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
Aspergers 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 Aspergers (36) descriptions
  and other autistic conditions (35) 320,000
  people in the UK).
• Baird, Simonoff et al (2006) 1161 per 10 000
  incl prevalence of childhood autism was (389)
  and other ASD (772) Ratio male female 41 -
  151.
• 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
  (N56,462)
• 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

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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 offencesHowever, a small number
  of serious crimes can be linked to the core
  features or comorbidity

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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 Aspergers
  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)
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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)
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Women in High security

• 10 women in high secure had PDD (Crocombe et al
  2006)

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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

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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).

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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

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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.

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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)

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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)

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Factors mediating offending in ASbottom-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

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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.

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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.

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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)

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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

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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).

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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)!

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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

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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?

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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)

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Autism and the CJS

• 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.

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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.

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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

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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 reduction via 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

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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).

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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_at_arcuk.org.uk
• 0131 663 4444