ASD, OCD and violence – a forensic case study

Holly Edwards (St Andrew's Healthcare, Birmingham, UK)
Lorraine Higham (St Andrew's Healthcare, Birmingham, UK)

Journal of Intellectual Disabilities and Offending Behaviour

ISSN: 2050-8824

Article publication date: 29 January 2020

Issue publication date: 24 February 2020

296

Abstract

Purpose

The purpose of this paper is to illustrate the formulation and psychological treatment of a complex case whereby a combination of autism spectrum disorder (ASD) and obsessive compulsive disorder (OCD) has resulted in violent and aggressive behaviour.

Design/methodology/approach

This paper provides a brief summary of literature in relation to ASD, OCD and risk-offending behaviour followed by a case study of a man (referred to as “John”) with a diagnosis of ASD and OCD who has an extensive history of institutional violence and aggressive behaviour.

Findings

This paper highlights the complexity of a case that may support research suggesting that impaired theory of mind, poor emotional regulation and problems with moral reasoning increase the risk of an individual with ASD engaging in violence, in addition to a comorbidity of ASD and OCD resulting in a more severe and treatment-resistant form of OCD.

Originality/value

This paper highlights the challenges faced when working with a patient with Asperger’s syndrome and OCD with entrenched beliefs that lead to the use of violence as a compulsion to temporarily overcome unpleasant thoughts related to low self-esteem.

Keywords

Citation

Edwards, H. and Higham, L. (2018), "ASD, OCD and violence – a forensic case study", Journal of Intellectual Disabilities and Offending Behaviour, Vol. 11 No. 1, pp. 1-8. https://doi.org/10.1108/JIDOB-07-2019-0015

Publisher

:

Emerald Publishing Limited

Copyright © 2020, Emerald Publishing Limited


Introduction

Autism is defined by the National Autistic Society (NAS) (2015) as “a lifelong, developmental disability that affects how a person communicates with and relates to other people and how they experience the world around them”. The prevalence of adults with autism spectrum disorder (ASD) in England is estimated at 1 per cent (Brugha et al., 2011), and in the western countries, prevalence is generally regarded to be approximately 1 in 100 (Baird et al., 2006), with males outnumbering females four to one (Chakrabarti and Fombonne, 2005). Autism is a spectrum condition that affects people differently, though core key difficulties are typically shared. The diagnostic manual, ICD-10, presents a number of possible autism profiles under the heading of Pervasive Developmental Disorders, defining it as “a group of disorders characterized by qualitative abnormalities in reciprocal social interactions and in patterns of communication, and by a restricted, stereotyped, repetitive repertoire of interests and activities. These qualitative abnormalities are a pervasive feature of the individual's functioning in all situations” (National Autistic Society, 2015). A core cognitive feature of ASD is a deficit in the theory of mind (ToM), which refers to the person’s inability to recognise that others hold different beliefs to their own. Clements (2005) suggested that some individuals with ASD who struggle to interpret others’ intentions and have difficulties in communicating emotions may experience intense rage as a result.

In the past, it has been suggested (Maras et al., 2015; King and Murphy, 2014; Mouridsen, 2012; Mouridsen et al., 2008; Lerner et al., 2012) that individuals with ASD are at low risk of engaging in illegal behaviours due to many people with ASD finding rules helpful (Murphy and King, 2014). However, others (Howlin, 2004; Newman and Ghaziuddin, 2008) have suggested that individuals with ASD may be more likely to engage in aggressive or law-breaking acts, due to a number of factors, including sensory hypersensitivity, an obsessional interest that may lead to the individual committing an offence in pursuit of that interest, and psychiatric comorbidity, including obsessive compulsive disorder, conduct disorder, schizoaffective disorder and depression. Other research supports the notion that ASD-related social functioning deficits, life events, mood disturbances, impulsivity and poor emotional regulation and coping skills contribute to offending in individuals with ASD (Allen et al., 2008; Im, 2016). In terms of risk for violence specifically, there is no evidence that individuals with ASD are more violent than those without ASD (Im, 2016). There is a small subgroup that does become involved with the criminal justice system (Murrie et al., 2002) and an even smaller subgroup of people with ASD who engage in violent offending. Of those who do become violent, Lerner et al.’s (2012) model suggests three main deficits that may contribute to violent criminal behaviour: ToM (which may lead to the misinterpretation of social intentions), emotion regulation difficulties (manifested by poor impulse control, aggression and negative peer interactions) and moral reasoning (difficulty understanding and predicting the beliefs and intentions of others). Other research has suggested that environmental factors also play a complex role in the relationship between ASD and violence. For example, Fallon (2013) suggests that exposure to trauma and/or poor parental bonding in childhood increases an individual’s propensity towards violence. In addition, case reports have described individuals with ASD committing violent acts who had a history of being bullied; a form of childhood trauma (Schwartz-Watts, 2005; Murie et al., 2002; Haskins and Silva, 2006; Tochimoto et al., 2011). Other research (Newman and Ghaziuddin, 2008) and studies of patients in hospital (Långström et al., 2009) suggest that risk factors for violent offending among individuals with ASD include male gender and psychiatric comorbidity.

Obsessive compulsive disorder (OCD) is defined in the ICD-10 as the presence of persistent and recurrent irrational thoughts (obsessions), resulting in marked anxiety and repetitive excessive behaviours (compulsions) as a way to decrease that anxiety. Higher prevalence of autistic traits has been found in OCD samples both in adults (Bejerot, 2007) and children (Ivarssib and Melin, 2008). Despite the suggestion of a potential link between the two disorders, little is known about the symptom profile of OCD in individuals with ASD. Some research suggests that OCD manifests separately from ASD and is characterised by a different profile of repetitive thoughts and behaviours (Cadman et al., 2015). Other research suggests that the comorbidity results in a more severe and treatment-resistant form of OCD, and that OCD with comorbid ASD should be recognised as a valid OCD subtype (Bejerot, 2007).

We aim to highlight the complexity of a case where an individual with a long-standing diagnosis of ASD and OCD led to problematic behaviour which resulted in detention in a low-secure psychiatric ward. Informed consent was sought from the patient and the pseudonym “John” is used throughout the paper to ensure anonymity.

Introduction of the patient

John is a 38-year-old white British male who is currently admitted to secure services under Section 3 of the Mental Health Act with long-standing diagnoses of OCD (mixed obsessional thoughts and acts) and ASD. He has been in secure services since the age of 29 years due to an extensive history of violence and aggressive behaviour, largely in response to hearing other people cough or make other noises.

Background

John grew up with his birth parents and older brother. There were no reported difficulties at his birth, and he appeared to have achieved normal developmental milestones. John describes having a happy childhood, and that he enjoyed primary school. However, he enjoyed secondary school less due to having fewer friends and being bullied. He reports there being some children who he did not get along with, and that he ended up getting into physical altercations with them.

In terms of qualifications, John reports doing quite well in examinations at the age of 16 years old and went onto higher education, which he enjoyed. John reports that he worked quite hard for his examinations and he set his standards high, as he wanted to go to a good university. Unfortunately, he did not achieve the grades that he was hoping for, and as a result, went to a university he deemed to be less renowned than his first choice. He enjoyed his first year and reports he made good friends; however, during the second year, he became very anxious, particularly about his living arrangements as his close friend had not returned for the second year. This increase in anxiety led to John struggling with his studies, and as a result, dropping out of university. He became homeless for a short period before eventually returning to live at home with his parents.

Whilst growing up, John described not getting on well with his brother and having a difficult relationship with his father. The difficult dynamics at home upon his return from university, reportedly led to arguments with his parents which escalated to physical fights on a few occasions. During this time, John also reported having severe OCD, which included switching things on and off as well as performing various rituals, for example, touching things. John stated he thought of himself as “nothing […] worthless”, and that themes of being a “failure” formed the basis of his intrusive thoughts, which would lead to him performing compulsive rituals to alleviate associated feelings of anxiety. He also reported experiencing intrusive thoughts that he was going to cause harm to himself or others, as well as fearing that he would be affected by something bad or that something bad would happen. John also started performing rituals in the hope of preventing these things from happening. John felt as though the “events in [his] life, such as failing [his] A-Levels and university, the way [his] life had worked out” resulted in the development of his OCD.

John’s first contact with mental health services was in 2006 as he had become increasingly isolated and rarely left the house due to having intrusive thoughts about others, particularly his neighbours and the noise they were making, which he believed was made deliberately to annoy him. This resulted in him making threatening remarks, as well as throwing a brick through the neighbour’s window. John has explained that his father initially drew his attention to the noise from the neighbour’s house. John described how he felt that “if [he] came up on [his] father’s side, [his father] would look upon [him] more favourably and wouldn’t be on [his] case”, i.e. arguing with him about the rituals he was performing. During John’s first admission, he was diagnosed with “severe OCD” as a result of his intrusive thoughts and ritualistic behaviours and compulsions. In 2008, following an increase in friction and arguments between himself and his parents, which often escalated to a physical altercation, particularly concerning his OCD symptoms, he was informally admitted to hospital for one week. An improvement was noted in his OCD symptoms and paranoia, and he returned to live with his parents. However, in 2010, John was formally admitted to hospital following an increase once more in him performing OCD rituals at home and the increase in assaultive behaviours towards others, often in response to hearing them cough. In 2012, during this admission, he was also formally assessed for ASD and received a secondary diagnosis of ASD largely related to his rigidity of thinking around his maladaptive interpretations of others’ behaviours and subsequent intrusive thoughts. He was transferred to a more appropriate rehabilitation service; however, he continued to be violent and displayed aggressive behaviour to a degree that he was no longer able to be managed in the rehabilitation service, and in late 2012, he was transferred to a hospital with a higher level of security. Whilst there, due to his risk, he was managed in isolation as it was felt that he presented as a high risk to others. During this time, his OCD rituals were prominent, and he continued to be violent towards staff. Following this, in 2015, John was transferred to a specialist ASD service, which was felt could better support his well-established pattern of maladaptive behaviour. He has remained in this service since this time and has continued to present with aggression and violence after hearing other people cough or make other noises, e.g. sneezing and whistling, that he deems “antisocial” or a technique used by others to be “disrespectful” towards him.

Progress

On the specialist ASD ward, John had access to a variety of treatments and interventions, including occupational therapy and education; however, he chose to focus on psychology and declined engagement in other areas. Psychology sessions commenced shortly after admission, and initial sessions focused on rapport building and identifying goals for future work. John appeared to show good insight into his difficulties and the areas to focus on, but lacked insight into his diagnoses and their impact on his cognitions and behaviour. John recognised that he is in hospital because of his aggressive behaviour directed towards others, generally after they have coughed. John acknowledged that he should not act aggressively but struggled to control his impulses once he had had the thought that the person was being disrespectful towards him. He would often minimise his behaviour by attempting to rationalise his actions. One of his goals for therapy was to become less reactive to noise.

A cognitive behavioural therapy (CBT) model was initially used to formulate and understand John’s difficulties with others coughing. As part of this, efforts were made to explore his thoughts, feelings and behaviour in relation to incidents where others have coughed in his presence. John appeared to adopt a distorted style of thinking when others coughed, such that he believed others were coughing deliberately to wind him up and “get at [him]”. Furthermore, he has reported a number of negative thoughts regarding himself which get triggered by others coughing, some of which include thoughts of being “weird”, “inferior”, “a loser”, “a wimp”, and that others hold low opinions of him. These thoughts result in John feeling low in mood, angry and anxious, which can then lead to him behaving in a verbally or physically aggressive manner towards male staff and patients. Psychological intervention focused on challenging his negative thoughts through exploring the evidence for and against the thoughts, with the aim of developing a more balanced and rational way of thinking, which would hopefully reduce his negative affect and the potential for him to react violently.

During this work, John also described coughing as a “cleansing mechanism to remove any influence another person has had on them”. He believed that people who cough and made loud noises are “expressive people”. John disliked coughing or making loud noises himself, as he felt it drew peoples’ attention to him, causing him to feel “vulnerable”. His experiences of feeling vulnerable possibly stemmed from bullying experiences at school when he felt “weak” and “powerless” and “lacking respect” from others. Also, John believed that when people cough, they are trying to “display dominance” over him and trying to be the “alpha male”. John reported that he lacked confidence around alpha males, which further reinforced his belief that he is a “wimp”, again demonstrating his low self-esteem.

Psychology sessions, therefore, also focused on exploring and improving his low self-esteem. John had a tendency to hold negative core beliefs about himself such as “I’m morally inferior” and “I’m unlovable”, which led him to follow unhelpful rules and assumptions such as “I must do everything I can to gain other’s approval because if I am criticised in any way it means I am not acceptable” and “people cough because they are trying to put me down”. Research has suggested that exposure to extreme trauma and/or poor parental bonding in childhood increases an individual’s propensity towards violence (Im, 2016). John had discussed in sessions how early life experiences, particularly his relationship with his parents, affected his self-esteem. It became apparent through these sessions that John’s perceptions of his relationship with his parents, particularly his father who he referred to as an “alpha male”, influenced his cognitions about himself and his perception of how men and women “should behave”. For example, John held stereotypical ideas regarding what it means to “be a man”, such as believing that a man should be muscular, drink beer and have facial hair, and that it is the norm for a man to use violence. John reported that he received positive reinforcement from both his parents when he engaged in physical altercations at school. John also reported witnessing his father using violence and aggression throughout his childhood, which is thought to have contributed to John believing that to be respected as a man he needs to assert himself in an aggressive and/or violent manner.

John’s perceived views of what it means to be a man appeared to impact on his ability to accept aspects of his own identity. Psychology sessions, therefore, also explored his self-identity, both the positive and negative aspects of himself. John struggled to consider his “current self” and his “ideal self” and demonstrated ambivalence regarding who he is and who he wants to be, often referring to himself as “Jekyll and Hyde”. He struggled to accept aspects of his “current self”, which related to his use of violence and his past sexual experiences, which resulted in feelings of shame and internal conflict related to his desire to be seen as “morally superior”. John described himself as being “sexually repressed”; however, when he attempted to explore his own sexuality, he perceived it to have been reinforced to him that it is wrong, either by external influences or due to his own misunderstanding of social norms due to his ASD. For example, when discussing pornography John reported his belief that “most people don’t watch [pornography]” and therefore took the view that he should not even if he wanted too. John also demonstrated limited insight into the normality of sexual drives and sexual preferences. John viewed these aspects of himself as vulnerabilities and, therefore, a sign of weakness to other people.

The idea of wearing a metaphorical “mask” was explored, and John acknowledged that he wore a “mask” when he felt vulnerable. John acknowledged that the “mask” presented itself either as “OCD or violence” and spoke about needing to “exude confidence” when he felt “out of his depths”. John explained that he used the mask to “try to get back to [his] old days as a kid. [He] refuses to accept that life is now more complicated”. He stated there is a part of him that does not want to accept that things have changed and he does not have the confidence to rely on his own instincts or have his own opinions so, “[he] copies [his] dad”. John showed good insight into how, if he disposed of the mask, it would help with his dislike of coughing as he would no longer feel vulnerable and therefore would not need to act assertively when someone coughs. He described feeling “on edge” when he put on his mask, but then when someone coughed and he reacted assertively, he felt better.

In summary, John’s experiences of being bullied at school were likely due to difficulties in forming and maintaining friendships as a result of his ASD and led to him developing the view that he is “weak” in and vulnerable compared to others, which led to him retaliating through the use of violence. In addition to holding a pro-violence attitude, he continued to hold negative core beliefs about himself and his own abilities. This led to high levels of anxiety for John, which he counteracted by performing obsessive compulsive rituals such as touching parts of his bathroom wall and even to the point where he described his assaults as a ritual. John explained that when someone coughed or made a noise he deemed to be “antisocial”, he experienced intrusive thoughts they are communicating something negative about him (e.g. that he is weird), which caused him to feel vulnerable and low in confidence. Therefore, he assaulted the person who had made the noise as a way of transferring his own anxieties onto the other person to gain a sense of power over them.

Discussion

Following extensive assessment and formulation with experienced clinicians, in addition to second opinions being obtained particularly regarding the consideration of alternative diagnoses, the working formulation was that his long-standing diagnoses of ASD and OCD would inform treatment. As a result, progress was made in terms of understanding the complex nature of the link between John’s trigger (e.g. a cough) and the behaviour shown (e.g. violence), although there were many challenges faced throughout therapy.

Although John had sensitivities with his sensory systems, including his auditory system (suggesting a propensity to struggle with excessive auditory stimuli), the cognitive distortions about himself and other’s intentions related to the auditory stimuli and the rigidity of these distortions led to challenges in therapy. The cognitions related to his low self-esteem and “antisocial noises” are long-standing, and it has been difficult for John to develop a more rational, balanced way of thinking. During discussions following an incident, John is able to acknowledge that the victim was coughing because of natural causes; however, he is unable to think rationally at the time of an incident, as his beliefs are so ingrained. Despite engaging in two years of regular psychology sessions, he continues to hold rigid beliefs. His belief that others hold negative opinions about him appears related to his poor ToM. John holds negative beliefs about himself, e.g. about his physical appearance and his masculinity, and due to poor ToM, he is unable to reflect on the contents of his own and other’s minds and understand that they are different and unrelated; he, therefore, believes that others also hold those negative beliefs about him. This is supported by previous research, which has found that as ToM becomes more advanced, individuals with ASD experience more difficulties, particularly with tasks that require individuals to identify underlying intentions and more advanced mentalising abilities such as irony and persuasion. Deficits in ToM have been suggested to contribute to an increase in violent criminal behaviour, as individuals with ASD take longer to understand social intentions, making it difficult to undertake spontaneous, quick and contextually appropriate social responses (Lerner et al., 2012). So, for example, in situations where John may be required to respond to a social situation whilst under duress, e.g. when experiencing high levels of anxiety, he may become overwhelmed by social information that he is unable to process, which may in turn lead him to resort to his instinctive response of using aggression.

Another challenge is John’s lack of insight into his ASD and the impact his condition has on his cognitions and his level of risk. A strong relationship has been suggested between cognitive distortions and violent behaviour (Chereji et al., 2012) and John’s limited insight into the rigidity of his thinking habits, therefore, has an impact on his continuing violent behaviour and subsequent level of risk to others. John continues to view coughing as unacceptable and antisocial, despite numerous explanations around the reasons why people cough. Furthermore, he remains of the view that other people cough as a method to communicate their low opinions of him. Although John has insight into the factors that can increase his propensity to engage in violent behaviour and recognises that certain triggers make him feel anxious and annoyed, he struggles to recognise that these are his own thoughts about himself.

John also lacks insight into the seriousness of his assaults and his level of risk. Following incidents, he minimises the seriousness of his behaviour, stating that he just wanted to “scare” the other person; failing to acknowledge the impact this can have on the victim. John holds the view that if the victim is scared of him and does not fight back the victim is “weak”. He struggles to accept responsibility for his own actions and consistently externalises blame onto the victim. Research has demonstrated a link between low empathy and ASD (Mathersul et al., 2013; Mazza et al., 2014), and further research has suggested a link between low empathy and violence. Jolliffe and Farrington (2006) found that males who bully in a violent manner have lower empathy than those who do not, based on the assumption that during a violent interaction, the emotions of the victim are clearly evident to the perpetrator, and an inability to react to these emotions would suggest a lack of empathy. However, it is important to recognise the impact that John’s poor ToM has on his ability to understand other’s behaviour and intentions.

John’s low self-esteem and high levels of anxiety, particularly related to how others perceive him, can lead to him trying to please everyone and ultimately not being true to himself. During therapy, he would often agree with what was being discussed and appeared trying to say the right thing, but he lacks insight into how this impeded upon his progress in therapy. Although this may be in part due to his desire to please people, it is also possibly linked to his difficulties accepting certain aspects of himself. For example, he will often deny that he was angry about something because he struggles to accept the fact that he experiences anger as this invalidates his view of his “ideal self” of a “morally superior” man.

Positively, despite his lack of insight into his diagnoses and his level of risk, John acknowledges that he needs to learn to accept his “current self” to rely on the “mask” less. He also acknowledges that if he disposed of “the mask”, it would help with his dislike of coughing as he would no longer feel vulnerable and, therefore, would no longer need to assert himself in response to someone coughing. However, the difficulties in achieving this goal, and therefore, the main areas to prioritise in future psychology work, are the rigid beliefs he holds, his experiences of internal conflict about aspects of his current self, the pressure he places upon himself to act a certain way and please others and external reinforcement of his beliefs about himself and others.

Work with John is still ongoing and he continues to be detained in low security due to his risk of assaults.

References

Allen, D., Evans, C., Hider, A., Hawkins, S., Peckett, H. and Morgan, H. (2008), “Offending behaviour in adults with Asperger’s syndrome”, Journal of Autism and Developmental Disorders, Vol. 38 No. 4, pp. 748-758.

Baird, G., Simonoff, E., Pickles, A., Chandler, L., Loucas, T., Meldrum, D. and Charman, T. (2006), “Prevalence of disorder of the autism spectrum in a population cohort of children in South Thames: the special needs and autism project (SNAP)”, The Lancet, Vol. 368 No. 9531, pp. 210-215.

Bejerot, S. (2007), “An autistic dimension: a proposed subtype of obsessive-compulsive disorder”, Autism, Vol. 11 No. 2, pp. 101-110.

Brugha, T.S., McManus, S., Bankart, J., Scott, F., Purdon, S., Smith, J., Bebbington, P., Jenkins, R. and Meltzer, R. (2011), “Epidemiology of autism spectrum disorders in adults in the community in England”, Archives of General Psychiatry, Vol. 68 No. 5, pp. 459-466.

Cadman, T., Spain, D., Johnston, P., Russel, I.A., Mataix-Cols, D., Craig, M., Deeley, Q., Robertson, D., Murphy, C., Gillan, N., Wilson, C.E., Mendez, M., Ecker, C., Daly, E., Findon, J., Glaser, K., MRC AIMS Consortium, Happe, F. and Murphy, D. (2015), “Obsessive-Compulsive disorder in adults with High-Functioning autism spectrum disorder: what does Self-Report with the OCI-R tell Us?”, Autism Research, Vol. 8 No. 5, pp. 477-485.

Chakrabarti, S. and Fombonne, E. (2005), “Pervasive developmental disorders in pre-school children: confirmation of high prevalence”, American Journal of Psychiatry, Vol. 162 No. 6, pp. 1133-1141.

Chereji, S.V., Pintea, S. and David, D. (2012), “The relationship of anger and cognitive distortions with violence in violent offenders population: a Meta-analytic review”, European Journal of Psychology Applied to Legal Context, Vol. 4 No. 1, pp. 59-77.

Clements, J. (2005), People with Autism Behaving Badly: Helping People with ASD Move on from Behavioural and Emotional Challenges, Jessica Kingsley, London and Philadelphia.

Fallon, J. (2013), The Psychopath inside: A Neuroscientist’s Personal Journey into the Dark Side of the Brain, Penguin.

Haskins, B. and Silva, J.A. (2006), “Asperger’s disorder and criminal behaviour: forensic-psychiatric considerations”, Journal of the American Academy of Psychiatry and the Law, Vol. 34, pp. 374-384.

Howlin, P. (2004), Autism: Preparing for Adulthood, 2nd ed., Routledge, London.

Im, D.S. (2016), “Template to perpetrate: an update on violence in autism spectrum disorder”, Harvard Review of Psychiatry, Vol. 24 No. 1, pp. 14-35.

Ivarssib, T. and Melin, K. (2008), “Autism spectrum traits in children and adolescents with obsessive-compulsive disorder (OCD)”, Journal of Anxiety Disorders, Vol. 22 No. 6, pp. 969-978.

Jolliffe, D. and Farrington, D.P. (2006), “Examining the relationship between low empathy and bullying”, Aggressive Behavior, Vol. 32 No. 6, pp. 540-550.

King, C. and Murphy, G.H. (2014), “A systematic review of people with autism spectrum disorder and the criminal justice system”, Journal of Autism and Developmental Disorders, Vol. 44 No. 11, pp. 2717-2733.

Långström, N., Grann, M., Ruschkin, V., Sjöstedt, G. and Fazel, S. (2009), “Risk factors for violent offending in autism spectrum disorder: a national study of hospitalised individuals”, Journal of Interpersonal Violence, Vol. 24 No. 8, pp. 1358-1370.

Lerner, M.D., Haque, O.S., Northrup, E.C., Lawer, L. and Bursztajan, H.J. (2012), “Emerging perspectives on adolescents and young adults with high-functioning autism spectrum disorders, violence and criminal law”, Journal of the American Academy of Psychiatry and Law, Vol. 40, pp. 177-190.

Maras, K., Mulchay, S. and Crane, L. (2015), “Is autism linked to criminality?”, Autism, Vol. 19 No. 5, pp. 515-516.

Mathersul, D., McDonald, S. and Rushby, J.A. (2013), “Understanding advanced theory of mind and empathy in high functioning adults with autism spectrum disorder”, Journal of Clinical and Experimental Neuropsychology, Vol. 35 No. 6, pp. 655-668.

Mazza, M., Pino, M.C., Mariano, M., Tempesta, D., Ferrara, M., De Beradis, D., Masedu, F. and Valenti, M. (2014), “Affective and cognitive empathy in adolescents with autism spectrum disorder”, Frontiers in Human Neuroscience, Vol. 7 No. 8, p. 791.

Mouridsen, S. (2012), “Current status of research on autism spectrum disorders and offending”, Research in Autism Spectrum Disorders, Vol. 6 No. 1, pp. 79-86.

Mouridsen, S., Rich, B., Isager, T. and Nedergaard, N. (2008), “Pervasive developmental disorders and criminal behaviour: a case control study”, International Journal of Offender Therapy and Comparative Criminology, Vol. 52 No. 2, pp. 52-196.

Murie, D.C., Warren, J.I., Kristiansson, M. and Dietz, P.E. (2002), “Asperger’s syndrome in forensic settings”, International Journal of Forensic Mental Health, Vol. 1 No. 1, pp. 59-70.

Murphy, G.H. and King, C. (2014), “A systematic review of people with autism spectrum disorder and the criminal justice system”, Journal of Autism and Developmental Disorders, Vol. 11 No. 11, pp. 2717-2733.

National Autistic Society (NAS) (2015), “About autism”, available at: www.autism.org.uk/ (accessed 03 August 2018).

Newman, S. and Ghaziuddin, M. (2008), “Violent crime in Asperger syndrome: the role of psychiatric comorbidity”, Journal of Autism and Developmental Disorders, Vol. 38 No. 10, pp. 1848-1852.

Schwartz-Watts, D.M. (2005), “Asperger’s disorder and murder”, Journal of the American Academy of Psychiatry and the Law, Vol. 33 No. 3, pp. 390-393.

Tochimoto, S., Kurata, K. and Munesue, T. (2011), “Time-slip phenomenon in adolescents and adults with autism spectrum disorders: case series”, Psychiatry and Clinical Neurosciences, Vol. 65 No. 4, pp. 381-383.

Corresponding author

Holly Edwards can be contacted at: hvedwards@standrew.co.uk

About the authors

Holly Edwards is based at St Andrew's Healthcare, Birmingham, UK.

Lorraine Higham is based at St Andrew's Healthcare, Birmingham, UK.

Related articles