Dr Clare Allely Reader in Forensic Psychology - PowerPoint Presentation

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Dr Clare Allely

Reader in Forensic Psychology University of Salford

Autism

in the

Prison and Secure Psychiatric Care

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Social communication and Interaction

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Study of penal register data regarding Hans Asperger's original group of 177 patients (Hippler et al., 2010). rate & nature of crimes committed by these individuals no different from the general population. In the case records spanning 22 years & 33 convictions, there were only 3 cases of bodily injury, 1 case of robbery and 1 case of violent and threatening behaviour.

Despite this, media and academic reporting of violent crime committed by offenders with ASDs has served to generate a speculative association between ASDs and offending behaviour. ASD and Offending

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Experiences of Prison Inmates with Autism Spectrum Disorders

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Many offenders with ASDs go undetected or misdiagnosed as a mental health disorder such as schizophrenia. They may only receive a proper diagnosis while in prison (Mayes, 2003) or while they are in a mental health facility (Scragg & Shah, 1994). Deficit of empathy can be misinterpreted as being remorseless, cold and calculating and therefore infer greater risk of re-offending (Murrie et al., 2002). Prevalence rate of ASDs in prisons is unknown (Robinson, Spencer et al., 2012).

Offenders with ASD

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Using the Autism Quotient (AQ-20), Underwood et al. (2016) identified high levels of unrecognised ASD traits among a group of male prisoners in an adult male prison in London in the UK (UK). Of the 186 adult males approached on the prison wings, 10 per cent screened positive and 2 per cent fulfilled the diagnostic criteria for ASD. Such findings strongly highlight the need for specialist assessment within the criminal justice system for individuals with neurodevelopmental disorders such as ASD. Based on this rate of 2 per cent, the Ministry of Justice (2015) suggests that in prisons in the UK there are approximately 1,600 men and 120 women with ASD (Ministry of Justice, 2015). Rates of ASD in prison may vary depending on its type (e.g. remanded or sentenced, high-secure, mainstream prisons, etc.) (

Underwood et al., 2013).Prevalence of ASD in Prison

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Experiences of Prison Inmates with Autism Spectrum Disorders and the Knowledge and Understanding of the Spectrum Amongst Prison Staff: An Extensive Review of the Literature

Over a decade ago, Howlin (2004: 308) expressed concern that: ‘unless an informed and flexible approach to management can be developed’ programmes specifically designed to modify offending behaviours ‘can be highly punitive and completely counterproductive for someone with autism’.

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Underwood, Forrester, Chaplin and McCarthy (2013) reviewed evidence on providing services to individuals with neurodevelopmental disorders in prison, particularly focusing on ASDs. Review identified 4 articles: Evaluation of a screening tool for individuals with ASDs in prisons (Robinson, Spencer, Thomson, Stanfield, Owens, Hall, & Johnstone, 2012), so was not focused on the experience of individuals with ASD in the prison environment. Investigated the knowledge of ASD among prison staff (McAdam, 2012). Case studies of prisoners with Asperger’s syndrome (Paterson, 2008).

Study conducted in Sweden which they could not obtain a copy of (Beir & Gillberg, 1995). Studies that included Experiences of Inmates with ASD while in Prison

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Articles Identified in ReviewAllen, D., Evans, C., Hider, A., Hawkins, S., Peckett, H., & Morgan, H. (2008). Offending behaviour in adults with Asperger syndrome. Journal of Autism and Developmental Disorders, 38(4), 748-58.

Gordon, R. (2002). Asperger Syndrome: One prisoner's experience. Prison Service Journal, 143, 2-4.McAdam, P. (2009). Knowledge and understanding of the autism spectrum amongst prison staff. Good Autism Practice (GAP), 10(1), 19-25.Morris, A. (2009). Offenders with Asperger's syndrome: Experiences from within prison (Doctoral dissertation, Pacific University). Retrieved from: http://commons.pacificu.edu/spp/525Paterson, P. (2008). How well do young offenders with Asperger syndrome cope in custody?. British Journal of Learning Disabilities, 36(1), 54-58.

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Paterson (2008) Study

Examined 2 cases of prisoners with Asperger’s disorder in the UK. Over 4 months, Paterson (2008) collected information through observations of the individuals and interviews with both the participants and a wide variety of prison staff. Despite only being based on two cases this study by Paterson (2008) enables some insight into how ASDs traits (e.g., obsessive compulsive traits, poor social skills, poor empathy ability, and difficulty with reading social situations), can impact on how the offender is able to handle the prison environment and the vulnerabilities that they are at greater risk of (such as bullying) (Cashin & Newman, 2009).

Study emphasises the limited resources

available for prisoners with ASDs.

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Paterson (2008) Study: Findings from Case 1 (Paul)

Allowed to customise his own routine in prison. Given permission to stay in his cell during the afternoons (which deviates from normal protocol) because of the difficulties he experienced with interacting with other inmates during this time. Exhibits a rather rigid adherence to certain prison regimes for instance he is obsessive about the routines he follows in cleaning his cell (Paul described, how he always stacks his magazines in a particular way between his sink and toilet, and there was one occasion ‘when the magazines would not stack properly I got pissed off and smashed my cell up’). Got into an altercation with another inmate because he had taken an extra item of food during one meal time – and (as Paul reasoned) ‘it was against prison rules’.Stated that he interacted well with other inmates and had a lot of friends.

Observation (i.e., his ‘gangsta

raps’) of his interactions with other inmates strongly suggested that this may not be the case as the observation revealed the superficial nature of his ‘friendships’.

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Paterson (2008) Study: Findings from Case 2 (Michael)Exhibited difficulties in being able to interact socially with others. Increased vulnerability to bullying was exacerbated as a result of his low-self esteem, poor social skills, lack of understanding in social situations and his tendency to avoid interacting with others and instead preferring the seclusion of his cell. Ultimately this meant that he was not complying with the prison regime.

Relocated to the healthcare centre, where he resided for the majority of his sentence, following numerous reports of him being bullied while residing in the general prison population. Isolation further compounded by his aggressive outburst due to frustration which the nursing staff were finding increasingly stressful to cope with. Michael’s co-morbidities (including depression, psychosis, sleeplessness and a tendency to self-harm), are exacerbated by his ASD. Poor quality relationships with other inmates. Difficulty in communicating effectively with many of the prison staff. Numerous instances when his misunderstanding of social situations caused him to get into altercations with other inmates.

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Allen et al. (2008) StudyUK Study - quantitative & qualitative methods to study participants with AS who had committed offences/been involved with the legal system.

16 gave consent to extensive data collection & 6 of these also gave consent to the qualitative interview. 2 questionnaires:Demographics, legal and psychiatric history & behavioural history. Information about the nature of the offence, offending and victimisation history, characteristics or factors leading to the offending behaviour. Also, The Asperger Syndrome Diagnostic Interview (Gillberg et al., 2001).

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Findings (Allen et al., 2008)In the qualitative section of Allen et al. 's (2008) study, 4 of the 6 participants had carried out a sentence in prison. The 4 participants’ experiences in prison frequently varied but all 4 reported general difficulties such as missing family, difficulties with making friends, or problems with roommates and prison staff.

Positive aspects of prison One participant found the structure of prison beneficial and another enjoyed having other inmates who listened to him and acknowledged him when he arrived. What participants thought could be improved on Dominant theme: Better understanding of AS among prison staff to increase quality of support.

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Knowledge and Understanding of ASD Amongst Prison Staff Scarce research, other than Myers in Scotland (2004) has even touched on the issue surrounding the knowledge and understanding of ASD in prison staff, or indeed lack of. Important that prison staff have at least an adequate understanding of ASD particularly given that many individuals with ASD struggle to communicate their needs and given their increased vulnerability in prison to bullying, etc (Jordan, 1999).

Extensive literature search of studies investigating knowledge and understanding of ASD in prison staffAn extensive literature search returned only one study which investigated this important issue (McAdam, 2009).

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Summary: Autism Spectrum Disorder in Prison

Many people with ASD face life being misunderstood and having their intentions misinterpreted. Those with AS may be vulnerable and open to victimisation and abuse by fellow inmates (Burdon & Dickens, 2009).

Current evidence in support of satisfactory outcomes for offenders with ASD is not encouraging

(Milton et al., 2002, Murphy, 2010).

Very little to guide service design to develop autism support services for people in prison

(

Cashin

& Newman, 2009).

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Understanding the Experience of Individuals with Autism in the Prison and Prison Staffs Understanding and Knowledge of Autism

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Stage 1: The Questionnaire: Prison Staff and Prisoners with ASDStage 2: Interviews: Prison Staff and Prisoners with ASDStage 3: 'Developing a Toolkit for Prison Staff to Increase Identification, Recognition and Understanding of Autism Spectrum Disorder within the Prison Environment‘Stage 4:

Evaluation of the Toolkit developed at Stage 3ASD and the Prison - HMP Risley

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3 looked at the prevalence of ASD in secure psychiatric hospitals. 1 study evaluated the clinical utility of the AQ screening tool to assess self-reported autistic traits in secure psychiatric settings. 3 explored any type of characteristics of patients with ASD detained in secure psychiatric hospitals. 1 study investigated the experiences or quality of life of patients with

an ASD detained in secure psychiatric care. 2 studies investigated awareness, knowledge and/or views regarding patients with ASD held by staff working within secure psychiatric hospitals. 3 studies (one of which was also included in the prevalence category above) looked at the effectiveness of interventions or treatment of patients with ASD in secure psychiatric hospitals.Findings from 12 Studies Identified in Review

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Scragg & Shah (1994) screened the entire male patient population (n=392) in Broadmoor Special Hospital by examination of case notes. 6 patients with a diagnosis of AS (prevalence rate of 1.5%). Only 2 of these 6 patients had previously been diagnosed as having AS which indicates that AS is not always recognized. Prevalence increases to 2.3% if the 3 equivocal cases are included.Hare et al. (1999) screened a total of 1,305 residents in the 3 special

hospitals in the UK. From the 215 cases of patients who scored over five on the screening questionnaire, 31 definite cases of autistic conditions were identified. equate to 2.4 per cent of the population screened. 31 equivocal cases. Esan et al. (2015) investigated the characteristics and prevalence of those with ASD treated within a 64-bed specialised forensic ID hospital in England compared to those without ASD. Of the 138 (cohort of patients treated over a six-year period), 42 (30%) had an ASD.Prevalence of ASD in secure psychiatric hospitals

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Murphy (2011) - 105 male patients detained within HSPC (~47.7% of the total patient population). 3 groups: mentally ill individuals with DSM-IV-defined psychotic disorders, such as paranoid schizophrenia, schizoaffective disorder (MI group, n=69), a group with a range of different personality disorders including borderline and anti-social (PD group, n=24) & a group of patients with an ASD (ASD group, n=12). Individuals with ASD exhibited significantly higher total AQ scores compared to those without a diagnosis of ASD. However, the social skill, communication and attention switching subscales of the AQ were found to be what significantly discriminated the patients with ASD from those with MI and PD

.2 of the AQ subscales (attention to detail and imagination) seemed to have less discriminative validity in this population of patients. Possible explanation for this is that these subscales “reflect common features associated with institutionalised psychiatric patients, such as a need for routine, a sensitivity to change in their immediate environment, as well as perspective taking and empathy difficulties” (p. 529).Evaluating the clinical utility of the AQ screening tool to assess self-reported autistic traits in secure psychiatric settings

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Haw et al. (2013). 45 ASD patients for inclusion in the study. The control group comprised all available 43 non-ASD low-secure admissions. In group of ASD patients, 12 patients (26.7%) only had a diagnosis of ASD, and 33 patients (73.3%) had psychiatric co-morbidities. Specifically, schizophrenia and related psychotic disorders were the most common psychiatric comorbidities (a small number of patients also had learning disabilities and hyperkinetic disorder). ASD group were found to be less likely to have a diagnosis of alcohol or substance misuse or dependence and were also found to be less likely to have a personality disorder.

Grievous bodily harm or homicide convictions in 33% of the patients with ASD but only 16% of the controls.Characteristics of patients with ASD detained in secure psychiatric hospitals

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Murphy (2014) investigated self-reported anger among individuals with an ASD detained in HSPC and whether preoccupations (POs) had an influence. 20 males with an ASD admitted to HSPC for assessment from January 2002 to December 2011. PO group were individuals with offending (index offending) directly linked to pursuing an intense PO (n=10). Non-preoccupied offending group (NPO) were comprised of individuals whose offending appeared to be unrelated to a PO (n=10).No significant differences in basic demographic and cognitive functioning details between the PO and NPO group. Based on the findings from the AQ &

the experience and expression of anger based on the State trait expression of anger inventory (STAXI 2) (Spielberger, 1999), findings indicated that individuals with ASD whose index offending is associated with their PO may have a particular sensitivity towards attending to details in their immediate environment and may even exhibit more difficulties with expressing anger outwardly. NPO group appeared to have more complex co-morbid psychiatric presentations (e.g. psychosis or a personality disorder) when compared to those whose offending behaviour was associated with pursuing a PO (80 vs 50%)Characteristics of patients with ASD detained in secure psychiatric hospitals

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Murphy, Murphy, Mullens and Mullens (2017) - Less stressful environment with more “therapeutic opportunities”.One of the hospital procedures described by some patients as difficult was having a limited time to eat meals. Loss of freedom and restrictions in what they are allowed in terms of personal possessions was reported as being extremely difficult for most patients with ASD admitted to HSPC. Restrictions in what they are allowed will be particularly challenging for patients with ASD whose items that are restricted are part of their specific interests. (e.g., one patient in the study was not allowed a pair of binoculars to watch aircraft. About half of those interviewed

reported significant stress due to the level of noise produced by other patients. Trying to get on with those viewed as being bullies or who had unpredictable mental states linked to their illness were also reported difficulties. Despite the majority of patients having lived on or being currently on wards with between 12 and 20 other patients, all felt isolated and without friends. Some individuals were happy with this isolation while others reported wanting increased contact with others they could relate to.Experiences and QoL of patients with an ASD detained in secure psychiatric care

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Murphy & McMorrow (2015) (N=206). half of staff reported the view that even though patients with ASD received some degree of benefit from the therapies they engaged in, the staff felt that they were not aware if an individual’s personal difficulties were taken into consideration in their care. Half of staff reported that patients with ASD should be managed differently. The majority of staff reported not having the necessary skills to work with ASD, expressed the wish for more training and argued that such training should be mandatory.Misra et al. (2013) - 100 completed forms returned, findings indicated that the majority of the staff were aware of ASD. However, most of the staff had not heard about “standard approach of care”. Most staff were willing to train and work within

a specialist ASD team.Awareness and views of ASD held by staff working within a secure psychiatric hospital

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MacDonald et al. (2017) investigated the challenges and positive experiences of staff members working with sexual offenders who have a diagnosis of ASD. They interviewed a total of 8 participants who worked on the autism specialist ward at a forensic secure hospital in the UK. Key findings from the study was the number of challenges that the staff group face and the majority of the staff stated that they would benefit from in-depth training in ASD. Study indicated that further training, more support and “higher levels of staffing may be indicators of organisational intervention points” (p. 49). Additionally, staff members would benefit from training on the difficulties in successfully treating sex offenders who have ASD. Such training would

help staff to manage their expectations in the level of impact and change that they can expect to see as a result of offence focused.Interventions/treatment outcomes with patients with ASD in secure psychiatric hospitals

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Murphy (2011) highlighted the urgent need for a forensic version of the AQ. Despite the clinical utility of the AQ in assessing the presence of ASD among patients admitted to high security psychiatric care, there are significant issues related with symptom validity (which are common to all self-report instruments). The AQ may be limited only to those individuals with sufficient literacy skills. Numerous studies have found “extremely poor literacy skills” in prisoners (e.g. Creese, 2016). Given the well-established high rate of patients and prisoners with poor literacy skills, Murphy (2011) recommends the need for an adapted version of the AQ which could be conducted using a semi-structured interview approach.

Screening for ASD: the clinical utility of the AQ with forensic psychiatric patients

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Need for more research not just looking at males with ASD in the prison but females with ASD in the prison.Studies which have suggested that females with ASDs are more vulnerable and at-risk of engaging in antisocial behaviour compared to females without ASD (Hare, 1999; Mouridsen, 2008). Crocombe et al. (2006) reported that in a high secure unit over 10% (6 out of 51 females) were found to fulfil the diagnostic criteria for ASD, using the ICD–10 (Crocombe, Mills, & Wing, 2006).Importance of Identifying Vulnerable

Females with ASD in the Prison Environment

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Females with ASD frequently take more steps to camouflage their impairments given that they tend to have more self-awareness and better expressive behaviours (e.g., reciprocal conversation, sharing interests) and exhibit less repetitive use of objects and different types of restricted interests compared to males with ASD. The phenotype of the disorder can be different in females. On average, it has been suggested that females with ASD exhibit less restricted, repetitive behaviours, and interests (RRBI). These findings are really important to consider because if RRBIs are used as key diagnostic criteria, many females with ASD will potentially not be referred for assessment and diagnosed (Rynkiewicz et al., 2016). Urgent Need for an Autism Screening Tool which is not Male-Biased

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Urgent need for good practice guidelines in order to assess risk in individuals with a diagnosis of ASD (Murphy, 2013). Such an “ASD sensitive risk assessment guide” would comprise of both the factors which may increase the vulnerability of individuals with ASD to engage in offending behaviour (e.g. communication; cognitive and sensory impairments; social awareness, vulnerability, sensitivities, POs, unusual interests, anxiety provoking situations and obsessions or compulsions) and the factors that may be protective (e.g. an immediate environment which is well structured and unambiguous). (Murphy, 2010a; Gunasekaran, 2012).Majority of risk assessments explore a number of factors which are not relevant for offenders with ASD (e.g. presence of delusions,

hallucinations, compliance with medication, use of illicit drugs and exacerbating psychotic symptoms) (Gunasekaran, 2012).The need to adapt risk assessment tools for offenders with ASD

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Ashworth High Secure Psychiatric Hospital Project

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Allely, C. S. (2018). A systematic PRISMA review of individuals with autism spectrum disorder in secure psychiatric care: prevalence, treatment, risk assessment and other clinical considerations. Journal of Criminal Psychology, 8(1), 58-79.Allely, C. S., & Cooper, P. (2017). Jurors’ and judges’ evaluation of defendants with autism and the impact on sentencing: a systematic Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) review of autism spectrum disorder in the courtroom. Journal of Law and Medicine, 25(1).Allely, C., & Creaby-Attwood, A. (2016). Sexual offending and autism spectrum disorders. Journal of Intellectual Disabilities and Offending Behaviour, 7(1), 35-51.Allely, C. S. (2015). Experiences of prison inmates with autism spectrum disorders and the knowledge and understanding of the spectrum amongst prison staff: a review. Journal of Intellectual Disabilities and Offending Behaviour, 6(2), 55-67.Allely, C. S. (2015). Autism spectrum disorders in the criminal justice system: police interviewing, the courtroom and the prison

environment. http://usir.salford.ac.uk/38698/1/Allely%20(2015)..pdfCooper, P., & Allely, C. (2017). You can’t judge a book by its cover: evolving professional responsibilities, liabilities and ‘judgecraft’ when a party has Asperger’s Syndrome. Northern Ireland Legal Quarterly, 68(1), 35-58.References

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Dr Clare Allely c.s.allely@salford.ac.uk@clareallely

Dr Toni Wood a.wood2@salford.ac.uk@ToniWood3