The Prevalence of Autistic Spectrum Condition amongst the Female Population of one Special Hospital. Dr Juli Crocombe Cons...
The Special Hospitals <ul><li>Criteria for admission: </li></ul><ul><li>Mental Disorder </li></ul><ul><li>Immediate risk o...
Background <ul><li>Growing interest from forensic / Special Hospitals sectors </li></ul><ul><li>Assumptions about ‘large n...
Early Reports <ul><li>Mawson, Grounds & Tantam  [1985] </li></ul><ul><li>Baron-Cohen  [1988] </li></ul><ul><li>Everall & L...
Prevalence of Offending Behaviour in Asperger Syndrome <ul><li>Scragg & Shah (1994)  </li></ul><ul><li>1.5% - 2.3% Broadmo...
A Preliminary Study of Individuals with ASC in three Special Hospitals in England Dougal Hare Judith Gould Richard Mills L...
Background to Preliminary Study  <ul><li>Growing interest from forensic/Special Hospitals sectors - 1994 Joint Seminar - 1...
Preliminary Study  <ul><li>Study of all three Special Hospitals 1995-1997 </li></ul><ul><li>To establish prevalence of ASC...
Aims of Study <ul><li>PRIMARY </li></ul><ul><li>Identify numbers of PwASC resident at that time </li></ul><ul><li>Raise aw...
Methodology  <ul><li>Stage 1 - literature review </li></ul><ul><li>Stage 2 - distribute screening questionnaire </li></ul>...
Preliminary Study  - All Special Hospitals Results following Case Note Evaluation Total Male Female Transsexual Not ASC 15...
Summary  <ul><li>Smaller numbers than forecast </li></ul><ul><li>2.37% definite ASC based on criteria used (ICD10) </li></...
ASC amongst the Female Population of One Special Hospital Dr Juli Crocombe Mr Richard Mills Dr Lorna Wing
Study Team <ul><li>Dr Juli Crocombe, Consultant Psychiatrist </li></ul><ul><li>Richard Mills, Director of Research, NAS </...
Reason for Study <ul><li>Follow up of earlier study which had ‘missed’ women who had been referred to researchers for clin...
Aims of Study <ul><li>Establish the prevalence of ASC within the female population of one Special Hospital </li></ul><ul><...
Method  <ul><li>Stage 1  - screening of entire female  </li></ul><ul><li>population </li></ul><ul><li>Stage 2  - standardi...
 
Results  <ul><li>Stage 1 </li></ul><ul><li>51 subjects screened on screen (9 questions) </li></ul><ul><li>14 subjects scor...
<ul><li>ASDI </li></ul>Area  Description Patient scores in each area 1 Severe Impairments in reciprocal social interaction...
Results  <ul><li>ASDI – no of categories met by subjects: </li></ul><ul><li>6 categories met by 5 subjects </li></ul><ul><...
Margaret Dewey Stories
In the Supermarket <ul><li>The supermarket where Robert regularly shopped had a sign that  </li></ul><ul><li>said “BARE FE...
In the Park <ul><li>Keith age 27 was a file clerk who worked in an office in the city. At noon he took lunch to a small pa...
 
Study 2 the women Conclusion Not ASC ASC Uncertain Autism symptoms elicited at diagnostic interview 0 6 5 Early Developmen...
 
 
 
 
Studies 1 and 2  Conclusion 1995 Total screened Followed up (FU) Definite ASC Not ASC Uncertain All Special hospitals  m /...
Discussion <ul><li>Study confirms underestimate of females in preliminary study  </li></ul><ul><li>Scatter of ‘autism symp...
Issues for policy makers, clinicians and service providers <ul><li>Diagnosis of ASC in complex cases and females requires ...
<ul><li>In how many cases would early diagnosis (in childhood) have prevented offending behaviour e.g. bullying? </li></ul...
<ul><li>With sincere thanks to all of the patients and staff who gave so generously of their time </li></ul><ul><li>Specia...
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Autism conditions, by Juli Crocombe

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Autism conditions, by Juli Crocombe

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  • Require high security because of, eg, risk of absconsion.
  • 1992 Review of Services for Mentally Disordered Offenders (DoH): concluded that greater understanding of the prevalence &amp; pattern of offending &amp; other law-breaking among PwASD was needed to inform the development of appropriate services to meet the needs of this group &amp; recommended that priority should be given to research in this area. Joint Seminar 1994 Scragg &amp; Shah study 1994 Reed Report
  • Mawson et al published a case study of a male patient with all the clinical features of Asperger’s syndrome who developed interests and behaviour which posed considerable potential hazards for others and which led to his continued detention in a Special Hospital. Baron-Cohen also wrote about a case of violence in a young man with Asperger’s Syndrome and asserts that this case shows the importance of Mawson’s prediction that many people who come to the attention of secure units because of violence may have Asperger’s Syndrome. He recommends that a study of the prevalence of such cases in prisons and secure units would be worthwhile. Everall wrote about an adolescent boy with Asperger’s Syndrome and a 1 yr history of fire-setting, and argue that the fire-setting arose from the disabilities inherent in this disorder. Ghaziuddin et al critically evaluated the literature regarding the occurrence of violence in Asperger’s Syndrome and found no evidence to support the speculation that violence is common in Asperger’s Syndrome. As a result, they advocated the urgent need for a community based study of the prevalence of violence in this syndrome using clear operationalised criteria. Chesterman describe a case of Asperger’s Syndrome where the diagnosis was made in adulthood after the patient had committed several sexual offences.
  • Conducted between 1995 – 1997 Funded by the Department of Health Study group from the NAS
  • Questionnaire – Gillberg &amp; Nylander 1991 Information gathered from case notes: Details of Index Offence Mental Health Act Status Primary psychiatric diagnosis Psychological / neuropsychological assessment Additional reliability / validity measures
  • Stage 1 – Gillberg &amp; Nylander screen 2000 conducted with staff who knew patient very well Stage 2 – ASDI; Gillberg et al 2001
  • Nature of social impairment noted to be key factor in diagnosis.
  • Most common reason for admission was ARSON (55%)
  • Most common diagnosis on admission was SCHIZOPHRENIA (67%) followed by PERSONALITY DISORDER (33%).
  • Autism conditions, by Juli Crocombe

    1. 1. The Prevalence of Autistic Spectrum Condition amongst the Female Population of one Special Hospital. Dr Juli Crocombe Consultant Psychiatrist, SSSFT Senior Lecturer, Keele University
    2. 2. The Special Hospitals <ul><li>Criteria for admission: </li></ul><ul><li>Mental Disorder </li></ul><ul><li>Immediate risk of serious harm to the public </li></ul><ul><li>High Security </li></ul>
    3. 3. Background <ul><li>Growing interest from forensic / Special Hospitals sectors </li></ul><ul><li>Assumptions about ‘large numbers’ in Special Hospitals </li></ul><ul><li>Growing public profile of ASC </li></ul><ul><li>High profile cases led to concerns about offending in a minority </li></ul>
    4. 4. Early Reports <ul><li>Mawson, Grounds & Tantam [1985] </li></ul><ul><li>Baron-Cohen [1988] </li></ul><ul><li>Everall & LeCouteur [1990] </li></ul><ul><li>Ghaziuddin et al [1991] </li></ul><ul><li>Chesterman & Rutter [1993] </li></ul><ul><li>Howlin [1994] </li></ul>
    5. 5. Prevalence of Offending Behaviour in Asperger Syndrome <ul><li>Scragg & Shah (1994) </li></ul><ul><li>1.5% - 2.3% Broadmoor population compared to 0.64% general population </li></ul><ul><li>Tantam (1998) </li></ul><ul><li>Secure Hospital (3.3%) </li></ul><ul><li>Isolated offences (44.4%) </li></ul><ul><li>Criminal offences (23%) </li></ul>
    6. 6. A Preliminary Study of Individuals with ASC in three Special Hospitals in England Dougal Hare Judith Gould Richard Mills Lorna Wing
    7. 7. Background to Preliminary Study <ul><li>Growing interest from forensic/Special Hospitals sectors - 1994 Joint Seminar - 1994 Scragg & Shah Study - 1994 ‘Reed’ Report </li></ul><ul><li>Assumptions about ‘large numbers’ in Special Hospitals </li></ul><ul><li>Higher public profile of Autism/Asperger Syndrome </li></ul><ul><li>Need for such a study advocated (Baron Cohen-1988/Mawson, Grounds & Tantam 1985) </li></ul>
    8. 8. Preliminary Study <ul><li>Study of all three Special Hospitals 1995-1997 </li></ul><ul><li>To establish prevalence of ASC through screening and case note examination </li></ul><ul><li>Study team Dougal Hare, Judith Gould, Richard Mills and Lorna Wing </li></ul><ul><li>Funded by the DoH </li></ul>
    9. 9. Aims of Study <ul><li>PRIMARY </li></ul><ul><li>Identify numbers of PwASC resident at that time </li></ul><ul><li>Raise awareness of their needs </li></ul><ul><li>Develop strategies and set up appropriate services within the Special Hospitals and other forensic settings </li></ul><ul><li>SECONDARY </li></ul><ul><li>Understand nature of offences / reasons for admission or continued detention </li></ul>
    10. 10. Methodology <ul><li>Stage 1 - literature review </li></ul><ul><li>Stage 2 - distribute screening questionnaire </li></ul><ul><li>- analyse data </li></ul><ul><li>- establish reliability / validity </li></ul><ul><li>Stage 3 - examine case notes </li></ul><ul><li>- review reliability / validity </li></ul>
    11. 11. Preliminary Study - All Special Hospitals Results following Case Note Evaluation Total Male Female Transsexual Not ASC 153 127 25 ASC 31 29 2 Uncertain 31 27 3 1 (Originally Male)
    12. 12. Summary <ul><li>Smaller numbers than forecast </li></ul><ul><li>2.37% definite ASC based on criteria used (ICD10) </li></ul><ul><li>Differences noted in offending patterns-low level of sex related offences; high recidivism </li></ul><ul><li>Figures probably (as a result of methodology) an underestimate, particularly in respect of women </li></ul><ul><li>ASC group stay longer (average 3.03yrs) than non-ASC group </li></ul>
    13. 13. ASC amongst the Female Population of One Special Hospital Dr Juli Crocombe Mr Richard Mills Dr Lorna Wing
    14. 14. Study Team <ul><li>Dr Juli Crocombe, Consultant Psychiatrist </li></ul><ul><li>Richard Mills, Director of Research, NAS </li></ul><ul><li>Dr Lorna Wing, Consultant Psychiatrist, NAS </li></ul><ul><li>working with </li></ul><ul><li>Dr Margaret Orr, Consultant Psychiatrist, </li></ul><ul><li>Broadmoor Hospital </li></ul>
    15. 15. Reason for Study <ul><li>Follow up of earlier study which had ‘missed’ women who had been referred to researchers for clinical reasons (LW & RM) </li></ul><ul><li>Pose particular problems for management and treatment within the Special Hospital setting </li></ul><ul><li>Identified by Special Hospital Medical Staff as timely </li></ul>
    16. 16. Aims of Study <ul><li>Establish the prevalence of ASC within the female population of one Special Hospital </li></ul><ul><li>Increase awareness and understanding of staff of ASCs </li></ul><ul><li>Identify issues for diagnosis, assessment, treatment and management </li></ul>
    17. 17. Method <ul><li>Stage 1 - screening of entire female </li></ul><ul><li>population </li></ul><ul><li>Stage 2 - standardised diagnostic interview </li></ul><ul><li>- review of clinical records & </li></ul><ul><li>history </li></ul><ul><li>- patient interview & assessment, inc </li></ul><ul><li>Margaret Dewey stories. </li></ul>
    18. 19. Results <ul><li>Stage 1 </li></ul><ul><li>51 subjects screened on screen (9 questions) </li></ul><ul><li>14 subjects scored ‘yes’ - at least 3 questions </li></ul><ul><li>2 subjects scored ‘maybe’ - at least 3 questions </li></ul><ul><li>1 subject scored ‘yes’ - 2 questions & ‘maybe’ to 2 questions </li></ul><ul><li>1 subject scored ‘yes’ -2 questions & ‘maybe’ to 1 question </li></ul><ul><li>32 subjects no to all questions </li></ul><ul><li>18 subjects progressed to second stage. </li></ul>
    19. 20. <ul><li>ASDI </li></ul>Area Description Patient scores in each area 1 Severe Impairments in reciprocal social interaction 16 2 All absorbing narrow interest patterns 14 3 Imposition of routines, rituals and interests 11 4 Speech and language peculiarities 11 5 Non verbal communication problems 11 6 Motor clumsiness 6
    20. 21. Results <ul><li>ASDI – no of categories met by subjects: </li></ul><ul><li>6 categories met by 5 subjects </li></ul><ul><li>5 categories met by 5 subjects </li></ul><ul><li>4 categories met by 2 subjects </li></ul><ul><li>3 categories met by 2 subjects </li></ul><ul><li>2 categories met by 3 subjects </li></ul><ul><li>1 category met by 1 subject </li></ul><ul><li>0 categories met by 1 subject </li></ul>
    21. 22. Margaret Dewey Stories
    22. 23. In the Supermarket <ul><li>The supermarket where Robert regularly shopped had a sign that </li></ul><ul><li>said “BARE FEET PROHIBITED BY LAW”. One day while shopping, Robert saw a pretty girl, around his age enter the supermarket. </li></ul><ul><li>She was wearing a long skirt but no shoes. ( ) </li></ul><ul><li>Robert wanted to warn her but was afraid to approach her as </li></ul><ul><li>strange things tended to happen when he talked to girls </li></ul><ul><li>Finally he decided to follow close behind her with his trolley shielding her feet from the store manager ( ) </li></ul><ul><li>She eventually arrived at the checkout that said 10 items or less. </li></ul><ul><li>She had 12 items in her basket ( ) </li></ul><ul><li>The girl then turned to Robert and said, </li></ul><ul><li>“ I don’t know why you're following me but </li></ul><ul><li>if you don’t go away I will call the police ( ) </li></ul>A. Fairly normal in that situation B. Rather strange in that situation C. Very eccentric in that situation D. Shocking behaviour in that situation
    23. 24. In the Park <ul><li>Keith age 27 was a file clerk who worked in an office in the city. At noon he took lunch to a small park and sat on a bench to eat it. </li></ul><ul><li>Often he tore part of a sandwich to bits, scattering it on the ground for the pigeons ( ) </li></ul><ul><li>One day a pram was parked next to his bench with a crying baby in it. A woman was swinging an older child nearby but did not hear because the swing was squeaking. Keith had learnt that babies sometimes cry because a nappy pin had come undone. </li></ul><ul><li>Rather than bother the mother Keith quickly checked the baby to see if he could feel an open pin ( ) </li></ul>A. Fairly normal in that situation B. Rather strange in that situation C. Very eccentric in that situation D. Shocking behaviour in that situation
    24. 26. Study 2 the women Conclusion Not ASC ASC Uncertain Autism symptoms elicited at diagnostic interview 0 6 5 Early Developmental History (EDH) supports diagnosis 0 6 4 Usual range of responses elicited from Margaret Dewey scenario 7 1 1 Unusual responses elicited from Margaret Dewey scenario’s 0 5 4
    25. 31. Studies 1 and 2 Conclusion 1995 Total screened Followed up (FU) Definite ASC Not ASC Uncertain All Special hospitals m / f 1305 (96%) 215 31 (2.37%) 153 of FU (71.16%) 1244 all (95.3%) 31 (2.37%) 2005 Total Followed up (FU) Definite ASC Not ASC Uncertain One Special Hospital f only 51 (100%) 49 (96%) 6 (11.76%) 40 of FU (78.43%) 5 (9.80%)
    26. 32. Discussion <ul><li>Study confirms underestimate of females in preliminary study </li></ul><ul><li>Scatter of ‘autism symptoms’ across the groups but nature of social impairment the key factor in diagnosis </li></ul><ul><li>ASDI useful with staff who knew patient well- More sensitive instrument needed to pick up on instinctive social responses, especially in the absence of EDH </li></ul><ul><li>Presence of ASC should be considered when assessing offenders with social and communication problems </li></ul>
    27. 33. Issues for policy makers, clinicians and service providers <ul><li>Diagnosis of ASC in complex cases and females requires special attention </li></ul><ul><li>Core features of ASC stable over time </li></ul><ul><li>Medication for core condition not effective </li></ul><ul><li>Reduction of anxiety a key feature of intervention and risk management- facilities and interactions important </li></ul><ul><li>Individuals with ASC stay longer in secure settings - Need for more specialist move on facilities </li></ul><ul><li>Need for continuing follow up and informed support </li></ul>
    28. 34. <ul><li>In how many cases would early diagnosis (in childhood) have prevented offending behaviour e.g. bullying? </li></ul><ul><li>How far are specific cognitive characteristics linked to specific risk of offending? </li></ul><ul><li>Is diagnosis the key to effective intervention, risk assessment and aftercare? </li></ul><ul><li>How many would remain resistant to all known interventions? </li></ul><ul><li>What are the legal/clinical implications of ASC diagnosis? </li></ul>
    29. 35. <ul><li>With sincere thanks to all of the patients and staff who gave so generously of their time </li></ul><ul><li>Special thanks to Dr Margaret Orr </li></ul><ul><li>for her support throughout this study </li></ul>

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