Heterogeneity within autism spectrum disorder in forensic mental health: the introduction of typologies

A Multi-Perspective Qualitative Study About Working With Autistic Individuals in Prison-Based Interventions to Address Sexual Offending

Research suggests that sexual offending is one of the more common forms of offending behaviour committed by autistic individuals. Despite this, very little research has investigated approaches to rehabilitation for autistic individuals who have sexually offended. The small body of literature that does exist suggests that interventions to address sexual offending may not be sufficiently adapted for this group. In this paper we present an exploratory qualitative study that (i) explores how prison-based interventions to address sexual offending are experienced by autistic individuals with sexual offense convictions and the staff who work with them, and (ii) identifies and explores the features of prison-based sexual offending interventions that may be challenging or beneficial for autistic individuals, from the perspective of those involved in treatment. Semi-structured interviews were conducted with 12 autistic men serving prison sentences for sexual convictions, and 13 members of prison staff. A multi-perspective phenomenologically-informed thematic (MPT) analysis identified three themes of 'Feeling overwhelmed', 'Out of the comfort zone', and '(Dis)connected to others'. These themes highlight some of the key issues relating to the format and delivery of interventions, as well as the impact of the broader prison context on rehabilitation.

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.

Reconciling Dimensional and Categorical Models of Autism Heterogeneity: A Brain Connectomics and Behavioral Study

BACKGROUND

Heterogeneity in autism spectrum disorder (ASD) has hindered the development of biomarkers, thus motivating subtyping efforts. Most subtyping studies divide individuals with ASD into nonoverlapping (categorical) subgroups. However, continuous interindividual variation in ASD suggests that there is a need for a dimensional approach.

METHODS

A Bayesian model was employed to decompose resting-state functional connectivity (RSFC) of individuals with ASD into multiple abnormal RSFC patterns, i.e., categorical subtypes, henceforth referred to as "factors." Importantly, the model allowed each individual to express one or more factors to varying degrees (dimensional subtyping). The model was applied to 306 individuals with ASD (5.2-57 years of age) from two multisite repositories. Post hoc analyses associated factors with symptoms and demographics.

RESULTS

Analyses yielded three factors with dissociable whole-brain hypo- and hyper-RSFC patterns. Most participants expressed multiple (categorical) factors, suggestive of a mosaic of subtypes within individuals. All factors shared abnormal RSFC involving the default mode network, but the directionality (hypo- or hyper-RSFC) differed across factors. Factor 1 was associated with core ASD symptoms. Factors 1 and 2 were associated with distinct comorbid symptoms. Older male participants preferentially expressed factor 3. Factors were robust across control analyses and were not associated with IQ or head motion.

CONCLUSIONS

There exist at least three ASD factors with dissociable whole-brain RSFC patterns, behaviors, and demographics. Heterogeneous default mode network hypo- and hyper-RSFC across the factors might explain previously reported inconsistencies. The factors differentiated between core ASD and comorbid symptoms-a less appreciated domain of heterogeneity in ASD. These factors are coexpressed in individuals with ASD with different degrees, thus reconciling categorical and dimensional perspectives of ASD heterogeneity.

Autism: Implications for high secure psychiatric care and move towards best practice

BACKGROUND/AIMS

To explore the role of high secure psychiatric care (HSPC) in the assessment and management of individuals with an Autism Spectrum Disorder (ASD) using published studies and clinical experience. Key areas of exploration include the prevalence of ASD within HSPC, some autism specific issues including clinical and cognitive characteristics, psychopathy and emotional regulation, presence of incompatibilities and use of seclusion, as well as experiences of being detained in HSPC. Developing best practice and a specialist ASD service in HSPC is also discussed.

METHOD

A discussion of available literature, supported by clinical experience.

CONCLUSIONS

Although individuals with an ASD admitted to HSPC comprise a small group, they are likely to be overrepresented relative to the general prevalence of ASD in the population and present with specific issues. Whilst individuals report a generally positive experience of HSPC, therapeutic outcomes are variable and the factors influencing them poorly understood. Staff knowledge and application of ASD theory and practice appears to have a significant influence on outcomes.

IMPLICATIONS

Although best practice concerning ASD secure services will continue to be improved and developed, the role of HSPC in the assessment and management of some individuals with an ASD who present with complex needs and high risk behaviours remains clear.

Diagnosis and treatment of ASD in women in secure and forensic hospitals

Purpose

The purpose of this paper is to explore the experience and possibilities for misdiagnosis of women with ASD in secure and forensic hospitals, via the medium of a lived experience case study. To consider the clinical value of the patient perspective of and insight into their disorder. The case study is supplemented by relevant associations to the MHA Code of Practice, the CQC report, Monitoring the Mental Health Act (MHA) 2016–2017, published on 27 February 2018 and current research findings in the fields of service provision, quality of care and treatment of female patients with a diagnosis of ASD.

Design/methodology/approach

A review and commentary of the author’s lived experience of a formal diagnostic assessment for ASD as a female patient in a secure and forensic hospital. In reviewing aspects of the author’s clinical assessment, the author has made contextual reference to the MHA Code of Practice, the CQC report, Monitoring the MHA 2016–2017, published on 27 February 2018, and current research findings. The account focuses on aspects of the author’s recent experience assessment and treatment for ASD which the author believes may be of use in informing clinical practice.

Findings

Open-ended exploration of a lived experience account/case study of a diagnostic assessment of an adult female patient for ASD, demonstrating the possible ambiguity of responses to questionnaire-based assessment tools and other deficiencies inherent to the assessment process and care and treatment of adult female ASD sufferers in secure and forensic hospitals.

Research limitations/implications

The author uses the lived experience as a patient to review and provide commentary on the clinical assessment for ASD. This review is, therefore, informed by an authentic patient perspective and not clinical perspectives. This paper highlights the need for further research into the diagnostic assessment of females for ASD in a secure and forensic hospitals.

Practical implications

First, to encourage practitioners to extend their range of thinking to be more inclusive of the patient perspective when performing a diagnostic assessment. Second, to increase practitioner awareness of the deficiencies in the current service provision for adult female patients diagnosed with ASD in secure and forensic hospitals.

Social implications

To improve patient experience of diagnostic assessment for ASD and the quality of the assessment and patient outcomes in secure and forensic hospitals.

Originality/value

The paper is original in concept in that it considers the inclusion of patient experience/views in assessment and formulation and links them to wider social policy and practice guidance. The case study is an authentic patient account informed by the author’s experience of secure and forensic psychiatric hospitals. The value of the paper may be determined by the extent to which the paper encourages practitioners to consider the patient perspective and experience of the diagnostic assessment and how this and subsequent care and treatment may affect the adult female patient in secure and forensic hospitals.

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.

A phenomenological approach to diagnosing psychosis in autism spectrum disorder and intellectual disability: a case series

Purpose

The diagnosis of psychosis in individuals with autism spectrum disorder (ASD) poses a unique clinical challenge. The presence of intellectual disability (ID) further complicates the diagnostic picture. Reliable and timely diagnosis of psychosis in such individuals minimises the duration of untreated psychotic symptoms and the subsequent impact on the quality of life of the patients concerned. The paper aims to discuss this issue.

Design/methodology/approach

The authors present four patients with psychosis, ASD and ID, who have received care within forensic mental health and ID settings. These examples demonstrate the interaction between these conditions, as well as issues pertaining to diagnosis and management.

Findings

In all four patients, sustained use of antipsychotic medication was objectively associated with an improvement in psychotic symptoms and quality of life. In instances where autistic phenomena were accentuated upon development of psychosis, such features returned to the baseline levels evident prior to the onset of psychosis.

Practical implications

The discussion and related case examples could improve the understanding of the possibility of psychosis in individuals with ASD and ID, and increase awareness of this diagnostic possibility among healthcare professionals.

Originality/value

This is the first published case series illustrating the challenges of diagnosing psychosis in individuals with ASD and ID.