Template to Perpetrate: An Update on Violence in Autism Spectrum Disorder

Game Changer: Exploring the Role of Board Games in the Lives of Autistic People

This mixed methods paper reports findings from three studies examining the overlap between autism and hobbyist board gaming. The first was a quantitative survey of over 1600 board gamers, showing that autistic individuals are overrepresented in this hobby compared to the general population and that autistic traits measured by the AQ are significantly elevated amongst board gamers. Study 1 also assessed gamers' motivations and preferences and reported key differences as well as similarities between autistic and non-autistic gamers. The second was a qualitative study that reported the results of 13 interviews with autistic individuals who are hobbyist board gamers. Using Interpretive Phenomenological Analysis (IPA), four key themes were uncovered, including a preference for systemising, escapism and passions, the social lubrication effect of games and difficulties with deception. In the third, 28 autistic individuals were introduced to board games in groups of 5-10 over an afternoon. Subsequent focus groups were then analysed using IPA. This analysis uncovered themes around how board games are challenging but encouraged growth and how they were an alternative vehicle for forging social relationships. Through this paper, we discuss how and why board games may be a popular hobby amongst the autistic population, and its potential utility for improving autistic wellbeing.

Close Relationships Despite the Challenges: Sibling Relationships and Autism

This study explores the experiences of siblings of autistic adolescents within families. Without the novel insights generated from engaging with siblings of autistic adolescents within a qualitative framework, it can be challenging to develop strategies for practicing effectively with this group or structuring interventions with these families. Using a social constructivist approach and qualitative participatory methodology, the exploratory study was conducted using in-depth interviews with ten non-autistic siblings, analyzed via a thematic analysis method. The results reveal a common feeling of uncertainty and apprehension in the relationships, leading siblings to physical and emotional detachment from their autistic brothers or sisters. The research emphasizes the caregiving roles predominantly taken up by sisters, especially when the autistic sibling is a brother with intellectual disability. These roles exert substantial demands, with unclear boundaries suggesting potential role confusion. The findings have important implications for family practice, necessitating the need to address role conflict and promote role clarity. They also underscore the gendered nature of caregiving, advocating for support to sister-siblings in these roles. This study revealed the complexities of sibling relationships in families with a member who is an autistic adolescent sibling. The study suggests interventions that promote open family dialogues for a balanced approach to family roles, providing valuable guidance to practitioners to enhance siblings and family well-being.

Identification and support of autistic individuals within the UK Criminal Justice System: a practical approach based upon professional consensus with input from lived experience

BACKGROUND

Autism spectrum disorder (hereafter referred to as autism) is characterised by difficulties with (i) social communication, social interaction, and (ii) restricted and repetitive interests and behaviours. Estimates of autism prevalence within the criminal justice system (CJS) vary considerably, but there is evidence to suggest that the condition can be missed or misidentified within this population. Autism has implications for an individual's journey through the CJS, from police questioning and engagement in court proceedings through to risk assessment, formulation, therapeutic approaches, engagement with support services, and long-term social and legal outcomes.

METHODS

This consensus based on professional opinion with input from lived experience aims to provide general principles for consideration by United Kingdom (UK) CJS personnel when working with autistic individuals, focusing on autistic offenders and those suspected of offences. Principles may be transferable to countries beyond the UK. Multidisciplinary professionals and two service users were approached for their input to address the effective identification and support strategies for autistic individuals within the CJS.

RESULTS

The authors provide a consensus statement including recommendations on the general principles of effective identification, and support strategies for autistic individuals across different levels of the CJS.

CONCLUSION

Greater attention needs to be given to this population as they navigate the CJS.

The application of adapted dialectical behaviour therapy concepts and skills in the treatment of adults with autistic spectrum disorder who display challenging or offending behaviours

Purpose

Despite some advances in the assessment and treatment of autism spectrum disorder (ASD), there remains a paucity of intervention and research literature in treating adults with ASD. There is growing evidence supporting a relationship between the core features of ASD and emotion dysregulation. There is an overlap between ASD and borderline personality disorder (BPD) characteristics such as emotional dysregulation, sensory issues and social skills deficits. This paper aims to explore the applications of dialectical behaviour therapy (DBT) concepts and skills in treating ASD individuals who display challenging or offending behaviours. The similarities in characteristics between ASD and BPD and the core issue of emotion dysregulation hold promise in the utility of DBT with ASD.

Design/methodology/approach

This is a conceptual paper that includes a case vignette.

Findings

A DBT-informed treatment approach using the adaptations and reconceptualization, i.e. risky mind–wise mind outlined in this paper, can be considered promising in addressing issues for ASD individuals, particularly those with challenging and/or offending behaviours. DBT incorporates different elements of applied behaviour analysis, cognitive behavioural therapy, mindfulness skills, sensory-based treatments, psychosocial interventions and emotion regulation skills, which makes it a more cohesive and integrated approach to treatment. The authors assert that DBT can be considered a more integrated, strengths-based, habilitative and trauma-informed approach which can be promising in its application to address challenging behaviours or offending in ASD individuals.

Research limitations/implications

It is recommended that research be carried out to evaluate the effectiveness of adapted DBT programs in treating ASD individuals presenting with challenging and/or offending behaviours. Future research can focus on evaluating the effectiveness of the different DBT concepts and skills and the different DBT modules to determine which components of the program are particularly useful for this client group.

Practical implications

Treatment manuals have already been developed for clients with intellectual disability and developmental disabilities who exhibit challenging and/or offending behaviour; hence, it is recommended that modifications be made to make it more applicable and appropriate for ASD individuals. Modifications should address ASD-specific issues (e.g. black and white thinking, cognitive rigidity, sensory issues, impaired theory of mind, emotion dysregulation issues, social skills deficits and anxiety issues). The use of DBT has much wider implications regarding addressing comorbid mental health conditions and personality issues in this client group.

Originality/value

There are limited psychological interventions that prove to be useful for individuals with ASD with complex presentations and challenging or offending behaviours. This paper discusses the application of adapted DBT concepts and skills that appear to be promising in the treatment of this client group.

The forensic implications of camouflaging: a study into victimisation and offending associated with autism and pathological demand avoidance

Purpose

This study aims to investigate the influence of social camouflaging on victimisation and offending in relation to autism and pathological demand avoidance (PDA) traits. Camouflaging aims to overcome or conceal difficulties in social and communication skills. Autistic individuals report camouflaging in response to threat and being verbally and physically assaulted when they have not camouflaged. Thus, camouflaging could be associated with victimisation. Camouflaging could also impact on specialist support available to an individual, potentially increasing the risk of victimisation or offending.

Design/methodology/approach

Cross-sectional study was conducted using 220 participants from the general population who completed online questionnaires measuring victimisation and offending, autism and PDA traits, camouflaging and symptoms of depression and anxiety.

Findings

Correlational analysis found positive associations between camouflaging and victimisation, and camouflaging and lifetime offending. Greater camouflaging and PDA traits predicted greater offending, whereas greater autism traits predicted fewer offending behaviours. While correlated, camouflaging was not significantly predictive of victimisation. Victimisation was predicted by symptoms of depression and PDA traits.

Originality/value

To the best of the authors’ knowledge, this study is the first to consider camouflaging as an influencing factor on offending and victimisation in autistic and PDA individuals.

ASD Symptoms, Social Skills, and Comorbidity: Predictors of Bullying Perpetration

Children with ASD are more likely to be involved in bullying compared to typically developing peers; however, studies rarely examine bullying perpetration and the contributing factors among this population. The primary aim of this study was to examine the extent to which parent-reported ASD symptoms, social skills, and comorbid externalizing and internalizing symptoms predicted bullying perpetration in a sample of 390 children with ASD without intellectual disability. Findings from hierarchical regression analyses indicated that social skill deficits, externalizing symptoms (i.e., hyperactivity, aggression, and conduct problems), and depressive symptoms were associated with higher likelihood of bullying perpetration, while severity of ASD symptoms and anxiety were not significant predictors. Further research is needed to better understand bullying perpetration among children with ASD.

Incels, violence and mental disorder: a narrative review with recommendations for best practice in risk assessment and clinical intervention

In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

Aberrant motor contagion of emotions in psychopathy and high-functioning autism

Psychopathy and autism are both associated with aberrant social skills and empathy, yet only psychopaths are markedly antisocial and violent. Here, we compared the functional neural alterations underlying these two groups that both have aberrant empathetic abilities but distinct behavioral phenotypes. We studied 19 incarcerated male offenders with high psychopathic traits, 20 males with high-functioning autism, and 19 age-matched healthy controls. All groups underwent functional magnetic resonance imaging while they viewed dynamic happy, angry, and disgusted faces or listened to laughter and crying sounds. Psychopathy was associated with reduced somatomotor responses to almost all expressions, while participants with autism demonstrated less marked and emotion-specific alterations in the somatomotor area. These data suggest that psychopathy and autism involve both common and distinct functional alterations in the brain networks involved in the socioemotional processing. The alterations are more profound in psychopathy, possibly reflecting the more severely disturbed socioemotional brain networks in this population.

Brain structural alterations in autism and criminal psychopathy

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Autism and psychopathy are both disorders of social cognition and share numerous of their features but still differ distinctively in their clinical phenotype.

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The lower grey matter volumes in the right temporal pole and the left inferior frontal gyrus are the most prominent findings distinguishing violent offenders with high psychopatic from ASD individuals.

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Violent offenders with high psychopatic traits and individuals with ASD both present similar lower grey matter volumes in the right precentral cortex compared to controls.

The goal of this study was to elucidate the anatomical brain basis of social cognition through two disorders with distinctively different phenotypes of social interaction. We compared structural MR images of 20 individuals with autism spectrum disorder (ASD), 19 violent offenders with high psychopathic traits, and 19 control participants using voxel-based morphometry (VBM). Our earlier study showed lower grey matter volume (GMV) values in the insula, frontal cortex, and sensorimotor cortex of the offender group compared to controls. In the present study, the images of the ASD group revealed lower GMV in the left precuneus, right cerebellum, and right precentral gyrus in comparison with controls. The comparison between the offender and ASD groups showed lower GMV values for the right temporal pole and left inferior frontal gyrus in the offender group. There was also an overlap of both disorders in the right pre-central cortex, showing lower GMV compared to controls. Our findings suggest structural differences between violent offenders with high psychopathy traits and ASD individuals in the frontotemporal social brain network areas, previously associated with empathy. We also provide evidence of similar abnormal structures in the motor cortex for both of these disorders, possibly related to uniting issues of social cognition.

Chinese College Students' Knowledge of Autism Spectrum Disorder (ASD) and Social Distance from Individuals with ASD: The Mediating Role of Negative Stereotypes

This study investigated whether negative stereotypes are responsible for the effect of ASD knowledge on social distance from individuals with ASD among college students. A sample of 869 neurotypical Chinese college students completed a cross-sectional survey to assess social distance, ASD knowledge, and negative stereotypes. Pearson correlation analysis yielded significant correlations between social distance, ASD knowledge, and negative stereotypes. Multiple mediation analysis showed that negative stereotypes mediated the link between social distance and ASD knowledge. Specifically, greater ASD knowledge predicted reduced social distance through decreased stereotyping related to dangerousness, personal responsibility for the disorder, and discontinuity, but also predicted greater social distance through increased stereotyping related to social inappropriateness. The findings deepen our understanding of the association between ASD knowledge and social distance by revealing the mediating role of negative stereotypes, and provide information that can help improve anti-stigma initiatives in college settings.

Self-harm and Mental Health Characteristics of Prisoners with elevated rates of autistic traits

BACKGROUND

Prevalence studies among prisoners have found rates of 1-4% for autism spectrum disorder (ASD) or autistic traits. However, little is known about those prisoners with high levels of autistic traits.

AIM

This aim of this study was to compare the mental health characteristics of prisoners with autistic traits with neurotypical prisoners not screening positive for neurodevelopmental disorders.

METHOD

The study recruited 240 male prisoners from a London prison and screened for autism spectrum disorder using the Autism Quotient (AQ) 20 and 10, and Autism Diagnostic Observation Schedule (ADOS). The Mini International Neuropsychiatric Interview was used to assess for depression, anxiety, self-harm behavior and suicide.

RESULTS

Screening using the AQ identified 46 prisoners with significant autistic traits, with 12 meeting the diagnostic threshold for ASD using the ADOS. Those screening positive with autistic traits were significantly more likely to have thought about self-harm and suicide in the past month than neurotypical prisoners and have a comorbid mental disorder. They were also significantly more likely to report having attempted suicide during their lifetime compared to neurotypical peers at a rate of 64.9 % compared to 11.6 % for the neurotypical prisoners.

CONCLUSION

Prisoners with elevated levels of autistic traits were more likely to report self-harm, suicidal thoughts and were more vulnerable to a range of mental disorders than neurotypical prisoners. There is a need for more evidence on the experience of autistic prisoners to inform how pathways should work to improve health outcomes through increased awareness and access to screening and subsequent diagnosis which currently prisons are currently not set up for.

Structural competency and the future of firearm research

In this critical literature review we develop a five-part agenda for pandemic-era research into mass shootings and multiple-victim homicides that promotes understanding the psychologies of individual shooters within larger structures and systems. We show how the momentous events set in motion by the COVID-19 virus, and the structural drivers of inequity and racism that its spread exposed, challenge mental health research on gun trauma to better account for broader terrains of race and place, as well as the tensions, politics, and assumptions that surround guns in the U.S. more broadly. Doing so will broaden mental-health interventions into epidemics of U.S. gun trauma, and challenge mental health research better recognize structural biases inherent in its own purview. We frame the agenda through the rubric of structural competency, an emerging framework that systematically trains health care professionals and others to recognize ways that institutions, neighborhood conditions, market forces, public policies, and health care delivery systems shape symptoms and diseases. Developing a structural framework around research into U.S. gun violence addresses the risks, traumas, meanings, and consequences that firearms represent for all communities-and highlights the importance of a renewed focus on mental health and safety for communities of color. Recognizing how gun violence reflects and encapsulates structures helps mental health experts address common sense gun policies within broader contexts-by fighting against structural racism or racially inflected gun policies for instance, or against economic policies that undermine access to mental health care more broadly.

Violence and mental disorders: a structured review of associations by individual diagnoses, risk factors, and risk assessment

In this Review, we summarise evidence on the association between different mental disorders and violence, with emphasis on high quality designs and replicated findings. Relative risks are typically increased for all violent outcomes in most diagnosed psychiatric disorders compared with people without psychiatric disorders, with increased odds in the range of 2-4 after adjustment for familial and other sources of confounding. Absolute rates of violent crime over 5-10 years are typically below 5% in people with mental illness (excluding personality disorders, schizophrenia, and substance misuse), which increases to 6-10% in personality disorders and schizophrenia spectrum disorders, and to more than 10% in substance misuse. Past criminality and comorbid substance misuse are strongly predictive of future violence in many individual disorders. We reviewed national clinical practice guidelines, which vary in content and require updating to reflect the present epidemiological evidence. Standardised and clinically feasible approaches to the assessment and management of violence risk in general psychiatric settings need to be developed.

Sensory Processing and Aggressive Behavior in Adults with Autism Spectrum Disorder

Autism spectrum disorder (ASD) may be accompanied by aggressive behavior and is associated with sensory processing difficulties. The present study aims to investigate the direct association between sensory processing and aggressive behavior in adults with ASD. A total of 101 Dutch adult participants with ASD, treated in outpatient or inpatient facilities, completed the Adolescent/Adult Sensory Profile (AASP), the Reactive-Proactive Aggression Questionnaire (RPQ), and the Aggression Questionnaire—Short Form (AQ-SF). Results revealed that sensory processing difficulties are associated with more aggressive behavior (f2=0.25), more proactive (f2=0.19) and reactive aggression (f2=0.27), more physical (f2=0.08) and verbal aggression (f2=0.13), and more anger (f2=0.20) and hostility (f2=0.12). Evidence was found for an interaction of the neurological threshold and behavioral response on total aggression and hostility. Participants with higher scores in comparison to the norm group in sensory sensitivity had the highest risk of aggressive behavior. In conclusion, clinical practice may benefit from applying detailed diagnostics on sensory processing difficulties when treating aggressive behavior in adults with ASD.

Young Adults with Autism Spectrum Disorder and the Criminal Justice System

This study describes charges, outcomes, and recidivism in both the juvenile and adult criminal justice systems (CJS) for young adults aged 17 to 23 years with autism spectrum disorder (ASD; n = 606). Results are compared to individuals with ID (n = 1271) and a population control group (n = 2973). About 3% of individuals with ASD were charged with at least one offense by the time they reached young adulthood. Few differences were found in CJS involvement across groups. Young adults with ASD were not over represented in the CJS in general, and were less likely to be involved in the adult justice system than their peers. They received similar charges and outcomes and were as likely to reoffend as their peers.

Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review

BACKGROUND

Autism spectrum disorder (ASD) is a neurodevelopmental disorder characterized by markedly impaired social interaction, impaired communication, and restricted/repetitive patterns of behavior, interests, and activities. In addition to challenges caused by core symptoms, maladaptive behaviors such as aggression can be associated with ASD and can further disrupt functioning and quality of life. For adults with ASD, these behaviors can portend adverse outcomes (e.g., harm to others or to the individual with ASD, hindering of employment opportunities, criminal justice system involvement). This article reviews the scientific literature to provide an update on evidence-based interventions for aggression in adults with ASD.

METHOD

A search of the electronic databases CINAHL, EMBASE, and PsycINFO was conducted using relevant search terms. After reviewing titles, abstracts, full-length articles, and reference lists, 70 articles were identified and reviewed.

RESULTS

The strongest (controlled trial) evidence suggests beneficial effects of risperidone, propranolol, fluvoxamine, vigorous aerobic exercise, and dextromethorphan/quinidine for treating aggression in adults with ASD, with lower levels of evidence supporting behavioral interventions, multisensory environments, yokukansan, and other treatments.

CONCLUSIONS

Additional randomized, controlled trials using consistent methodology that adequately addresses sources of bias are needed to determine which treatments are reliably effective in addressing aggression in adults with ASD. In the meantime, considering efficacy and adverse effect/long-term risk profiles, a practical approach could start with functional assessment-informed behavioral interventions along with encouragement of regular, vigorous aerobic exercise to target aggression in adults with ASD, with pharmacotherapy employed if these interventions are unavailable or inadequate based on symptom acuity.

The face validity of an initial sub-typology of people with autism spectrum disorders detained in psychiatric hospitals

Autistic adults who have a history of committing crimes present a major problem for providers of services in terms of legal disposal options and possible interventions, and greater understanding of this group and their associated needs is required. For this reason, we aimed to investigate the face validity of a proposed sub-typology of autistic adults detained in secure psychiatric hospitals in the United Kingdom. Initially, a focus group was completed with psychiatrists, clinical psychologists, healthcare workers, family members and autistic adults who had been detained in hospital, leading to revisions of the sub-typology. Following this, a consensus rating exercise of 10 clinical vignettes based on this sub-typology with three rounds was completed with 15 psychiatrists and clinical psychologists; revisions to the vignettes to improve clarity were made following each round. The findings indicated that these subtypes possess face validity and raters were able to classify all 10 clinical case vignettes into the sub-typology, and percentage of agreement ranged from 96% to 100% for overall subtype classification. This study suggests that the further validity of the sub-typology should be investigated within a larger study, as these subtypes have the potential to directly inform the hospital care pathway such that length of stay can be minimised.

Autism Spectrum Condition, Good and Bad Motives of Offending, and Sentencing

It has been proposed that the ways in which the criminal justice system treats offenders with Autism spectrum condition (ASC) should duly account for how the condition influences the offenders’ behavior. While the recommendation appears plausible, what adhering to it means in practice remains unclear. A central feature of ASC is seen to be that people with the condition have difficulties with understanding and reacting to the mental states of others in what are commonly considered as adequate ways. This article aims to clarify how the difficulties affect the moral weight to be given to the good and bad motives of offending in sentencing offenders with ASC. I start by explicating the main points of departure of the endeavor. After that I assess the moral significance of the good and bad motives of offenders with ASC in view of four cases and a comparison with how we commonly treat people who are not as able to understand and react to the mental states of others as neurotypical adults. I suggest that considerations pertaining to what has been called the primary orientation of morality provide grounds for deeming the good motives of offenders with ASC as morally significant as those of otherwise similar neurotypical offenders and the bad motives of offenders with ASC as less morally significant than those of otherwise similar neurotypical offenders. After considering three possible objections to the suggestion, I conclude by briefly elucidating its purported import.

A Novel Approach to Assess Violent and Homicidal Ideation: The I-HAVAT©

Background:

Child and adolescent psychiatrists and clinicians often assess individuals who present with homicidal and violent thoughts. These assessments are critical, for patient safety and societal protection. The psychiatrist must ultimately decide if the patient can return to the community safely, regardless if the patient has initially presented to inpatient, outpatient, emergency room or school settings. While there is some consensus regarding the best practice in assessing risk for serious self-harm, approaches to the assessment of homicide and violence are far more disparate. Clinicians often determine risk based on known risk factors and type of violence threatened, and many offer a “risk level”. However, in the absence of an easy to use tool to assess risk, the judgment relies on clinician experience, talent and training, at the expense of a uniform, organized and comprehensive approach.

Methods:

We describe an assessment tool that uses a semi-structured interview to comprehensively evaluate an individual’s risk for violence. The tool guides the clinician to gather a detailed description of the current episode, then reviews the salient risk and protective factors and ends with a structured mental status exam developed to help characterize typical pathways to violence.

Discussion:

The steps in assessing children and adolescents presenting with homicidal threats in various clinical settings, as well as the steps in determining the appropriate level of care and treatment plan, will be discussed. The implementation of the assessment tool in an inpatient setting and the clinicians’ reaction to using it will also be discussed.

Conclusion:

The I-HAVAT© (Institute of Living-Homicide and Violence Assessment Tool) is a semi-structured method of assessing patients presenting with violent or homicidal threats by collecting and streamlining pertinent clinical information and ultimately increases the clinicians’ confidence level in making decisions and recommendations for determining the level of care and appropriate treatment plan.

"The Need to See and Respond": The Role of the Child and Adolescent Psychiatrist in School Threat Assessment

Child and adolescent psychiatrists are on the front lines of performing challenging school threat assessments. With respect to school climate, clinicians should be aware of the presence of zero tolerance policies and inappropriate profiling. Removing a student from school does not eliminate the risk to the school community. School shootings often present similarly horrific themes and failures to respond properly to warning signs. Threatening communications in social media posts, drawings, and writings are significant clues to potential violence. Fascination with prior mass shooters is a potential high-risk warning sign. Thorough assessment of weapon access is essential. If there are significant concerns about a student's Internet activities, police can access a student's telephone and computer; the Federal Bureau of Investigation can also be contacted. Even if a threat appears to be relatively minor, a comprehensive psychiatric evaluation should still be performed, as important psychiatric concerns may be present. After threat assessment completion, it can be extremely challenging to find appropriate school placements for students with complex psychiatric problems who make serious threats. If indicated, a judge can order a forensic evaluation or remand the student to a hospital or residential programs. Ultimately, it is up to the psychiatrist to decide on the severity of the threat and the proper course of action, in collaboration with a school-based threat assessment team. The child and adolescent psychiatrist who performs a comprehensive threat assessment is likely to be in the best position to make these judgments to ensure the safety of all.

Evaluation of autism awareness training provided to staff working in a high secure psychiatric care hospital

Purpose

The purpose of this paper is to evaluate autism awareness training provided to staff working in a high secure psychiatric care (HSPC) hospital.

Design/methodology/approach

An online survey of staff views who had completed an autism awareness training day.

Findings

All staff who completed the evaluation questionnaire reported that an autism awareness training day had been useful and had increased their knowledge of how to work with individuals who have autism. However, most staff also reported that one day was not long enough and that more case discussion would have been helpful. Although most staff also reported that autism awareness training should be mandatory, motivation to attend such training was considered important. In terms of the number of staff who had completed the training, whilst a wide range of staff groups had attended training, only a minority had done so, with the number of staff completing the training each year remaining relatively constant over a five-year period.

Research limitations/implications

Within the context of promoting Enabling Environments in forensic settings and the recent government consultation paper exploring whether autism awareness training should be mandatory for all those working in health care, further investigation is required into how to increase staff motivation to attend autism awareness training and to explore how it is used during everyday work with patients.

Originality/value

As an initial evaluation of optional autism awareness training delivered in HSPC, the project offers some valuable information in terms of the number of staff who attend such training, what they find useful and how it might be improved for this setting.

Autism spectrum disorders in high secure psychiatric care: a review of literature, future research and clinical directions

Purpose

The purpose of this paper is to review available literature targeting the assessment and management of individuals with an autism spectrum disorder (ASD) admitted to high secure psychiatric care (HSPC). Key areas of examination include the prevalence of ASD in HSPC, how individuals with an ASD differ from other patient groups in clinical and cognitive characteristics, the views of staff regarding patients with an ASD, an exploration of the experiences and quality of life of patients with an ASD, as well as treatment and interventions.

Design/methodology/approach

A review of the published literature.

Findings

Although individuals with an ASD comprise a relatively small proportion of the total HSPC cohort, they appear to be over represented relative to the general population prevalence. Several research projects suggest that individuals with an ASD present with difficulties and needs different to other patient groups, as well as being viewed by staff as potentially vulnerable and requiring a different care approach. Individuals with an ASD report both positive and negative aspects to life in HSPC.

Practical implications

Suggestions are made with regard to how individuals with an ASD might be better managed in HSPC. Following the spirit of various pieces of government legislation such as the Autism Act (2009) and the Equalities Act (2010) the role of a specialist ASD HSPC service is proposed.

Originality/value

This paper provides a detailed review of the research to date exploring the assessment and management of individuals with an ASD detained in HSPC. It outlines key research findings, highlights limitations with it and provides a personal perspective on future research and clinical targets.

The Measurement of Adult Pathological Demand Avoidance Traits

Pathological ("extreme") demand avoidance (PDA) involves obsessively avoiding routine demands and extreme emotional variability. It is clinically linked to autism spectrum disorder (ASD). The observer-rated EDA Questionnaire (EDA-Q) for children was adapted as an adult self-report (EDA-QA), and tested in relation to personality and the short-form Autism Screening Questionnaire (ASQ). Study 1 (n = 347) found the EDA-QA reliable, univariate, and correlated with negative affect, antagonism, disinhibition, psychoticism, and ASQ scores. Study 2 (n = 191) found low agreeableness, greater Emotional Instability, and higher scores on the full ASQ predicted EDA-QA. PDA can screened for using this tool, occurs in the general population, and is associated with extremes of personality. Future studies will examine if PDA occurs in other clinical populations.

Higher Autistic Traits Among Criminals, But No Link to Psychopathy: Findings from a High-Security Prison in Portugal

The relationship between autism, criminality and psychopathy has gained increased attention in recent years, although research has focused on autism spectrum disorders, and not autistic traits. We measured autistic traits (with the Autism Spectrum Quotient) in a sample of 101 inmates from a high-security prison and compared them to a control group, using a logistic regression model that included age, education, psychopathology, psychopathy and attention deficit-hyperactivity disorder as covariates. Prisoners had more autistic traits (OR 1.13, p = 0.002) due to higher scores in the communication (OR 1.23) and imagination (OR 1.30) domains. No correlations were found between autistic and psychopathic traits. Our study points to the presence of autistic traits as being independent risk factors for imprisonment, although not associated with psychopathy.

Social cognition in aggressive offenders: Impaired empathy, but intact theory of mind

Aggressive, violent behaviour is a major burden and challenge for society. It has been linked to deficits in social understanding, but the evidence is inconsistent and the specifics of such deficits are unclear. Here, we investigated affective (empathy) and cognitive (Theory of Mind) routes to understanding other people in aggressive individuals. Twenty-nine men with a history of legally relevant aggressive behaviour (i.e. serious assault) and 32 control participants were tested using a social video task (EmpaToM) that differentiates empathy and Theory of Mind and completed questionnaires on aggression and alexithymia. Aggressive participants showed reduced empathic responses to emotional videos of others' suffering, which correlated with aggression severity. Theory of Mind performance, in contrast, was intact. A mediation analysis revealed that reduced empathy in aggressive men was mediated by alexithymia. These findings stress the importance of distinguishing between socio-affective and socio-cognitive deficits for understanding aggressive behaviour and thereby contribute to the development of more efficient treatments.

Are we good and are we safe? Measuring quality and assessing risk in an adult autism diagnostic service

Purpose

Leeds autism diagnostic service is an adult autism diagnostic service for people of any intellectual ability which also offers consultancy to service users/carers or professionals, as well as a wide range of autism training. The service was set up as a pilot in 2011 and a paper describing the service development was published in this journal in November 2015. The purpose of this paper is to describe the approach taken to measure the quality of the service the authors provide and accurately assess risk in adults with autism.

Design/methodology/approach

The process of evaluating appropriate outcome measures is described, along with considering appropriate risk assessment tools for use in the community. Over 200 people each year complete the autism diagnostic pathway, and 164 patients were invited to respond to service evaluation questionnaires in 2014.

Findings

To date, the most useful outcome measures for this group include a prospective service user questionnaire which enables service user opinion to influence service development. In the absence of any appropriate autism-specific risk assessment tools, the service has developed one which it is currently piloting. This has proved particularly useful in the consultancy setting

Originality/value

This paper is a follow-up paper looking at the day-to-day issues that the team have had to grapple with – how do you assess whether what you are doing is providing the best possible service for the people that you serve and how do you accurately assess risk in this population?

Autism and offending behaviour: needs and services

Purpose

Autism spectrum disorder (ASD) brings out the limitations of the Criminal Justice Service. The purpose of this paper is to review some of the salient issues and their remedies.

Design/methodology/approach

A narrative review based on the literature and the clinical experience of the authors.

Findings

ASD’s hidden disabilities, even without the frequent coexistence of other disorder, derail the standard responses to offending.

Practical implications

Management of these individuals as offenders depends on awareness of the issues, adaptation and the input of a variety of other services, especially health, social care and employment.

Originality/value

Although this is a very active field of work, there is relatively little written about it.