Asperger Syndrome and Offending

1
Asperger Syndrome and Offending

• Dr Ian Ensum
• Consultant Psychologist
• Bristol Asperger Syndrome Service
• The Hayes Independent Hospital
• 17.4.09

2
Outline

• Introduction
• Definition/diagnosis
• Clinical issues
• Asperger Syndrome and offending
• Prevalence studies
• Characteristics of AS linked to offending
• Range of offending treatment
• General treatment issues
• Motivation to change
• Containment or treatment

3
Definition

• Asperger Syndrome is a pervasive developmental
  disorder, and as such is a lifelong condition
• It is an autism spectrum disorder essentially
  describes high functioning end of autism
  spectrum
• i.e. people with all the social impairments of
  autism, but with normal/high IQ - ?AS vs HFA?
• Characterised by qualitative, pervasive
  impairments in social interaction, communication
  imagination the triad of impairments

4
Clinical issues

• People with AS have variety of very complex
  needs, including
• Profound difficulties relating to other people,
  and to the world in general.
• Very high levels of social exclusion -doubly
  excluded
• Huge vulnerability to exploitation
• Uneven, jagged cognitive profile
• High rates of comorbidity (depression, anxiety,
  OCD, transient psychotic episodes, Tantum, 2000
  Howlin, 2000)
• Problems poorly understood by mainstream services

5
Prevalence of AS

• Prevalence among adults unknown - estimates based
  on child studies vary from
• Sponheim Skjeldal (1998) - 0.003
• Ehlers Gillberg (1993) - 0.36
• Kadesjö et al (1999) - 0.48
• first ever national prevalence study announced
  this year (Brugha, University of Leicester),
  results due Spring 2009
• The reality is that the vast majority of adults
  with AS in the UK remain undiagnosed.

6
Prevalence of offending

• Little evidence that people with AS are more
  likely to offend than the general population
• Two kinds of research indicating apparent
  association between AS offending
• Case studies (Baron-Cohen, 1988 Barry-Walsh
  Mullen, 2004 Chen et al, 2003 Everall
  LeCouteur, 1990 Murrie et al, 2004 Palermo,
  2004 Silva et al, 2002, 2004)
• Large-scale surveys of secure hospital
  populations (Scragg Shah, 1994 Hare et al,
  1999 Myers et al, 2004)

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Prevalence of offending

• Case studies
• interesting clinical insightscontribution to
  the task of informing service development is
  limited (Woodbury-Smith et al, 2006)
• Large scale surveys
• Scragg Shah (1994) prevalence 1.5
• Hare et al (1999) prevalence 1.6
• People with AS stay approx. 3 years longer
• Myers et al (2004) - lower prevalence (0.46 -
  1.39)
• Ghaziuddin et al (1991) failed to find
  association between AS and violence

8
Conclusions on prevalence

• Over-represented in high secure hospitals
• May be for number of reasons length of stay
• Absence of epidemiological data makes comparison
  difficult
• Problems extrapolating findings to general
  population
• Overall evidence on prevalence of offending
  equivocal at best
• Majority of people with AS scrupulously
  law-abiding (Murrie at al, 2004) but subset who
  do offend disproportionately expensive
  challenging to mainstream services

9
Characteristics of AS suggested to be related to
offending

• Various researchers have suggested ways in which
  specific features of AS might be linked to
  offending (Howlin, 2004, 1997 Berney, 2004
  Barry-Walsh Mullen, 2004 Murrie et al, 2002).
  
• Lack of empathy fewer brakes, potential for
  offence that is disproportionally extreme
• Executive functioning (lack of awareness of
  outcomes, poor problem-solving, impulsivity etc)
• Poor self-monitoring of emotional states
• Problems with peer group relationships, social
  naivety, misinterpretation of social rules
• Intense, over-riding interests/obsessions

10
Types of offending treatment

• Little data as to precise nature of the range of
  offending behaviour among people with AS
• Anecdotal experience, along with data from
  published case studies (cited in Allen et al,
  2008) suggests likelihood of three broad
  categories
• Violent offending
• Sexual offending
• Criminal damage, particularly arson

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Violent offending

• Two main categories
• i) lashing out in response to intolerable
  stress - wrong time, wrong place kind of
  offence
• Arguably most common form of violent offending in
  people with AS
• Stressors can be idiosyncratic (sudden,
  unexpected change, violation of personal rules,
  demand avoidance, sensory/cognitive overload)
• Violence tends to be poorly planned, impulsive
  unsophisticated

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Violent offending

• ii) deliberate, instrumental aggression - rare
• Various motivations, including revenge,
  entertainment, to achieve a change in
  circumstances (i.e. a new placement), to prevent
  a change in circumstances (i.e. a new placement)
• Can be more sophisticated the result of
  prolonged rumination
• Behaviour can be disproportionate to the
  situation - e.g. wants to prevent discharge -
  serious, sustained assault on nurse previously
  had good relationship with

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Treatment

• Environmental manipulation
• low arousal, autism-friendly environment
• Provision of structure predictability
• Work on recognising, labelling and
  self-regulation of emotions
• Increase awareness of triggers/cues
• Develop more appropriate coping strategies
• Aim decrease likelihood of build-up of chronic
  stress states
• Treatment of co-morbid psychiatric conditions

14
Treatment

• Problem solving skills
• Offending as response to poor problem-solving
• Tendency towards binary, dichotomous thinking
• Work to help people generate wider range of more
  appropriate solutions when confronted with
  problems
• Development of highly prescriptive strategies for
  people to follow when distressed

15
Treatment

• Work to facilitate communication
• Assumption that other people are aware of their
  problems
• Over-reliance on oblique methods of communicating
  distress
• Need to develop more effective ways of
  communicating and asking for help
• Use of visual cues, structured talk-time etc
• Assertiveness training

16
Sexual offending

• Three broad categories
• i) Stalking/harassment
• Stokes Newton (2004) deficits in social skills
  and understanding mean people with AS might
  naively engage in inappropriate and/or intrusive
  courtship behaviour in an attempt to initiate
  interpersonal relationships.

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Risk factors around stalking

• Same needs for closeness and intimacy as general
  population
• Lacking cognitive/emotional architecture to
  enable these needs to be met
• Social exclusion - lack of opportunities to learn
  and practice appropriate social behaviour
• Rules defining normal courtship behaviour
  ambiguous, inconsistent implicit
• Particularly hard for people with AS to infer

18
Sexual offending

• ii) Sexual offending against children
• Either true paedophilia, or a function of
  long-term difficulty relating to age peers
• Developmental delay in some people with AS as
  extending to emotional development - impaired
  social mental age
• Emotional congruence with much younger people,
  children as social/emotional peers

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Treatment

• Supervision
• Potentially close ongoing
• Aim to provide individual with safe space to
  mature develop more appropriate sexual identity
• Concrete, AS-specific strategies to develop
  skills around empathy and/or mentalising
• Intensive individual work, followed by group
• Use of visual materials and role play
• Repeated across number of contexts - problems
  with generalisation of learning

20
Treatment

• Increase social competence
• Social skills training
• Development of real, supportive social networks
• Opportunites to learn practice skills
• Access to age-appropriate partners
• Education re. appropriate sexual behaviour -
  provision of explicit, concrete rules about
  whats ok whats not
• Clear communication of consequences of continued
  deviant behaviour

21
Criminal Damage

• Similar pattern/motivation as for violent
  offending towards people
• Suggested to be more common form of instrumental
  aggression than interpersonal violence for people
  with AS
• Can be powerful means of committing dramatic
  offence against individuals, organisations or
  society without having to interact with victims
• Can be linked to special interests i.e. arson
• Treatment as for violent offending, possible need
  for ongoing supervision if related to interests -
  can be modified

22
General Treatment Issues

• Carpenter (personal communication) suggests
  existence of two broad groups of people with AS
  who offend
• Those who recognise they have a problem, and are
  motivated to change
• Those who do not see their behaviour as a
  problem, and who want the world to change to fit
  them
• First group often keen to develop new skills
  participate in treatment.
• Possibility of sudden, discontinuous change

23
General Treatment Issues

• Second group present much more significant
  therapeutic challenge
• Similar to Tantums group of malicious
  offenders, and Newsons construct of pathological
  demand avoidance (Tantum, 1999 Newson et al,
  2003)
• Focus more on containment, in the hope of gradual
  maturation skills development
• Key issue is to what extent they have the skills
  and/or intelligence to achieve aim of dominating
  their environment making the world fit around
  them

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General Treatment Issues

• If not, typically respond to environmental
  manipulation (low arousal, imposition of external
  structure etc.), although skills take longer to
  develop
• Those who are capable (through aggression,
  intimidation, litigation non-compliance) of
  exerting significant levels of control over their
  environment clearly much more challenging group

25
General Treatment Issues

• Need for staff teams, governance systems
  environments resilient enough to manage extremity
  of behaviour
• Realistic expectations of likely rate of change -
  need to be transparent with commissioners about
  this
• Focus on keeping safe, while relentlessly
  providing opportunities for progress
  development
• How to avoid warehousing?

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The End

• Thank you very much for listening please feel
  free to get in contact to discuss this further.
• I am contactable at
• ian.ensum_at_awp.nhs.uk