Adapting Risk Assessment and Treatment to meet the needs of Offenders on the ASD Spectrum

1. By Dr David Murphy Consultant Clinical Psychologist Broadmoor Hospital & Sam Cooper-Evans Consultant Clinical Psychologist St Andrews Healthcare Adapting Risk Assessment and Treatment to meet the needs of Offenders on the ASD Spectrum

2. Aims of the session • To share considerations about what to include when compiling a risk assessment involving a person with ASD in terms of: • Assessments • Considering ongoingmanagement and treatment in secure settings • Application to a clinical case by Dr Murphy • Questions

3. Adapting SPJ tools for ASD offenders • The impact of ASD requires consideration within offence formulation both in static (historical) and dynamic factors: • Historical: • How did the ASD contribute to the offending behaviour? • Dynamic: • How is ASD impacting on current functioning; • what ASD specific considerations will need to be made with regard to treatment and risk management?

4. Triad of impairments refresher http://www.autism.org.uk/living-with-autism/education/transition-issues-in-education/breaking-down-barriers-to-learning/asperger-syndrome-the-triad-of-impairments.aspx RISK

5. Risk Assessment Process

6. Risk Assessment ctd Current environmental influences Past environmental influences Future environmental influences Risk Formulation & predicted scenarios

7. Reporting ASD in a risk assessment • Current structured risk assessment (SPJ) tools discuss the presence and relevance of a risk factor over time • For example, the HCR-20 considers • Historical factors • Current clinical factors • Future risk management factors • ASD specific considerations need to be made and these can be included as ‘other’ factors: • For example, having a diagnosis of ASD is not necessarily an indicator of risk but the triad can help inform the risk factors. • Risk scenarios and formulation help to draw all the factors together to predict likely risk situations.

8. Reporting ASD in a risk assessment: Historical Items • Presence: - when was the diagnosis made? - how did it impact their social-emotional functioning & development, particularly with their understanding of social rules as well as behaviour and how this relates to the offending/risk behaviour; • were sensory issues relevant in their offence e.g. tactile; over/under-stimulation; sensory-seeking (e.g. arsonists) • Relevance: • ASD is pervasive disorder therefore will remain relevant in terms of ongoing and future risk management in terms of this person's specific presentation • Neuropsychological presentation is important in terms of treatment and management

9. Reporting ASD in a risk assessment: Clinical Items • Presence • how is the ASD impacting on current functioning in current environment • What is their level of motivation, insight and awareness into their ASD and how this relates to their offending? • Relevance • How well are they able to respond to available treatment i.t.o. abilities and motivation/insight • Based on neuropsychological assessment and observation, how can treatment be shaped to optimise their ability to learn and benefit?

10. Reporting ASD in a risk assessment: Risk Management Items • Presence • Impact of changes in environment • Ability to make use of available support • Consider protective factors e.g. coping/strengths • Relevance • Pervasive diagnosis therefore requires expertise in management i.e. specialist services • What services are available? What ASD specific considerations will need to be taken into account to optimise outcome?

11. Practical ideas for enhancing engagement in assessment and treatment a) Managing anxieties about the unknown: - Clear explanation about the process (preferably supported by visual aids either written or pictorial) and how this may benefit them • Eg. Social Story Handouts: what is a structured risk assessment? • E.g. Following a written list of questions that client has choice over b) Supporting central cohesion • visual aids (use of timelines/family trees) • Repetition (checking retention and comprehension)

12. Practical ideas for enhancing engagement in assessment and treatment (2) • Sensory needs to support emotional regulation • Sensory rooms • Sensory profiling and care planning • More general strategies: • Encouraging active participation • Direct feedback about progress • Consistency in approach

13. Management Considerations for Clients • ASD specific knowledge preferable within team particularly regarding sensory issues; • Explicit and consistent ‘rules’/expectations • Clearly communicated processes that are rigidly adhered to e.g. smoke times, how to get unescorted leave, what happens in ward round? • Advanced warning about potential changes and a clearly communicated plan about how this will be implemented before changes occur • Structure and routine & environmental issues • All of the above contribute to ability to cope and manage risks safely

14. Management Considerations for Teams • ASD specific knowledge is essential • Essential to agree and adhere to the ‘rules’ • where are what decisions made?e.g. what happens in ward round • Who makes what decisions? • Being mindful of the impact of changes on presentation of clients (e.g. new admissions/discharges) and how this may escalate risks • Being robust enough to take ASC honesty!!! e.g. my ‘clumpy’ mascara

15. Can offenders with ASD be treated and managed safely? A few thoughts for consideration….. Pros Cons • Most can manage well with clarity and structure once they are able to predict ‘the rules’ • Many can learn skills to recognise and manage their emotions in specific settings • Many do see the need for treatment and do want help to develop social skills • Many learn to communicate their feelings and use available support once they have established its consistency. • Co-morbity: those with more deviant pathology can take advantage of such clearly communicated processes and of other patients. • Can these skills be generalised? • Some, despite significant support will not shift their views about treatment • Some, may never show overt signs of aggression (due to ASC) or choose to communicate it

16. Extreme violence in a man with an autistic spectrum disorder:Assessment and treatment within high security psychiatric care

17. Violence & ASD • No formal evidence to suggest that adults with ASD receive more convictions for violent offences than rest of population • Prevalence studies of high security psychiatric care (HSPC) misleading (highly specific patient group, not all violent) • Groups studies suggest ASD patients may have lower violence ratings for index offence & unlikely to have a history of violence in comparison to other patient groups (e.g. Murphy, 2003) • Several case studies describing highly unusual violent offending among some individuals with AS (e.g. Murrie et al., 2002) • Very few case studies of homicide in ASD • 1999 survey found homicide offences occurred at rate consistent with base rate for HSPC patients • Most case studies highlight role of cognitive difficulties in contributing to occurrence of violence, but with less emphasis on how these interact with development of dysfunctional coping • Rage may be a problem for some (an extreme reaction completely out of proportion to any provocation) / Intermittent Explosive Disorder (IED)

18. Admitted to high security psychiatric care for assessment, following killing ofco-worker (supervisor) • Plea of manslaughter on the grounds of diminished responsibility • Detained under Section 45A of MHA (1983) classification MI SHE GOT ME FIRED SHE HAD TO DIE.. Cold-blooded words of McDonald's killer The Mirror Sacked burger man killed manager McDonald’s worker stabbed his boss during a children’s party The Times

19. Background • No pregnancy or birth complications • Minor problem with healing of umbilical cord • Born with small abnormality in outer ear • Described as a quiet baby & reached milestones with acceptable limits • Speech slow to develop (in comparison to older sister) & did not talk very much • Described as being ‘different’ from an early age (preferred being alone & did not engage in imaginative play) • Very picky about foods & dislike of some tastes (ginger & toothpaste) • Dislike of certain noises (e.g. vacuum cleaner, lawnmower & telephone) • A ‘detached’ manner (uninterested in immediate environment) • No history of alcohol or illicit substance abuse • No previous forensic history

20. Background cont’d • Family live in an isolated rural area • Helped with basic tasks, avoided contact with public • Maternal uncle described as ‘odd’ (ASD?) • Early problem incidents at school (a wish to stab a girl at school who had been taunting him & of ‘losing it’ with a teacher) • Some descriptions of a history of self harm & sudden rages

21. Developmental history – key points • Delayed speech development • Reading & writing difficulties • Referred to an educational psychologist during childhood (but not followed up) • Significant difficulties within school (‘difficult’ behaviour dealt with by removing him from classroom & allowing him to complete work in corridor) • Appeared to benefit from a more structured & consistent teaching approach • No friends (reports having friends, but unable to describe any details & did not spend any time with others outside of school) • A dislike of being touched & of any physical affection • Left school at 16 years old with 7 GCSEs, with grades ranging from B to E

22. Interests • Electronics • Buying shares • Used to collect plastic bottles (liked the patterns & colours)

23. Background to offence • Working as a part time cleaner (approximately one year prior to arrival of victim) • Reported job as okay (money & a free meal), but disliked contact with public & complaints • Wished to move into kitchens (to be away from public & victim of offence / supervisor & more money) • Felt under some pressure from parents to find another job (told to apply for two a week) • Did not socialise with other work colleagues

24. Context of index offence • Assaulted a teenage girl approximately one week prior to index offence (punched her in the face following her throwing ‘free food’ around & taunting him) • Anxious about break being moved forward & inspectors visiting on same day (had to work a longer shift than usual) • Victim was his supervisor (has never accepted this) • Felt she was always complaining about him & being unreasonable • Assault incident witnessed by supervisor & reported to management • Dismissed as a result • Following dismissal, left restaurant, bought a knife, returning to stab the victim numerous times in front of public • Expressed view that the victim was responsible for losing his job & to blame (for breaking ‘company rules’ – giving out free food)

25. Triad of impairments Diagnostic Interview for Social & Communication Disorders (DISCO) Autistic Spectrum Diagnostic Interview (ASDI) DIAGNOSIS OF ASD Adult Asperger’s Assessment (AAA) Neuropsychology Sensory oddities Diagnostic process

26. Autistic Quotient comparison * Baron Cohen et al. (2001), † Murphy (submitted)

27. Neurophysiology • EEG examination • Posterior temporal slow waves (PTSW) • an ‘immature profile’ • MRI scan • Overall conservative view ‘normal’, but possible developmental disturbance / pathology • Possible asymmetry • Possible cyst in caudate nucleus of right hemisphere With thanks to Dr John Lumsden, Head of Neurophysiology, Broadmoor hospital

28. EEG

29. MRI scan

30. Neuropsychological functioning

31. Qualitative impressions • Inappropriate eye contact (tendency to stare) • Receptive & expressive communication difficulties • Speech lacked prosody & monotone • No spontaneous information • Lack of reference (& displayed confusion) to feelings & mental states (own & others) / poor perspective taking • Motor tics (facial grimaces, scratching his hands & head) • Odd gait • Extremely concrete, literal & rigid in thinking & understanding • Lack of central cohesion (focus on irrelevant details rather than overall context of situation / circumstances) • Easily irritated when asked about subjects that relate to his responsibility in his offence (difficulty in accepting personal responsibility & being counter challenged)

32. WAIS III profile

33. WAIS III profile

34. WMS III abbreviated

35. Literacy • Speed & Capacity of Language Processing test (SCOLP) • Spot the word • Scaled score 3 • 1st percentile • Speed of comprehension test • Scaled score 5 • 5th percentile

36. Visual spatial organisation/planning (Rey CFT)

37. CFT

38. Executive functioning • Poor performance in Verbal fluency, Stroop test, Trail Making Test, WCST, Hayling Sentence Completion, Brixton Spatial Anticipation test & Iowa gambing task • Poor verbal organisation • Poor cognitive flexibility • Poor rule attainment • Slow speed of information processing • Impaired working memory • Cautious response style

39. Suggestibility • Performance in the Gudjonsson Suggestibility Scale (GSS) suggested some vulnerability to suggestibility, i.e. changing responses to some leading questions – specifically a shift in some responses • Consistent with qualitative observations • May question capacity at police interview

40. Theory of mind † from Baron-Cohen et al. (2001) adults with AS, n=15. * Male patients (aged between 20 to 40 years) detained in high secure psychiatric care, n = 30 (Murphy, 2006).

41. The revised eyes task

42. Personality & anger assessment

43. Millon Clinical Multiaxial Inventory III(MCMI III) • A 175 self report item true / false measure of 14 personality patterns & 10 clinical syndromes for use with adults (18 years & above) being evaluated in mental health settings • One of the most frequently used instruments in the examination of personality disorders & major clinical syndromes • Consists of a validity index, modifying indices (disclosure, desirability & debasement), clinical personality pattern scales, severe personality pathology scales, clinical syndrome scales (axis I symptom scales) & severe syndrome scales • No ASD comparative data as yet

44. AB’s MCMI III profile • A valid profile • Modifying indices acceptable, suggesting AB answered questions honestly & did not attempt to hide difficulties, portray a positive image or fake bad • Within clinical personality patterns, AB produced clinically significant scores within the ‘schizoid’ & ‘dependent’ personality traits (primary problems) • Schizoid traits associated with severe relationship difficulties & restricted emotional expression. Individuals appear aloof, introverted, emotionally bland & detached, with flat affect & low need for social contact • No clinically significant scores within any severe personality pathology dimensions (i.e. schizotypal, borderline or paranoid) • Within clinical syndromes, ‘anxiety’ significant (high level of generalised anxiety) • No clinically significant scores within any of the severe clinical syndromes (i.e. thought disorder, major depression or delusional disorder)

45. AB’s MCMI III profile

46. Psychopathy * Murphy (2007), † Hare 2003 (N=1117)

47. STAXI II profile • State Trait Anger Expression Inventory II • Designed to evaluate experience, expression & control of anger • A 57 item self report measure comprised of 6 scales, 5 subscales & an anger expression index (providing an overall measure of the expression & control of anger) • State anger (S Ang) • Feeling angry (S Ang / F • Feel like expressing anger verbally (S Ang / V) • Feel like expressing anger physically (S Ang / P) • Trait anger (T Ang) • Angry temperament (T Ang / T) • Angry reaction (T Ang / R) • Anger expression out (AX-O) • Anger expression in (AX-I) • Anger control out (AC-O) • Anger control in (AC-I) • Overall measure of expression & control of anger (AX index)

48. State Trait Anger Expression Inventory II(STAXI II) admission & one year > 75th & < 25th percentiles considered problematic

49. STAXI II interpretation • S Ang high (his ‘state’ anger frequently high) • S Ang / F high (frequently feels intense anger - current) • S Ang / V high (feels like expressing anger verbally- current) • AX-O low (outward expression of anger low – verbally & physically) • AX-I high (inward expression of anger high, i.e. angry feelings are experienced, but not expressed - suppressed) • AC-O high (significant control / perhaps ‘over control’ of outward expression of anger) • Overall, AB likely to frequently experience / feel intense anger, but over controls expression, probably because of inadequate way of expressing / communicating feelings • Some individuals with ASD detained in hospital display a similar STAXI profile

50. Assault on girl (punch on face following her taunting him & throwing food) / interpersonal conflict & inability to deal with this ANGER / RAGE / BLAME OF VICTIM Dismissal from job Index offence Visit by inspectors (need to keep restaurant clean) Failure to recognise authority of victim / supervisor Change in routine (break time moved, working longer shift) Context factors Vulnerability factors STRESS Belief that money is important for future & parental pressure to find jobs Poor interpersonal coping strategies for dealing with interpersonal situations / stresses & conflict Lack of early diagnosis & appropriate assistance / education Poor processing of internal information Core cognitive impairments in perspective taking, cognitive rigidity, executive dysfunction Poor anger management (Suppressed) Communication difficulties Formulation of index offence