People with autism spectrum disorders (ASD) have been associated with criminal acts and affiliation with groups and organisations with violent ideology and practice. The purpose of this paper is to present patients in mental health services with both ASD and psychosis, who are affiliated with such groups.
Three vignettes are used as examples. Some of the information is combined for the three participants for presentation. They were scored for mental health symptoms and behaviour problems on admission and discharge from inpatient care.
The combination of ASD and psychosis aggravates the problems of both conditions, which may elicit a collapse of both cognitive functioning and especially impulse control, and of the ability to judge whether situations are dangerous or offensive or not.
The present paper may contribute to a better understanding of the combination of ASD, psychosis and affiliation with groups and organisations as described, especially regarding the importance of identifying psychosis.
Inderberg, A.M.S., Horndalsveen, K., Elvehaug, A.-H., Mehmi, Y., Jørstad, I. and Bakken, T.L. (2019), "Autism, intellectual disabilities and additional psychosis, and affiliation to groups with violent ideology: short communication", Journal of Intellectual Disabilities and Offending Behaviour, Vol. 10 No. 1, pp. 1-7. https://doi.org/10.1108/JIDOB-09-2018-0010Download as .RIS
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Autism spectrum disorder (ASD) is considered to be a neurodevelopmental disorder. Core symptoms include impaired communication and social interaction, and a restricted repertoire of activities and interests (APA, 2013). Besides these core symptoms, ASD is closely associated with impaired executive functions, central coherence and mentalising. Impaired mentalising includes not seeing other people’s perspectives, and also introspection (Lind and Williams, 2011). Experiencing intellectual disabilities (ID) in addition to ASD aggravates these problems. The core symptoms of psychosis include delusions, hallucinations and severely disorganised speech and behaviour. The most severe psychosis, schizophrenia, also encompasses negative symptoms such as apathy, fatigue, lack of motivation and emotional dysfunction (APA, 2013). When people with ASD (with or without ID), develop psychosis, their impaired cognitive, emotional and practical functioning caused by ASD and/or ID will be severely aggravated (Bakken, 2014; Bakken et al., 2007). They may show severe global functional deterioration and disorganised speech and behaviour, and be unable to maintain basic self-care tasks and social relationships (Bakken, 2014).
Recent research indicates that adolescents and adults with ASD may have extensive difficulties in understanding that their actions can cause other people pain and suffering, physically and/or psychologically (Helverschou et al., 2015). There are indications of an association between ASD and violent offences in convicted adults who have ASD (Billstedt et al., 2017; Im, 2016; Søndenaa et al., 2014). Case descriptions indicate that adolescents and young adults with ASD may start associating with political or religious groups that spread violent ideologies and practice (Faccini and Allely, 2017; Palermo, 2013). There is no evidence to suggest that people with ASD are more violent than neurotypicals (Im, 2016). However, a recent review on mass shootings showed that people with ASD were highly overrepresented in such acts. Nevertheless, knowledge about violent offenders with ASD is generally limited (Chaplin et al., 2013; Helverschou et al., 2018).
In a study comparing adults with and without ASD in a low-security unit in the UK, Haw et al. (2013) found that within the ASD group three out of four had mental illness, with psychosis being the most frequent. The results of this study correspond to clinical experience in a regional specialised psychiatric unit for adult patients with ID at Oslo University Hospital, Oslo, Norway. During the last 5–10 years, an increasing number of young men with ASD and additional psychosis who have associated with groups with violent ideologies and practice have been admitted to this unit. Clinical experience from this unit indicates that patients with ASD and additional psychosis who have committed crimes will engage in less violent and criminal acts once they have been properly assessed and their psychosis has been adequately treated.
This paper aims to highlight that identifying and treating psychosis in adults with ASD who associate with violent groups may reduce the chances of them engaging in criminal acts.
This study uses information from case files. First, a systematic search was conducted using the terms autism/ASD and psychosis/psychotic disorder/schizophrenia and prisoners/criminals/violence/terrorism/delinquency. This approach yielded zero hits. An additional hand search was conducted using Google Scholar and relevant websites, which also yielded zero hits. Combining the first and third search terms yielded 11 hits, of which 4 were relevant to the present study (Billstedt et al., 2017; Im, 2016; Helverschou et al., 2015). As the treatment of psychosis is crucial to this paper, outcome measures following admission to a specialist psychiatric inpatient unit for patients with ID/ASD were scored by using the Psychopathology in Autism Checklist (PAC) (Helverschou et al., 2009) and the Aberrant Behaviour Checklist (ABC) (Aman and Singh, 1986). The PAC and ABC were first scored upon admittance and at discharge. The scores were analysed using the Wilcoxon signed-rank test, a non-parametric test.
The setting is an adult regional specialist psychiatric inpatient and outpatient unit for adults with ID and/or autism (SPID) in the South-East Health Authority in Norway (Bakken and Høidal, 2018).
Three males in their 20s were invited to participate. Permission to conduct the study was granted by the director of the SPID and the hospital’s Privacy Protection Supervisor. Parents or legal guardians gave their informed consent for participation on behalf of the patients. Background information, diagnostic and treatment information and information about scores have been provided on a group level in order to ensure confidentiality.
Cases A, B and C
The three male participants are in their 20s. Two have mild ID, and one has a borderline IQ. Two have been diagnosed with disorders in the autism spectrum, one with autistic traits. The latter was diagnosed in adulthood. Two have been diagnosed within the schizophrenia spectrum, and one in the affective spectrum. The three patients had difficulties socialising with peers from their early adolescence. Before being admitted to the SPID, A, B and C had been active on the internet and had associated with radicalised religious groups. This resulted in them being monitored by the police authorities. An overview of psychotic symptoms and warning signs was prepared for the three patients during inpatient stays at the SPID. The following warning signs were reported: insufficient sleep, insufficient food intake, severe physical aggression, verbal threats, paranoid ideations and delusions. The three patients had already received a diagnosis in the autism spectrum before their SPID stay. The Social Communication Questionnaire (Rutter et al., 2003) was used to confirm a previous ASD assessment. Psychiatric diagnoses were conducted using the ICD 10 and also using psychometric instruments: the PAC and the MINI Plus, as well as clinical interviews and 24/7 observation of symptoms at the SPID. Risk assessments were conducted for A and C and indicated a high risk of violence, associated with a high psychotic symptom load.
The three patients received similar treatment, including milieu therapy that emphasised safe surroundings, activities and psychological validation (Bakken et al., 2017), psychotherapy, as well as psychotropic medication. Upon discharge, the three patients showed no positive psychotic symptoms. They were followed up by the SPID for six months. They engaged in no criminal acts during follow-up. The patients were discharged in accordance with the Norwegian Mental Health Act on involuntary care outside a psychiatric hospital. This means that a patient is obliged to co-operate regarding the follow-up plan, which is one of the conditions of discharge. The patients were also monitored by the police authorities following discharge.
The global functioning of Case A had deteriorated severely two years prior to admission to the SPID. From early adolescence, he was involved in serious criminal activity. He had also used harmful drugs regularly for several years. Through a friend, A had started associating with an Islamic group that encouraged the use of violence. When admitted to the SPID, A was agitated, hostile and suffered from severe anxiety and paranoid delusions. He was disorganised, tense and had impaired attention. The patient stayed at the SPID for a few months. He showed limited social understanding and experienced difficulties in seeing other people’s perspectives, combined with limited insight into social relations and emotions. He quickly came into conflict with others. His social, extrovert yet disturbed interaction with others demonstrated a serious inability to understand how his behaviour impacted others. The patient appeared to be surprised at how his behaviour affected others.
Case B was diagnosed with ID and ASD in primary school. His problems escalated in upper secondary school and he developed additional symptoms of anxiety. He became interested in radical Islam and started associating with people in Islamic groups. At the same time, he experienced a severe deterioration in global functioning that encompassed tasks, social relationships and self-care. He suffered from delusions. During hospitalisation at the SPID, B attended weekly psychotherapeutic sessions, including psycho-education about ASD. B stayed at the SPID for around six months. Psychotherapy and milieu therapy were adjusted to his cognitive impairments and his mental illness symptoms.
Case C adapted socially when at primary school; he played with friends and he played football. His cognitive skills were behind his peers. Consequently, he was moved into a class for pupils with special needs. He was diagnosed with ID and was found to have ASD traits during his adolescence. When he was in his teens, his family moved to a rough neighbourhood. C changed and stopped socialising and playing football. He also withdrew socially and his practical and self-care skills declined. He showed concurrent psychotic symptoms including delusions, hallucinations and disorganised speech and behaviour. He committed his first crime during his teens. Several incidents occurred after this. In his late adolescence, he associated with a group known for its violence and conservative religious ideology. He started using alcohol and illicit drugs. C was admitted to the SPID and stayed for more than six months.
A, B and C – scores
A, B and C were scored for behavioural problems and mental health problems on two checklists, the ABC and the PAC. The scores are presented in Table I.
Table I shows a clinically-relevant reduction in irritability and social withdrawal scored by the ABC, as well as a reduction in general problems including passivity, irritability, aggression/violent behaviour and breaking items, psychosis and anxiety. However, clinically-relevant differences were not significant using a non-parametric test. This is probably due to the low number of participants.
As we were unable to find any articles on this specific phenomenon, it is not possible to state how widespread it is, other than that psychosis is found to be a risk factor for violent behaviour in people with ASD (Im, 2016). The three patients had been in frequent contact with the police authorities. We are aware that certain religious groups may offer simple rules about what to do and what not to do, as well as a strong social cohesion. It is easy to imagine that rules and a sense of social cohesion may be attractive to young people who, for the most part, have no friends, are unemployed and living on the margins of society. The three patients had developed severe mental health problems in their adolescence. At the SPID, thorough observations of symptoms were conducted – addressing in particular to separate ASD symptoms from psychotic symptoms, mood symptoms and anxiety symptoms. The clinical implications of the findings suggest that it is crucial to differentiate between ASD and psychosis as ASD is considered a life-long condition, while psychosis can be treated and achieve a successful outcome, as in the three cases presented. Maintaining the psychotic symptoms of this patient group at the lowest possible level could help to prevent them from engaging in criminal activities.
Differentiating between ASD and psychosis might be difficult, as the manner in which the patient speaks or behaves could be interpreted as a single disorder (Nylander, 2014; Helverschou and Martinsen, 2011). Conversely, ASD may easily be overlooked in people with mental disorders who are treated by the general psychiatric services (Nylander and Gillberg, 2001). It is essential to organise the categories of symptoms. Furthermore, it is essential to recognise the warning signs, because psychotic and mood disorders tend to relapse (Birchwood et al., 2000). The clinical experience of the SPID is that people with autism, even those with IQs in the general range, are unable to cope with recognising signs that they are experiencing a relapse, even if they have been given a list of warning signs. Thus, the symptom load should be closely monitored by the specialist psychiatric services.
Another clinical perspective is that improved mental health may also enhance the patients’ relationships with significant others, especially family members. A, B and C improved their family relationships, in which there had previously been severe conflicts on occasions, including physical attacks. During follow-up by SPID, the patients did not engage in any violent behaviour or crimes. The ABC and PAC scores reflect the significant improvement in both mental health and behavioural problems for A, B and C. Another perspective on mental health services is their twofold mandate: to improve mental health in the individual patient, thereby preventing any recurrent criminal behaviour through an improvement in their mental health. Studies into ASD and crime have suggested that excessive preoccupations and rigid routines may lead to criminal acts when a person with ASD becomes isolated (Haskins and Silva, 2006). Combined with a lack of understanding of other people’s emotions, it may contribute to the way such people fail to understand the implications of their actions until they have been arrested by the police (Sutton et al., 2013). In the current examples, the patients’ troubled lives were the result of a combination of impaired cognitive and practical skills resulting from ID, ASD, psychosis, drug use and criminal activity at a young age, and then being attracted to radical religious groups and becoming involved in violence. Multidisciplinary and cross-service co-operation may be essential to keeping these young men out of the criminal justice (Haw et al., 2013). They may become less at risk through a more accurate diagnostic assessment of their psychosis and an overall understanding of their complex diagnostic states. Follow-up by the mental health services and discharge from inpatient care to involuntary care outside a psychiatric hospital may be necessary to ensure that the patient does not engage in criminal acts.
Young men who have experienced social and cognitive difficulties from an early age and who are attracted to groups that hold extreme and violent ideological views should be examined carefully for signs of a combination of ASD and psychosis, or other severe mental illness, if they display any kind of psychotic symptoms. A combination of ASD and psychosis aggravates the problems of both conditions, which could lead to both a severely impaired cognitive functioning and impulse control in particular, and of the ability to judge whether or not situations are dangerous or offensive. Follow-up should be maintained after discharge from psychiatric units.
Paired differences of ABC and PAC scores, at admission and at discharge
|At admission||At discharge|
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About the authors
Ann Magritt Solheim Inderberg is based at the Oslo University Hospital, Oslo, Norway.
Kristin Horndalsveen is based at the Oslo University Hospital, Oslo, Norway.
Arne-Henrik Elvehaug, is based at the Oslo University Hospital, Oslo, Norway.
Yugbadal Mehmi is based at the Oslo University Hospital, Oslo, Norway.
Ingvild Jørstad is based at the Oslo University Hospital, Oslo, Norway.
Trine Lise Bakken is Head of Advisory Unit at the Oslo University Hospital, Oslo, Norway.