Title: Adapting Risk Assessment and Treatment to meet the needs of Offenders on the ASD Spectrum
1Adapting 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
2Aims 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
3Adapting 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?
4Triad 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
5Risk Assessment Process
6Risk Assessment ctd
Current environmental influences
Past environmental influences
Future environmental influences
Risk Formulation predicted scenarios
7Reporting 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.
8Reporting 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
9Reporting 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?
10Reporting 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?
11Practical 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)
12Practical 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
13Management 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
14Management 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
15Can offenders with ASD be treated and managed
safely? A few thoughts for consideration..
- 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
16Extreme violence in a man with an autistic
spectrum disorderAssessment and treatment
within high security psychiatric care
17Violence 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)
18- 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
19Background
- 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
20Background 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
21Developmental 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
22Interests
- Electronics
- Buying shares
- Used to collect plastic bottles (liked the
patterns colours)
23Background 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
24Context 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)
25Diagnostic process
26Autistic 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)
27Neurophysiology
- 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
28EEG
29MRI scan
30Neuropsychological functioning
31Qualitative 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)
32WAIS 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
33WAIS 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
34WMS 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
35Literacy
- Speed Capacity of Language Processing test
(SCOLP) - Spot the word
- Scaled score 3
- 1st percentile
- Speed of comprehension test
- Scaled score 5
- 5th percentile
36Visual 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
37CFT
38Executive 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
39Suggestibility
- 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
40Theory 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)
41The revised eyes task
42Personality anger assessment
43Millon 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
44ABs 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)
45ABs MCMI III profile
46Psychopathy
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)
47STAXI 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)
48State Trait Anger Expression Inventory II(STAXI
II) admission one year
gt 75th lt 25th percentiles considered
problematic
49STAXI 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
50Formulation of index offence
51Interventions within high security psychiatric
care
52Management 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
53Specific 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)
54Potential 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
55Immediate 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
56Risk future management
57Issues 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)
58Future 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.)
59Issues / 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)
60Conclusions
- 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!
61Question Time
- Any questions or examples to share?
- What do you think are realistic or acceptable
markers of change in an ASD offender population?
62Contact 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