Autism and the Criminal Justice System from a clinician's perspective. Dr Samantha Walker Calderstones NHS foundation partnership trust

Who are we? A large secure provision in the North West for people with a learning disability. We have medium, low and “step down” facilities. We cater for both male and female clients We admit people on section and through home office jurisdiction We also have individualised models of care around specific individuals who have “failed” in other services

Our client group National Estimates ASC (reported in Emerson & Baines, 2010) Individuals with co-morbid ASC and learning disabilities: 20 – 30% Adults with learning disability and ASC in residential care: % Calderstones Inpatient Services (July 2011) Approximately 20% of our inpatient population

Psychological Formulation A psychological formulation provides a means to understanding how individuals’ difficulties have been generated and how they continue to present a problem. It is in essence, a story about the individual and the problems they experience. The formulation enables us to make informed judgements about the most appropriate support strategies and treatment approach.

Generally struggles to make eye contact, but will often make fleeting glances. Staff feel that he seems to look at the side of an individual rather than at them. When talking about a topic he feels is important he may make excess eye contact throughout the short interaction. Face is typically empty of expression and often would not know what he is feeling from expression. Does smile but not known to laugh. Does invade other’s personal space but seems to do this for comfort e.g. cuddling. Doesn’t do this in general conversation. Historically has engaged in this behaviour. Stiff and clumsy body movements. Touches other people in a non-sexual way without appearing to recognise that it is inappropriate. Wants friends but doesn’t really know how to make them. Fails to share interests with peers in a reciprocal manner. Fails to engage in activities with peers which are of interest to both (one sided interactions). Enjoys going to the club/work but not for the social aspect, rather for his drink/chocolate and because it is part of his routine. Would prefer to go to his bedroom if a few people were in the lounge, however will use the lounge if it is empty. Approach's others predominately to have his needs met rather than for social interaction / comfort Interrupt others when in conversation to get own needs met Would respond negatively if good things happened to his peers. Communicates verbally Does appear to use gesture to communicate—this appears quite exaggerated and may be learnt. Only engages in conversation about things of interest to himself. Interjects into others conversations Appears to engage appropriately in reciprocal conversation but this is for a short time—he eventually gets the topic around to something of interest to himself Appears to switch off when someone else is talking about something not of interest to him The topics he talks about are limited to: trips out, shopping, TV, computer games and cars. These may be age appropriate. Has at least one idiosyncratic word to describe things—e.g. a staff members child is always referred to as an infant. Speaks in a monotone voice with little evidence of inflexion. Repeatedly asks questions—about events that are due to happen in the near future. Repeats inappropriate comments made by another client when in conversation with him despite his dislike of the nature of the comments Has interests which historically have described as obsessive e.g. ‘ need to get back to Burnley’. This appears to have abated somewhat. Others interests are: his gaming console, cars and wildlife programmes. The team felt that these were appropriate in intensity and form for his age group. Typically is not distressed by changes in routine., imperfections within the environment etc however it is hypothesised that he can’t deal with uncertainty about daily events and therefore repeatedly asks questions to gain concrete answers. Evidence was also provided that he is concerned about staff keeping to times they are due to leave. Repeatedly cracks the joints of his knuckles and neck. He has unusual repetitive hand movements when engaging in conversation. IMPAIRMENTS OF COMMUNICATION IMPAIRMENTS OF IMAGINATION IMPAIRMENTS OF SOCIAL INTERACTION CLIENTS NAME TRIAD OF IMPAIRMENTS Results from CAST assessment **DATE** ADDITIONAL AUTISTIC CHARACTERISTICS: Becomes overloaded very easily: this can occur in response to noise (blicks going off), too much information, and when too many people are around. Becomes very distressed as a result. Generally struggles to make eye contact, but will often make fleeting glances. Staff feel that he seems to look at the side of an individual rather than at them. When talking about a topic he feels is important he may make excess eye contact throughout the short interaction. Face is typically empty of expression and often would not know what he is feeling from expression. Does smile but not known to laugh. Does invade other’s personal space but seems to do this for comfort e.g. cuddling. Doesn’t do this in general conversation. Historically has engaged in this behaviour. Communicates verbally Does appear to use gesture to communicate—this appears quite exaggerated and may be learnt. Only engages in conversation about things of interest to himself. Interjects into others conversations Appears to engage appropriately in reciprocal conversation but this is for a short time—he eventually gets the topic around to something of interest to himself Has interests which historically have described as obsessive e.g. ‘ need to get back to Burnley’. This appears to have abated somewhat. Others interests are: his gaming console, cars and wildlife programmes. The team felt that these were appropriate in intensity and form for his age group. IMPAIRMENTS OF COMMUNICATION IMPAIRMENTS OF IMAGINATION IMPAIRMENTS OF SOCIAL INTERACTION CLIENTS NAME TRIAD OF IMPAIRMENTS ADDITIONAL AUTISTIC CHARACTERISTICS: Becomes overloaded very easily: this can occur in response to noise (blicks Example of a one page profile:

Individualised Person centred ASC as a key component Focus on offending behaviour / difficulties which led to admission to services Shared understanding Consider strengths as well as difficulties

Once we have a diagnosis and a formulation... At all times remaining aware of the individuals ASC and moderating approaches and expectations regarding outcomes accordingly. Individual Interventions Sharing the formulation Individual therapy using a range of models / approaches e.g. Cognitive Behavior Therapy, (CBT), Cognitive Analytic Therapy (CAT). Psycho-educational intervention Positive behavioural approaches Group Interventions Good Touch / Bad Touch Social Problem Solving Assertion Skills Managing Anger Adapted Sex Offender Treatment Group (ASOTP) Conversation groups (SALT led) Managing Meetings (SALT led)

...and therapy runs alongside... Environmental Management  Interactional Style  Communication Strategies  Pro-active problem solving  Sensory Awareness  Resources  Staffing levels / personality  Staff training  Activities / goal setting ASD Friendly Treatment and care Plans ASD Friendly Management Guidelines

OFFENCE SPECIFIC / NON ASC CARE PATHWAY DIAGNOSIS ASSESSMENT, FORMULATION AND TREATMENT /CARE PLAN ENGAGEMENT AND INTERVENTION TRANSITION PLANNING RESETTLEMENT ASC SPECIFIC ASC TEAM CONSULTATION (as required) THE AUTISM TEAM: Default Care Pathway

Supporting an individuals communication Total Communication Makaton Intensive Interaction Communication Profiles Environment (Noise, Lighting, Low stimuli, TV) Time of the day Clear and concise communication Picture boards/ planners/Diaries Social Stories sequences (comic strips) scripts picture exchange objects of reference

Establishing a person-centred plan catering to an individuals specific preferences and needs Person-centred support allows us to establish what and who is important to an individual; including daily routines, likes and dislikes, what is important to the person now, what is important to the person in the future and how this can be achieved. Helps us understand how to match support to the person’s needs Knowing how to use information about a person to improve quality of life It can be seen that person-centred planning will enhance quality of life and self esteem to grow. Person-centred planning is ideal for individuals with Autism as it focuses on the individual. Sometimes the tools may need to be adapted and terminology changed so that it is understood. Help’s someone understand their own autism Promotes empathy for the person you support, therapeutic relationships and ‘un- conditional positive regard’ Helps understand what triggers anxiety and stress for the person you support

Families/Parents/Carers are important! Planning should build the person's circle of support and involve all of the people who are important in that person's life. Person centred planning is owned and controlled by the person (and sometimes with their closest family and friends). These are the individuals the person wants to be part of developing their person centred plan and who can help them make things happen. These are the committed people in the person’s life who know and care about them. It is a good way to learn how to work collaboratively with families and carers, other professionals and the person themselves

Techniques and approaches to support individuals with an autistic spectrum condition to learn and develop new skills The planning process and people with autism In order to make the person centred planning process meaningful for people with autistic spectrum disorders we have incorporated the SPELL approach by the National Autistic Society. That means the process has: a clear structure (there are key questions to ask); it focuses on the person’s positive attributes (their gifts and strengths); there is an empathetic approach (for example, using the means of communication that the person understands best); low arousal (i.e. too many people present at a meeting can be stressful for some); links with the most important people and things in the person’s life. Understand why it is important to support someone to take risks – risk taking is a part of human development

How we reduce sensory overload, or increase sensory stimulation, by making adaptations to the physical and sensory environment Ways to help Be aware: look at the environment to see if it is creating difficulties for people with an ASD. Can you change anything? Be creative: think of some positive sensory experiences Be prepared: tell people with an ASD about possible sensory stimuli they may experience in different environments. Sight: Hypo (under-sensitive) Increase the use of visual supports. Hyper (over-sensitive) Reduce fluorescent lighting - use deep-coloured light bulbs instead. Wear sunglasses. Create a workstation in the classroom: a space or desk with high walls or divides on both sides to block out visual distractions. Use blackout curtains. Sound: Hypo Use visual supports to back up verbal information. Hyper Shut doors and windows to reduce external sounds. Prepare a person before going to noisy or crowded places. Wear ear plugs. Listen to music. Create a workstation. Touch: Hypo Use weighted blankets or sleeping bags. Hyper Warn a person if you are about to touch him or her; always approach him or her from the front. Remember that a hug may be painful rather than comforting. Gradually introduce different textures - have a box of materials available. Allow a person to complete activities themselves (eg, hair brushing and washing) so that they can do what is comfortable for them.

How we reduce sensory overload, or increase sensory stimulation, by making adaptations to the physical and sensory environment Taste: Some people with an ASD are hyper- or hyposensitive to taste, and may limit themselves to bland foods or crave very strong-tasting food. We have not included any ways to help because as long as someone eats a bit of a varied diet, this isn't necessarily a problem. For more information about ASD and restricted diets Smell: Hypo Use strong-smelling products as rewards and to distract people from inappropriate strong-smelling stimuli (like faeces). Hyper Use unscented detergents or shampoos, avoid wearing perfume, make the environment as fragrance-free as possible. Balance: Hypo Encourage activities that help to develop the vestibular system. For children this could include using rocking horses, swings, roundabouts and seesaws. For adults, try games like catching a ball or practise walking smoothly up steps or curbs. Hyper Break down activities into small, more easily manageable steps; use visual cues such as a finish line. Body awareness: Hypo Position furniture around the edge of a room to make navigation easier. Put coloured tape on the floor to indicate boundaries. Use the 'arm's-length rule' to judge personal space. This means standing an arm's length away from other people. Hyper Do 'fine motor' activities like lacing

Case Examples

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