PurposeEvidence suggests that autistic individuals are overrepresented within forensic psychiatric settings and present with different difficulties and needs compared to their neurotypical counterparts. With respect to high secure psychiatric care (HSPC), a 2017 survey examining the experiences of autistic patients found most reported both positive and negative aspects associated with their care, and variable quality of life (QoL) ratings. Since this, several significant changes have occurred including moving to a new hospital site, the introduction of the mandatory Oliver McGowan autism awareness training and the national strategy for autistic children, young people and adults outlining the need to improve autistic individuals' experience of the criminal justice system. This paper describes a repeat survey of patient experiences to see whether they may have changed or improved in light of these changes.Design/methodology/approachQualitative data about the experiences of autistic individuals detained in a UK HSPC hospital was gathered using semi-structured interviews and the forensic QoL questionnaire.FindingsConsistent with the previous survey, the number of autistic patients interviewed remains relatively small yet diverse, and they report positive and negative experiences within the hospital and different QoL ratings. Positive experiences include support and therapeutic opportunities, whereas the negatives echo those in the 2017 survey - notably the perception of staff knowledge of autism and inconsistency of care. The variation in patient demographics is significant as well as their experiences and QoL ratings, illustrating the importance of individualised treatment.Originality/valueThe small scale survey highlights that whilst there have been many aspects of change and development in one HSPC hospital, individual experiences and QoL remain varied for autistic patients and similar to those reported in 2017, with perceived inconsistent care, a lack of awareness of individual autistic features by staff, and environmental issues frequently reported. The repeat survey suggests that despite modernisation in the physical environment, availability of more training around autism and the introduction of a national autism strategy, there remain ongoing challenges many autistic patients face within HSPC. Whilst staff autism training remains important, qualitative impressions suggest that it is not enough and there are other factors including perhaps consistency of staff that are important for an autism informed model of care.

The Autistic Spectrum, published almost 30 years ago, remains an important text for all those who work with autistic individuals. This brief article highlights the significant contribution of Lorna Wing to how we view autism, including the observation that many of the issues being highlighted today regarding the appropriate management of autistic individuals are not new and can be found in the thoughts of Dr Wing.

Purpose The link between sleep disturbance and aggression among forensic psychiatric patients is well established. However, the relationship between subjective experience of sleep quality and sleep hygiene, reported head injury, age, neuropsychological functioning and risk within these populations remains poorly understood. A study is described examining the relationships between these factors in a sample of individuals deemed a “grave and immediate” risk toothers. The aim of this study is to explore these relationships in more detail. Design/methodology/approach A service evaluation project examining the prevalence of self-reported sleep dysfunction, age and the relationship with neuropsychological functioning, reported head injury and dynamic risk appraisals of a UK high secure psychiatric patient sample is described ( n = 84). Findings Self-reported poor sleep quality and poor sleep hygiene is present among 65% of patients, especially those in admission and high dependency wards. Whilst there are no differences between those with a self-reported head injury history in sleep quality, there is in sleep hygiene. Older patients also report more sleep hygiene problems. The combination of poor sleep quality, poor sleep hygiene and performance within selective aspects of executive functioning tasks has some relationship with dynamic risk. Practical implications The importance of sleep management and cognitive remediation is discussed, as is the need for more robust research and inclusion of an assessment of sleep within forensic neuropsychological and psychiatric evaluations. Originality/value To the best of the authors’ knowledge, this is the first study to examine the relationship of sleep disturbance, neuropsychological functioning and head injuries and risk within a high secure psychiatric patient sample.

BACKGROUND:The term neurodiversity is an umbrella term for any atypical pattern of cognitive ability, including but not confined to neurodevelopmental disorders. Research suggests that several neurodivergent conditions are overrepresented in offender populations, with a recent survey suggesting that over half of those coming into contact with the criminal justice system may have a neurodivergent condition. Considerable effort has been invested in trying to divert people with such conditions out of long-stay hospitals, but nevertheless, a few studies in secure hospitals suggest that while prevalence in hospitals may be lower than in prisons, it is high relative to the general population. AIMS:To determine the prevalence of recorded neurodivergent conditions in one high secure hospital. METHODS:We conducted a records survey of a resident cohort of men in one high secure hospital in England during December 2022. RESULTS:Records were accessed for all 197 resident men. According to these records, over one-half (115, 58%) of the men had at least one neurodivergent condition; nearly a third (56, 29%) had more than one form of neurodivergent condition. The most frequently recorded form of neurodivergent condition was general cognitive dysfunction (24%), followed by general language difficulties (16%), ADHD (15%) and autism (14%) and those with a history of seizures (14%) and atypical brain scans (12%). Dyslexia was reported within 6.5% of patient notes, acquired brain injury 5% and chromosomal disorders 2%. The survey also suggests some differences in the prevalence of neurodivergent disorders across clinical groups, with higher rates among people with mental illness than with personality disorder. Prevalence was also unevenly distributed across nature of ward type. CONCLUSIONS:With the survey suggesting that the majority of patients in one high secure psychiatric hospital have at least one form of neurodivergent condition, it raises questions around how useful the term is and what the term neurodivergence means in this population. With each form of neurodiversity having different needs, the diversity of conditions present also raises questions around what a 'neurodiverse informed model of care' would look like in forensic mental health services.

BACKGROUND:Whilst there is increasing recognition and interest in how staff who have neurodivergence are represented and contribute to industry, to date, there has been very little exploration of neurodivergence among healthcare staff and none with those working in forensic psychiatric services. AIMS:To estimate the prevalence of neurodivergence among staff working in a UK high-secure psychiatric hospital and explore their experiences. METHODS:All staff were invited to complete a confidential online self-report questionnaire consisting of both closed and open questions. RESULTS:A fifth of the staff responded (n = 124), but two did not report their neurodivergent status, so were excluded. Nearly 40% of responders reported having some form of neurodivergence, with Attention Deficit Hyperactivity Disorder (ADHD) being the most common, followed by dyslexia, autism and dyspraxia. Over a third (36%) of those reporting neurodivergence said that they had chosen not to disclose this to the organisation and around a quarter (23%) reported not feeling valued or supported by the organisation. Of the staff cohort who responded, most expressed the view that neurodiversity in the workforce is beneficial to patient care, despite the majority being unsure whether neurodivergence is an advantage or a barrier for the individual themselves. Over half of staff completing the survey felt there was not enough awareness of neurodiversity among staff and that more training on the subject would be beneficial. CONCLUSION:This survey suggests gaps in our recognition and understanding of neurodivergence among hospital staff. Although the prevalence figure should be treated with caution, given the low response rate, in this first survey of neurodivergence among staff in a secure hospital, our findings suggest substantial numbers of staff with neurodivergence and the likelihood that neither they nor the organisation are optimising this situation. The further steps should include the development and evaluation of strategies exploring ways of improving recognition and relevant support for staff, as well as discovering ways in which neurodivergence in staff might inform and optimise care and treatment for patients.

BACKGROUND:Although the prevalence is unknown, psychopathy can be a possible co-occurring condition associated with autism especially among forensic populations. However, the relationship between these two conditions remains poorly understood. AIMS:To carry out a systematic review of the available literature exploring the relationship between autism and psychopathy. METHODS:A systematic literature review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using terms for autism and psychopathy to search the literature databases Scopus, Pubmed, Web of Science, ASSIA, APA Psych Info, Medline and EMBASE from 1980 to March 2024. For inclusion, we required that a recognised measure of autism and psychopathy or associated features of the latter had been used. RESULTS:Of the 4230 potential articles identified, 37 met the selection criteria. Insufficient and inconsistent methodologies for data pooling meant that a narrative analysis was used. Although there is some overlap, four broad themes emerged relating to (1) assessment and frequency of co-occurrence, (2) behavioural and neurophysiological expressions of empathy, (3) behavioural contagion effects, mirroring, mimicry and other linking mechanisms and (4) emotional face perception and theory of mind characteristics. Within these areas there are some specific differences between the two conditions. However, the research to date examining the relationship between autism and psychopathy has mostly been with children and males, carried out with non-clinical non-forensic populations, as well as using self-report measures and parental ratings. Prior research has also largely focused on looking for differences between these conditions rather than co-occurrence. CONCLUSION:This review outlines a case for considering autism and psychopathy as distinct, but potentially co-occurring conditions and highlights the need for more research into how the two conditions interact with clinical populations. There also appears to be a need for guidelines on when and how to assess psychopathy with autistic individuals and a better understanding of the therapeutic needs and factors influencing the long-term outcomes of autistic individuals who may also present with co-occurring psychopathy.

SUMMARY Autism spectrum disorders (ASDs) are a group of lifelong neurodevelopmental disorders characterised by difficulties in social interactions and social communication, and restricted and repetitive behaviours. Relative to the general population, individuals with ASDs are likely to be overrepresented in secure psychiatric care and custodial settings. Outcomes vary and can be problematic in the context of co-occurring intellectual disability, psychiatric disorder and challenging behaviours. To date, there is little in the way of specialised clinical guidance on the prescription of psychotropic medicines for individuals with ASDs, particularly information on any differences in efficacy and/or tolerability of specific medications. This review summarises the key research to date on the prescription of psychotropic medication in ASD with and without comorbid psychiatric or neurodevelopmental disorders, within the context of the existing clinical guidance. Some critical analysis is provided to aid clinicians in following a safe, effective and individualised approach to prescribing for people with ASDs.

Inpatient ward social climate and sense of community can influence the recovery and care experiences of forensic mental health patients. This research evaluated an intervention designed to improve social climate and sense of community within a high-secure psychiatric hospital in the UK. The intervention was offered across six wards: two wards received the full intervention, two received the partial intervention, and two received no intervention (control). Social climate and sense of community were measured prior to the start of the intervention 6 and 18 months into the intervention, using the Essen Climate Evaluation Schema and the Sense of Community Index-2. Changes in frequency of disruptive behaviour were also monitored across time points. Results revealed that the full and the partial intervention groups reported greater feelings of social climate than the control group. This effect was also observed across time points, with higher social climate scores in the full and partial intervention groups compared to control group at 6 and 18 months. Furthermore, social climate scorespredicted a significant reduction in frequency of incidents across time in the full intervention. These findings provide longitudinal evidence of the importance of developing ward social climate and sense of community within forensic inpatient settings.

In the context of police investigation or custodial interview, some autistic individuals may not necessarily be recognised as immediately vulnerable by the police, as a result of their apparent competent use of language and by virtue of the fact that they appear to be intellectually capable. However, despite their apparent abilities, many autistic individuals may experience considerable difficulties in being able to understand and cope with police demands, as well as high levels of distress in the custody context. It is imperative that there is an understanding of the influence that having a diagnosis of autism can have on the investigative interview process given the important function that interviews can have within a number of forensic contexts. For many autistic individuals, a formal interview can cause significant sensory overload and distress which leads to a negative experience or a poor level of engagement, as well as reducing the quality of information obtained. This chapter will explore how the efficacy of forensic interviews can be affected by features of autism, including detailed discussion of memory impairments, impairment in ability to recall events in a sequential manner, issues with compliance, lack of (or reduced) emotional expression, awkward or inappropriate expressions or behaviours, impaired social communication and interaction, issues with time to respond, misinterpretation or lack of understanding of repetitive interests or behaviours, and unusual ways of speaking. It will conclude by providing a number of recommendations for criminal justice professionals when carrying out an investigative interviews with autistic individuals, designed to improve both the experience for suspects and the outcomes.

The neuropsychological assessment of individuals with a mental disorder and deemed to be a ‘grave and immediate’ risk of harm to others admitted to one UK high-secure psychiatric care (HSPC) hospital makes an important contribution to the formulation of their difficulties and treatment needs. Included within the assessments is the DEX S questionnaire, assessing the subjective experience of any executive dysfunction (ED). An examination of 205 DEX S profiles suggests ED is common, particularly among younger individuals and with no difference between those who self-report a history of head injuries. Whilst a non-clinical non-forensic classification system suggested 43.9% of individuals fall into a ‘high deficit’ category and 24.4% fall into a ‘moderate deficit’ category, a HSPC classification system suggests higher thresholds, with 22.4% and 33.2% falling in ‘high deficit’ and ‘moderate deficit’ categories, respectively. Frequently endorsed items are associated with difficulties understanding others unless things are kept simple and straightforward, acting without thinking, expressing emotions, feeling restless, and problems sitting still for any length of time and being easily distracted. Results are discussed in terms of increasing awareness of ED among those involved in the care of mentally disordered offenders, cognitive remediation and the potential for a forensic psychiatric version of the DEX.

Purpose This paper aims to provide a discussion and summary of a clinician survey exploring the experiences of suspected feigned autism. Design/methodology/approach This study is an online survey targeting a range of autism professionals, with varying levels of experience, working in different clinical settings. Findings Approximately half of the professionals who completed the survey reported experiencing situations of suspected feigning of adult autism across a range of clinical contexts and with various motivations. In terms of best indications of potential feigning, most clinicians reported “textbook” self-descriptions of problem behaviours with vague examples, as well as inconsistent presenting problems and mismatch with any known developmental history. Approximately half of clinicians expressed the view that autism was more difficult to feign than a psychiatric disorder and had experienced situations involving differences in professional opinion as to an individual autism diagnosis. Research limitations/implications The survey is limited by a potential sample bias and no information regarding the clinical characteristics of those suspected to have feigned autism. However, these initial findings offer further questions for future research to pursue. Originality/value As an initial examination of practicing clinicians’ experiences of suspected feigned autism, the survey highlights the complexities of an autism diagnosis and suggests feigning is a potential clinical scenario. Some guidance as to when to suspect possible feigned autism is also offered, as well as a provisional assessment protocol.

SUMMARY In recent years, mass violence associated with men who identify as involuntary celibates (incels) has been of increasing concern. Incels engage in an online community where misogyny and incitements to violence against women are prevalent, often owing to the belief that women are denying them a ‘right’ to sex. Indeed, inceldom can be considered a form of extremism. Information released about the prepetrators of incel-associated violence consistently suggests that mental disorder is a contributory factor and may increase vulnerability to engaging with the incel community. Depression, autism and personality disorder are particularly relevant. To date, there has been little research into the mental health of incels and how, in some, this contributes to violence. This article considers the associations between mental disorder and inceldom, including the risk factors for incel-related violence, and makes recommendations for best practice in risk assessment and clinical intervention.

Purpose This paper aims to examine the relationship between neuropsychological functioning as assessed following admission to a high secure psychiatric care (HSPC) hospital and subsequent time spent in long-term segregation (LTS). Evidence from forensic populations suggests neuropsychological functioning difficulties can increase vulnerability to interpersonal violence. However, the impact of this relationship on restrictive interventions used in these settings is poorly understood. Design/methodology/approach This study quantitatively examined the neuropsychological profiles of 80 male HSPC patients as assessed during routine admission assessments, comparing data against any subsequent LTS duration during a one-year period, and a non-LTS control (n = 27). Findings Analysis found individuals who were willing and able to complete a routine neuropsychological admissions assessment spent significantly less time in LTS than those unable to complete the assessment. Performance within a test of novel problem solving (Key Search Test) was significantly worse in the LTS group than controls. Performance within a visual memory task (Immediate Recall section of the Rey Complex Figure Test) significantly correlated with LTS duration. Additional findings suggest the absence of self-reported planning difficulties as measured by a Dysexecutive Questionnaire (DEX) negatively correlated with LTS duration, while self-reported restlessness was positively correlated with LTS. Practical implications This has implications for early assessment of LTS risk and potential use of cognitive interventions to reduce the use of restrictive practices. Originality/value The results suggest some aspects of neuropsychological performance as assessed during admission to a HSPC hospital appear to be related to subsequent time spent in LTS.

The present study describes the Wechsler Adult Intelligence Scale (WAIS) full scale IQ (FIQ) of admissions to one UK High Secure Psychiatric Care hospital. WAIS IV comparative data and the FIQ of admissions from the 1960s to the 2010s are presented (n = 639). Results suggest 75% of current admissions have FIQs within the 'low average' and 'extremely low' classifications, with significant discrepancies between composite scales being common and processing speed being the most compromised area of cognitive functioning. A one standard deviation decline in FIQs of admissions since the 1960s to the 2010s is also present. The results are discussed in terms of the changing clinical presentations of admissions, along with research and clinical implications.

Aims Autism Spectrum Disorder (ASD) is a common neurodevelopmental disorder associated with difficulties in social communication and language development, preoccupations, a need for routine, sensory sensitivities and emotional dysregulation. People with autism who have violently offended may be prescribed psychotropic medications to treat comorbidities, or off-license to manage aggressive or challenging behaviours. However, the evidence base for their use remains scarce. Method This was a retrospective audit at Broadmoor Hospital, a high security psychiatric hospital in the United Kingdom, into the safe and appropriate prescribing of psychotropic medicines in those with an ASD compared to guidance from the National Institute for Health and Care Excellence (CG142): “Autism spectrum disorder in adults: diagnosis and management”. This first cycle was undertaken during May and June 2020 and included all patients with a confirmed or equivocal diagnosis of ASD in the preceding five years. Result A total of 22 participants were included in this study. Of these, 17 participants had a confirmed diagnosis of ASD and five participants had a suspected diagnosis of ASD, but without formal confirmation with neurocognitive testing. A total of 13 (76.5%) participants with confirmed ASD were prescribed antipsychotic medication, nine of whom had an established comorbid mental disorder with psychotic symptoms. Of the remaining four, three had a diagnosis of a personality disorder. Three participants in this study had a confirmed diagnosis of ASD without any additional comorbid mental health diagnoses. No patients were prescribed psychotropic medicines for the core symptoms of ASD. The specific documentation of off-license use of antipsychotic medicines in those without a diagnosis of a psychotic disorder was poor. This was not recorded in any such participant in the preceding 12 months. Conclusion This audit highlighted that dual diagnoses of ASD alongside non-affective psychosis and personality disorder are over-represented in this high security setting. The NICE clinical guidelines CG142 guidelines state that “antipsychotic medications should only be used for behaviour that challenges if …. the risk to the person or others is very severe”. By definition, all patients admitted to high security are deemed to be a grave and imminent risk to the public. Psychotropic medicines may therefore be clinically indicated at a much earlier stage than in community patients, instigated alongside appropriate psychosocial interventions and treatment of comorbid conditions. It may be that catered guidelines need to be formulated to support the safe and appropriate prescribing of psychotropic medicine in forensic settings.

Background/aims: To explore the role of high secure psychiatric care (HSPC) in the assessment and management of individuals with an Autism Spectrum Disorder (ASD) using published studies and clinical experience. Key areas of exploration include the prevalence of ASD within HSPC, some autism specific issues including clinical and cognitive characteristics, psychopathy and emotional regulation, presence of incompatibilities and use of seclusion, as well as experiences of being detained in HSPC. Developing best practice and a specialist ASD service in HSPC is also discussed. Method: A discussion of available literature, supported by clinical experience. Conclusions: Although individuals with an ASD admitted to HSPC comprise a small group, they are likely to be overrepresented relative to the general prevalence of ASD in the population and present with specific issues. Whilst individuals report a generally positive experience of HSPC, therapeutic outcomes are variable and the factors influencing them poorly understood. Staff knowledge and application of ASD theory and practice appears to have a significant influence on outcomes. Implications: Although best practice concerning ASD secure services will continue to be improved and developed, the role of HSPC in the assessment and management of some individuals with an ASD who present with complex needs and high risk behaviours remains clear.

Purpose The purpose of this paper is to review available literature targeting the assessment and management of individuals with an autism spectrum disorder (ASD) admitted to high secure psychiatric care (HSPC). Key areas of examination include the prevalence of ASD in HSPC, how individuals with an ASD differ from other patient groups in clinical and cognitive characteristics, the views of staff regarding patients with an ASD, an exploration of the experiences and quality of life of patients with an ASD, as well as treatment and interventions. Design/methodology/approach A review of the published literature. Findings Although individuals with an ASD comprise a relatively small proportion of the total HSPC cohort, they appear to be over represented relative to the general population prevalence. Several research projects suggest that individuals with an ASD present with difficulties and needs different to other patient groups, as well as being viewed by staff as potentially vulnerable and requiring a different care approach. Individuals with an ASD report both positive and negative aspects to life in HSPC. Practical implications Suggestions are made with regard to how individuals with an ASD might be better managed in HSPC. Following the spirit of various pieces of government legislation such as the Autism Act (2009) and the Equalities Act (2010) the role of a specialist ASD HSPC service is proposed. Originality/value This paper provides a detailed review of the research to date exploring the assessment and management of individuals with an ASD detained in HSPC. It outlines key research findings, highlights limitations with it and provides a personal perspective on future research and clinical targets.