The Prevalence of Autistic Spectrum Condition amongst the Female Population of one Special Hospital.

Transcription

1 The Prevalence of Autistic Spectrum Condition amongst the Female Population of one Special Hospital. Dr Juli Crocombe Consultant Psychiatrist, SSSFT Senior Lecturer, Keele University

2 The Special Hospitals Criteria for admission: Mental Disorder Immediate risk of serious harm to the public High Security

3 Background Growing interest from forensic / Special Hospitals sectors Assumptions about large numbers in Special Hospitals Growing public profile of ASC High profile cases led to concerns about offending in a minority

4 Early Reports Mawson, Grounds & Tantam [1985] Baron-Cohen [1988] Everall & LeCouteur [1990] Ghaziuddin et al [1991] Chesterman & Rutter [1993] Howlin [1994]

5 Prevalence of Offending Behaviour in Asperger Syndrome Scragg & Shah (1994) 1.5% - 2.3% Broadmoor population compared to 0.64% general population Tantam (1998) Secure Hospital (3.3%) Isolated offences (44.4%) Criminal offences (23%)

6 A Preliminary Study of Individuals with ASC in three Special Hospitals Dougal Hare Judith Gould Richard Mills Lorna Wing in England

7 Background to Preliminary Study Growing interest from forensic/special Hospitals sectors Joint Seminar Scragg & Shah Study Reed Report Assumptions about large numbers in Special Hospitals Higher public profile of Autism/Asperger Syndrome

8 Preliminary Study Study of all three Special Hospitals To establish prevalence of ASC through screening and case note examination Study team Dougal Hare, Judith Gould, Richard Mills and Lorna Wing Funded by the DoH

9 Aims of Study PRIMARY Identify numbers of PwASC resident at that time Raise awareness of their needs Develop strategies and set up appropriate services within the Special Hospitals and other forensic settings SECONDARY Understand nature of offences / reasons for admission or continued detention

10 Methodology Stage 1 - literature review Stage 2 - distribute screening questionnaire - analyse data - establish reliability / validity Stage 3 - examine case notes - review reliability / validity

11 Preliminary Study - All Special Hospitals Results following Case Note Evaluation Total Male Female Transsexual Not ASC ASC Uncertain (Originally Male)

12 Summary Smaller numbers than forecast 2.37% definite ASC based on criteria used (ICD10) Differences noted in offending patterns-low level of sex related offences; high recidivism Figures probably (as a result of methodology) an underestimate, particularly in respect of women ASC group stay longer (average 3.03yrs) than non-asc group

13 ASC amongst the Female Population Dr Juli Crocombe Mr Richard Mills Dr Lorna Wing of One Special Hospital

14 Study Team Dr Juli Crocombe, Consultant Psychiatrist Richard Mills, Director of Research, NAS Dr Lorna Wing, Consultant Psychiatrist, NAS working with Dr Margaret Orr, Consultant Psychiatrist, Broadmoor Hospital

15 Reason for Study Follow up of earlier study which had missed women who had been referred to researchers for clinical reasons (LW & RM) Pose particular problems for management and treatment within the Special Hospital setting Identified by Special Hospital Medical Staff as timely

16 Aims of Study Establish the prevalence of ASC within the female population of one Special Hospital Increase awareness and understanding of staff of ASCs Identify issues for diagnosis, assessment, treatment and management

17 Method Stage 1 - screening of entire female population Stage 2 - standardised diagnostic interview - review of clinical records & history - patient interview & assessment, inc Margaret Dewey stories.

18 Screening questionnaire for Asperger syndrome (Gillberg and Nylander 1991) 1. Does the patient have any problems regarding contacts with others? E.g. cannot find same- age friends or reciprocally satisfying sexual partners? 2. Is the patient odd, eccentric, one of a kind? yes no maybe 3. Do you find the patient compulsive or rigid, occupied by rituals, routines or rules? 4. Has the patient trouble with grooming or personal care eg wears old fashioned or ill fitting clothing? 5. Has the patient special or intense interests? 6. Has the patient bizarre language or strange voice pitch grammatically correct- pedantic- monotonous shrill or whining voice? 7. Has the patient unusual non-verbal communication e.g. abnormal gaze, gesture, facial expression, unusual posture? 8. Does the patient seem to lack common sense, not foreseeing consequences of their actions? 9. Is the patient uneven in their abilities e.g. very skilful in some areas lacking basic knowledge in others

19 Results Stage 1 51 subjects screened on screen (9 questions) 14 subjects scored yes - at least 3 questions 2 subjects scored maybe - at least 3 questions 1 subject scored yes - 2 questions & maybe to 2 questions 1 subject scored yes -2 questions & maybe to 1 question 32 subjects no to all questions 18 subjects progressed to second stage.

20 Are Description ASDI a Patient scores in each area 1 Severe Impairments in reciprocal social interaction All absorbing narrow interest patterns Imposition of routines, rituals and interests Speech and language peculiarities Non verbal communication problems 11 6 Motor clumsiness 6

21 Results ASDI no of categories met by subjects: 6 categories met by 5 subjects 5 categories met by 5 subjects 4 categories met by 2 subjects 3 categories met by 2 subjects 2 categories met by 3 subjects 1 category met by 1 subject 0 categories met by 1 subject

22 Margaret Dewey Stories

23 In the Supermarket The supermarket where Robert regularly shopped had a sign that said BARE FEET PROHIBITED BY LAW. One day while shopping, Robert saw a pretty girl, around his age enter the supermarket. She was wearing a long skirt but no shoes. ( ) Robert wanted to warn her but was afraid to approach her as strange things tended to happen when he talked to girls Finally he decided to follow close behind her with his trolley shielding her feet from the store manager ( ) She eventually arrived at the checkout that said 10 items or less. She had 12 items in her basket ( ) The girl then turned to Robert and said, I don t know why you're following me but if you don t go away I will call the police ( ) A. Fairly normal in that situation B. Rather strange in that situation C. Very eccentric in that situation D. Shocking behaviour in that situation

24 In the Park Keith age 27 was a file clerk who worked in an office in the city. At noon he took lunch to a small park and sat on a bench to eat it. Often he tore part of a sandwich to bits, scattering it on the ground for the pigeons ( ) One day a pram was parked next to his bench with a crying baby in it. A woman was swinging an older child nearby but did not hear because the swing was squeaking. Keith had learnt that babies sometimes cry because a nappy pin had come undone. Rather than bother the mother Keith quickly checked the baby to see if he could feel an open pin ( ) A. Fairly normal in that situation B. Rather strange in that situation C. Very eccentric in that situation D. Shocking behaviour in that situation

25 Conclusion NOT ASC 40 ASC 6 UNCERTAIN Case 1 Notes support diagnosis but declined interview Case 2 psychotic at interview Case 3 insufficient EDH- walked out of interview Insufficient information or discharged before conclusion 2 TOTAL 51

26 Study 2 the women Conclusion Not ASC ASC Uncertain Autism symptoms elicited at diagnostic interview Early Developmental History (EDH) supports diagnosis Usual range of responses elicited from Margaret Dewey scenario Unusual responses elicited from Margaret Dewey scenario s

27 Primary reason for admission ASD Probable/Uncertain TOTAL NO CONVICTION * Management in previous setting CONVICTION Murder/Manslaughter Violence/assault Threatening to kill/hostage taking Arson Sexual offending TOTAL

28 Recorded diagnosis and classification of ASC and uncertain group on admission ASC Uncertain Legal Classification Schizophrenia 4 3 Mental Illness ASC 0 0 Personality Disorder 2 2 Psychopathic Disorder Total 6 5

29 Other diagnoses during stay ASC Uncertain Schizophrenia 5 3 ASC 4 1 Anxiety disorder 1 1 Mood disorder 1 2 PD 2 4 Psychosis (NS) treatment resistant schizophrenia 1 0 OCD 2 0 PTSD 1 1 Schizo-affective/ schizo-typal disorder 1 1 Cross gender disorder 1 0 Catatonia 0 1

30 Circumscribed interests, repetitive routines and obsessional behaviours Not ASC ASC Uncertain Circumscribed interests Repetitive routines Obsessional behaviour (OCD like) Likes order and routine None noted NK 2 0 0

31 Studies 1 and 2 Conclusion 1995 Total screened Followed up (FU) Definite ASC Not ASC Uncertain All Special hospitals m / f 1305 (96%) (2.37%) 153 of FU (71.16%) 1244 all (95.3%) 31 (2.37%) 2005 Total Followed up (FU) Definite ASC Not ASC Uncertain One Special Hospital 51 (100%) 49 (96%) 6 (11.76%) 40 of FU (78.43%) 5 (9.80%) f only

32 Discussion Study confirms underestimate of females in preliminary study Scatter of autism symptoms across the groups but nature of social impairment the key factor in diagnosis ASDI useful with staff who knew patient well- More sensitive instrument needed to pick up on instinctive social responses, especially in the absence of EDH Presence of ASC should be considered when assessing offenders with social and communication problems

33 Issues for policy makers, clinicians and service providers Diagnosis of ASC in complex cases and females requires special attention Core features of ASC stable over time Medication for core condition not effective Reduction of anxiety a key feature of intervention and risk management- facilities and interactions important Individuals with ASC stay longer in secure settings - Need for more specialist move on facilities Need for continuing follow up and informed support

34 In how many cases would early diagnosis (in childhood) have prevented offending behaviour e.g. bullying? How far are specific cognitive characteristics linked to specific risk of offending? Is diagnosis the key to effective intervention, risk assessment and aftercare? How many would remain resistant to all known interventions? What are the legal/clinical implications of ASC diagnosis?

35 With sincere thanks to all of the patients and staff who gave so generously of their time Special thanks to Dr Margaret Orr for her support throughout this study