A systematic PRISMA review of individuals with autism spectrum disorder in secure psychiatric care: prevalence, treatment, risk assessment and other clinical considerations

Publication Date05 Feb 2018
AuthorClare S. Allely
SubjectHealth & social care,Criminology & forensic psychology,Criminal psychology,Sociology,Sociology of crime & law,Deviant behaviour,Public policy & environmental management,Policing,Criminal justice
A systematic PRISMA review of
individuals with autism spectrum disorder
in secure psychiatric care: prevalence,
treatment, risk assessment and other
clinical considerations
Clare S. Allely
Purpose 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 toidentify and review all the
studies which have been carried out investigating any aspect of ASD in relation to secure hospital settings.
Design/methodology/approach Seveninternet-based bibliographic databaseswere used for the present
review.The review followedthe PreferredReporting Itemsfor Systematic reviewsand Meta-Analysesguidelines.
Findings 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 lifeof 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.
Originality/value To the authors 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.
Keywords Autism spectrum disorder, Secure hospital, Aspergers syndrome, High secure psychiatric hospital,
HSPC, Secure forensic settings
Paper type Literature review
Autism spectrum disorders (ASDs) are neurodevelopmental disorders characterised by
impairments in social reciprocal interactions and communication and restricted, repetitive
pattern of interests and behaviour (American Psychiatric Association, 2000, 2013). The true
prevalenceof ASD is not known (Fernell et al., 2012). As highlightedby Lyall et al. (2017) in a recent
paper, only one rigorous study of ASD prevalence in adults has been conducted to date
(Brugha et al., 2011). This investigation, conducted in England in 2007, actively sampled adults
from the communityand it employed an active two-stagescreening-confirmationapproach which
produced an estimateof ASD in 1 per cent in the general population.This prevalence is consistent
with the findings from some other studies (e.g. Simonoff, 2012). The male-female ratio for ASD
prevalence is between 4 and 5:1 in the general population (Fombonne, 2009). The Diagnostic
StatisticalManual fifth editions (DSM-V) (American Psychiatric Association,2013) now defines two
Received 23 June 2017
Revised 7 September 2017
Accepted 20 September 2017
© Clare S. Allely, 2017. Published
by Emerald Publishing Limited.
This articleis published underthe
CreativeCommons Attribution
(CC BY 4.0) licence. Anyone may
reproduce,distribute, translate
and create derivative works of this
article( for bothcommercial &
non-commercial purposes), subject
to full attribution to the original
publication and authors.The full
terms of thislicence may be seen
at http://creativecommons.org/
Compliance with ethical standards:
there are no conflicts of interest to
declare.The paper did not received
any funding.
Clare S. Allely is a Reader in
Forensic Psychology at the
School of Health Sciences,
University of Salford,
Manchester, UK; and an
Affiliate Member of the Gillberg
Neuropsychiatry Centre,
Sahlgrenska Academy,
University of Gothenburg,
Gothenburg, Sweden.
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VOL. 8 NO. 1 2018, pp. 58-79, Emerald Publishing Limited, ISSN 2009-3829 DOI 10.1108/JCP-06-2017-0028
core areas of impairment in ASD (previously three core areas): persistent deficits in social
communication and social interactionand restricted, repetitive patterns of behavior, interests, or
activities. Impairment to these two core areas varies across individuals in terms of symptoms
and levels of severity. There has been much criticism over the proposed changes and final
changes made in the DSM-Vs new criteria for ASD (see Waterhouse, 2013; Wing et al.,2011;
McPartlandet al., 2012; Ritvo, 2012; Fernell et al., 2012).However, a thorough discussionof this is
outside the scope of this review.
Rates of overlap between intellectual disability (ID) and ASD
ID and ASD are the most common developmental disorders and combined, they affect between
3 and 5 per cent of the population(Srivastava and Schwartz, 2014, p. 161). Postorino et al.
(2016), in a recent paper investigating the prevalence of ID and ASD in an Italian sample of
children and adolescents, cited a number of studies which have found that there is a frequent
co-occurrence between ID and ASD, and that both these disorders have been argued to share
genetic substrates (e.g. Bölte and Poustka, 2002; Bonora et al., 2014; Charman et al., 2011;
Deth, 2012; Fombonne, 2003, 2009; Mefford et al., 2012; Nicholl et al., 2014; Srivastava and
Schwartz, 2014). Srivastava and Schwartz (2014) also suggest that these two disorders are
significantly likely to be associated, both biochemically and molecularly. Studies have found that
as many as 70 per cent of individuals with ASDs have some level of ID while the other 30 per cent
have some form of disability (e.g. speech, behaviour) which is not cognitive dysfunction
(Mefford et al., 2012; Newschaffer et al., 2007; Wilkins and Matson, 2009). However, it is
interesting to note studies which have looked at this from the other perspective the prevalence
of ASD in individuals with ID. About 10 per cent of individuals with ID have ASDs. Additionally,
some ID conditions have been found to have a greater prevalence of co-occurrence with ASD
than others (Srivastava and Schwartz, 2014).
However, Postorino et al. (2016) have argued that the studies published to date have reported a wide
range of rates of ID prevalence in ASD with reported prevalence ranging from 16.7 to 84 per cent
(Bairdet al., 2000, 2006; Bertrand et al., 2001; Bölte and Poustka, 200 2; Bölte et al., 2009; Carlsson
et al., 2013; Centers for Disease Control and Prevention, 2014; Chakrabarti and Fombonne, 2005;
Charman et al., 2011; De Bildt et al.,2004;Fombonne,2003;Gillberget al.,1991;KeenandWard,
2004; La Malfa et al., 2004; Magnússon and Saemundsen, 2001; Matson and Shoemaker, 2009;
Miller et al., 2012; Oliveira et al., 2007). The majority of these studies main research focus, however,
was examining the epidemiology of ASD rather than specifically investigating the rate of comorbidity of
ID in individuals with ASD (Postorino et al., 2016). Despite the well-established high co-morbidity
between ID and ASD, the present paper focuses on studies which specifically look at individuals with
ASD because there has been relatively little research investigating ASD in the criminal justice system.
However, there is a significant amount of research which has looked at ID in the criminal justice system
(e.g. Ali et al., 2016; Boer et al., 2016; Cootes, 2016; Eadens et al.,2016;Murphy,Gardner,and
Freeman, 2017; Murphy, Chiu, Triantafyllopoulou, Barnoux, Blake, Cooke, Forrester-Jones, Gore and
Beecham, 2017). This study is interested in the particular experiences of individuals with ASD given
their unique features, challenges and needs.
ASD and offending behaviour
The types of offending behaviours which have been found to be associated with offenders with ASD
include: violent behaviour, sexual offending, fire setting, obsessive harassment (stalking)
and computer/cyber-crimes (Ledingham and Mills, 2015; Sabet et al., 2015; Allely and
Creaby-Attwood, 2016). It is important to highlight that most individuals with ASD are law-abiding
(Murphy, 2017). There is no evidence to suggest that individuals with ASD have higher rates of
offending behaviour (King and Murphy, 2014). However, it is important to draw attention to the
increasing body of research which indicates that it is those individuals with ASD who also have
psychiatric co-morbidities who are more at risk of engaging in offending behaviour (e.g. Chaplin et al.,
2013). Some of the most common co-morbidities in individuals with ASD include: mood disorders
such as depression and anxiety (e.g. Ghaziuddin et al., 2002; Hammond and Hoffman, 2014; Matson
and Williams, 2014; Moss et al., 2015; Bruggink et al., 2016), and behavioural disorders including
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