Autistic Spectrum Conditions in a High Secure Environment: Clinical Experiences Dr Natasha Purcell, Clinical Psychologist The State Hospital, Learning Disability Service

Who are we? The only high security psychiatric hospital covering Scotland and Northern Ireland. One of four high secure hospitals in the UK. 140 high-secure beds for male patients requiring high secure care (no females). 12 beds specifically for patients with a learning disability. Patients not requiring the high security of the State Hospital will be transferred to less secure units—usually medium and low (occasionally community....). The least restrictive alternative is always borne in mind

Admissions to TSH Under the provisions of: The Criminal Procedure (Scotland) Act 1995— the majority The Mental Health (Care and Treatment) (Scotland) Act And other related legislation because of their “dangerous, violent or criminal propensities”.

Learning Disability Ward 12 beds Currently only 1 patient has a diagnosis of autism (2 patients with ASC recently discharged) 1 other has ‘traits’ Primary reasons for admission Violent offences Sexual offences or ISB Challenging behaviours

Challenges of ASC in a High Secure Environment Mixed ward—range of needs Not a specialist service- square peg, round hole. The environment Staff changes Minimal staff training (but this is gradually being addressed)

Challenges of ASC in a High Secure Environment But…. we are good at  Rule based and structured  Boundaries  Good care plans  Person centred  MDT approach  Formulations and risk assessments  Role modelling pro social behaviour  Adapted interventions

Characteristics of ASC Characteristics of ASC that could be viewed as ‘forensic’ can be summarised into 2 areas:

1: Underlying psychological deficits Poor perspective taking skills, e.g. ability to infer what others are thinking, their beliefs, desires, feelings. Rigid cognitive style Limited awareness of ‘social rules’ and difficulty reading social cues. Executive functioning deficits, e.g. inhibiting impulsivity regulating emotional responses, inflexible responding. (Vicki Gibbs, Clinical Psychologist Diagnostic Assessment Service Autism Spectrum Australia)

2. Unusual, Repetitive or Narrow Interests Strong interests in certain topics. Inflexible adherence to routines or rituals. Sensory-processing difficulties –may engage in sensory seeking behaviours or sensory avoidance. (Vicki Gibbs, Clinical Psychologist Diagnostic Assessment Service Autism Spectrum Australia)

How this manifests ‘forensically’ Unaware of the harm they have caused their victim. No expression of remorse or empathy. May not be able to read the necessary social cues telling them to stop a behaviour. Possible impulsivity in reacting to situations. May not be aware of the impact of their actions on others. Unable to think through consequences to self and others (and legal consequences) Poor emotional regulation can lead to anxiety or anger outbursts

How this manifests ‘forensically’ May break laws in pursuit of a special interest or obsession May react aggressively to avoid, or remove themselves from distressing stimuli. May persist with routine or ritualised behaviour, even when legal boundaries may be broached.

Mr P 24 year old Male Contact with psychiatric and LD services since age 15, largely related to offending behaviour or behavioural problems. Breaching SOPO conditions X3, breach of the peace and fraud. He had a lengthy forensic history with numerous convictions for breach of the peace, fraud and inappropriate sexual behaviours, including towards children. Given his lengthy forensic history, poor engagement with services, high risk of re-offending, borderline learning disability and (recent) diagnosis of Autistic Spectrum Condition, it was felt that a period of assessment and treatment within a secure health setting was warranted.

Mr P Where services went wrong: Late to diagnose What worked: Boundaries Clear consistent communication Adapted ISB Anger management Social skills Formulation and reformulation Challenges in generalisation of skills Now in low security….

Mr A 18 year old male Mild learning disability Hx aggressive behaviours and staff assaults Interest in ‘Powder Puff Girls’/ ‘Harry Potter’ Interest in nappies (not sexual in nature) Abscond and assault in pursuit of access; obsession since the age of 7 years. Limited empathy

Mr A What worked: Boundary and limit setting. Restrained on only 1 occasion No access to nappies, no ‘talk time’ More positive ‘obsessions’ were encouraged Structure and routine Clear social boundaries and consistent response Reduced stimulation Passed on care and management plans to specialist setting (where doing well)

Mr B 40 year old male Mild learning disability Autistic spectrum condition Schizoaffective disorder Unpredictability with ongoing potential for aggression (was State Hospital’s most challenging patient...) Hx Inappropriate sexual behaviour Poor insight into his illness and its impact on his behaviours. Little empathy towards peers or staff Anxiety Hx aggression/poor impulse control although greatly reduced in frequency when mental state more stable Sensitive to high clinical activity on the ward and an increase noise levels.

Mr B What's working: Good care plans Weekly care meeting Delivered ASC awareness training to staff Firm boundary setting Behavioural modification: ‘relaxation’ ‘hands down’ ‘talk to staff’ Monitor activity levels As low stimulus environment as we can Individual and person centred care plans

Questions……