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The purpose of this paper is to explore the experience and possibilities for misdiagnosis of women with ASD in secure and forensic hospitals, via the medium of a lived experience case study. To consider the clinical value of the patient perspective of and insight into their disorder. The case study is supplemented by relevant associations to the MHA Code of Practice, the CQC report, Monitoring the Mental Health Act (MHA) 2016–2017, published on 27 February 2018 and current research findings in the fields of service provision, quality of care and treatment of female patients with a diagnosis of ASD.

A review and commentary of the author’s lived experience of a formal diagnostic assessment for ASD as a female patient in a secure and forensic hospital. In reviewing aspects of the author’s clinical assessment, the author has made contextual reference to the MHA Code of Practice, the CQC report, Monitoring the MHA 2016–2017, published on 27 February 2018, and current research findings. The account focuses on aspects of the author’s recent experience assessment and treatment for ASD which the author believes may be of use in informing clinical practice.

Open-ended exploration of a lived experience account/case study of a diagnostic assessment of an adult female patient for ASD, demonstrating the possible ambiguity of responses to questionnaire-based assessment tools and other deficiencies inherent to the assessment process and care and treatment of adult female ASD sufferers in secure and forensic hospitals.

The author uses the lived experience as a patient to review and provide commentary on the clinical assessment for ASD. This review is, therefore, informed by an authentic patient perspective and not clinical perspectives. This paper highlights the need for further research into the diagnostic assessment of females for ASD in a secure and forensic hospitals.

First, to encourage practitioners to extend their range of thinking to be more inclusive of the patient perspective when performing a diagnostic assessment. Second, to increase practitioner awareness of the deficiencies in the current service provision for adult female patients diagnosed with ASD in secure and forensic hospitals.

To improve patient experience of diagnostic assessment for ASD and the quality of the assessment and patient outcomes in secure and forensic hospitals.

The paper is original in concept in that it considers the inclusion of patient experience/views in assessment and formulation and links them to wider social policy and practice guidance. The case study is an authentic patient account informed by the author’s experience of secure and forensic psychiatric hospitals. The value of the paper may be determined by the extent to which the paper encourages practitioners to consider the patient perspective and experience of the diagnostic assessment and how this and subsequent care and treatment may affect the adult female patient in secure and forensic hospitals.

A significant number of people held within the secure forensic hospital estate in this country suffer from neuropsychological deficits (e.g. Lowings, 2010; Williams et al., 2010). These deficits, many of them cognitive, have a detrimental impact on patient's abilities to benefit from psycho-educational materials thereby slowing the progress of their rehabilitation. Understanding these difficulties enables interventions to be more effectively targeted and facilitated to the patients’ cognitive strengths. It was against the backdrop of the evidence that a review was commissioned into neuropsychological activity at Rampton Hospital.

The review of the neuropsychological assessment activity was confined to the male patients residing within Mental Health Services (MHS) and the National High Secure Learning Disability Service (NHSLDS) of the hospital. With regards to the MHS, 129 patient files were examined in order to identify the volume of neuropsychological assessment previously undertaken and the make up of the neuropsychological test batteries administered with the current patient group. With regard to the NHSLDS 48 files were similarly examined. In addition, MHS psychologists were surveyed to assess their knowledge of patients within that service who to their knowledge had previously suffered an acquired brain injury (ABI) or had suffered a significant neurological illness likely to have resulted in cognitive impairment.

A scoping exercise identified that a significant amount of neuropsychological assessment was being undertaken, albeit in an unstructured way. This led to a number of patients being subjected to a significant delay before the need for neuropsychological testing and rehabilitation possibilities became apparent. There was a huge variance on when a patient was tested ranging from one month to 14 years and the size of the test battery used, with the number of tests conducted per patient ranging between one single test to 16 tests during a patients stay at the hospital.

Opportunities to more appropriately place patients based upon their abilities could be achieved if the hospital were to adopt a policy of conducting neuropsychological assessments, including cognitive functioning, for all patients upon admission to the hospital. A proportion of patients were known to have had a ABI or a significant illness likely to have resulted in cognitive impairment. This was considered to be an underrepresentation and the taking of a thorough history specifically covering ABI and specific illnesses known to have an impact on cognitive ability and behaviour was also recommended.

In light of this review, services are to take a more systematic approach to assessing neuropsychological difficulties. Consideration is being given to neuropsychological screening becoming part of the admission process.

There are high levels of psychiatric morbidity amongst people in prisons. In England and Wales, prisoners who present with the most acute mental health needs can be transferred to hospital urgently under part III of the Mental Health Act 1983. This project reviewed all such transfers within one region of England, with an emphasis on differences across levels of security.

Over a six-year period (2010–2016) within one region of England, 930 psychiatric referrals were received from seven male prisons. From these referrals, 173 (18.5%) secure hospital transfers were required. Diagnostic and basic demographic information were analysed, along with hospital security categorisation (high secure, medium secure, low secure, psychiatric intensive care unit and other) and total time to transfer in days.

There were substantial delays to urgent hospital transfer across all levels of hospital security. Prisoners were transferred to the following units: medium security (n = 98, 56.9%); psychiatric intensive care units (PICUs) (n = 34, 19.7%); low secure conditions (n = 20, 11.6%); high secure conditions (n = 12, 6.9%); other (n = 9, 5.2%). Mean transfer times were as follows: high secure = 159.6 days; other = 68.8 days; medium secure = 58.6 days; low secure = 54.8 days; and psychiatric intensive care = 16.1 days.

In keeping with the wider literature in this area, transfers of prisoners to hospital were very delayed across all levels of secure psychiatric hospital care. Mean transfer times were in breach of the national 14-day timescale, although transfers to PICUs were quicker than to other units. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved.

This paper extends the available literature on the topic of transferring prisoners with mental illness who require compulsory treatment. There is a small but developing literature in this area, and this paper largely confirms that delays to hospital transfer remain a serious problem in England and Wales. National work, including research and service pilots, is required to understand whether and how these transfer times might be improved. This could include different referral and transfer models as a component of service-based and pathways research or combining referral pathways across units to improve their efficacy.

The Wechsler Adult Intelligence Scale – Fourth Edition (WAIS-IV) (Wechsler, 2008) is a cognitive assessment that is often used in secure forensic settings, however it has not been normed on this population. The purpose of this paper is to develop forensic normative data.

Patient files in a high secure forensic hospital were reviewed in order to obtain completed WAIS-IV (Wechsler, 2008) assessments and scores from the five indexes (verbal comprehension, perceptual reasoning, working memory, processing speed and full scale intelligence quotient (FSIQ)). This included reviewing patient files from all directorates, including male mental health, male learning disability, male personality disorder and the women’s service, yielding a sample size of n=86.

The qualitative descriptors obtained across the hospital ranged between extremely low and superior. The learning disability service scored significantly lower than the mental health and personality disorder services in verbal comprehension index, perceptual reasoning index, working memory index and FSIQ, and significantly lower than the mental health, personality disorder and women’s services in processing speed index. Mean scores from this study were significantly lower in comparison to those from the UK validation study (Wechsler, 2008).

The significant difference between scores from the current study and those from the UK validation study (Wechsler, 2008) highlights the need to have appropriate normative data for forensic populations. Clinicians should consider interventions that may serve to increase cognitive function, such as cognitive remediation therapy.

Whilst several special group studies have previously been conducted, this study is the first to develop forensic normative data for the WAIS-IV (Wechsler, 2008). Whilst the sample size was relatively small with limited female participants, the data collated will enable clinicians working in forensic establishments to interpret their assessments in light of this information.

Many people within secure forensic settings are expected to take part in psycho‐educational programmes as part of their treatment and rehabilitation. Many are hampered in their progress due to cognitive difficulties. This paper aims to outline the scale of the problem and to offer potential solutions.

The numbers of people who are placed in secure settings with known neuropsychological difficulties and the range of their cognitive problems are explored. It is proposed that individual education plans based on neuropsychological profiles together with guidance on the preparation and delivery of educational materials could improve the efficacy of psycho‐educational programmes.

Many people within the secure forensic estate have neuropsychological deficits. Many have suffered traumatic or other acquired brain injury or have deficits associated with substance misuse or even childhood emotional trauma. Others have cognitive difficulties specific to their mental health and occasionally their prescribed medication. A significant number will have intellectual disability (IQ<70) or be within the borderline range (IQ between 70 and 79).

Understanding neuropsychological difficulties would mean that best use is made of the psycho‐educational materials presented, thus speeding up and improving the efficacy of the rehabilitation process and potentially reducing the risk that the person poses to themselves and others. There are resources, which offer guidance to teachers of children with neuropsychological difficulties but not for the adolescent and adult forensic population. This paper addresses this gap.

The purpose of this paper is to provide a commentary on “diagnosis and treatment of asd in women in secure and forensic hospital”.

The approach is a commentary on a personal experience of services.

Women with ASD are often not diagnosed until adult years which may impact on their long-term outcomes. Secure services may not always have care teams who are appropriately trained to support a woman with ASD.

A commentary on an original viewpoint piece published in this special edition on women with autism spectrum disorder.

The purpose of this paper is to undertake a systematic literature review to appraise the current evidence relating to the factors associated with violence and aggression in adult psychiatric hospital inpatient settings.

A systematic search of following four databases was conducted: Scopus, PsychINFO Medline, CIHAHL and PsychArticle. Following the application of the inclusion criteria, ten papers were extracted and included in the review. A quality appraisal tool, Mixed Methods Appraisal Tool (MMAT) version 2011 (Pluye et al., 2011), was employed for the appraisal of the qualitative and quantitative studies. MMAT has been designed for systematic literature reviews that include qualitative, quantitative and mixed methods studies. Of these, eight were of quantitative methodology and two were of qualitative studies.

These ten papers provide an insight into factors associated with violence and aggression towards nursing staff. Three main themes were identified: the environment, attitudes/interaction of staff, and the patient’s mental illness. The themes were important factors in the causes of violence but were interlinked highlighting the complex nature of violence towards nursing staff. The findings support the need for training for nursing staff and the development of ongoing support and for organisations to consider both the environment and the restrictive procedures to help reduce violence and aggression towards nursing staff.

The paper concludes by outlining the importance of considering the three main themes for clinical practice, training and development of secure services.

This paper gives insight into the factors associated with patient violence and aggression towards nursing staff in a secure setting.

Autistic women and girls have received comparatively less attention within clinical practice and research. Research suggests women tend to be diagnosed later than men, and are more likely to experience misdiagnosis.

This paper aims to report a narrative literature review that examines research on the presentation, recognition, and diagnosis of autistic women and girls.

Findings suggest that autistic females present differently to males and highlight low recognition of the female presentation of autism among the general public, in social spheres, educational, clinical and forensic settings. This lack of recognition appears to affect the likelihood of females being referred for diagnosis, the reliability of diagnostic assessments and subsequent access to support.

Recommendations for clinical practice focus on initiatives to increase awareness of the female presentation of autism, improving the diagnostic process for females, increasing female representation within autism training and for future research to support these goals.

The purpose of this paper is to inform understanding of female offenders who commit domestic violence. This contentious area of research is growing and there are strong indications that men and women perpetrate similar levels of domestic violence. This has resulted in increasing interest in understanding the characteristics of such offenders as well as considering treatment pathways.

In this study, female prisoners (n=92) completed a measure of psychological and physical aggression (Revised Conflict Tactics Scales, Straus et al., 1996) to explore the types of domestic violence experienced and perpetrated in most recent and previous relationships.

Results indicated high levels of psychological aggression and physical assaults both experienced and perpetrated by female offenders in current and previous relationships. Physical assaults tended to be severe and high levels of mutual violence were reported both in most recent and previous relationships.

The findings suggest the importance of service provision and treatment pathways for female domestic violence perpetrators. On the basis of the findings, treatment needs of such offenders are considered and potential treatment pathways are reflected upon.

There are little known publications exploring the prevalence and characteristics of female domestic violence perpetrators in prison. Research has also tended to focus on current relationships as opposed to considering both current and previous relationships. This paper explores these areas and will be of interest to practitioners working with this client group.

Patients with autism spectrum disorder (ASD) present with specific assessment, specific difficulties, needs and therapeutic issues and therefore are a challenging group for forensic services. Given the challenge that individuals with ASD present to forensic services, the suggested increase in the number of this group within this setting and the relatively little amount of research which suggests they face a number of difficulties within the prison environment, the purpose of this paper is to identify and review all the studies which have been carried out investigating any aspect of ASD in relation to secure hospital settings.

Seven internet-based bibliographic databases were used for the present review. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines.

A total of 12 studies were included in this review; 3 looked at the prevalence of ASD in secure psychiatric hospitals. One study evaluated the clinical utility of the AQ screening tool to assess self-reported autistic traits in secure psychiatric settings. Three explored any type of characteristics of patients with ASD detained in secure psychiatric hospitals. One study investigated the experiences or quality of life of patients with an ASD detained in secure psychiatric care. Two studies investigated awareness, knowledge and/or views regarding patients with ASD held by staff working within secure psychiatric hospitals. Lastly, three studies (one of which was also included in the prevalence category above) looked at the effectiveness of interventions or treatment of patients with ASD in secure psychiatric hospitals. Clinical recommendations and future research directions are discussed.

To the author’s knowledge, this is the first review to explore what research has been carried out looking specifically at patients with ASD in relation to secure forensic settings.