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Forensic Aspects of Autism Spectrum Disorders


Forensic Aspects of Autism Spectrum Disorders Dr Kiriakos Xenitidis Adult ASD & ADHD Service, The Maudsley Hospital, SLAM Dept of Forensic and Neurodevelopmental ... – PowerPoint PPT presentation

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Title: Forensic Aspects of Autism Spectrum Disorders

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

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

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

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

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 -
  • Unclear whether the increase is true or due to
    better ascertainment, broader diagn. criteria.

ASD in Adulthood
  • Brugha et al (2011) Community prevalance 0.9
  • Nylander, Gillberg (2013) ADHD or ASD diagnoses
    entified in an adult psychiatry register
  • 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

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

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

Rates in high security Broadmoor Hospital
  • Screened male population (N 392) for Aspergers
  • 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
  • Two of six had prior diagnosis.
  • Unique challenges in terms of management

Scragg Shah (1994)
Broadmoor, Rampton and Moss Side
  • All 1305 residents screened for ASD. 93.5 male
    6.5 female.
  • 31 definite ASD 31 information insufficient for
  • 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)
Women in High security
  • 10 women in high secure had PDD (Crocombe et al

  • ASD prevalence in prisons not known.
  • Fazel, Xenitidis Powell (2008) meta analysis of
    12000 prisoners 0.5-1.5 had intellectual
  • 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

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
  • Administrative bias, e.g.
  • Reluctance to link mental disorder with
  • Tolerance of disturbed behaviour in people with
  • An unwillingness to prosecute where conviction
    unlikely (Berney, 2004).

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

All Party Parliamentary Group on Autism
  • Autism and the Criminal Justice System April
  • 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
  • No rates of offending for people with autism.
  • - Only figures available are for those in the
    special hospitals.

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)

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)

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

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.

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
  • 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.

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

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

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

Empathy (Blair 2005)
  • Cognitive Empathy (Theory of Mind)
  • Normal in psychopaths, abnormal in ASD
  • Emotional Empathy
  • Affective response to social-emotional signals of
  • Selective deficits in psychopaths (fear and
  • 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).

PDD and psychopathy
  • PDD at Broadmoor
  • None of PDD patients greater than cut off on
  • 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
  • Most people with PDD do not share these
    characteristics (even with ASPD)!

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

ADHD and offending
  • Court records
  • Youths 4 5x more likely arrested
  • Multiple arrests and convictions
  • Prison studies (USA, Sweden, Norway, Canada,
  • 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?

Late Diagnosis
  • Probably more common where IQ high
  • May be more difficult because Leads to
  • Absence of childhood informants Failure of
  • Confounds of comorbidity Decreased
  • 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

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)

Autism and the CJS
  • Autism a guide for criminal justice
  • 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.

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
  • 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.

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

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.

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

Service implications
  • Prisoners with ASD (/_ ID) are a vulnerable
  • 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).

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.

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

  • Supporting Offenders with learning disabilities
  • 0131 663 4444
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