By Dr C Thomas (Consultant Forensic Psychiatrist) Dr S Gunasekaran (Consultant Forensic Psychiatrist) Ella Hancock- Johnson (Research Assistant) Dr

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1 By Dr C Thomas (Consultant Forensic Psychiatrist) Dr S Gunasekaran (Consultant Forensic Psychiatrist) Ella Hancock- Johnson (Research Assistant) Dr Alessandra Girardi (Research Associate)

2 Why do we use HCR 20? Where did the factors come from?

3 χ2 = 42.88, p <.000 CFI =.944 TLI =.926 RMSEA =.050 Correlated Model Dimensions on the HCR- 20 (Douglas & Lavoie, 2006) F1 F2 F3 H1. Previous Violence.60 H2. Young Age 1st Violence.61 H7. Psychopathy.89 H8. Early Maladjustment.71 H9. Personality Disorder.72 H10. Prior Supervision Failure.63 H3. Relationships Problems.62 H4. Employment Problems.81 H5. Substance Use Problems.41 C1. Lack of Insight.64 C2. Negative Attitudes.82 C4. Impulsivity.59 C5. Unresponsive to Treatment.80 R4. Noncompliance.82 R1. Plans Lack Feasibility.83 F1: Chronic Antisociality R2. Exposure to Destabilizers.76 F4 F2: Life Dysfunction R3. Lack of Personal Support.65 F3: Disagreeableness R5. Stress.54 F4: Destabilizing Context Cross-validation N = 2,047

4 People with ASD are over represented in forensic populations Scragg 1994, Hare 1999, Langstrom et al., 2009

5 Deficient empathy, Interpersonal Naivety, Sexual Frustration, Immediate confession and Links to preoccupation Less likely to have an obvious gain Less likely to involve illicit drugs/alcohol Less commonly occurred at night Less able to recognise fear in others Bowler and Worley (1994), Murrie et al (2002), O Brien and Bell (2004), Barry-Walsh & Mullen (2004), Berney (2004), Woodbury-Smith et al (2005) 5

6 Characteristics of Offences More common Among High functioning: Threats to kill Arson Sexual offending Criminal damage Stalking Less common Acquisitive offences Drug related offences Assaults Bowler and Worley (1994), Murrie et al (2002), O Brien and Bell (2004), Barry-Walsh & Mullen (2004), Berney (2004), Woodbury-Smith et al (2005) 6

7 Theory/ Literature Cognitive Theories Social Theories ABA Theories Social Model of Disability Literature in relation to violence and autism associations Predictive validity study at STAH Updated systematic review Clinical Experience Study on 40 patients with ASD at STAH Notts. Clinical Experience of OT s, Psychologists, social workers, nursing staff and psychiatrists

8 Literature concerning violence and aggression within Autistic Spectrum Disorders (ASD) has been criticised as lacking understanding of underlying reasons and risk factors for the relationship. Prevalence of ASD in secure settings has been reported at 5.3% (Hare, Gould, Mills & Wing, 1999).

9 Theory of Mind deficits In Bjorkly (2008) s literature review of risk factors for violence in Asperger s Syndrome, 35% of violence towards others was reportedly attributed to social misinterpretations of the victims intentions. Barry-Walsh and Mullen (2004) suggest that weak central coherence can result in preoccupations and rigidities that may lead to criminal behaviour. Burdon and Dickens (2009) have noted that impairment in understanding social cues may influence criminal behaviour, in individuals with Asperger s Syndrome.

10 Psychiatric comorbidities The prediction of comorbidities on violence in ASD has been substantiated by Langstrom, Grann, Ruchkin, Sjostedt and Fazel (2008) who found that comorbid substance use disorders and personality disorders were risk factors for violent offending behaviours in ASD. Quek, Sofronoff, Sheffield, White and Kelly (2012) found that depression was a significant predictor of anger in young people with ASD. Richards et al (2012) found that participants with ASD that engaged in SIB have significantly lower mood than those who did not exhibit SIB. Kerns, Kendall, Zickgraf, Franklin, Miller and Herrinton (2015) found that comorbid anxiety disorders were associated with increased patient-reported self-harm in youths with ASD.

11 Sociodemographic factors Amongst sociodemographic factors investigated by Langstrom, Grann, Ruchkin, Sjostedt and Fazel (2008), it was found that male gender and higher chronological age were associated with engagement in violent crimes. Kanne and Mazurek (2011) reported various demographic variables that were associated with violence in children with ASD; including lower chronological age and coming from a family with higher income.

12 Intellectual functioning and Intelligence Quotient (IQ) Lower IQ has been found to be associated with aggression in children with ASD (Kanne & Mazurek, 2011). Sensory processing In Bjorkly (2008) s literature review, sensory hypersensitivity was the second largest cause of violence towards others. Severity of ASD symptoms The severity of ASD symptoms have been found to be significant predictors of SIB in ASD (Baghdadli et al, 2003; McClintock et al, 2003), though the former research studied a sample of children, limiting generalizability to adults with ASD.

13 HCR-20 Factor H1 Previous Violence Comments Each act of violence needs to be captured in detail including the antecedents and consequences of the action. This would be vital in eliciting the ToM deficits, Weak Central Coherence and links to stereotypical behaviour and fixed interests. This would be important in formulating the risk management plan. H2 Other Antisocial Behaviour Lack of social awareness needs to be differentiated. This may be linked to ToM, executive function deficits, weak central coherence or stereotypical behaviour. H3 Relationships Problems Lack of a relationship indeed may be a protective factor for a patient with ASD who may find intimate relationships stressful and a trigger for violence. H4 Employment Problems The specific interpersonal, social communication deficits, deficits in executive function would give a clearer indicator of risk. The employment problems may not be linked to future violence hence marking the relevance would be important.

14 H5- Substance Misuse Is this an addiction or stereotypical behaviour? H6 Major Mental Disorder It would be useful to elaborate on the symptoms, Executive function deficits, cognitive and behavioural developmental deficits. H7 Personality Disorder This is a highly controversial area due to overlap of symptoms, hence again the relevance of description of individual symptoms. H8 Traumatic Experiences This is highly contextual and what is traumatic to a person with autism may not fit the description of trauma in general. For example a relationship breakup may not be as traumatic as a disruption in structure to a person with ASD. H9 Violent Attitudes May be highly fixed and maintained by stereotypical behaviour. It may be an expression of a sensory need rather than instrumental aggression or a manifestation of anger. H10 Problems with Supervision or Treatment They may attend regularly however fail to benefit due to ToM deficits, executive dysfunction and weak central coherence. Response.

15 C1 Insight May have intellectual insight but completely lack emotional insight. C2 Violent Ideation or These may be situation or person specific and not generalizable. Intent C3 Symptoms of Major Mental Disorder More relevant to describe the individual deficits rather that the diagnosis. C4 - Instability This may be linked to specific triggers or disruption in routine. It may be signature behaviour to achieve a desired outcome or avoid a situation. C5 Treatment or Supervision Response Responsiveness rather that compliance would be a key measure. Lovaas and Smith s (1989) theory highlights the importance of environmental modifications in maintaining stability.

16 R1 Future Problems with Professional Services and Maintaining structure, routine and addressing sensory and communication difficulties are priority areas. Plans R2 Future Problems with As described in R1 Living Situation R3 Future Problems with As described in R1 Personal Support R4 Future Problems with As described in R1 Treatment or Supervision Response R5 Future Problems with Stress or Coping Future problems are likely to be in the related to changes in structure and behavioural support. Difficulty in communicating their bio-psycho- social needs to a new professional may be related to destabilisation and acting out. Return to previous patterns of behaviour in the context of stress, changes in staff and structure have been commonly observed in ASD.

17 Important to be aware of the factors associated with risk of violence in autism How significantly do these factors effect risk Remember to use the relevance option and other risks to elaborate so that the risk is accurately assessed and described

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