24 months
30 months
36 months
48 months
Rape 7
8
5
2
1
1
2
2
2
Voyeurism 5
5
5
2
0
0
1
0
1
Exhibitionism 6
5
5
2
0
0
1
0
0
Stalking 8
5
3
1
0
0
1
0
0
Dating abuse 4
5
4
5
0
0
0
0
2
Children 11
12
9
8
2
1
2
2
2
Social desirability 5
5
4
4
3
5
4
4
4
It can be seen from Table 21.2 that Andrew endorsed an unusually high number of cognitive distortions prior to the onset treatment. As treatment progressed, the number of cognitions that he endorsed reduced from high to relatively low levels. A follow-up assessment at four years, one year after the cessation of formal treatment, indicated that the improvements had maintained. Andrew did not reoffend during the period of treatment or follow-up and there were no further indications that he showed any sexual interest in children.
21.5.4 Outcome Studies Evaluating Sex Offender Interventions
Three fairly large-scale studies have appeared recently, describing the characteristics of sex offenders living in the community, their treatment and the outcome of the treatment process. Following a programme of the institutionalisation in Vermont, USA, McGrath et al. (2007), reviewed the treatment and management regime in 403 adult sex offenders with ID. Treatment included procedures to promote social and the living skills and skills for managing risk. Over half of the offenders had a history of committing more than one type of sexual offence. In an 11-year follow up, with an average of 5.8 years, they reported 11% reoffending. McGrath et al. (2007) compared this cohort to other samples. First, they reported on 195 treated and untreated adult male sexual offenders with ID who had been imprisoned and then followed up for an average period of 5.72 years, 23% of whom were charged with a new sexual offence at some point in the follow up period. In a second comparison, they reported on 122 treated and untreated male sexual offenders without ID who had received probation orders and follow-up of 5.24 years, 6.5% of whom were charged with a new sexual offence. Therefore, their experimental sample had a reoffending rate of 11% compared with 23% for the imprisoned sex offenders with ID who had no community follow-up.
From a scientific point of view, as with other studies, one of the difficulties in the McGrath et al. (2007) ID cohort was that 62% had received 24-hour supervision, which limited the access to potential victims. However, they also considered that this level of supervision resulted in a more comprehensive identification of future incidents when compared to the two other cohorts who had remained unsupervised. They also reported a considerable amount of harm reduction in that 83% of participants were classified as contact offenders while only 45% of the offences were contact offences.
Lindsay and colleagues (Lindsay et al., 2004, 2006; Lindsay, Steptoe, Wallace, Haut, & Brewster, 2013) have published a series of reports evaluating the effectiveness of a community forensic ID service. The most recent report has tracked 309 offenders with ID cumulated over a period of 20 years. Of those individuals, 156 men had committed a sexual offence or sexual abuse, 126 men had committed another type of offence and 27 were female. Women made up 9% of this cohort, indicating that the relative numbers of women and men amongst offenders with ID was consistent with that in the general population. Treatment in the service was comprehensive, including sex offender treatment, anger management treatment, individual psychiatric review, nursing interventions, occupational therapy, the establishment of work and educational placements and individual treatment as appropriate. The main outcome measure was reoffending over the 20-year period. As with the McGrath et al. (2007) study, all participants were monitored closely in the community by social work and community nursing staff and so any incident of reoffending, whether or not it was reported to the police, was likely to be reported to the forensic ID service.
Unlike the McGrath et al. (2007) study, all participants had free access to the community and lived in some community setting such as the family home, an independent flat, a supported tenancy or a group home. They reported a reoffending rate among sex offenders of 16%, which was high compared to other studies. However, it must be remembered that all participants had open access to the community and it is likely that any incident would be reported back to the service and be counted in the study. Since they had such comprehensive information on incidents, these authors also calculated the amount of harm reduction over 20 years. They compared the number of incidents two years prior to referral with the number of incidents up to 20 years after referral and found that for reoffenders only, the sex offenders recorded a 70% reduction in the number of incidents. Taking into account the full cohort of sex offenders, the reduction in recidivism was over 95%. These were highly significant results with very large effect sizes.
Murphy et al. (2010) conducted a treatment study of 46 sex offenders with ID who were living in community settings. Treatment groups were conducted over a period of one year and assessments included several attitudinal measures. They found that sexual knowledge, victim empathy and cognitive distortions improved significantly following treatment but only improvements in sexual knowledge and reduced cognitive distortions were maintained to six month follow up. They also reported that 9% of their sample reoffended after a one-year treatment programme. Two incidents were of sexual touching (outside clothing) and the rest were non-contact offences (public masturbation and stalking). Separately, Murphy and Sinclair (2006) reported that although the study was designed as a treatment controlled trial, it proved difficult to recruit and retain control participants. Heaton and Murphy (2013) followed up 34 of these men with an average period of 44 months after treatment. They found that 32% had committed a further sexual incident although only two (6%) had been changed with an offence.
Although these various studies are service evaluations and treatment trials without a treatment control, it is possible to conclude tentatively that in terms of treatment of sex offenders with ID, psychological treatment based on cognitive behavioural principles and structured interventions appear to yield reasonable outcomes. Longer periods of treatment result in better outcomes, these outcomes maintain over several years and organised forensic ID services seem to produce significant reductions in the amount of harm done to local communities.
21.5.5 Treatment of Fire-setters
There has been a historical association between fire-setting and low intelligence in the literature (e.g. Walker & McCabe, 1973), although more recent research found that fire-setting accounted for only a small proportion (4%) of those referred to ID services due to offending and antisocial behaviour (O’Brien et al., 2010). On the other hand, the proportion of people in secure ID services with histories of fire-setting is significant. Hogue et al. (2006) found that just over 21% of those detained in low/medium secure services in a UK study sample had an index offence of arson. Looking at the same population, Taylor et al. (2004) found that 19% of patients had arson convictions and a further 13% had documented histories of fire-setting.
Over the last 30 years, there have been a number of case studies, case seri
es and pre-post group studies showing that interest in fire and a propensity to set fires can be treated successfully, but there have been no systematic, controlled evaluations. Rice and Chaplin (1979) conducted a study that involved the delivery of a social skills training intervention to 10 fire-setters (two groups of five) in a high security psychiatric facility in North America. One of the groups was reported to be functioning in the “mild to borderline range of mental retardation” [sic] (p. 105). Following treatment, both groups improved significantly on a reliable observational rating scale of role-played assertive behaviour. At the time of reporting, 8 out of the 10 patients treated in this study had been discharged for around 12 months and none had been convicted or suspected of setting fires.
Clare, Murphy, Cox and Chaplin (1992) reported a case study involving a man with mild ID admitted to a high secure hospital following convictions for two offences of arson. He had a prior history of arson and making hoax telephone calls to the emergency services. Following his transfer to a regional specialist inpatient unit, he received a comprehensive treatment package, including social skills and assertiveness training, development of coping strategies, covert sensitisation, and facial surgery (for a significant facial disfigurement). Significant clinical improvements were observed following treatment. The client was discharged to a community setting and had not engaged in any fire-related offending behaviour at 30-months follow-up.
More recently cognitive behavioural approaches to working with fire-setters have been developed. Hall, Clayton and Johnson (2005) considered arson in relation to people with ID and described how Cognitive Analytical Therapy (CAT), an integrative model of short-term psychotherapy (Ryle, 1993), can be applied to arsonists with ID to successfully reformulate the origins of the distress and maladaptive coping strategies that result in fire-setting behaviour. The same authors also described the delivery of a 16-session group cognitive-behavioural approach to six male patients with ID and histories of fire-setting detained in a UK specialist NHS medium secure unit. The intervention aimed to help patients identify personal risk factors associated with their fire-setting and develop alternative coping strategies to reduce the risk of reoffending. The programme involved three sequential phases: (1) “Introduction to fires”, which considers the dangers of fires and the views of society and the media concerning arson and fire-setters; (2) “Personal fire-setting”, which looks at individual patients fire-setting behaviour and offending cycles within a behavioural framework; and (3) “Alternative ways of coping”, which includes work on identifying personal risk factors and strategies for managing these. To facilitate the programme aims, following completion of the initial 16 sessions two group follow-up sessions were held, the first six weeks after the original group and the second after six months.
Although Hall et al. (2005) describe a pre-post intervention A-B design to evaluating the group intervention using fire-specific and clinical assessments, no post-treatment data were provided. However, most group participants were reported to have responded positively to the intervention in terms of their clinical presentations, and two patients were successfully transferred to less secure placements following completion of the programme.
Taylor et al. (2002) reported a group study involving 14 men and women with ID and arson convictions who were assessed pre- and post-treatment on a number of fire-specific, anger, self-esteem and depression measures. The intervention is a cognitive behaviourally framed approach developed especially for this patient group. It is a multi-faceted programme based on the approach outlined by Jackson (1994), which is underpinned by the “functional analysis paradigm” (Jackson et al., 1987, p. 175). It comprises seven modules delivered over approximately 40 sessions that involve work on offence cycles, education about the costs associated with setting fires, training of skills to enhance future coping with emotional problems associated with previous fire-setting behaviour, and work on personalised plans to prevent relapse. Given the demonstrated importance of anger and/or revenge as an antecedent to fire-setting in this population (Murphy & Clare, 1996; Taylor et al., 2002) up to 10 sessions are dedicated to developing anger coping strategies using an evidence-based intervention developed by Taylor and Novaco (2005).
The intervention described by Taylor et al. (2002) successfully engaged these patients, all of whom completed the programme delivered over a period of four months. Despite their intellectual and cognitive limitations, all participants showed high levels of motivation and commitment. Following treatment, significant improvements were obtained on the fire-specific and anger and self-esteem scales.
In an extension of this work, Taylor et al. (2004) described a case series of four detained men with ID and convictions for arson offences who were evaluated before and after completion of the same treatment procedure. The patients engaged well in treatment, and all showed high levels of motivation and commitment that were reflected in generally improved attitudes with regard to personal responsibility, victim issues and awareness of risk factors associated with their fire-setting behaviour.
Taylor et al. (2006) used the same methods in a further case series of six women with ID and convictions for arson. Once again, the participants were reported to have engaged well and all completed the programme. Their scores on measures related to fire-specific treatment targets generally improved following the intervention. All but one of the participants had been discharged to community placements at two-year follow-up, and there had been no reports of participants setting any fires or engaging in fire risk-related behaviour.
21.6 AUTISM SPECTRUM DISORDERS AND CRIME
In the last 15 years here has been an increase in clinical and research interest in any possible relationship between offending and autism spectrum disorder (ASD) (Debbaudt, 2004; Howlin, 2004; Attwood, 2007; Browning & Caulfield, 2011) and the nature of the contact between those with ASD and the legal system (Freckelton, 2013). There have been claims that people with ASD may be up to seven times more likely to come into contact with the police than those in the general population (Debbaudt 2004, cited by Kelley, 2007, and Browning & Caulfield 2011). In the Cambridge Longitudinal study of 451 boys born in 1953, Farrington et al. (2006) reported that 167 (36%) recorded offences while in a study on 15,117 people born in 1953 in Stockholm, Hodgins (1992) found that around 29% of those with no mental disorder had committed crime by 1983. Given these figures it would seem remarkable if those with ASD had a seven-fold increase in offending likelihood.
In an early review, Ghaziuddin, Tsai, and Ghaziuddin (1991) analysed the rates of violence in 132 cases described across 21 studies on ASD published from 1944 to 1990. Definite violence was recorded in three cases (2.3%) and possible violence in 5.6%. They concluded that violent crime was no more likely in those with ASD than those without. Larsen and Mouridsen (1997) used a 30-year register of people with ASD and followed up 18 individuals. Only one had been convicted of a crime (theft). Mouridsen, Rich, Isager, and Nedergaard (2008) followed up 313 adults with ASD in Denmark, referred between 1960 and 1984. They compared them to a matched group of 933 control participants from the general population recorded in the Danish population register. They found that 9% of the ASD group and 18% of controls had a record on the Danish Register of Criminality. Additionally they compared those diagnosed with childhood autism (CA), atypical autism (AA) and Asperger syndrome (AS). Offending was almost absent in the CA group, around two-thirds the frequency of the controls in the AA group and equivalent to the controls in the AS group suggesting that those with milder ASD had a rate of offending similar to that of people without ASD.
Woodbury-Smith, Clare, Holland & Kearns (2006) studied community samples of 25 people with ASD and 20 controls. There were no differences between the groups on age, gender and IQ. In a self-report procedure, 48% of the ASD group admitted to ever having engaged in illegal behaviour compared with 80% of controls. Only 8% of the ASD group were convicted and the proportion of the controls with convictions was not reported. Allen, Evans, Hilder, Hawkins, Peckett
, and Morgan (2008), in a comprehensive review of 98 services, identified 126 people with ASD and found that 33 (26%) had engaged in criminal behaviour. Of 16 offender participants studied in greater depth, around 40% had no criminal justice contact and violent offences predominated with no notable elevation in other offences. Hippler, Viding, Klicpera, and Happe (2010) conducted a careful review of 177 patients diagnosed in Asperger’s original clinic with “autistic psychopathy”. On the Austrian Penal Register they found a rate of convictions similar to that of the general population. Comparing those with classic features against those with less typical features of ASD they found lower rates of offending in the former. Therefore these various studies have found no increase or lower rates of offending behaviour in those diagnosed with ASD. These studies also suggest that those with greater degrees of ASD have lower rates of offending behaviour while those with milder forms of ASD have rates consistent with the general public.
Some have considered that people with ASD might commit unusual offences or a different pattern of offending consistent with the presentations in ASD (Baron-Cohen 1988). However, Hippler et al. (2010) found no differences in the types of offending compared with patterns in the general population with property damage, theft and car crime the most common. They found low rates of drug offences and no sexual offences with no over-representation of any offence types. In the study by Mouridsen et al. (2008) there was a significantly elevated rate of arson in the ASD group compared to controls. Woodbury-Smith et al. (2006) found significantly higher rates of minor property damage (spray painting walls, damaging cars) and lower rates of drug abuse than control participants.
Both Barry-Walsh and Mullen (2004) and Katz and Zemishlany (2006) published case series on offenders with ASD. In most cases, these authors linked the criminal behaviour to expressions of the disorder itself. They describe the way in which poor understanding of the feelings of others, pursuit of a specific interest, or unwittingly invading the space of others resulted in offending behaviour. Poor theory of mind leading to misunderstanding of social cues or underdeveloped empathic responses has been implicated as a cause of offending behaviour by many authors (e.g. Attwood, 2007; Howlin, 2004; Murrie, Warren, Kristiansson, & Dietz, 2002). Woodbury-Smith, Clare, Holland, Kearns, Staufenberg, and Watson (2005) conducted a matched comparison study of offenders with ASD, non-offenders with ASD and general public controls. The offending ASD group had no deficits in theory of mind or the recognition of sadness but were significantly poorer in recognising the expression of fear. Therefore no consistent patterns of offences or consistent differences in patterns between those with and without ASD have emerged from research reports.
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