (S Ang / V)
• Feel like expressing anger physically (S Ang / P)
• Trait anger (T Ang)
• Angry temperament (T Ang / T)
• Angry reaction (T Ang / R)
• Anger expression out (AX-O)
• Anger expression in (AX-I)
• Anger control out (AC-O)
• Anger control in (AC-I)
• Overall measure of expression control of anger
  (AX index)

48
State Trait Anger Expression Inventory II(STAXI
II) admission one year
gt 75th lt 25th percentiles considered
problematic
49
STAXI II interpretation

• S Ang high (his state anger frequently high)
• S Ang / F high (frequently feels intense anger -
  current)
• S Ang / V high (feels like expressing anger
  verbally- current)
• AX-O low (outward expression of anger low
  verbally physically)
• AX-I high (inward expression of anger high, i.e.
  angry feelings are experienced, but not expressed
  - suppressed)
• AC-O high (significant control / perhaps over
  control of outward expression of anger)
• Overall, AB likely to frequently experience /
  feel intense anger, but over controls expression,
  probably because of inadequate way of expressing
  / communicating feelings
• Some individuals with ASD detained in hospital
  display a similar STAXI profile

50
Formulation of index offence
51
Interventions within high security psychiatric
care
52
Management within HSPC

• General strategy (SPELL guidelines)
• Structure
• Positive approach
• Empathy
• Low arousal
• Links
• Education / information about ASD
• Individual adapted CBT / problem solving
• Perspective taking
• Social cognition / knowledge
• Emotion recognition exercises (using computer
  software package)
• Education, OT work activities

53
Specific adaptations for CBT

• Structured (time course of intervention very
  clear) problem focused
• Motivation cognitive factors may affect
  performance (short sessions - 10 / 15 minutes)
• Reciprocal understanding regarding process of
  change use of concrete analogies (avoid
  interpretative approaches use of metaphor)
• Non anxiety provoking (avoid increase in arousal
  levels, maintain relaxed safe situation)
• Use of visual imagery (may be helpful as a
  channel of communication cues to particular
  thoughts in CBT)

54
Potential limitations of therapy

• Concrete thinking may lead to rejection (e.g.
  focus on biological model reject role of
  psychological)
• May reject the role of self in treatment, but
  still demands help (avoidance complaints of
  being put under pressure)
• Problem of coping with perceived social pressure
• Avoid direct challenges as these can be easily
  misinterpreted
• Limited social understanding may lead to
  increased negative reactions (e.g. awareness of
  power dynamics problem of developing a
  collaborative relationship individual with ASD
  may adopt superior role to therapist)
• Awareness of possible fixations (e.g. feelings,
  gender of therapist)
• Lack of conceptual understanding / impaired
  inter-subjectivity (e.g. understanding thoughts,
  voices other internal sounds)
• Problem of generalisation of experience

55
Immediate outcome

• Accepts ASD diagnosis recognises differences,
  but externalises key problems
• CBT outcome very modest (recognition of future
  risk poor, maintains view that he was justified
  for assaulting girl index offence, victim was
  to largely to blame)
• Anger management remains potentially problematic
• Emotion recognition / regulation remains limited
• Ward adherence to SPELL guidelines varied,
  including little appreciation of specific
  cognitive difficulties associated with ASD
• Major factor linked with outcome may be
  inconsistency in management

56
Risk future management
57
Issues for risk assessment

• Insight into situation very concrete poor
• Continues to express view that victim was
  responsible to blame (employer failed to deal
  with her so I dealt with her that punching
  girl was a reasonable response to protect
  company property)
• Conventional guides of risk assessment for
  interpersonal violence (e.g. HCR 20 START) do
  not capture unique, but significant contributing
  factors for future risk (many variables either
  irrelevant or need to be expanded to be useful)
• Need to consider cognitive impairments including
  ToM, central cohesion, executive functioning,
  generalising learning from one situation to
  another
• Need to consider receptive expressive
  communication difficulties
• Sensory impairments (including speed of
  processing social information)
• Risk of self injury / suicide (but suicidal
  ideation attempts only present since being
  within Broadmoor)
• Holds a pessimistic very concrete view of
  future (no job or money)

58
Future risk management

• Move to new specialist environment
• Need for realistic expectations of change
  define acceptable levels of risk
• Scenarios of risk protective factors (highlight
  need to consider role of anger, cognitive
  difficulties, need for clarity, optimum stress /
  arousal, avoid conflict situations, improving
  communication / when to ask for help)
• Appropriate supervision
• Appropriate employment (avoid opportunities for
  social / interpersonal conflict)
• Questionable mental capacity in some situations
  (cognitive difficulties clearly influence
  impair decision making in some circumstances,
  capacity to weigh up relevant information, etc.)

59
Issues / questions

• Illustrate importance of early diagnosis
  receiving appropriate education / assistance
• Mental capacity
• Difference between psychological psychiatric
  views?
• Neuropsychological / cognitive functioning key
  factors in risk assessment / management
• What is acceptable marker of change? (Wrong to
  use same criteria as mainstream offenders)
• What is acceptable risk?
• Need for appropriate supervision support
  communication between relevant agencies (as well
  as family)
• Any future employment needs to avoid face to face
  encounters or interaction with public (potential
  for areas of conflict)
• Use of habilitation / risk management aids (what
  to do in X situation, when to ask for help)

60
Conclusions

• No hard and fast rule!
• Standardised risk assessments need to be expanded
  to include ASD specific considerations, both in
  what you collect and how you collect information.
• Do consider the impact of structure and routine,
  sensory issues in emotional regulation, and what
  the function special interests fulfil as part of
  risk assessment and management
• Do consider the underlying neurological profile
  due to variation within the population
• Do pay attention to the extent of fixed/rigid
  thinking i.t.o. treatment and risk management
  planning
• Do enjoy the clinical complexities and quirks of
  each case!

61
Question Time

• Any questions or examples to share?
• What do you think are realistic or acceptable
  markers of change in an ASD offender population?

62
Contact Details

• Many thanks for your time and contributions!
• Dr David Murphy, Broadmoor Hospital Autistic
  Diagnostic Research Centre, Southampton,
  david.murphy_at_wlmht.nhs.uk
• Sam Cooper-Evans, St Andrews Healthcare
• Scooper-evans_at_standrew.co.uk