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PBS Autism and PBS Autism and OffendingOffendingDr Lesley Steptoe Dr Lesley Steptoe Chartered Forensic PsychologistChartered Forensic PsychologistNHS Tayside, Forensic Learning Disability NHS Tayside, Forensic Learning Disability Services and Behavioural Support and Services and Behavioural Support and Intervention Acute ServicesIntervention Acute Services

Dr Amy KilbaneDr Amy KilbaneHighly Specialist Clinical PsychologistHighly Specialist Clinical PsychologistAutistic Spectrum Condition ServiceAutistic Spectrum Condition Service

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TopicsTopics

Service difficultiesService difficulties Individual AssessmentIndividual Assessment PBS/Good Lives Model and Quality of PBS/Good Lives Model and Quality of

Life (QOL)Life (QOL) PBS and Psychological InterventionsPBS and Psychological Interventions Risk Management - How does that Risk Management - How does that

fit?fit? Case StudyCase Study

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Service Difficulties Service Difficulties (Dein & Woodbury-Smith, 2009)(Dein & Woodbury-Smith, 2009)

Small but significant group Small but significant group Specific vulnerability factors may increase risk Specific vulnerability factors may increase risk Typically forensic services struggle to provide Typically forensic services struggle to provide

adequate placementadequate placement Difficulties in understanding an individuals Difficulties in understanding an individuals

everyday functioning that contributes to everyday functioning that contributes to shortfall in appropriate careshortfall in appropriate care

Diagnosis rarely directly informs an Diagnosis rarely directly informs an understanding of the persons specific understanding of the persons specific difficultiesdifficulties

How does Autism affect Gary, John, Jim, JeanHow does Autism affect Gary, John, Jim, Jean

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Individual AssessmentIndividual Assessment

Functional Assessment of behaviourFunctional Assessment of behaviour Sensory impairmentsSensory impairments Dysfunctional coping strategiesDysfunctional coping strategies Functions of challenging behaviourFunctions of challenging behaviour Reinforcement schedulesReinforcement schedules Elements of psychopathy also need Elements of psychopathy also need

clarificationclarification Understanding and working with these issues Understanding and working with these issues

will offer increased success in attempts at will offer increased success in attempts at social inclusion and preventing offending social inclusion and preventing offending (Murphy, 2010)(Murphy, 2010)

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Positive Behavioural Positive Behavioural Support (PBS)Support (PBS) Primary prevention, Secondary Primary prevention, Secondary

Prevention, Reactive StrategiesPrevention, Reactive Strategies Autism – difficulties in Autism – difficulties in

understanding the social world to understanding the social world to varying degrees varying degrees

Difficulties for interventionDifficulties for intervention Risk managementRisk management How does PBS fit?How does PBS fit?

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PCP and ELPPCP and ELP

Depicts how to support the individual Depicts how to support the individual using Person Centred Planning (PCP) using Person Centred Planning (PCP) (important TO the person) and Essential (important TO the person) and Essential Lifestyle Planning (ELP) (important FOR Lifestyle Planning (ELP) (important FOR the person)the person)

What’s important to the offender – What’s important to the offender – increased quality of life – desist from increased quality of life – desist from offending?offending?

What’s important for the offender – What’s important for the offender – relapse prevention - risk management relapse prevention - risk management

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Difficulties for Difficulties for InterventionIntervention Rule based - moral rules? Rule based - moral rules? Egocentric – lack of theory of mind (lack of Egocentric – lack of theory of mind (lack of

empathy) consequences to self of offendingempathy) consequences to self of offending Rigid thinking patterns– difficulties in Rigid thinking patterns– difficulties in

changechange Good Lives Model – increase quality of life Good Lives Model – increase quality of life

and gain desistance from offending.and gain desistance from offending. QOL for the Autistic person may be very QOL for the Autistic person may be very

different to that of non autistic individuals.different to that of non autistic individuals.

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Combine PBS with Combine PBS with interventionintervention Combine PBS with interventionsCombine PBS with interventions PBS provides consistency in supportPBS provides consistency in support Informs strategies that suit the individualInforms strategies that suit the individual Avoids unilateral decision making by staffAvoids unilateral decision making by staff Aims to maintain consistency of support Aims to maintain consistency of support

to prevent challenging behaviour and risk to prevent challenging behaviour and risk management (reactive strategy)management (reactive strategy)

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Case StudyCase Study

Mr A – 47 year old man - Autistic Mr A – 47 year old man - Autistic Spectrum Disorder – COROSpectrum Disorder – CORO

1992 x 2 separate appearances – 1992 x 2 separate appearances – (admonished, compensation order £150 (admonished, compensation order £150 and subsequently 1 year probation– and subsequently 1 year probation– vandalism and obscene phone callsvandalism and obscene phone calls

1994 – vandalism to car – inpatient 1994 – vandalism to car – inpatient assessmentassessment

1995 – vandalism to car – Probation 1995 – vandalism to car – Probation Order 3 years direction to attend day Order 3 years direction to attend day care servicescare services

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Index BehaviourIndex Behaviour

1996 –– Behavioural escalation, further 1996 –– Behavioural escalation, further vandalism, threat to kill carer and being vandalism, threat to kill carer and being found near her home carrying a knife. found near her home carrying a knife. Admitted to inpatient setting informally Admitted to inpatient setting informally – continued to express violent and – continued to express violent and murderous fantasies in relation to carer murderous fantasies in relation to carer – detained. – detained.

Breach of Probation, Criminal Justice Breach of Probation, Criminal Justice (Scotland Act x2 - Wilful and Reckless (Scotland Act x2 - Wilful and Reckless Damage resulted in a Hospital Order, Damage resulted in a Hospital Order, Section 59 CPA)Section 59 CPA)

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Background HistoryBackground History

Childhood – happy and uneventfulChildhood – happy and uneventful Attended local schools and Attended local schools and

transferred to specialist LD school transferred to specialist LD school as a result of educational as a result of educational difficultiesdifficulties

YTS placement – participated in a YTS placement – participated in a number of work placements number of work placements including work as a sweeper for including work as a sweeper for the Cleansing Departmentthe Cleansing Department

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Developing IssuesDeveloping Issues

1991 – contact with psychiatry due to an 1991 – contact with psychiatry due to an obsessive attachment which he had obsessive attachment which he had developed towards a female member of developed towards a female member of staffstaff

Noted as becoming aggressive when his Noted as becoming aggressive when his approaches to this member of staff were approaches to this member of staff were not welcomed – obscene phone callsnot welcomed – obscene phone calls

Intervention showed little impact on his Intervention showed little impact on his presentation. presentation.

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Obsessive BehavioursObsessive Behaviours

Reluctance to discuss sexual matters – Reluctance to discuss sexual matters – worried at being labelled homosexualworried at being labelled homosexual

Anxiety displayed at separation from Anxiety displayed at separation from the particular carerthe particular carer

Telephoned her at 5.20am when he Telephoned her at 5.20am when he was leaving for work as a road sweeperwas leaving for work as a road sweeper

1992 - Appeared at her house - noted 1992 - Appeared at her house - noted as following her to various different as following her to various different places – continued to phone her places – continued to phone her inappropriately along with episodes of inappropriately along with episodes of damage to her propertydamage to her property

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Sexual Fantasy and Sexual Fantasy and Social IsolationSocial Isolation Fantasy – imagining he was having sex Fantasy – imagining he was having sex

with carer and her friendwith carer and her friend Also noted as at times expressing wanting Also noted as at times expressing wanting

to hurt her (related to damage to her car)to hurt her (related to damage to her car) At home – mum trying to risk manage his At home – mum trying to risk manage his

behaviour by locking him in his room – he behaviour by locking him in his room – he managed to leave and damage carers car.managed to leave and damage carers car.

He was described as socially isolated and He was described as socially isolated and as having poor interpersonal skillsas having poor interpersonal skills

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Pornography and Pornography and Sexual FantasySexual Fantasy 1996 – ideas of sexuality were derived from 1996 – ideas of sexuality were derived from

viewing Pornographic videos involving rape viewing Pornographic videos involving rape amongst other activitiesamongst other activities

Also noted as having sexual fantasies of rape Also noted as having sexual fantasies of rape towards female nursing staff – harassing towards female nursing staff – harassing three members of nursing staff for their three members of nursing staff for their phone numbers and addressesphone numbers and addresses

Reported wanting to rape one member of Reported wanting to rape one member of staff as she had blonde hair - struck her on staff as she had blonde hair - struck her on the face with a towelthe face with a towel

Similarities in appearance were noted Similarities in appearance were noted between member of staff and victim of index between member of staff and victim of index behaviourbehaviour

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Challenging BehaviourChallenging Behaviour

Otherwise presenting as:Otherwise presenting as: Challenging Challenging Awkward Awkward Stubborn Stubborn Unco-operativeUnco-operative Non Compliant at timesNon Compliant at times

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Autistic Spectrum Autistic Spectrum DisorderDisorder Difficulties in approaching others to advise of Difficulties in approaching others to advise of

problemsproblems Taking control of his environment – not getting Taking control of his environment – not getting

up – not going to workshop sessions – functions up – not going to workshop sessions – functions of CB – to escape from task demands – of CB – to escape from task demands – expression of emotional arousal and expression of emotional arousal and annoyance. annoyance.

Initially in small group therapy – sitting away Initially in small group therapy – sitting away and with his back to othersand with his back to others

Turned up but refusal to engageTurned up but refusal to engage Uncomfortable in group situation – that’s ok?Uncomfortable in group situation – that’s ok? Lack of theory of mind – lack of empathyLack of theory of mind – lack of empathy

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MDT InterventionMDT Intervention

Forensic PsychologyForensic Psychology Adapted SOTP based on the Good Lives ModelAdapted SOTP based on the Good Lives Model Allowed him to be alone within the group as long Allowed him to be alone within the group as long

as he attended and listened which he didas he attended and listened which he did Once he became comfortable he integrated well Once he became comfortable he integrated well

and is now a valued member of the group (12 and is now a valued member of the group (12 men)men)

Focussed on rule based initiativesFocussed on rule based initiatives Now excellent at advising the others of the rules Now excellent at advising the others of the rules

to risk and self managementto risk and self management Working with staff team to increase quality of life Working with staff team to increase quality of life

(Good Lives Model and PBS)(Good Lives Model and PBS) Aim at desistance from offending behaviourAim at desistance from offending behaviour

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Nursing ColleaguesNursing Colleagues

Nursing ColleaguesNursing Colleagues Daily working with challenging behaviour and Daily working with challenging behaviour and

risk management – consistency –communicationrisk management – consistency –communication Improving quality of life within a risk managed Improving quality of life within a risk managed

framework – social outings, budgeting, football.framework – social outings, budgeting, football. Risk – intermittent episodes of attraction to Risk – intermittent episodes of attraction to

particular female members of staff with blonde particular female members of staff with blonde hair – often two or three at a timehair – often two or three at a time

Mr A takes an avoidant strategy to trying to Mr A takes an avoidant strategy to trying to problem solve this (dysfunctional coping problem solve this (dysfunctional coping strategy)strategy)

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Psychiatric ColleaguesPsychiatric Colleagues

Introduction and management of Introduction and management of medication to assist with medication to assist with obsessional thoughts obsessional thoughts

Ongoing monitoring of mental Ongoing monitoring of mental health health

RMO management re CORO and RMO management re CORO and as part of MDTas part of MDT

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Occupational Therapy Occupational Therapy colleaguescolleagues Full timetable of work based Full timetable of work based

activitiesactivities Increasing activities in line with QOLIncreasing activities in line with QOL Involved in risk management of Mr Involved in risk management of Mr

A during work based activities with A during work based activities with nursing colleaguesnursing colleagues

Managing their own interpersonal Managing their own interpersonal style to communicate effectivelystyle to communicate effectively

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PBS Approach & Good Lives PBS Approach & Good Lives Model – increase QOL.Model – increase QOL.

PBS approach looking to ‘need’ within PBS approach looking to ‘need’ within Autistic Spectrum Disorder to provide Autistic Spectrum Disorder to provide support through primary and secondary support through primary and secondary prevention – increase quality of life – manage prevention – increase quality of life – manage triggers to behaviourtriggers to behaviour

PBS a means of support at baseline and PBS a means of support at baseline and within early indicators (triggers) of within early indicators (triggers) of challenging/offending behaviourchallenging/offending behaviour

PBS Reactive Strategies - Dynamic Risk PBS Reactive Strategies - Dynamic Risk Management (ELP)Management (ELP)

Dynamic risk reduction – return to Primary Dynamic risk reduction – return to Primary and secondary prevention to support Mr A and secondary prevention to support Mr A within Autistic Spectrum Disorder.within Autistic Spectrum Disorder.

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PBS Autism and PBS Autism and OffendingOffending PBS Approach aims to prevent challenging PBS Approach aims to prevent challenging

behaviour. behaviour. People with Autistic Spectrum Disorder may People with Autistic Spectrum Disorder may

offend for various reasons but they still require offend for various reasons but they still require support with how their Autism affects them.support with how their Autism affects them.

Appropriate support through PBS results in a Appropriate support through PBS results in a lower level of arousal in general and allows for lower level of arousal in general and allows for individual dynamic risk management strategies individual dynamic risk management strategies to be employed more consistently within a to be employed more consistently within a staff teamstaff team

Avoids unilateral decision making and assists Avoids unilateral decision making and assists in consistent dynamic risk managementin consistent dynamic risk management

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OngoingOngoing

Intermittent attraction to blond female staffIntermittent attraction to blond female staff Through PBS he has learned to approach Through PBS he has learned to approach

staff to report difficultiesstaff to report difficulties Non punitiveNon punitive Reactive strategies in response to report Reactive strategies in response to report

may reduce QOL for a limited period of may reduce QOL for a limited period of timetime

Return to PBS once risk reduced = Return to PBS once risk reduced = increased QOL once again. increased QOL once again.

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CurrentlyCurrently

Mr A recently openly reported attraction to a Mr A recently openly reported attraction to a member of staff who had moved to another area member of staff who had moved to another area (change)(change)

Obsessive thought processes reported (same)Obsessive thought processes reported (same) Asked for support (Change)Asked for support (Change) Reported he did not wish to offend, quite Reported he did not wish to offend, quite

distressed and worried by the thought of doing so distressed and worried by the thought of doing so (Change)(Change)

Dynamic Risk – Reactive Strategy – ‘net tightened’Dynamic Risk – Reactive Strategy – ‘net tightened’ Increase in MedicationIncrease in Medication Two week – lower levels of stimulationTwo week – lower levels of stimulation End of week 1 – improvement in behavioural End of week 1 – improvement in behavioural

presentationpresentation

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Refs and interesting Refs and interesting readingreading Dein K. & Woodbury-Smith M. (2009). Asperger Dein K. & Woodbury-Smith M. (2009). Asperger

Syndrome and Criminal Behaviour. Syndrome and Criminal Behaviour. Advances in Advances in Psychiatric TreatmentPsychiatric Treatment; 15: 37-43.; 15: 37-43.

Berney T. (2004) Asperger Syndrome from childhood Berney T. (2004) Asperger Syndrome from childhood into adulthood, into adulthood, Advances in Psychiatric TreatmentAdvances in Psychiatric Treatment; 10: ; 10: 341-51.341-51.

Murphy D. (2007). Hare PCL-R profiles of male patients Murphy D. (2007). Hare PCL-R profiles of male patients with Aspergers syndrome detained in high security with Aspergers syndrome detained in high security psychiatric care.. Journal of Forensic psychiatry and psychiatric care.. Journal of Forensic psychiatry and psychology; 18: 120-26.psychology; 18: 120-26.

Rogers J., Viding E., Blair J., et al (2006) Autism Rogers J., Viding E., Blair J., et al (2006) Autism spectrum disorder and psychopathy: shared cognitive spectrum disorder and psychopathy: shared cognitive underpinnings or double hit? Psychological Medicine; underpinnings or double hit? Psychological Medicine; 36: 1789 - 9836: 1789 - 98