Positive light on the spectrum?

I read with interest the letter by Sarah Ashworth and Ruth Tully entitled 'Adult autism – hidden in forensic settings' (September 2016). The Autism Act 2009 appeared to have had a significant effect on public awareness, recognising the needs but also abilities of people with ASC (autistic spectrum condition – a preferable term to autistic spectrum disorder, in my opinion). While autism awareness courses run in criminal justice settings are to be welcomed, they can often raise as many questions as they answer – for instance issues around accuracy of diagnosis and the treatment needs that become apparent once ASC has been correctly diagnosed. Many people with ASC who I have worked with have previously been undiagnosed and simply languished in the prison system, their needs unidentified and unmet. Even where ASC has been indicated in medical and other records, diagnoses have sometimes been inconclusive or not based on a recognised assessment methodology. As Ashworth and Tully say, the crucial need for a detailed neurodevelopmental history from a parent, carer or close family member can make this kind of assessment problematic for people managed by criminal justice agencies – although in many cases such information has been usefully accessed.

I have been fortunate to form very productive partnerships with a number of academics and professionals from non-forensic backgrounds (including clinical psychologists specialising in learning disability, speech and language therapists and social workers, as well as trainers with autism and staff from the National Autistic Society) in developing a better understanding of people with ASC who offend. This work included undertaking a prevalence study of ASC in a community offender sample which identified 4.5 per cent of offenders (N = 336) screening positive using a recognised screening tool (the AQ-10). Further analysis where relevant information was available indicated that approximately 2 per cent of these cases met diagnostic thresholds – roughly the expected rate of ASC in a (largely) male population. Although ASC is not thus markedly overrepresented in community forensic population, the challenges presented to criminal justice staff and the person with ASC themselves can be significant, often relating directly to presenting autistic symptoms – e.g. problematic communication skills, lack of perspective-taking abilities and obsessional behaviours.

Constructive professional co-working has led to the development of screening tools and clinical assessment methods to identify ASC in cases managed by the probation service locally, although accessing what are very limited services in the community remains problematic. Such services are primarily geared towards diagnosis and then self-help, although changes in legislation covering adult social care have been very helpful in addressing the needs of some offenders with ASC.

Elsewhere, developments in understanding ASC in a forensic population have had very positive results – in particular being able to reconsider the risks and needs presented by an individual once they have been accurately diagnosed. However, sometimes prisoners serving Indeterminate Sentences for Public Protection or life sentences have been refused progression through the prison system due, for example, to an observed lack of (victim) empathy or problematic social presentation in groupwork treatment by assessing psychologists. In certain cases a subsequent diagnosis shows their presentation reflects expected symptoms of ASC rather than antisocial attitudes or hostility. I have known prisoners incarcerated for more than 10 years when I would expect them to be released in less than half that time, if assessment reports had taken into account the eventual ASC diagnosis and altered the formulation to understand both their original offending and subsequent presentation in custody.

However, even with an accurate diagnosis, further complications arise when considering the management of such individuals and where it might best be delivered. Unfortunately, people who exhibit extreme ASC symptoms can still be very dangerous and particularly resistant to behavioural change or treatment. The government's Transforming Care agenda is to be welcomed in moving people with learning disabilities and autism out of hospitals and out into properly supported settings in the community; however, such facilities often do not yet properly exist. Fewer, not more, specialist hospital placements are expected to be provided for the more severely disturbed offenders with ASC. I hope that the developments which have taken place in this field will lead to a greater focus on awareness raising and wide-scale screening and accurate assessment and diagnosis of offenders with ASC throughout correctional agencies in order to make sure that their needs are better met by psychologists and other professionals working with them.

Andrew Bates
Registered Forensic Psychologist National Probation Service

Whilst I acknowledge the negative experiences of some individuals with an ASD within some aspects of the criminal justice system (CJS), it's important to highlight the significant progress that has been made within the CJS in identifying and addressing their needs, especially over the 22 years since the completion of Scragg and Shah's seminal and frequently cited paper highlighting the presence of Asperger's syndrome within one high-secure psychiatric hospital.

As highlighted by Ashworth and Tully there are some specialist forensic ASD services available across the UK. In fact, there now exists a wide range of community and secure specialist ASD services (independent and NHS) within mental health services. Whilst there has been some catch-up with developing an awareness of ASD within the prison system, progress continues to be made as illustrated by one prison obtaining accreditation by the National Autistic Society (NAS) and others set to follow. The NAS also provides a set of free guidelines for professionals at all levels working in the CJS.

Although the exact number of individuals with an ASD who find themselves within custodial environments remains uncertain, it is likely that in comparison to 'neurotypical' offenders, individuals with an ASD comprise a relatively small sample, albeit with complex needs that require a different approach. Ashworth and Tully highlight the need for greater assessment within forensic settings, emphasising obtaining a diagnosis before appropriate management within the forensic system (this was certainly promoted by Lorna Wing). However, in my experience, a comprehensive assessment of the key factors associated with having an ASD that inform any psychological formulation of offending and risk management is more important than a diagnosis per se (i.e. function of any preoccupations, role of any sensory hypersensitivity, neuropsychological functioning of an individual including their thinking styles and presence of any emotional regulation difficulties). The potential impact of any psychiatric comorbidity on interventions and risk also requires appropriate assessment. Whilst the ASD screens mentioned by Ashworth and Tully are sometimes useful as an initial step they should never be a substitute for a detailed diagnostic assessment, especially within such a heterogeneous population.

Where Ashworth, Tully and I would no doubt agree is that the availability of specialist ASD expertise within UK forensic services unfortunately remains fragmented. This is particularly frustrating after several years of arguing similar points. However, with the benefit of a long-term perspective of working within the CJS and an active interest in ASD, my impression is that significant progress continues to be made in recognising the difficulties and needs of this group of individuals – indeed, an awareness of ASD at all levels of the CJS has never been better. I am also optimistic that appropriate services will continue to develop. I would argue that, rather than further debate, there is a need perhaps for more direct action such as ASD awareness training of all prison officers, as well as greater cooperation and sharing of information as to what helps (such as good practice guidelines for assessing risk in ASD) between organisations and those with a vested interest.

Dr David Murphy 
Broadmoor High Secure Psychiatric Hospital, and Autism Diagnostic Research Centre, Southampton

For too long the world of forensics has ignored the plight of many adults with ASD, who find themselves at odds with the law. High-profile cases such as hacking into government computers are picked up by the media and highlight how such crimes are motivated by an individual's rigid and excessive interest in a favourite pastime.

I am in the unfortunate position of being a mother of an adult with ASD who has been incarcerated. The lack of support and understanding of my daughter's ASD has no doubt led her to develop mental health issues. Her secure environment ignores the fact that she is easily upset by a failure in routine; she is expected to manage the daily echoes of the corridors and screams of the other patients; her meltdowns are dealt with harshly with increases in medication.

My daughter has been in a prison hospital now for 25 years! She is one of Simon Baron-Cohen's 'lost generation' (The Lancet, November, 2015). Her symptoms in the late 1980s were not 'classic' autism. Her excessive interest in the police led her into systematic episodes of shoplifting because she enjoyed being picked up and interviewed by the police. When social services became involved, she was a vulnerable young girl and easily manipulated by peers into a life of crime with more socially adept teenagers. Social services, of course, blamed the parents, even though the evidence points to her behaviour worsening after they became involved. From that time on our voice was not heard!

My daughter ended up being moved from a social services placement to a prison and then to a secure hospital. She has received different diagnoses over time, and only recently has her autism been recognised. However, the treatment she receives continues to rely on high levels of medication to manage her anxiety and meltdowns rather than supporting her autistic characteristics.

Her crimes are far less severe than the population she is placed with, and the lack of understanding of autism by her forensic team results in mismanagement of her behaviour and condition. It is definitely time for change. My daughter has been waiting far too long, and I fear the process is moving too slowly to save her from spending the rest of her life in a high-secure prison hospital. The deliberate ignorance by the forensic services over the years has a lot to answer for – autism should be an integral part of the training of professionals involved in forensics, and more especially psychiatrists.

Name and address supplied

The magnitude and complexity of the criminal justice system causes limitations as to where the process of identification begins and how research can be implemented to support this. In my recently conducted research with carers and practitioners from the fields of autism, it was implied that although autism is a hidden condition and their socio-communicative differences may make them more suggestible or vulnerable within the criminal justice system, the sense of frustration and negative perception of the way the police, in particular, support individuals with autism is increasingly tangible.

Last year's Justice Inspectorates report on the welfare of vulnerable people recognised the police as the gateway to the criminal justice system, yet new research by Laura Crane and colleagues finds that only 39 per cent of 249 police respondents have received training about autism spectrum conditions, often leading to a lack of confidence in their interactions with these individuals. This was further supported by the themes found in my research whereby expansive areas of improvement within police interaction with individuals on the spectrum were awareness and training of police officers. In addition, it was suggested that there is a need for this training to be standardised across all forces.

If identification of individuals on the spectrum is made earlier in the criminal justice process, this may make for a smoother journey into forensic settings for individuals with autism. Additionally, identification can go further than assessment tools, but simply being able to spot slight diagnostic symptoms of the condition. Supporting the work proposed by Ashworth and Tully, it is important to assess each stage of the criminal justice system, police, custody, partnerships, courts, forensic settings and prisons separately before building a representative picture of how individuals with autism can be better supported in the criminal justice system as a whole, whilst also increasing policing and forensic research evidence and developing more inclusive processes and communities.

Alice Corbally MSc (Psychology) 
Doctoral Researcher in Criminology School of Law, University of Sheffield