PBS Autism and Offending

1. PBS Autism and Offending Dr Lesley Steptoe Chartered Forensic Psychologist NHS Tayside, Forensic Learning Disability Services and Behavioural Support and Intervention Acute Services Dr Amy Kilbane Highly Specialist Clinical Psychologist Autistic Spectrum Condition Service

2. Topics • Service difficulties • Individual Assessment • PBS/Good Lives Model and Quality of Life (QOL) • PBS and Psychological Interventions • Risk Management - How does that fit? • Case Study

3. Service Difficulties (Dein & Woodbury-Smith, 2009) • Small but significant group • Specific vulnerability factors may increase risk • Typically forensic services struggle to provide adequate placement • Difficulties in understanding an individuals everyday functioning that contributes to shortfall in appropriate care • Diagnosis rarely directly informs an understanding of the persons specific difficulties • How does Autism affect Gary, John, Jim, Jean

4. Individual Assessment • Functional Assessment of behaviour • Sensory impairments • Dysfunctional coping strategies • Functions of challenging behaviour • Reinforcement schedules • Elements of psychopathy also need clarification • Understanding and working with these issues will offer increased success in attempts at social inclusion and preventing offending (Murphy, 2010)

5. Positive Behavioural Support (PBS) • Primary prevention, Secondary Prevention, Reactive Strategies • Autism – difficulties in understanding the social world to varying degrees • Difficulties for intervention • Risk management • How does PBS fit?

6. PCP and ELP • Depicts how to support the individual using Person Centred Planning (PCP) (important TO the person) and Essential Lifestyle Planning (ELP) (important FOR the person) • What’s important to the offender – increased quality of life – desist from offending? • What’s important for the offender – relapse prevention - risk management

7. Difficulties for Intervention • Rule based - moral rules? • Egocentric – lack of theory of mind (lack of empathy) consequences to self of offending • Rigid thinking patterns– difficulties in change • Good Lives Model – increase quality of life and gain desistance from offending. • QOL for the Autistic person may be very different to that of non autistic individuals.

8. Combine PBS with intervention • Combine PBS with interventions • PBS provides consistency in support • Informs strategies that suit the individual • Avoids unilateral decision making by staff • Aims to maintain consistency of support to prevent challenging behaviour and risk management (reactive strategy)

9. Case Study • Mr A – 47 year old man - Autistic Spectrum Disorder – CORO • 1992 x 2 separate appearances – (admonished, compensation order £150 and subsequently 1 year probation– vandalism and obscene phone calls • 1994 – vandalism to car – inpatient assessment • 1995 – vandalism to car – Probation Order 3 years direction to attend day care services

10. Index Behaviour • 1996 –– Behavioural escalation, further vandalism, threat to kill carer and being found near her home carrying a knife. Admitted to inpatient setting informally – continued to express violent and murderous fantasies in relation to carer – detained. • Breach of Probation, Criminal Justice (Scotland Act x2 - Wilful and Reckless Damage resulted in a Hospital Order, Section 59 CPA)

11. Background History • Childhood – happy and uneventful • Attended local schools and transferred to specialist LD school as a result of educational difficulties • YTS placement – participated in a number of work placements including work as a sweeper for the Cleansing Department

12. Developing Issues • 1991 – contact with psychiatry due to an obsessive attachment which he had developed towards a female member of staff • Noted as becoming aggressive when his approaches to this member of staff were not welcomed – obscene phone calls • Intervention showed little impact on his presentation.

13. Obsessive Behaviours • Reluctance to discuss sexual matters – worried at being labelled homosexual • Anxiety displayed at separation from the particular carer • Telephoned her at 5.20am when he was leaving for work as a road sweeper • 1992 - Appeared at her house - noted as following her to various different places – continued to phone her inappropriately along with episodes of damage to her property

14. Sexual Fantasy and Social Isolation • Fantasy – imagining he was having sex with carer and her friend • Also noted as at times expressing wanting to hurt her (related to damage to her car) • At home – mum trying to risk manage his behaviour by locking him in his room – he managed to leave and damage carers car. • He was described as socially isolated and as having poor interpersonal skills

15. Pornography and Sexual Fantasy • 1996 – ideas of sexuality were derived from viewing Pornographic videos involving rape amongst other activities • Also noted as having sexual fantasies of rape towards female nursing staff – harassing three members of nursing staff for their phone numbers and addresses • Reported wanting to rape one member of staff as she had blonde hair - struck her on the face with a towel • Similarities in appearance were noted between member of staff and victim of index behaviour

16. Challenging Behaviour • Otherwise presenting as: • Challenging • Awkward • Stubborn • Unco-operative • Non Compliant at times

17. Autistic Spectrum Disorder • Difficulties in approaching others to advise of problems • Taking control of his environment – not getting up – not going to workshop sessions – functions of CB – to escape from task demands – expression of emotional arousal and annoyance. • Initially in small group therapy – sitting away and with his back to others • Turned up but refusal to engage • Uncomfortable in group situation – that’s ok? • Lack of theory of mind – lack of empathy

18. MDT Intervention • Forensic Psychology • Adapted SOTP based on the Good Lives Model • Allowed him to be alone within the group as long as he attended and listened which he did • Once he became comfortable he integrated well and is now a valued member of the group (12 men) • Focussed on rule based initiatives • Now excellent at advising the others of the rules to risk and self management • Working with staff team to increase quality of life (Good Lives Model and PBS) • Aim at desistance from offending behaviour

19. Nursing Colleagues • Nursing Colleagues • Daily working with challenging behaviour and risk management – consistency –communication • Improving quality of life within a risk managed framework – social outings, budgeting, football. • Risk – intermittent episodes of attraction to particular female members of staff with blonde hair – often two or three at a time • Mr A takes an avoidant strategy to trying to problem solve this (dysfunctional coping strategy)

20. Psychiatric Colleagues • Introduction and management of medication to assist with obsessional thoughts • Ongoing monitoring of mental health • RMO management re CORO and as part of MDT

21. Occupational Therapy colleagues • Full timetable of work based activities • Increasing activities in line with QOL • Involved in risk management of Mr A during work based activities with nursing colleagues • Managing their own interpersonal style to communicate effectively

22. PBS Approach & Good Lives Model – increase QOL. • PBS approach looking to ‘need’ within Autistic Spectrum Disorder to provide support through primary and secondary prevention – increase quality of life – manage triggers to behaviour • PBS a means of support at baseline and within early indicators (triggers) of challenging/offending behaviour • PBS Reactive Strategies - Dynamic Risk Management (ELP) • Dynamic risk reduction – return to Primary and secondary prevention to support Mr A within Autistic Spectrum Disorder.

23. PBS Autism and Offending • PBS Approach aims to prevent challenging behaviour. • People with Autistic Spectrum Disorder may offend for various reasons but they still require support with how their Autism affects them. • Appropriate support through PBS results in a lower level of arousal in general and allows for individual dynamic risk management strategies to be employed more consistently within a staff team • Avoids unilateral decision making and assists in consistent dynamic risk management

24. Ongoing • Intermittent attraction to blond female staff • Through PBS he has learned to approach staff to report difficulties • Non punitive • Reactive strategies in response to report may reduce QOL for a limited period of time • Return to PBS once risk reduced = increased QOL once again.

25. Currently • Mr A recently openly reported attraction to a member of staff who had moved to another area (change) • Obsessive thought processes reported (same) • Asked for support (Change) • Reported he did not wish to offend, quite distressed and worried by the thought of doing so (Change) • Dynamic Risk – Reactive Strategy – ‘net tightened’ • Increase in Medication • Two week – lower levels of stimulation • End of week 1 – improvement in behavioural presentation

26. Refs and interesting reading • Dein K. & Woodbury-Smith M. (2009). Asperger Syndrome and Criminal Behaviour. Advances in Psychiatric Treatment; 15: 37-43. • Berney T. (2004) Asperger Syndrome from childhood into adulthood, Advances in Psychiatric Treatment; 10: 341-51. • Murphy D. (2007). Hare PCL-R profiles of male patients with Aspergers syndrome detained in high security psychiatric care.. Journal of Forensic psychiatry and psychology; 18: 120-26. • Rogers J., Viding E., Blair J., et al (2006) Autism spectrum disorder and psychopathy: shared cognitive underpinnings or double hit? Psychological Medicine; 36: 1789 - 98