Challenging behaviour in Asperger Syndrome in early adulthood. Professor Terry Brugha University of Leicester with Staufenberg E., U.

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1 Challenging behaviour in Asperger Syndrome in early adulthood Professor Terry Brugha University of Leicester with Staufenberg E., U. of East Anglia

2 Introduction There is no doubt that people with Autism Spectrum Disorder can present with difficult and challenging behaviour, particularly if they also have significant learning difficulties. That is not at issue The question is do they pose a greater risk of harm to others and a higher risk of criminal offending?

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4 Outline What is the question? Minor offences and major misunderstandings Grave offences - rare but high profile Evidence from population studies Research we need to answer questions Conclusions

5 What is the question? Is autism spectrum disorder in responsible adults (i.e. normal IQ, age 16 or older) associated with challenging / violent behaviour? The null hypothesis is that there is no such difference until proven otherwise

6 Method Dialogue with colleagues Media search, e.g. Pubmed search:- Autism or Asperger Syndrome AND Violence or Dangerousness OR - [MESH terms] Violence, Theft, Suicide, Social behavior disorder, Sex offences, Risk, Risk assessment, Punishment, Prison, Paraphilia

7 Minor offences and major misunderstandings Close family members (mother, partner) often report instances of minor physical violence that hardly ever come to the attention of authorities Minor but common offending issues that can arise out of misunderstanding e.g. indecent exposure, behaviour intended to cause offence to another Being passively coaxed or duped into minor criminal behaviour such as vandalism

8 Minor offences and major misunderstandings Other minor offending issues a poorly socialised adult with Asperger's repeatedly steals bicycles repetitive behaviour that causes a public nuisance so called stalking behaviour - repetitive staring at people / silent telephone calls / bizarre letters, with no sense of potentially untoward consequences (failure to recognise rejection signs) Obsessive pursuit of an object of fascination interpreted as sexual by neurotypical people

9 Minor offences and major misunderstandings Minor they may be, but there are implications for primary care, general psychiatry and the criminal justice system in reacting appropriately and sensibly to these kinds of incidents Practitioners are at the road junction of selective referral pathways - not all of us will see such cases

10 Minor offences and major misunderstandings There were virtually no references to such incidents in the literature Only adequately conducted population studies and well designed criminological studies will reveal the extent, cost, burden and distress due to such day to day incidents How many such cases end in custody?

11 Grave offences - rare but high profile Teenager guilty of girl s murder A teenager has been sentenced to life in prison for the murder of a 10-year-old girl at a Christmas party

12 Grave offences A small but growing number of cases in which homicide has occurred in the context of an Autism Spectrum Disorder Leading to a manslaughter instead of murder verdict Leading to change to lesser offence on appeal successful diminished responsibility plea?

13 Grave offences Are these cases more common than chance? Are they associated with other mental pathology such as sociopathy? What expertise is needed to advise the courts in the light of recent concerns about professional expert witnesses? Questions of culpability and of ability to plead and to give evidence

14 Grave offences - lessons from the published literature? Mawson Grounds Tantam a single case study: odd offending behaviour including repeated attempts to stab strangers without motivation; mistakenly diagnosed with schizophrenia, detained in a high secure hospital; did not relapse off medication

15 Grave offences - lessons from the published literature? Arturo Silva et al. The case of Jeffrey Dahmer: sexual serial homicide 2002 well known high profile US case. Father s biography points to a developmental history typical of an ASD however other psychopathology also described and explored (possibly coexisting abnormalities)

16 Grave offences - lessons from the published literature? Henrik Soderstrom et al Adult psychopathic personality with childhood-onset hyperactivity and conduct disorder: a central problem constellation in forensic psychiatry Psychiatry Res grave adult forensic referrals were assessed: 55% had neurodevelopmental disorders (AD/HD, LD, tics, ASD) forming complex comorbidity patterns with abnormal adult personality development including psychopathy John Milton et al, case history of co-morbid Asperger's syndrome and paraphilic behaviour. Med Sci Law these may be hard to help

17 Grave offences - lessons from the published literature? Tantam 2003, The challenge of adolescents and adults with Asperger Syndrome Child Adolesc Psychiatric Clin N Am valuable overview of the issues, discussion of implications for diagnosis, treatment, services describes common problems with temper tantrums, hitting family members, and rarer more serious problems drawing public attention

18 Staufenberg: deconstructing complex needs and risk appraisal in forensic developmental neuropsychiatry Risk appraisal tools in forensic neurodevelopmental disorders Recording and communicating information Prediction and prognosis based on neurodevelopmental level of the individual

19 Risk appraisal in forensic developmental neuropsychiatry Central coherence and risk appraisal - weak CC ( less integration / fragmentation ) - strong CC ( gist person - overview ) NB: affects all somato-sensory domains!

20 Risk appraisal in forensic developmental neuropsychiatry Victim Environment Perpetrator Assess factors and influences on the above: Physical Social Psychological

21 Evidence from population studies The parallel example of psychosis -? Clinic studies including long-term follow-ups of large cohorts tend to support the view held by forensic psychiatrists of strong important effects Population psychosis studies are few and support small relative risks (when compared with alcohol and drug misuse and of comorbid personality disorder) and show small effects attributable to psychosis at a population level of doubtful public health value...

22 Evidence from population studies Prevalence of Asperger Syndrome in secure hospitals prevalence of Asperger Syndrome estimated as between 0.6% and 3.3% in males in Broadmoor (6/392 cases) (Scragg & Shah, 1994) as this was thought at the time to be above the estimated general population rate for AS the authors (Scragg and Shah) inferred this is excessive compared to the general population I disagree! [ Footnote: The actual SH rate probably lies somewhere between the two extremes of 2.4% and 5.3% particular characteristics of the special hospitals population do not permit conclusions concerning over representation among offenders in general. Hare, Gould, Mills, Wing, 1999 (3 special hospitals study).]

23 Evidence from population studies Our systematic knowledge of the epidemiology of autism including Asperger Syndrome is based entirely on studies of children and adolescents What evidence is there that these children are more violent than other psychiatric cases or than children who are not cases?

24 Prevalence of pervasive developmental disorders in the British nationwide survey of child mental health (Fombonne et al 2001) The prevalence of PDD in the 1999 nationwide British survey of child and adolescent mental health was investigated in 1997 Method: A randomized, stratified sample of children (N= 12,529) aged 5 to 15 years was generated from the Child Benefit Register. Trained interviewers interviewed parents and youths aged 11 or older with a standardised diagnostic interview (Development and Well-Being Assessment), and questionnaire data (Strengths and Difficulties Questionnaire) were obtained from teachers and parents, who also completed self-report measures of psychological distress. Final diagnostic determination was achieved by a team of experienced clinicians using all data sources Results: A total of 10,438 (83%) interviews were conducted. There were 27 children with PDD: (weighted prevalence: 26.1/10,000 in A new repeat national survey in 2004 using more systematic questions suggests prevalence in childhood is approximately 1% - or 100/10,000)

25 Children's behavioural difficulties Total SDQ scores were higher in PDD children than in other psychiatric disorders, which were also higher than in normal controls Parents did rate their PDD children as having the same conduct subscores as for other psychiatric disorders, which were higher than for normal controls However, subscores on which PDD children were outstanding were impact on functioning (parent rating), peer relationships (parent and teacher ratings), prosocial behaviour (parent rating) and hyperactivity (parent rating) And the conduct subscore was rated by teachers as higher in psychiatric disorders compared to control and normal controls (which did not differ significantly)

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27 Research we need to answer these questions We need to develop and use methods for studying ASD (traits or diagnoses) in adults in the general population We need to use these methods in large scale surveys in which data area also collected on offending behaviour and on other forms of mental disorder such as Anti- Social P.D. and on possible determinants of Autism Spectrum Disorder

28 Conclusions The null hypothesis stands largely unchallenged: There is no adequate evidence that children or adults with ASD are more likely to offend than are other individuals But it is possible that ASD co-exists with other developmental and neuropsychiatric disorders in cases of grave offending that may be rare Whether minor or grave, where offences occur or are alleged, expert advice should be provided to the criminal justice system and to health and social care agencies to ensure appropriate outcomes ASD epidemiology research in adulthood is overdue

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