Understanding offenders with autism-spectrum disorders: what can forensic services do?

Summary

This commentary aims to support and elaborate on some of the specific issues raised by Dein & Woodbury-Smith. Although I agree with many of their comments, I believe that the role of neuropsychological and sensory impairments, as well as dysfunctional coping strategies among individuals with an autism-spectrum disorder who offend, need to be expanded from a psychological perspective. In my experience, the assessment of these factors plays a crucial role in guiding opinions on mental capacity, individual interventions, risk assessment and management. Elements of psychopathy in autism also require clarification. It could be argued that by understanding these issues, any attempts at social inclusion and preventing offending will be more successful.

As highlighted by Dein & Woodbury-Smith (2010, this issue), individuals with an autism-spectrum disorder, including Asperger syndrome, who offend represent a small but significant group. Although it is important to consider that there is no evidence to suggest that individuals with autism are more likely to offend than the ‘neurotypical’ population, specific vulnerability factors may increase an individual's risk within the context of social exclusion.

Typically, forensic services struggle to manage and provide adequate placements for individuals with autism-spectrum disorders. Although a failure to diagnose autism-spectrum disorder appropriately is significant, it is probably a failure to understand the implications for an individual's everyday functioning that contributes more to a shortfall in appropriate care. It is also significant that the diagnostic criteria for an autism-spectrum disorder remain ‘a work in progress’ (Attwood 2007) and that a diagnosis rarely directly informs an understanding of a person's specific difficulties. Individual presentations vary, and it is therefore necessary to have an individualised assessment of the cognitive strengths and weaknesses associated with having autism, of respective coping strategies for dealing with conflict and of any sensory dysfunction.

Reasons for offending

Regardless of the offence committed, there is rarely a single responsible factor, with most explanations being framed in terms of the associated cognitive, sensory and social naivety difficulties.

Consistently reported factors highlighted in a range of cultural contexts are cognitive difficulties with theory of mind (specifically difficulties with empathy and perspective taking), central cohesion (appreciating the whole context of a situation rather than often irrelevant details) and in different dimensions of executive functioning (notably in organisation, cognitive rigidity, appreciating the consequences of one's actions, as well as generalising learning from one situation to another). For some individuals, dealing with sensory overload or hypersensitivity is relevant. Cognitive dysfunction combined with social naivety may also lead to specific difficulties. However, for all individuals, it is the interaction between their specific difficulties and their immediate environment, including other people, that determines actions, often at critical periods in their lives.

Dysfunctional coping strategies

Within the context of social exclusion, a number of less-explored but nonetheless significant factors contribute to the vulnerability to offend of some individuals with autism-spectrum disorders. These include the development of dysfunctional and restricted coping strategies, dealing with feelings of resentment and the perception that there is no alternative way of behaving.

In terms of interpersonal violence, significant features for many people with autism include a profound alienation from other adults and mal-adaptive coping strategies (such as developing vivid and controlling daydream worlds) for dealing with emotional regulation and interpersonal anxiety. Many experience intense feelings of being wronged in some way and are hypersensitive to perceived incidents of criticism. Significant difficulties with perspective taking, empathy (especially in appreciating rather than strictly recognising the views of others) and with central cohesion are also common. ‘Suppressed’ anger styles (low outward expression of emotion and anger) also appear to be common among individuals with explosive anger difficulties.

Psychopathy

In terms of the possible comorbidity between autism-spectrum disorders and psychopathy it is important to clarify the distinction between the reported neurocognitive features found among individuals rated high in psychopathy (i.e. fear recognition impairments) and the defining behavioural features (e.g. callous superficial charm and lack of empathy).

Among the limited research there is no clear association between autistic traits and psychopathic traits as measured using the Psychopathy Checklist – Revised (PCL–R; Hare 2003) (the accepted gold standard method of assessing psychopathy). However, I found that a sample of individuals with autism in a high secure psychiatric setting tended to have specific PCL–R profiles characterised by elevated Factor 2 scores, i.e. affective features including a lack of remorse or guilt, shallow affect, callousness/lack of empathy and a failure to accept responsibility for own actions (Murphy 2007). Some independence of autism-spectrum disorder and psychopathy was also found among adolescent boys (Rogers 2006), but with the idea of a ‘double hit’ for those who displayed an impairment of empathic responses to distress cues.

Although the examination of the relationship between autism and psychopathy is important, particularly given the strong evidence for a neurodevelopmental component to psychopathy, no doubt the most sensible approach for the assessment of psychopathy is to follow Hare's (2003) recommendation to ‘exercise clinical judgement with the interpretation of psychopathic traits among individuals with unusual presentations’.

Mental capacity and suggestibility

As highlighted, individuals with an autism-spectrum disorder present with specific issues in relation to making valid decisions, fitness to plead and assessing the reliability of their information as a witness. A detailed assessment of an individual's cognitive strengths and weaknesses is essential in making judgements about their capacity to make specific decisions. Within the Mental Capacity Act 2005 definition of capacity (Department of Constitutional Affairs 2007), cognitive difficulties may put into question an individual's understanding of information relevant to a specific decision, their capacity to retain information and the ability to prioritise information appropriately. The challenge for clinicians is to enhance capacity by using advocates and ensuring that information is compatible with an individual's cognitive strengths and weaknesses.

The issue of interrogative suggestibility (i.e. vulnerability to being influenced by leading questions) is also relevant: one study of adults with autism suggests an eagerness to please, the avoidance of confrontation and greater compliance to requests (North 2008).

Case management

Within high-security psychiatric care, implementing the National Autistic Society's SPELL principles (emphasis on Structure, a Positive approach, Empathy, Low arousal, and Links with other professionals) appears useful (for an outline go to www.nas.org.uk/nas/jsp/polopoly.jsp?d=1351&a=3362). However, in my individual work with patients with autism-spectrum disorders I attempt to develop more adaptive coping strategies for dealing with interpersonal stress, promoting greater cognitive flexibility and an appreciation of the wider context of a situation, as well as alternative perspectives.

The rationale for such work is the possibility that the cognitive deficits associated with autism may change over an individual's lifespan and interact with environmental factors. Although my practice has been influenced by clinicians experienced in using modified cognitive–behavioural therapy (Gaus 2007), my outcomes have been mixed: I have had some success in addressing some of the functional impairments; ‘failures’ have been associated with difficulties in engagement and with individuals who present with significant egocentricity, take limited personal responsibility and reject their diagnosis.

Consistent with the observations of other clinicians (Attwood 2007), I have also found that some individuals take an immediate dislike to professionals. For these people, a key problem is agreeing goals and recognising the need to change problem behaviours. Perhaps the most realistic goal in such challenging cases is to identify specific risk factors and address how these can be managed by avoidance of known difficult situations and development of improved coping strategies, with appropriate supervision. Managing risk in individuals with autism-spectrum disorders with forensic histories, as with all forensic patients, is a complex business. However, specific issues include framing risk within the context of any cognitive and sensory difficulties. A frequent situation is that risk management is guided by a particular clinical team's views of what they consider useful for most patients rather than evidence-based practice for autism. A good example of the former is the recommendation of participation in group programmes. With the exception of social skills and support groups, there is limited evidence exploring how offenders with an autism-spectrum disorder might benefit from group work that attempts to address forensic issues but is not specific to autism-spectrum disorders.

Can offending be prevented?

Despite evidence suggesting that positive outcomes among individuals with autism are related to early support (Howlin 2000), services are limited. Indeed, the recommendations of two reports commissioned by the National Autistic Society highlighting how the needs of individuals with an autism-spectrum disorder could be addressed remain relevant (Barnard 2000, 2001). In addition to late diagnosis, the lack of transition planning between adolescence and adulthood were concerns. Consistent with the suggestion of the ‘therapeutic limbo’ for many individuals with autism (Berney 2004), the gap between mental health and learning disability services was also identified.

In terms of recommendations, the reports suggest government guidance to all relevant agencies clarifying their statutory duties and responsibilities regarding the needs of individuals with an autism-spectrum disorder. Specific target issues were identified within health, diagnostic services, education, housing, public transport, employment, advocacy, forensic services and the training of all relevant practitioners. Powell (2002) suggested that services should have an appreciation that most individuals with autism have a qualitatively different view of the world. Perhaps requiring the greatest adjustment was the recommendation for a broader model of disability in which ‘problems’ are located in society and not just in an individual with an autism-spectrum disorder.

Time will tell as to whether the government's current national survey into the prevalence and needs of individuals with autism will improve available services (Social Care, Local Government and Care Partnerships Directorate 2009).

The future

Despite an expanding literature, I support the need for further research with this population, specifically outcome studies and identifying protective/risk factors linked with offending. However, current figures suggest a clear need for more specialist forensic facilities (at all levels of security) and for better communication between them. Consistent with the need for a national strategic framework for individuals with an autism-spectrum disorder who offend, the formation of a special interest group for forensic issues linked to autism may help bring like-minded clinicians together in exchanging ideas, expertise, information and experience.