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Autsim and law, by Kalpana Dein
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Autsim and law, by Kalpana Dein

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  • preliminary evidence that females have significantly greater abnormalities in brain than males to express the same symptom severity of ASD (i.e. the female brain is "protective" against developing ASD).
  • the case of a 15-years old adolescent with autism whose severe tantrums and violent behaviours were not improved by risperidone or haloperidol but were drastically improved with clozapine (more than 40% reduction of violent events). The anti aggressive effect of clozapine has been sustained for one year of follow-up.
  • comorbid psychotic and substance use disorders are associated with violent offending. We conclude that violent offending in ASD is related to similar co-occurring psychopathology as previously found among violent individuals without ASD. (Langstrom et al, 2009). Circumscribed interests (Woodbury-Smith et al, 2010)
  • Also we present preliminary evidence that, in adults, clinical services for autism in the United Kingdom are experiencing very significantly increased demand; but that just over 50% of people seeking a diagnosis from one expert service do not have ASD. This consumes very significant health care resources, and so we need to identify new cost-effective methods to aid current diagnostic practice. We present initial evidence offering proof of concept that brain anatomy can be used to accurately distinguish adults with autism from healthy controls, and from some other neurodevelopmental disorders (ADHD). Hence further studies are required to determine if sMRI can become an aid to current diagnostic practice in young adults with ASD.
  • Precipitating factors were identified in 30% of cases and are mainly represented by the situations of failure and the changes in the environment of the autistic child.
  • Between 2001 and 2005, we reviewed the charts of all adolescents with autism (N=29, mean age=14.8 years, 79% male)

Autsim and law, by Kalpana Dein Autsim and law, by Kalpana Dein Presentation Transcript

  • Meeting the Needs of Female Offenders with Autism Kalpana Dein MRCPsych MSc (Psychiatric Research) Consultant Forensic Psychiatrist
  • Contents
    • Epidemiology
    • Gender differences in Crime
    • ASD and Offending
    • Women with ASD who commit criminal offences
    • Women with Extreme Male Brains?
    • Issues in Managing Women Offenders
      • Diagnosis
      • Management
    • Case study
    • Are women with Autism more at risk of offending than their non-autistic peers?
  • Epidemiology
    • Baron-Cohen 1999
      • Autism is predominantly a male condition *
      • Male : Female of Asperger’s (normal IQ range) 9:1
    • Fombonne 2009
      • Autism is associated with mental retardation in about 70% of the cases
      • Overrepresented among males (with a male : female ratio of Autism 4.3:1)
      • *The female brain is protective against developing autism (Murphy et al, 2011)
  • Gender differences in Crime
    • Bennett et al 2005
    • Studies have consistently shown higher rates of offending for males, and especially higher rates of violence
      • Gender differences in the development of social cognition may help to explain gender differences in crime and violence
    • Females have lower rates of offending because:-
      • they acquire social cognitive skills earlier in life than males do
      • they have better pro-social skills
    • The superior social cognitive skills of females are influenced by many factors
      • Better interhemispheric communication
      • Fewer frontal lobe deficits
      • Greater verbal ability
      • Differential socialization by parents and peers
  • ASD and Offending (Dein et al, unpublished) Study n Participants Prevalence Scragg & Shah (1994) 392 Entire male population of Broadmoor hospital 1.5% (CI 95%; 0.6-3.3%) Gillberg & Gillberg criteria Hare et al 1999 1305 High Secure units in England 1.68% Siponmaa et al, 2001 126 Forensic referrals in Sweden 12% 15%(definite ASD) 12 (probable ASD) (making up 27%) Hawes, 2003 72 Referrals to DSPD unit at HMP Whitemoor 2.7 – 8.3% ICD-10 or DSM IV Myers 2004 State Hospital (Carstairs), Scottish Prisons, secure accommodations (children), inpatient units 0.46% in secure units and 0.93% in prisons Gallagher et al 2006 81 HMP Barlinnie, Scotland 7.5-14.6% Crocombe et al (2006) 51 Female inpatients in an English high secure unit over 10% (ICD-10) Kumagami & Matsura 2009 428 Juvenile court cases in 4 family courts* between April 2006 to March 2007 in Japan 1.3 to 6.7% 7.1% of these were female Ginsberg et al 2010 34 Norrtälje Prison: Male inmates in a high secure prison in Sweden 25%
  • Women Offenders with ASDs
    • 2 out of 30 females (Hare et al, 1999)
    • Over 10% (Crocombe et al, 2006)
      • 51 female patients
      • 6 diagnosed with ASD
      • 5 probable ASD
      • None of them were diagnosed with ASD prior to admission
      • 4 (of 6 ASD group) diagnosed prior to study
      • 1 (of 5 “probable ASD”) diagnosed prior to study
    Sparse Literature ↑ Prevalence
  • Characteristics of Female Offenders
    • Types of Offences
      • Crocombe et al (2006)
        • Arson (50%, n=3)
        • Violence (17%, n=1)
        • Threat to kill/hostage-taking (17%, n=1)
    • Other Psychiatric Disorders
      • Crocombe et al (2006)
        • Schizophrenia
        • PD
    • Circumscribed Interests (Woodbury-Smith et al, 2010)
    “ Females with PDD had similar risk for being convicted as males. The males from the comparison sample (without PDD) had much higher rates of convictions than females” (Mouridsen et al, 2008).
  • Women with Extreme Male Brains?
    • Baron-Cohen 1999
      • Autism is predominantly a male condition
      • Male : Female of Asperger’s (normal IQ range) 9:1
      • At Birth
        • Female babies attend to faces, males to mobiles
        • Release of prenatal testosterone determine the male or female brain type
      • Women > Men
        • Language tasks
        • Tests of social judgement
        • Measures of empathy and cooperation
        • Fine-motor coordination
      • Men> Women
        • Mathematical reasoning
        • Targeted motor skills
      • “ Male brain type”
        • “ folk physics” > “folk psychology” /”mind reading”
        • Regardless of sex
      • 3 brain types
        • Male brain type
        • Female brain type
        • Cognitively balanced
      • Autism
        • “ Extreme male brain type”
        • Folk physics >> folk psychology
  • Managing Women Offenders
    • Issues
    • Screening: especially if fire-setting risk
    • Diagnosis
    • Little empirical evidence
  • Difficulties with AQ that are evident with the prison population (Gallagher et al, 2006)
    • Poor literacy skills: could not be “self-rated”
    • 5 statements are directly related to reading behaviour e.g. Q13. ‘I would rather go to the library than a party’
    • Some of the language used was outside the experience of many prisoners e.g. Q34. ‘I enjoy doing things spontaneously’,
    • Some statements required prisoners to consider aspects of their character that they had never reflected on in the past e.g. Q3. ‘If I try to imagine something I find it difficult to create a picture of it in my mind’
    • Some statements required the prisoners to abandon a ‘hard, macho’ image in order to respond truthfully Q27. ‘I find it easy to “read between the lines” when someone is talking to me’
    • Some statements were irrelevant to the culture of many prisoners e.g. Q24. ‘I’d rather go to the theatre than the museum’
  • Diagnosis (Dein & Woodbury-Smith, 2010)
    • Training
    • Screening may improve diagnosis
    • Obtain a developmental history from a childhood carer
    • A childhood carer of an adult offender?!!
    • Using validated instruments: time-consuming
    • Distress/relief of the interview
    • Guilt about missing the diagnosis
    “ The researchers (using MRI) detected autism with over 90% accuracy” (BBC report, 10 th August 10)
  • Case study
    • Miss X
    • Born in 1965
      • Born “homeless”
    • Single mother
    • Abused x 2 ?x3
    • Love of horses
    • “ left” at 12 years
    • 20 years in secure units
    • Diagnosis
      • PD
    • Hates change:
      • setting, medication, staff, new patients
    • Risks
      • Head-banging, stripping, extreme violence
      • Reactive aggression
  • Treatment -1
    • Rules of Engagement
    • No Surprises! Inform them about meetings in advance
      • Exceptions to the above rule
      • Be predictable:
    • Familiarity: Initial meetings with someone they are comfortable with.
    • Don’t be subtle (Bjorkly, 2009)
    • Be positive
    • Talk about “pet topics”
    • Write: down plan at the end of the meeting
    • Set clear written targets with pictures
    • Therapeutic Environment
    • Appropriate Ward Environment (Crocombe et al, 2001)
      • Low stimulus environment
      • Quiet area – avoid banging doors, sound-proof
      • The purpose of rooms is clear
      • Reduced fixtures
    • Beware of restraining ASD patients!
    • Avoid frequent changes (Touhami et al 2011 Change precipitates violence in ASD children)
      • in staff
      • Patient population
    • Manage change
    • Clear unambiguous communication
  • Meeting with Dr D
    • Thank you for meeting with me on 2 nd March 2011. You are doing very well. We agreed to this plan:-
      • I will chase up the date of your tribunal
      • You can go to the hospital shop for 30 minutes every evening with one nurse
      • You can buy an ipod, but this will have to go through the security nurse
      • I wrote out a plan for the next few weeks. If you stick to it, you can have a milkshake! If you don’t Consequences …
      • I will see you at ward rounds on Monday
      • I will see you again on Tuesday 15 th March 2011
      • Keep up the good work! Well done!!
  • Miss X’s goals for the month March 2011: Never stop trying! Sun Mon Tue Wed Thu Fri Sat RISKS     1 2 3 4 5   DON’T Head-bang Strangle Strip your clothes     KD         6 7 8 9 10 11 12     WR           13 14 15 16 17 18 19       KD         20 21 22 23 24 25 26     WR     REWARD!         27 28 29 30 31 In Case of Risks                 Consequences !!  
  • Treatment - 2
    • Comprehensive psychological assessment
    • Comprehensive physical – rule out epilsepy *
    • Reduce risk behaviours
    • MEDICATION: Clozapine, mood-stabilisers (Lambrey et al, 2009)
    • Psychological
      • MIND reading
      • DBT
    • Occupational Therapy
      • Social skills training
      • Education and Employment
      • *21% of cases, uncontrolled seizures were identified as the cause of disturbed behaviour
      • (Perisse et al, 2010)
  • Overt Aggression Scale - Frequency
  • Are women with Autism more at risk of offending than their non-autistic peers?
    • Do autistic women have an extreme male brain?
    • Do men offend more than women because of “autistic traits”?
      • Poor “folk psychology” skills
      • Difficulties in socialising
      • Difficulties in verbal communication
      • Lack of empathy (due to poor understanding of “other” states of mind, or mind reading skills)
    • Are they over-represented within the offender populations (prisons, secure units)?
    • What do you think?
  • Are women with Autism more at risk of offending than their non-autistic peers?