Increasingly, secure forensic mental health services must balance reducing restrictive practices on one hand with keeping a violence free environment on the other. Nursing staff and other hospital staff have the right to work in a safe environment. They should not be subject to intimidation and assaults in the work setting. Patients have the right to care in a safe environment and they need to have confidence that staff members can keep them safe during their in-patient stay. Minimising in-patient violence and minimising past violence for forensic patients is undermining an area of significant treatment need and may seriously limit the patient’s chance of a future successful discharge in the community. We posit in this chapter that active and careful management of ward milieu and dynamics, and active treatment of psychotic and other symptoms, together with proportionate use only of restrictive practice and thorough evaluation of any and all restrictive practice is the most effective way of managing a forensic in-patient setting to effectively reduce and prevent incidents of violence.

This chapter defines the terminological differences between the terms ‘fire-setting’, ‘arson’ and ‘pyromania’, including their place in current diagnostic manuals. An epidemiological perspective on fire-setting in those with mental disorder as well as classification systems and theories of fire-setting with prevailing conceptual models of fire-setting and mental disorder is described. Current approaches in the risk assessment of fire-setting and psychological and pharmacological interventions in fire-setting are discussed. Finally, a care pathway to guide clinical and risk assessment of the patient with fire-setting as a feature of their behaviour or history is suggested.

Psychologists are often called in personal injury and workplace discrimination cases to help determine the extent of psychological damages (e.g., psychological trauma). We apply a rigorous five-stage temporal model to guide forensic evaluators in providing a robust, evidence-based psychological perspective on the nature and extent of the injury, how that injury arose, and the effects of that injury in the future. Functionality of the plaintiff is assessed in daily activities, in the workplace, in intimate relationships, in social and recreational activities, and in relation to their family. Systematic analysis of the functioning of the plaintiff in these areas from the period before the legally relevant event until litigation concludes allows decisions to be made about the nature and source of any impairments. This method includes consideration of alternative hypotheses, integral to decisions about causation. Psychologists’ decisions thus affect outcomes for injured parties. Future research and practice implications are discussed.

Neurodevelopmental disorders is an umbrella term that incorporates a range of conditions characterised by some form of disruption to ‘typical’ brain development. These disorders share aetiological pathways that have genetic, social and environmental risk factors. Neurodevelopmental disorders often have core features in common and they frequently co-occur. Long-term impairment is characteristic, although key features may vary over the life span. This chapter covers key aspects of the aetiology of neurodevelopmental disorders, in particular focusing on those found in forensic settings (such as autism spectrum disorder, intellectual disability, attention deficit and hyperactivity disorder and fetal alcohol spectrum disorder). The impact of genetic, social and environmental risk factors is considered. The chapter considers the aetiology of neurodevelopmental disorders as relevant to forensic settings.

The prevalence of intellectual disability (ID) in offender services is higher than in the general population. Identifying offenders with ID in the criminal justice system can be a challenge. It is essential to recognise offenders who may have ID and assess them. Screening offenders for ID is potentially less time consuming and effective in identifying those who would benefit from full assessment. Screening tools such as the LDSQ and HASI have been developed in community and in forensic settings, which have good sensitivity and specificity. Screening for adaptive functioning skills is important when considering the presence of ID that may be difficult to elucidate in a forensic setting. The treatment of offenders with ID requires commitment from staff to support people through levels of security. Adapting treatment strategies is key to treating people. Treatment programmes for offences such as sex offences, fire setting and violence can be adapted successfully to work with people with cognitive impairments. Alternatives to custodial and hospital care are developing where people are diverted from prison to hospital or to appropriate community support.

The chapter provides an introduction to neurodevelopmental disorders and summarises recent advances in published research, focusing on the very early development and function of the human brain. The main influences on the current delivery and development of forensic healthcare services is set within the context of available policy and guidance, which is limited in part by the available research evidence to inform it. The book is divided into three sections. The first provides an overview with an introduction to individual disorders and covers aetiology, prevalence, comorbid mental disorder and relevant policy to date. The second section focuses on the clinical aspects of the range of disorders including screening, assessment, diagnosis, risk assessments and therapeutic approaches. The final section examines the pathways through the criminal justice system from police to court to disposal and addresses the specific aspect of fitness to plead or stand trial for those with neurodevelopmental disorders. This section also describes current relevant legislation within the UK as well as forensic services for those with such disorders from a national and international perspective.

The significantly high prevalence of attention deficit hyperactivity disorder (ADHD) in prison populations raises the importance of assessment and treatment. Identification of prisoners for ADHD using screening tools is helpful. Those who are screened positive for ADHD can then undergo a full psychiatric assessment to confirm the diagnosis. The assessment also needs to focus on other potential comorbid mental disorders given the high prevalence of autism, intellectual disability, mental illness and personality disorders in prison/forensic population. Presence of comorbid mental disorders can also complicate the diagnostic process for ADHD. Treatment of ADHD is important given the strong evidence base for pharmacological treatment outcomes. Treatment needs to be personalised, taking into account many different factors. Stimulant or non-stimulant medications can be used, non-pharmacological interventions need to be offered alongside pharmacological treatments. Treatment of other comorbid mental disorders is equally important to achieve better outcomes. These may include pharmacological, psychological and social interventions within and when released from prison/forensic settings.

The developed countries of the Australasian region have legislative and healthcare systems similar to the UK, consistent with their relatively recent colonial history. Australia and Aotearoa New Zealand both demonstrate varying approaches to provision of healthcare, disability support services and legislative frameworks for people with neurodevelopmental disabilities who commit offences. Particular areas of need are described, including the impact of the lack of capacity in neurodevelopmental disability healthcare and also the additional skills and understanding required to develop cultural competence to better support and work with the Indigenous people of both countries facing additional disadvantage. The challenges of service delivery across vast geographic areas of low population density are also discussed. Common features of both countries are discussed initially, then unique aspects in Australia andAotearoa New Zealand. Significant improvements have been made in recent years, but both countries still suffer from a lack of capacity in the workforce and sufficient funding to deliver high-quality services to people with neurodevelopmental disabilities who commit offences.

Forensic psychiatry is a medical discipline, developed from the foundations of the asylum era, which focuses on the assessment and treatment of offenders with mental disorders. The complexity of the patient cohort is arguable reflected in the complexity of their clinical pathways, which necessitates some understanding of the legal system that for most patients, works in parallel to that of health and social care. In this chapter, we briefly review the historical context through which modern forensic psychiatry has emerged within England and Wales. This includes some high-profile individual cases that led to the development of concepts such as fitness to plead and the psychiatric defence of not guilty by reason of insanity. We then provide an outline of how inpatient secure services are structured, the relevant criminal sections of the Mental Health Act at each stage of the trial process and some of the challenges associated with managing this complex cohort of individuals.