Regi AlexanderConsultant Psychiatrist, Hertfordshire Partnership University NHS

Foundation Trust , Honorary Senior Lecturer, University of Leicester& Editor, Oxford Textbook of Psychiatry of Intellectual Disability

Acknowledgement: Dr Tom Berney for his wisdom on this topicand some of the slides too…

ASD in the Criminal Justice & Forensic Mental Health

Systems

ASD Prevalence &

Arbitrariness of the forensic label

Co-morbidity-

The pathology porrridge

ASD & Law breaking:

Mechanisms, interventions & outcomes

Typologies

TERTIARY CARE

(SECURE HOSPITALS)

SECONDARY CARE

(HOSPITALS)

SECONDARY CARE (CMHTs)

PRIMARY CARE (GPs)

THE EATS

TEAM

THE EATS-

CFS TEAM

POPULATION SAMPLE

Prevalence of ASD- 1% (9.8-11 per 1000)

LD POPULATION SAMPLE

Prevalence of ASD- 7.5%

HOSPITAL SAMPLES

2.4-10%

Much higher in excluded studies

from selected populations

COURT SAMPLE

Prevalence of ASD- 10%

PRISON SAMPLE

Prevalence of ASD- 4%

Law breaking in community

samples- similar or less

In selected forensic hospital

settings, higher than expected

rates

Prevalence

In females within such settings,

much higher than expected.

Types of offences

Arson(Hare 1999, Siponmaa 2001,

Mouridsen 2008)

Sex Offences Less: (Hare 1999, Elvish 2007)

More: (Kugmagami & Matsuura 2009)

ViolenceLess: (Murphy 2003)

Same: (Hare 1999)

More: (Woodbury Smith 2006, Elvish 2007)

Alcohol / drug

related (O’Brien & Bell

2001, Murphy 2003, Woodbury

Smith 2006, Wahlund &

Kristiansson 2006, Mouridsen

2008)

Conviction

Prosecution

Arrest

Offence

ASD Prevalence &

Arbitrariness of the forensic label

Co-morbidity-

The pathology porrridge

ASD & Law breaking:

Mechanisms, interventions & outcomes

Typologies

What is ASD?

FriendshipsEmotional reciprocity Social skills

Impaired social interaction

ConversationCommunicationabnormalities

Language anomalies

Imagination & creativity

Restricted, repetitive& circumscribed interests

Focal interests

Stereotypic / idiosyncratic speech

Rituals & routinesSensory interests

ASD

AgeBirth 16 yrs.

The developmental trajectoryImproves with age

Grow out of it?

Speed?Extent?

Normal developmental change

Compensatory, learned adaptations

Less testing environs

What is ASD?

Birth 16 yrs.

ADHD

Tics

OCD

Developmental Disorders

ASD

Epilepsy

Developmental Disorders

Communication

impairment

Social

impairment

Restricted

repetitive

behaviours

& Interests

Orion’s BeltOrion

Vocal

Tics

Restricted

repetitive

behaviours

& Interests

Social

impairment

Communication

impairment Tics

Impulsivity

Dyscalculia

Dyslexia

AD

Sensory

(in)sensitivities

OCD

Alexithymia

Dyspraxia

Overactivity

Executive

function

Central

Coherence

Epilepsy

Catatonic

symptoms

ASD Tourette

Developmental Disabilities

ADHDArticulation

disorder

Comorbid disorderHybrid disorderThe wide, star-studded skyOrion’s Belt

Comorbid mental illnesses & PD

Inattentiveness, hyperactivity & impulsivity

Mood disorder, PsychosisPD

Core components

Sociability

Communication

Rigid , repetitive & stereotypic behaviourFocal interests

Other developmental disabilities

Obsessive – Compulsive

Epilepsy

What is ASD? Pathology porridge

ASD & Psychosis

Specific sub type of ASD linked to

co-morbid psychosis

Atypical psychosis- particularly

with affective features

ASD- fewer stereotyped interests

and behaviours

Cluster B (“Flamboyant”): clinically relevant andof prognostic significance

Cluster C (“anxious/ avoidant”): Realistic dependency needs in those with LD. Hence diagnosis of limited utility.

Personality Disorders

Cluster A (“odd and eccentric”): overlap with ASD.Hence diagnosis difficult and of limited utility.

ASD Co- morbidities

Affective

instability...

Impulsivity

in at least two

areas that are

self damaging

Intense unstable

relationships alternate

idealisation

and devaluation ...

Recurrent

suicidal

gestures

Inappr.

anger

difficulty

controlling

anger......

Efforts

to avoid real

or imagined

abandonment ....

Chronic feelings

of emptiness

Transient

paranoid

ideation......Unstable

self image

ASD & BPD (EUPD)

Antisocial PD, Psychopathy & ASD

Autism Psychopathy

Autonomic

response to

distress

Cognitive

empathy (ToM)

Emotional

empathy?

Motor empathy

(imitation)

Perceive

emotions

general

subtle

happy, angry

sad, fear, disgust

(Blair ‘05)

Capacity to offend: empathy

ASD Prevalence &

Arbitrariness of the forensic label

Co-morbidity-

The pathology porrridge

ASD & Law breaking:

Mechanisms, interventions & outcomes

Typologies

ASD and offending behaviour

Similar factors as everybody else: Personality disorder /

Psychopathy / Co-morbid Mental illnesses

ASD specific: two broad domains

Deficits in theory

of mind

Mindblindness

Risk factors for offending 1

• Misinterpretation

of social cues

(“cluelessness”)

• Lack of empathy

• Social naivete

Abnormal,

repetitive narrow

interests

Lack of central

coherence

Risk factors for offending 2

•Disruption of

routines

•“Obsessive”

preoccupations

Sensory Overload

http://www.nice.org.uk/CG142

Diagnosis: Screening

complicated by a number of difficulties such as:

comorbid psychiatric disorders

a lack of a reliable developmental history and

some degree of clinical and phenomenological overlap.

ASDASQ

•Nylander & Gillberg (2001)

•10 items

http://gillbergcentre.gu.se/di

gitalAssets/1615/1615794_as

dasq--english.pdf

Shared Formulation

Predisposing

Precipitating

Maintaining

HELP

1. Health

2. Environmental issues

3. Lived experience

4. Psychiatric problems10 DIAGN PLANES

1. LD degree

2. LD cause

3. ASD

4. Other DD

5. Ment illness

6. PD

7. Sub abuse

8. Physical

9. Psychosocial disdv

10.CB types

Treatment Approaches

THERAPEUTIC

MILEU

& SPELL

APPROACH

THE 10 PTP

1. Diagnosis

2. Psych formulation

3. Beh support plan

4. Psychotherapy

5. Psychotherapy- off specific

6. Pharmacotherapy

7. Physical illness

8. Structured day programme

9. Community participation

10.Transition

OUTCOMES

ASD vs No ASD:

No difference in outcomes??

Something more than the ASD diagnosis

alone

ASD Prevalence &

Arbitrariness of the forensic label

Co-morbidity-

The pathology porrridge

ASD & Law breaking:

Mechanisms, interventions & outcomes

Typologies

ASD

PSYCHOPATHY (C&UE TRAITS)

PSYCHOSIS

BEHAVIOUR- INTENSITY & FREQUENCY

Typologies 1

Diagnostic confusion &

boundary disputes- ID/

PD/ etc

Moderate to severe

intensity and frequency

Accurate diagnosis- ASD,

SPELL approach

Early discharge possible

Typologies 2

ID, ASD, HKCD

ASPD, EUPD

High arousal, daily

problems

No placements

Typologies 3

Odd, few friends, ASD

diagnosis

Fascinaton with knives-

knows obscure details and

collects them

Unemotional and

detached accounts

Model patient on the

ward, but remains

detained

Typologies 4

ASD, Odd beliefs

Intervening Psychosis

Content may be same,

form different

Length of stay depends

on prognosis of

psychosis

Prevalence-

over represented

Screening and Diagnosis

Key messages

Core features & extensive

co-morbidity

Formulation, HELP

& the 10 diagnostic planes

Therapeutic mileu, SPELL

& the 10 PTP

Key messages

Treatment outcomes &

Typologies

https://www.minded.org.uk/

regialexander@nhs.net

@regalexa

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