asd in the criminal justice & forensic mental health systems · 2019. 6. 14. · aspd, eupd...
TRANSCRIPT
Regi AlexanderConsultant Psychiatrist, Hertfordshire Partnership University NHS
Foundation Trust , Honorary Senior Lecturer, University of Leicester& Editor, Oxford Textbook of Psychiatry of Intellectual Disability
Acknowledgement: Dr Tom Berney for his wisdom on this topicand some of the slides too…
ASD in the Criminal Justice & Forensic Mental Health
Systems
ASD Prevalence &
Arbitrariness of the forensic label
Co-morbidity-
The pathology porrridge
ASD & Law breaking:
Mechanisms, interventions & outcomes
Typologies
TERTIARY CARE
(SECURE HOSPITALS)
SECONDARY CARE
(HOSPITALS)
SECONDARY CARE (CMHTs)
PRIMARY CARE (GPs)
THE EATS
TEAM
THE EATS-
CFS TEAM
POPULATION SAMPLE
Prevalence of ASD- 1% (9.8-11 per 1000)
LD POPULATION SAMPLE
Prevalence of ASD- 7.5%
HOSPITAL SAMPLES
2.4-10%
Much higher in excluded studies
from selected populations
COURT SAMPLE
Prevalence of ASD- 10%
PRISON SAMPLE
Prevalence of ASD- 4%
Law breaking in community
samples- similar or less
In selected forensic hospital
settings, higher than expected
rates
Prevalence
In females within such settings,
much higher than expected.
Types of offences
Arson(Hare 1999, Siponmaa 2001,
Mouridsen 2008)
Sex Offences Less: (Hare 1999, Elvish 2007)
More: (Kugmagami & Matsuura 2009)
ViolenceLess: (Murphy 2003)
Same: (Hare 1999)
More: (Woodbury Smith 2006, Elvish 2007)
Alcohol / drug
related (O’Brien & Bell
2001, Murphy 2003, Woodbury
Smith 2006, Wahlund &
Kristiansson 2006, Mouridsen
2008)
Conviction
Prosecution
Arrest
Offence
ASD Prevalence &
Arbitrariness of the forensic label
Co-morbidity-
The pathology porrridge
ASD & Law breaking:
Mechanisms, interventions & outcomes
Typologies
What is ASD?
FriendshipsEmotional reciprocity Social skills
Impaired social interaction
ConversationCommunicationabnormalities
Language anomalies
Imagination & creativity
Restricted, repetitive& circumscribed interests
Focal interests
Stereotypic / idiosyncratic speech
Rituals & routinesSensory interests
ASD
AgeBirth 16 yrs.
The developmental trajectoryImproves with age
Grow out of it?
Speed?Extent?
Normal developmental change
Compensatory, learned adaptations
Less testing environs
What is ASD?
Birth 16 yrs.
ADHD
Tics
OCD
Developmental Disorders
ASD
Epilepsy
Developmental Disorders
Communication
impairment
Social
impairment
Restricted
repetitive
behaviours
& Interests
Orion’s BeltOrion
Vocal
Tics
Restricted
repetitive
behaviours
& Interests
Social
impairment
Communication
impairment Tics
Impulsivity
Dyscalculia
Dyslexia
AD
Sensory
(in)sensitivities
OCD
Alexithymia
Dyspraxia
Overactivity
Executive
function
Central
Coherence
Epilepsy
Catatonic
symptoms
ASD Tourette
Developmental Disabilities
ADHDArticulation
disorder
Comorbid disorderHybrid disorderThe wide, star-studded skyOrion’s Belt
Comorbid mental illnesses & PD
Inattentiveness, hyperactivity & impulsivity
Mood disorder, PsychosisPD
Core components
Sociability
Communication
Rigid , repetitive & stereotypic behaviourFocal interests
Other developmental disabilities
Obsessive – Compulsive
Epilepsy
What is ASD? Pathology porridge
ASD & Psychosis
Specific sub type of ASD linked to
co-morbid psychosis
Atypical psychosis- particularly
with affective features
ASD- fewer stereotyped interests
and behaviours
Cluster B (“Flamboyant”): clinically relevant andof prognostic significance
Cluster C (“anxious/ avoidant”): Realistic dependency needs in those with LD. Hence diagnosis of limited utility.
Personality Disorders
Cluster A (“odd and eccentric”): overlap with ASD.Hence diagnosis difficult and of limited utility.
ASD Co- morbidities
Affective
instability...
Impulsivity
in at least two
areas that are
self damaging
Intense unstable
relationships alternate
idealisation
and devaluation ...
Recurrent
suicidal
gestures
Inappr.
anger
difficulty
controlling
anger......
Efforts
to avoid real
or imagined
abandonment ....
Chronic feelings
of emptiness
Transient
paranoid
ideation......Unstable
self image
ASD & BPD (EUPD)
Antisocial PD, Psychopathy & ASD
Autism Psychopathy
Autonomic
response to
distress
Cognitive
empathy (ToM)
Emotional
empathy?
Motor empathy
(imitation)
Perceive
emotions
general
subtle
happy, angry
sad, fear, disgust
(Blair ‘05)
Capacity to offend: empathy
ASD Prevalence &
Arbitrariness of the forensic label
Co-morbidity-
The pathology porrridge
ASD & Law breaking:
Mechanisms, interventions & outcomes
Typologies
ASD and offending behaviour
Similar factors as everybody else: Personality disorder /
Psychopathy / Co-morbid Mental illnesses
ASD specific: two broad domains
Deficits in theory
of mind
Mindblindness
Risk factors for offending 1
• Misinterpretation
of social cues
(“cluelessness”)
• Lack of empathy
• Social naivete
Abnormal,
repetitive narrow
interests
Lack of central
coherence
Risk factors for offending 2
•Disruption of
routines
•“Obsessive”
preoccupations
Sensory Overload
http://www.nice.org.uk/CG142
Diagnosis: Screening
complicated by a number of difficulties such as:
comorbid psychiatric disorders
a lack of a reliable developmental history and
some degree of clinical and phenomenological overlap.
ASDASQ
•Nylander & Gillberg (2001)
•10 items
http://gillbergcentre.gu.se/di
gitalAssets/1615/1615794_as
dasq--english.pdf
Shared Formulation
Predisposing
Precipitating
Maintaining
HELP
1. Health
2. Environmental issues
3. Lived experience
4. Psychiatric problems10 DIAGN PLANES
1. LD degree
2. LD cause
3. ASD
4. Other DD
5. Ment illness
6. PD
7. Sub abuse
8. Physical
9. Psychosocial disdv
10.CB types
Treatment Approaches
THERAPEUTIC
MILEU
& SPELL
APPROACH
THE 10 PTP
1. Diagnosis
2. Psych formulation
3. Beh support plan
4. Psychotherapy
5. Psychotherapy- off specific
6. Pharmacotherapy
7. Physical illness
8. Structured day programme
9. Community participation
10.Transition
OUTCOMES
ASD vs No ASD:
No difference in outcomes??
Something more than the ASD diagnosis
alone
ASD Prevalence &
Arbitrariness of the forensic label
Co-morbidity-
The pathology porrridge
ASD & Law breaking:
Mechanisms, interventions & outcomes
Typologies
ASD
PSYCHOPATHY (C&UE TRAITS)
PSYCHOSIS
BEHAVIOUR- INTENSITY & FREQUENCY
Typologies 1
Diagnostic confusion &
boundary disputes- ID/
PD/ etc
Moderate to severe
intensity and frequency
Accurate diagnosis- ASD,
SPELL approach
Early discharge possible
Typologies 2
ID, ASD, HKCD
ASPD, EUPD
High arousal, daily
problems
No placements
Typologies 3
Odd, few friends, ASD
diagnosis
Fascinaton with knives-
knows obscure details and
collects them
Unemotional and
detached accounts
Model patient on the
ward, but remains
detained
Typologies 4
ASD, Odd beliefs
Intervening Psychosis
Content may be same,
form different
Length of stay depends
on prognosis of
psychosis
Prevalence-
over represented
Screening and Diagnosis
Key messages
Core features & extensive
co-morbidity
Formulation, HELP
& the 10 diagnostic planes
Therapeutic mileu, SPELL
& the 10 PTP
Key messages
Treatment outcomes &
Typologies
https://www.minded.org.uk/