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Heterogeneity Within Autism Spectrum Disorder in Forensic Mental Health: the Introduction of Typologies Kent Academic Repository Full text document (pdf) Citation for published version Alexander, Regi T. and Langdon, Peter E. and Chester, Verity and Barnoux, Magali F.L. and Gunaratna, I. and Hoare, S. (2016) Heterogeneity within Autism Spectrum Disorder in Forensic Mental Health: The Introduction of Typologies. Advances in Autism, 2 (4). pp. 201-209. ISSN 2056-3868. DOI https://doi.org/10.1108/AIA-08-2016-0021 Link to record in KAR http://kar.kent.ac.uk/56761/ Document Version Author's Accepted Manuscript Copyright & reuse Content in the Kent Academic Repository is made available for research purposes. Unless otherwise stated all content is protected by copyright and in the absence of an open licence (eg Creative Commons), permissions for further reuse of content should be sought from the publisher, author or other copyright holder. Versions of research The version in the Kent Academic Repository may differ from the final published version. Users are advised to check http://kar.kent.ac.uk for the status of the paper. Users should always cite the published version of record. Enquiries For any further enquiries regarding the licence status of this document, please contact: [email protected] If you believe this document infringes copyright then please contact the KAR admin team with the take-down information provided at http://kar.kent.ac.uk/contact.html Advances in Autism Heterogeneity within Autism Spectrum Disorder in Forensic Mental Health: The Introduction of Typologies Advances in Autism Journal: Advances in Autism Manuscript ID AIA-08-2016-0021 Manuscript Type: Research Paper Autism Spectrum condition, Autism Spectrum Disorder, Behavioural Key ords: Phenotypes, Forensic, Intellectual Disability, Mental Disorder Page 1 of 11 Advances in Autism 1 2 3 4 Heterogeneity within Autism Spectrum Disorder in Forensic Mental Health: The 5 Introduction of Typologies 6 7 8 9 Abstract 10 11 12 Purpose: Individuals with diagnoses of Autism Spectrum Disorder (ASD) within criminal 13 justice settings are a highly heterogeneous group. Although studies have examined 14 differences between those with and without ASD in such settings, there has been no 15 examination Advancesof differences within the ASD group. in Autism 16 17 Design methodology approach: Drawing on the findings of a service evaluation project, this 18 paper introduces a typology of ASD within forensic mental health and learning disability 19 settings. 20 21 22 Findings: The eight sub-types that are described draw on clinical variables including 23 psychopathy psychosis and intensity/ frequency of problem behaviours that co-occur with 24 the ASD. The initial assessment of inter rater reliability on the current version of the typology 25 revealed excellent agreement multirater Kfree % .90. 26 27 Practical implications: The proposed typology could improve understanding of the 28 relationship between ASD and forensic ris( identify the most appropriate interventions and 29 provide prognostic information about length of stay. Further research to refine and validate 30 the typology is ongoing. 31 32 33 Originality value: This paper introduces a novel typology based approach which aims to 34 better serve people with ASD within criminal justice settings. 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Advances in Autism Page 2 of 11 1 2 3 Introduction 4 5 Prevalence data about offending behaviours amongst people with an autistic spectrum 6 disorder (ASD) suggest that this group is no more at ris( than the general population 7 (Mouridsen ,ich Isager - .edergaard 2000). 1owever there is some evidence that 8 9 people with an ASD may be over represented in specialist forensic mental health or learning 10 disability settings with reported rates between 1.3 and 305 (Scragg - Shah 19947 11 Alexander et al. 20117 Esan Chester :unaratna 1oare - Alexander 2013). Prevalence 12 estimates are unavailable for prison as there is currently no policy of routine screening yet 13 people with ASD also appear over represented (Underwood Forrester Chaplin - McCarthy 14 2013). It has been suggested that people with ASD experience disadvantage when interacting 15 with criminalAdvances justice agencies particularly induring Autismpolice interviews (.orth ,ussell - 16 :udjonsson 20007 Archer et al. 2013) and in court (Allely 2013). Those with adequate 17 language s(ills may not initially appear vulnerable meaning that police and courts fail to 18 19 provide support to assist with communication and protect the individual’s rights. Archer et al. 20 (2013) note that often defendants with ASD present with a lac( of empathy or remorse and 21 hence may be sentenced more harshly. 22 23 Woodbury-Smith et al. (2003) highlighted that when considering vulnerability to offending 24 by people with ASD specific ASD factors such as poor social understanding or 25 circumscribed interests difficulties in adjusting to the diagnosis and the impact of social 26 exclusion are relevant. The sensory issues often present in ASD can also directly impact ris( 27 of violence on occasion (e.g. Mawson :rounds - Tantam 1903). 1owever Woodbury- 28 29 Smith et al. 2003) noted that ris( factors identified in general criminological literature are 30 also relevant such as low IQ poor school achievement truancy aggressive behaviour and 31 hyperactivity-impulsivity-inattention. This sentiment is echoed by Berney and Pierce (2016) 32 who stated that automatically assuming a causal relationship between ASD and an 33 individuals’ offending behaviour is a reductionist approach which can overshadow other 34 pertinent ris( factors for offending and subsequently a lac( of tailored treatment. Mouridsen 35 et al. (2000) suggested that neurocognitive problems and associated psychiatric illness are 36 important ris( factors to consider. Indeed antisocial personality disorder has been noted 37 amongst offenders with ASD (Dein - Woodbury-Smith 20107 ABngstrCm :rann ,uch(in 38 39 SjCstedt - FaDel 2009). It is possible that such difficulties remain undiagnosed if a 40 diagnosis of ASD is present. ABngstrCm et al. (2009) reported that people with ASD who had 41 committed violent crimes were more li(ely to have comorbid psychosis substance misuse 42 and personality disorder. 43 44 Questions remain regarding the role of psychopathy which increases the probability of 45 socially deviant behaviour in affected individuals and can co-occur in ASD (Eones et al. 46 2009). Woodbury-Smith and colleagues (2003) reported that offenders with ASD had an 47 impaired ability to recognise fear compared with non-offenders with ASD which could 48 49 suggest co-morbid psychopathy. Despite this some behaviours that are seen in both 50 individuals with psychopathy and those with ASD may appear superficially similar (e.g. 51 unemotionality and behavioural dyscontrol)7 however the neurocognitive underpinnings may 52 be quite different (,ogers Fiding Blair Frith - 1appG 2006). Indeed ,ogers et al. (2006) 53 suggest that different aspects of empathy are impaired in individuals with ASD traits and 54 those with psychopathic traits(Department of 1ealth 2012). Whilst individuals with ASD 55 have difficulty in understanding what others thin( (Hcognitive empathy’) individuals with 56 psychopathic traits have difficulty in resonating with other people’s feelings (Haffective 57 empathy’). ,esonating with other people’s feelings is thought to be particularly important for 58 59 60 Page 3 of 11 Advances in Autism 1 2 3 feeling true empathy towards others’ suffering. This suggests that psychopathy is a 4 particularly important feature to consider when assessing and treating forensic mental health 5 problems while autistic symptomatology although related may be of less clinical 6 importance in some individuals. 7 8 9 The idea that specific neurocognitive problems and comorbid psychopathology can explain 10 forensic ris( in this population is somewhat reflected in the studies which examined the 11 specific clinical and forensic profiles of those with ASD within forensic services as 12 compared to those without. For example Murphy (2003) reported no high-secure hospital 13 patients with Asperger syndrome had any history of serious antisocial behaviour or criminal 14 convictions before age 10. It has been noted that offenders with ASD perpetrated 15 significantly Advancesmore violent or sexual crimes against in people Autism but less property offences (Cheely 16 et al. 20127 Iumagami and Matsuura 2009). 1aw ,adley and Coo(e (2013) compared 31 17 male forensic patients with ASD in a low-secure forensic psychiatry service to 43 patients 18 19 without ASD. The ASD group were younger (27 vs. 33 years) and younger at their first 20 contact with psychiatric services. Those with ASD were more li(ely to be admitted from 21 prison or courts rather than civil pathways suggesting more serious level of offending. Over 22 735 had a history of physical violence and a third had convictions for serious violence or 23 homicide. Offending behaviour was described as atypical involving uncommon offences 24 e.g. harassment or stal(ing. Esan et al. (2013) conducted a similar study in a forensic 25 intellectual disability population and found that patients with ASD had similar rates of 26 convictions in broad categories of violence arson and sexual offending. In terms of clinical 27 comorbidity 1aw reported that almost 735 of those with ASD had psychiatric comorbidity 28 29 most commonly schiDophrenia and 4.45 had personality disorders. Drug and alcohol 30 disorders were uncommon although many had histories of misuse. Similarly Esan et al. 31 (2013) found that although comorbidity rates were lower than the comparison group those 32 with ASD had a wide range of comorbid diagnoses including psychosis (145) bipolar 33 disorder (105) substance misuse (125) personality disorder (365) and epilepsy (265). 34 Woodbury-Smith et al. 2003) reported that 195 of an offender group with Asperger’s 35 syndrome met antisocial personality disorder criteria. 36 37 Furthermore this idea has considerable implications for the inpatient care-pathway of 38 39 patients with ASD detained in hospital.
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