In this article Dr Colin Dale, Chief Executive of Caring Solutions (UK) Ltd, and Brenda Crossley, an Associate of Caring Solutions (UK) Ltd, discuss the support available for autistic people in the criminal justice system.
The article includes a case study of a man detained due to his challenging behaviour, and outlines the approach used to support him.
Autism and the criminal justice system
An individual with autism spectrum condition (ASC) experiences differences in the way they understand the world and others within it. These difficulties can lead them to come into contact with the Criminal Justice System (CJS). The CJS includes:
- the police service
- and secure services
The latter would usually warrant detention under the Mental Health Act 1983.
The number of people with ASC who have offended is not clear as many in the CJS are undiagnosed. The CJS, and prison services in particular, have an assessment screening tool which is completed on admission. However the diagnosis of ASC requires observation of the individual over some time by someone who knows what to look out for. The CJS has neither the tools nor the resources available to implement this. The reason for identifying the individual may not be to transfer them to the NHS or some other lesser secure services, but to make ‘reasonable adjustments’ for them in their current location.
Whilst people with ASC might present as ‘odd’ or ‘different’, in some ways the CJS is dealing with large numbers of people who can often present with unusual behaviours which do not meet any diagnostic criteria. The prisons themselves are almost overwhelmed with people with severe forms of mental disorder and drug abuse.
Individuals with ASC within the CJS present with difficulties which affect their experiences within it. They may not recognise the inappropriateness of their behaviours and vulnerabilities such as lacking in empathy, impulsiveness, misinterpretation of social cues and repetition of behaviours, can lead to the individual being bullied or appearing difficult and non-compliant.
Existing intervention programmes aimed at the general prison population are often difficult for individuals with ASC to access as they may not have the required level of cognitive functioning to engage. Some of the interventions which are available, albeit inconsistently, include:
- Problem-solving skills development and psychosocial interventions, based on the core symptoms of autism and enhancing life skills (NICE, 2012)
- Least restrictive practice and positive behaviour support principles (DoH, 2014)
- Cognitive behavioural therapies - more likely to be effective with individuals who are functioning at a higher cognitive level
- Behavioural programmes - for those with lesser cognitive abilities
- Self-awareness, social skills training, relationship development and exploration of the index offence [i]
- The SPELL framework (Structure, Positive approaches and expectations, Empathy, Low arousal and Links) which aims to build on strengths and reduce disability (NAS)
There is no evidence of a standardised approach to interventions, especially within the CJS, and staff awareness of the condition is generally poor.
This anonymised case study demonstrates how a specific intervention model based on positive behaviour and cognitive rehabilitation principles, the Therapeutic Intervention Model for Optimism and Recovery (TIMOR), enabled an individual to access community based activities and resulted in a significant decrease in incidents of aggression.
Joe was admitted to a Medium Secure NHS service aged 25. With a diagnosis of autism, Joe’s life was preoccupied with obsessional ruminations, verbalisations and impulsive actions in response to these. He frequently caused damage within his home and the community where he lived. There were reports of regular physical assaults on family and supporting staff, and violence in public places.
In the nine months following his admission to the secure service there were 55 incidents of aggression, most of which necessitated a physical intervention response. Joe’s behaviour restricted his exposure to activities and access to community facilities. As a result, he spent most of his time living isolated from others and with limited opportunities.
The multi-disciplinary team felt that he would benefit from a structured routine with a consistent approach from the staff team. The TIMOR intervention model was introduced into his care plan.
The aims of the model were to:
- enhance Joe’s social functioning
- provide person centred support for his cognitive difficulties
- reduce the frequency and impact of behaviours that were severely challenging
To begin with, staff were trained in the model. They then developed a daily planner and a structured routine, negotiated with Joe, which included access to activities focussed solely on his strengths and interests. A key feature was to keep Joe engaged in the planned activities through consistent prompts and systems introduced to reduce cognitive demands. They ensured that Joe was successful on all tasks in order to raise his self-esteem and motivation to engage. Additionally, staff carefully managed Joe’s environment and reduced his known triggers.
The planner sought to ensure that all his needs were met and that it evolved over time to include community based activities. Through a systematic and consistent approach from staff and family, Joe made significant progress and there was a substantial reduction in incidents of aggression. Within 18 months, there were no incidents at all and Joe was ready for discharge.
It is important to note, however, that the symptoms of autism remain and the TIMOR model of intervention and low levels of expressed emotion will continue to be a necessary cognitive support for Joe.
Department of Health (DoH) (2014) Positive and Proactive Care: reducing the need for restrictive interventions
Hall, I., Crossley, B, & Mercer M (2013) Resetting the balance: from despair to self-determination Journal of Intellectual Disabilities and Offending Behaviour Vol. 4 NO. 3/4, pp. 70-76
National Autistic Society (NAS) SPELL Framework
National Institute for Health and Care Excellence (NICE) (2012) Autism: recognition, referral, diagnosis and management of adults on the autism spectrum
Image courtesy of Stuart Miles at FreeDigitalPhotos.net
Author: Dr Colin Dale, Brenda Crossley
Date added: 20 October 2015
[i] An index offence refers to the crime that the offender committed which resulted in contact with the CJS, or admittance to a prison or secure service. If there is more than one offence then it would generally refer to the most serious. Many interventions aim to identify the reasons why the offence was committed and which treatment response would prevent a repeat.