Psychotropic medication prescribing in people with autism spectrum disorders with and without psychiatric comorbidity

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.

Examining the relationship between neuropsychological functioning assessed during admission to a high secure psychiatric care hospital and vulnerability to long-term segregation

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.

Evaluation of autism awareness training provided to staff working in a high secure psychiatric care hospital

Purpose The purpose of this paper is to evaluate autism awareness training provided to staff working in a high secure psychiatric care (HSPC) hospital. Design/methodology/approach An online survey of staff views who had completed an autism awareness training day. Findings All staff who completed the evaluation questionnaire reported that an autism awareness training day had been useful and had increased their knowledge of how to work with individuals who have autism. However, most staff also reported that one day was not long enough and that more case discussion would have been helpful. Although most staff also reported that autism awareness training should be mandatory, motivation to attend such training was considered important. In terms of the number of staff who had completed the training, whilst a wide range of staff groups had attended training, only a minority had done so, with the number of staff completing the training each year remaining relatively constant over a five-year period. Research limitations/implications Within the context of promoting Enabling Environments in forensic settings and the recent government consultation paper exploring whether autism awareness training should be mandatory for all those working in health care, further investigation is required into how to increase staff motivation to attend autism awareness training and to explore how it is used during everyday work with patients. Originality/value As an initial evaluation of optional autism awareness training delivered in HSPC, the project offers some valuable information in terms of the number of staff who attend such training, what they find useful and how it might be improved for this setting.

The atmosphere of the ward: Attunements and attachments of everyday life for patients on a medium-secure forensic psychiatric unit

The climate or atmosphere of a ward in secure psychiatric care is typically studied by examining the relationship between social and environmental factors. However the experiences of patients are irreducible to a set of discrete dimensions or factors. Drawing on recent work in affect theory and architectural studies, we argue for an approach to atmosphere that places it ‘in-between’ persons and space, as a ‘spatially extended quality of feeling’ of which patients are intimately aware. The article discusses empirical material drawn from a broader study of inpatient medium-secure forensic care in a large hospital in the South of England. We show how the process of becoming attuned to the fluctuations and shifts in the atmosphere of the ward is a critical aspect of everyday life for patients. Attunement cuts across existing notions of power and resistance in these settings. We also demonstrate how attachments to a range of objects, some created by patients, can either expand or punctualize attunement, enabling change in the overall atmosphere. We conclude by speculating on how we might rethink spaces of recovery on an ethospheric basis.

Autism spectrum disorders in high secure psychiatric care: a review of literature, future research and clinical directions

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.

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

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 to identify and review all the studies which have been carried out investigating any aspect of ASD in relation to secure hospital settings. Design/methodology/approach 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. 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 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. Originality/value 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.

Incompatibilities and seclusion of patients with an autism spectrum disorder detained in high-secure psychiatric care

Purpose Whilst individuals with an autism spectrum disorder (ASD) represent a relatively small proportion of patients detained in high-secure psychiatric care (HSPC), previous research suggests that such individuals present with difficulties and needs significantly different from non-ASD patient groups. However, to date, there has not been any formal examination of how individuals with an ASD are represented in records of key risk management actions (i.e. seclusions and incompatibilities with other patients). The paper aims to discuss these issues. Design/methodology/approach An observation of hospital data examining two key risk management actions for a group of individuals with an ASD is detained in one HSPC hospital. These include the number of formal incompatibilities with other patients and the number of, and hours in, seclusion. Both actions require extra staff and security provisions and can decelerate the rehabilitation and recovery process. Findings In addition to suggesting an overall increase in the general prevalence of ASD within the hospital compared to previous estimates, individuals with an ASD appear to have a disproportionately higher number of incompatibilities with other patients compared to those patients without an ASD and experience more and longer periods of seclusions. Originality/value Although the methodological limitations of the study are acknowledged, explanations for the findings are discussed along with future research and recommendations as to how ASD patients might be best managed in the hospital. It is argued that the findings add further support for a specialist ASD service within HSPC.