Risk Factors for Violent
Offending in Autism
A National Study of Hospitalized
Karolinska Institutet, Sweden
Little is known about risk factors for violence among individuals with autism
spectrum disorder (ASD). This study uses data from Swedish longitudinal
registers for all 422 individuals hospitalized with autistic disorder or
Asperger syndrome during 1988-2000 and compares those committing vio-
lent or sexual offenses with those who did not. Thirty-one individuals with
ASD (7%) were convicted of violent nonsexual crimes and two of sexual
offenses. Violent individuals with ASD are more often male and diagnosed
with Asperger syndrome rather than autistic disorder. Furthermore, comorbid
psychotic and substance use disorders are associated with violent offending.
We conclude that violent offending in ASD is related to similar co-occurring
psychopathology as previously found among violent individuals without
ASD. Although this study does not answer whether ASDs are associated with
increased risk of violent offending compared with the general population,
careful risk assessment and management may be indicated for some individ-
uals with Asperger syndrome.
Keywords: autism spectrum disorder; autism; Asperger syndrome; violence;
Autism spectrum disorders (ASDs) are characterized by abnormal
development of communication and social interaction and a restricted
repertoire of activity and interests. The most common ASDs (for which
the ICD-10 [International Classification of Diseases; World Health
Journal of Interpersonal
Volume XX Number X
Month XXXX xx-xx
© 2008 Sage Publications
J Interpers Violence OnlineFirst, published on August 13, 2008 as doi:10.1177/0886260508322195
Copyright 2008 by SAGE Publications.
Organization, 1992] and the Diagnostic and Statistical Manual of Mental
Disorders, fourth edition, text revision [DSM-IV-TR; American Psychiatric
Association, 2000] use similar diagnostic categories) are autistic disorder
(childhood autism), Asperger’s disorder (or Asperger syndrome), and per-
vasive developmental disorder—not otherwise specified or atypical autism
(Fombonne, 2003; Yeargin-Allsopp et al., 2003).
Research from different countries indicates that psychotic disorders,
substance use, and personality disorders increase the risk of violent crimi-
nal behavior (e.g., Arseneault, Moffitt, Caspi, Taylor, & Silva, 2000; Fazel
& Grann, 2006; Grann & Fazel, 2004; Johnson et al., 2000). However, the
association of ASDs and violent crime is uncertain. Single case reports have
described odd, bizarre, and occasionally unpredictable interpersonal vio-
lence committed by adolescent and adult men with Asperger syndrome
(Bankier, Lenz, Gutierrez, Bach, & Katschnig, 1999; Baron-Cohen, 1988;
Everall & LeCouteur, 1990; Kohn, Fahum, Ratzoni, & Apter, 1998;
Mawson, Grounds, & Tantam, 1985; Milton, Duggan, Latham, Egan, &
Tantam, 2002). However, Ghaziuddin, Tsai, and Ghaziuddin (1991)
reviewed the early literature and showed that among 132 individuals diag-
nosed with Asperger syndrome, only 3 (2.3%) were described as violent.
More recent reports have included case series of violent and sexual offend-
ers with Asperger syndrome (Barry-Walsh & Mullen, 2004; Haskins &
Silva, 2006; Murrie, Warren, Kristiansson, & Dietz, 2002; Schwartz-Watts,
2005). Using a high-security forensic psychiatric hospital sample in the
United Kingdom, Murphy (2003) compared 13 male adult inpatients with
Asperger syndrome with age-matched male patients with schizophrenia
and personality disorder, respectively. Individuals with Asperger syndrome
had low rates of prior violence and substance misuse and committed less
violent index offenses than did the two comparison groups.
Three prevalence studies have suggested that the prevalence of ASDs
and Asperger syndrome in highly selected samples of violent offenders is
several orders of magnitude higher than usually found in the general popu-
lation (Fombonne, 2003). Scragg and Shah (1994) found an Asperger syn-
drome prevalence of 1.5% (n=6) using case files and diagnostic follow-up
interviews with screen-positive offenders in a U.K. secure forensic hospi-
tal. Hare, Gould, Mills, and Wing (1999) screened all patients in three
2 Journal of Interpersonal Violence
Authors’ Note: We are grateful to Professor Anthony Bailey for helpful comments on a
previous draft. Correspondence concerning this article should be addressed to Niklas
Långström, Centre for Violence Prevention, Karolinska Institutet, P.O. Box 23000, S-104 35
Stockholm, Sweden; e-mail: firstname.lastname@example.org.
English special forensic hospitals (participants from the Scragg and Shah,
1994, study constituted a subsample). Among 1,305 screened patients, 31
(2.4%) had ASD on case reviews, and 21 of these (1.6% of the total sam-
ple) had Asperger syndrome. Homicide and other violent index offenses
were equally often found among ASD and non-ASD patients, whereas
arson was overrepresented (16% vs. 10%) and sexual offenses underrepre-
sented (3% vs. 9%). Finally, Siponmaa, Kristiansson, Jonson, Nydén, and
Gillberg (2001) reported a 3% base rate of Asperger syndrome in a study of
file-only retrospective ratings of case records among 15- to 22-year-old
forensic psychiatric examinees in Sweden.
Very little research has been published on the association between ASD and
violence in nonforensic or general population samples. However, Raja and
Azzoni (2001) found histories of violence in all 5 males diagnosed with
Asperger syndrome in a consecutive series of 2,500 patients admitted to a psy-
chiatric intensive care unit in Rome, Italy. As violence toward others was most
likely a strong contributing reason for referral, however, this sample is not rep-
resentative. Woodbury-Smith, Clare, Holland, and Kearns (2006) conducted a
better quality investigation. They studied self-reported offending in a general
population–based sample of U.K. adults with high-functioning autism or
Asperger syndrome. Primary care services, mental health services, specialist
learning disability services, and local media were involved in identifying all
potential ASD participants in a health district. Twenty-five individuals with
ASD and full-scale IQs of 70 or more were identified and compared with a con-
trol sample of paid corporate employees. Overall rates of any self-reported vio-
lent offending were similar between the two groups (30% vs. 25%). However,
the attrition rate was high: Only 45% of the eligible group of ASD individuals
decided to participate, and the validity of the self-reporting of violent criminal
behaviors might have differed between ASD and non-ASD participants.
In addition to the uncertainties about violent offending in individuals with
ASD compared with the general population (compare Hall & Bernal, 1995), it is
not known if sociodemographic factors confer increased violence risk in individ-
uals with ASDs. Moreover, a substantial proportion may suffer from comorbid
psychopathology, including psychosis, attention-deficit/hyperactivity dis-
order, substance abuse, and personality disorders (e.g., Ghaziuddin, Weidmer-
Mikhail, & Ghaziuddin, 1998; Gillberg & Billstedt, 2000; Tantam, 2003;
Wing, 1981). It is unknown if such comorbidity adds to the risk for violence
in individuals with ASD (e.g., Palermo, 2004).
Therefore, we used Swedish national registers to investigate sociodemo-
graphic and clinical characteristics of hospitalized individuals with autistic
or Asperger syndrome that increase the risk for violent convictions.
Långström et al. / Violent Offending in Autism Spectrum Disorder 3
In Sweden, all residents, including immigrants on arrival to the country, are
given a unique 12-digit personal identification number that is used in national
registers for health care and crime. With a population of just above 9 million,
Sweden has the largest national inpatient hospital register in the world. This
register includes all individuals admitted to any general or psychiatric hospital
for assessment and/or treatment, including secure hospitals and the few private
providers of health care. All patients are given one or more clinical diagnoses
on discharge—registered by their personal identification number—according
to the ICD revisions 9 (1987-1996) and 10 (from 1997). Hospital discharge
diagnoses are comprehensive in terms of national coverage from 1988. The
register is of high quality; for example, of the 1,421,795 discharges from hos-
pital with psychiatric diagnoses from 1988 to 2000, a personal identification
number was lacking for only 13,669 discharge episodes (1.0%).
We extracted information on all individuals discharged from hospital
from January 1, 1988, to December 31, 2000, with any principal diagnosis
of a psychiatric disorder who were 15 years and older (the age of legal
responsibility in Sweden) at the end of the study period. Previous research
has demonstrated that data in the inpatient/hospital discharge register are
reliable for diagnoses of severe mental illness—for instance, Dalman,
Boms, Cullberg, and Allebeck (2002) found that 86% of those diagnosed
with schizophrenia also fulfilled criteria for that diagnosis on a file review
by psychiatrists. Consequently, the register has been used in a variety of
recent epidemiological investigations (Fazel & Grann, 2004, 2006; Grann
& Fazel, 2004, Hjern, Lindblad, & Vinnerljung, 2002).
Considering that Asperger syndrome was not specified as a separate
diagnostic category in the ICD-9, analyses were conducted with two groups
of individuals. The first group included those who had childhood autism or
autistic disorder (ICD-9 and ICD-10 diagnostic codes 299.1 and F84.0, cor-
respondingly) as the principal diagnosis during an episode of hospitaliza-
tion that occurred between 1988 and 2000 (N=925, 76.5% males). The
second group consisted of individuals diagnosed with Asperger syndrome
(ICD-10 diagnostic code F84.5 as the principal diagnosis) during an
episode of hospitalization that occurred between 1997 and 2000 (N=164,
4 Journal of Interpersonal Violence
75.6% males). Because of expected diagnostic heterogeneity (including a
proportion of participants who probably had Asperger syndrome but were
not classified in a separate category before the introduction of the ICD-10
in 1997), individuals diagnosed with pervasive developmental disorder, not
otherwise specified (atypical autism), were not studied. When an individual
had more than one inpatient episode involving either of the two studied
ASDs, only the diagnosis assigned during the first hospitalization was
included. A total of 1,089 individuals (76.4% males) had received a diag-
nosis of autistic disorder or Asperger syndrome.
A substantial number of patients were also diagnosed with comorbid dis-
orders throughout the study period, such as substance abuse, personality dis-
order, depression, or psychosis. Comorbidity was defined as any inpatient
diagnosis of another psychiatric disorder throughout the 13-year period of
study, but the exact temporal relationship was not further analyzed. Notably,
the prevalence of psychiatric comorbid diagnoses could reflect not only true
comorbidity but also that ASDs may be difficult to diagnose, requiring
nuanced appreciation of symptoms, onset, and course of illness. Subsequently,
participants younger than 15 years at the end of the study period (2000) were
excluded from the analyses as they were under the age of legal responsibility
and contributed no person-years at risk for a criminal conviction. In all, this
meant that 574 individuals with autism and 57 with Asperger syndrome were
excluded, limiting the study groups to 351 and 107 individuals, respectively
(total N=458, 69.9% males). Finally, individuals deceased at the end of the
study period were also excluded (34 individuals with autism and 2 individuals
with Asperger syndrome). The final autism/Asperger study group consisted of
422 individuals (71.3% males), including 317 individuals with autism (69.4%
males) and 105 individuals with Asperger syndrome (77.1% males,
χ2=2.3, p=.13). Individuals with Asperger syndrome were significantly older
at first hospitalization than those with autism (24.5 [SD =11.0] vs. 16.3 [SD =
12.0] years, t=6.15, df =1, p <.0001; median age 20 vs. 13 years).
Comorbid Psychiatric Disorders
For the psychoses, we included diagnostic codes for schizophrenia
(295.0-6, 295.8-9, and F20-21), schizoaffective disorder (295.7, F25), affec-
tive psychoses (296), paranoid states (297), other nonorganic psychoses
(298, F28, F29), persistent and induced delusional disorders (F22, F24),
acute and transient psychotic disorders (F23), manic episode (F30), bipolar
affective disorder with psychotic symptoms (F31.2, F31.5), and depressive
disorders with psychotic symptoms (F32.3, F33.3). For nonpsychotic mood
Långström et al. / Violent Offending in Autism Spectrum Disorder 5
disorders, we included neurotic depression (300.4), depressive disorders
without psychotic symptoms (F32-33.0/1/2/8/9), and persistent and other
mood disorders (F34, F38, F39). For substance use disorders, we included
alcohol dependence (303, F10), drug dependence (304, F11-19), and drug-
induced psychoses (291-292). Finally, for personality disorders, diagnostic
codes 301 and F60 were used. Consistent information on possible mental
retardation/learning disability and IQ was not available as IQ testing is not
routinely done with hospitalized individuals.
Violent Criminal Offending
We obtained unique personal identification numbers from the national
crime register on all individuals aged 15 (the age of criminal responsibility)
and older who committed a violent crime during 1988-2000. Of the 205,846
violent convictions, 105 (0.05%) were without a personal identification
number and hence excluded from subsequent analyses. For the purposes of
this study, a violent crime was defined as homicide and attempted homicide,
aggravated assault (life threatening or causing severe bodily harm), common
assault, robbery, unlawful threat or harassment, and arson. A sexual offense
was defined as rape, sexual coercion, indecent exposure, or child molestation
but excluded prostitution, hiring of prostitutes, or possession of child pornog-
raphy. As only two participants diagnosed with ASD were convicted of sexual
offenses, no further analyses were undertaken to analyze risk of sexual
offending. We used conviction data because in Sweden, in common with a
few other countries in the world, individuals with mental disorders who are
charged by the courts are convicted as if they did not have mental disorders
(i.e., regardless of their mental state at the time of the offense), although sen-
tencing does take offender mental health into account. Therefore, conviction
data include those where the court ruling involves a mental health disposal
based on the finding of legal insanity (most clearly for those who suffered
from psychosis regardless of etiology at the time of the offense according to
a court-ordered forensic psychiatric evaluation). It also includes cases where
the prosecutor decided to caution or fine (e.g., in less serious violent crimes
and some juvenile cases). In addition, as plea bargaining is not permitted in
the Swedish legal system, conviction data more accurately reflect the charac-
ter of the country’s officially resolved criminality. Sweden does not substan-
tially differ from other members of the European Union in the rates of violent
crime and its resolution (Dolmén, 2001). The crime register does not hold
information on victims or modus operandi.
6 Journal of Interpersonal Violence
Data on individuals discharged from hospital with a diagnosis of an ASD
(autistic disorder or Asperger syndrome) were linked to data in the crime
register. Any patient with an inpatient diagnosis of autistic disorder/
Asperger syndrome during 1988-2000 and convicted of a violent offense
during 1988-2000 was included, regardless of the timing of the hospital dis-
charge and the violent conviction. The study was approved by the Ethics
Committee of Huddinge University Hospital, Sweden (#194/02).
Age, gender, urbanization of living area, educational level, and immi-
grant status were initially chosen as potential sociodemographic correlates
of risk for violent offending (Table 1). However, educational level was not
analyzed further as most individuals with autistic disorder do not enter the
regular public school system causing a high degree of missing data on this
variable. Univariate and multivariate binary (binomial) logistic regression
analyses using SPSS (version 11.5) produced odds ratios (ORs) with 95%
confidence intervals (CIs) on the difference in sociodemographic correlates
Långström et al. / Violent Offending in Autism Spectrum Disorder 7
for 422 Individuals Diagnosed With ICD-9/ICD-10
Autistic Disorder or Asperger Syndrome During
Inpatient Care in Sweden 1988-2000
Autism Spectrum Disorder (N=422)
Number of Participants
Variable n(%) With Data
Age M= 18.36 years 422
Male gender 301 (71.3%) 422
Immigrant status 115 (27.3%) 422
Living in metropolitan area 120 (28.5%) 421
Highest level of education — 142
Not completed elementary school 47 (33.1%) —
Elementary school 68 (47.9%) —
High school 22 (15.5%) —
College/university 5 (3.5%) —
Diagnosis of Asperger syndrome 105 (24.9%) 422
Note: ICD =International Classification of Diseases.
and comorbid psychiatric disorder among individuals with ASDs who com-
mitted violent offenses compared with those who did not.
Basic sociodemographic data for participants diagnosed with autistic dis-
order and Asperger syndrome are presented in Table 1. Individuals with ASD
8 Journal of Interpersonal Violence
Associations of Sociodemographic Characteristics and Comorbid
Psychiatric Disorders With Violent Crime Among Individuals
Diagnosed With Autistic Disorder or Asperger Syndrome
Any No Odds Ratio Odds Ratioa
Variable (n= 31) (n= 391) (95% CI) (95% CI)
Age (years) M=26.19 M=17.73 1.04 1.04
(SD =9.53) (SD =12.23) (1.02-1.07) (1.02-1.07)b
Male gender 29 (93.5%) 272 (69.6%) 6.34 6.69
Immigrant status 9 (29.0%) 106 (27.1%) 1.10 1.30
Living in metropolitan 11 (35.5%) 109 (27.9%) 1.42 1.38
area (0.66-3.06) (0.63-3.05)
Comorbid schizophrenia 8 (25.8%) 36 (9.2%) 3.43 3.61
or other psychosis (1.43-8.22) (1.38-9.44)
Comorbid depressive 0 (0.0%) 15 (3.8%) 0.00 —
Comorbid substance 5 (16.1%) 2 (0.5%) 37.40 64.10
use disorder (6.92-202.14) (7.86-522.53)
Comorbid personality 3 (9.7%) 6 (1.5%) 6.88 4.47
disorder (1.63-28.96) (0.99-20.16)
Any comorbid 12 (38.7%) 50 (12.8%) 4.31 4.21
psychiatric disorder (1.97-9.41) (1.82-9.75)
Diagnosis of Asperger 21 (67.7%) 84 (21.5%) 7.68 5.82
syndrome (vs. (3.48-16.92) (2.56-13.22)
Note: CI =confidence interval. 95% CIs not including 1.00 indicate that the association of the
correlate or risk factor and violent offending is significant at the 5% level.
a. adjusted for age and gender.
b. adjusted for gender alone.
c. adjusted for age alone.
who committed violent crimes were more likely to be older and male (Table
2). They also had significantly higher levels of comorbid psychopathology
diagnosed at any time throughout the study period than those without a
history of violent crime. Psychotic disorder, any substance use, and person-
ality disorder were significantly associated with violent convictions in indi-
viduals with ASD. When diagnoses of autistic disorder and Asperger
syndrome were considered separately, we found that only 3.2% (n=10) had
been convicted of a violent crime in the autistic disorder group, compared
with 20.0% (n=21) in the Asperger group.
We explored characteristics associated with violent offending among
individuals diagnosed with ASDs over a 13-year period. The study was
based on data from longitudinal Swedish national registers for inpatient
treatment and criminal convictions. Risk factors for violent offending
among individuals with ASD were male gender, older age, comorbid psy-
chosis (identified at any time during the study period), substance use disor-
der, and personality disorder, respectively.
Male gender was an unsurprising risk factor consistent with an extensive
criminological and forensic mental health literature. The more unexpected
increased risk of violent crime with older age is related to the cross-
sectional nature of the study design as the likelihood increases over time
that an individual will appear in cumulative crime registers. The risk
increase associated with comorbid psychopathology, in particular substance
abuse, has been found in other studies of violent behavior in patients with
psychiatric disorder discharged from hospital (e.g., Steadman et al., 1998).
The finding that criminal violence was more common among participants
diagnosed with Asperger syndrome is probably due to unimpaired intellec-
tual capacity and better social skills and interest of such individuals increas-
ing the likelihood of violent offending, relative to participants with autistic
disorder. In addition, the latter often live in supervised settings where staff
or others might help to resolve conflicts and manage anger.
Several limitations with this study should be considered. The findings on
the prevalence of violent offending in ASDs must be interpreted cautiously
as the sample was selected based on being hospitalized. A proportion of
these individuals may have been admitted to hospital due to behavior dis-
turbances and are therefore not representative of all individuals with ASDs
in the community. Despite this, the rates of offending are not remarkably
Långström et al. / Violent Offending in Autism Spectrum Disorder 9
high compared to those found among individuals with schizophrenia dis-
charged from hospital (Fazel & Grann, 2006). The design of this study pre-
cludes conclusions about direct causality between tested sociodemographic
risk factors and psychiatric comorbidity on one hand and violent offending
on the other, a limitation shared by other register-based investigations (e.g.,
Fazel, Sjöstedt, Långström, & Grann, 2007). For example, some individu-
als might have committed violent behavior and later been diagnosed with
psychopathology, ASDs, or comorbid disorders. Our definition of comor-
bidity as any inpatient diagnosis of another psychiatric disorder throughout
the study period has been used previously (Brennan, Mednick, & Hodgins,
2000; Fazel et al., 2007; Fazel & Grann, 2006). For psychoses and person-
ality disorders, we believe that this approach is reasonable because the aver-
age age of violent offending in this study was 26 years—considerably
higher than the likely age of onset of these disorders. For substance abuse,
the assumption is that an inpatient diagnosis is a highly specific marker of
severe problems that predate hospitalization. For depression, however, the
assumption is less strong. We did not specifically test the validity of ASD
diagnoses from the hospital discharge register. However, there is nothing to
suggest that the diagnoses are not valid and data on diagnoses of schizo-
phrenia (Dalman et al., 2002) suggest good concordance for severe mental
Any investigation of the relationship between psychiatric morbidity and
offending faces the methodological challenge to delineate whether it is the
psychiatric disorder in itself and/or some factor(s) associated with case
ascertainment that accounts for the observed association. Although we tested
a series of sociodemographic risk factors and comorbid psychiatric disorders
that could be associated with violent offending in individuals with ASDs,
there are undoubtedly other potential correlates, such as attention-deficit/
hyperactivity disorder (Palermo, 2004) and psychopathy (Rogers, Viding,
Blair, Frith, & Happé, 2006), that are seldom diagnosed in inpatient settings.
Considering the disabling nature and low prevalence of ASDs, and that
a minority of our sample was convicted of violent offenses, these disorders
are not likely to account for a large proportion of violent crimes in the
society (compare Siponmaa et al., 2001). This study cannot answer if there
is a generally increased risk of violent offending in individuals with ASDs
compared with individuals in the general population. Nevertheless, as pre-
viously suggested (Palermo, 2004), our data indicate that participants with
ASDs who are violent are characterized by sociodemographic and psychi-
atric features consistently found among violent individuals without ASDs.
Overall, 7% (31/422) of individuals with ASD offended violently (Table 2).
10 Journal of Interpersonal Violence
However, 19% (12/62) of individuals with any psychiatric comorbidity
offended violently and corresponding proportions were 18% (8/44) for
comorbid schizophrenia, 33% (3/9) for personality disorder, and 71% (5/7)
for substance misuse. This strongly suggests that the assessment and man-
agement of co-occurring psychopathology may be helpful to reduce
violence risk in individuals with ASD.
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Niklas Långström, MD, PhD, is a board-certified adolescent psychiatrist, associate professor,
and director of the Centre for Violence Prevention at Karolinska Institutet, Sweden. He stud-
ies the development of and interventions against violent and sexually abusive behavior.
Martin Grann, PhD, is a professor of psychology and director of development at the Swedish
Prison and Probation Service, Norrköping, Sweden, and is also with the Centre for Violence
Prevention, Karolinska Institutet, Sweden.
Vladislav Ruchkin, MD, PhD, is a board-certified adult psychiatrist associated with the
Centre for Violence Prevention, Karolinska Institutet, Sweden; the Centre for Forensic
Psychiatry, Skönvik Psychiatric Hospital, Sweden; and the Child Study Center, Yale
University School of Medicine, United States.
Gabrielle Sjöstedt, PhD, works at the Swedish National Police and is affiliated with the
Centre for Violence Prevention, Karolinska Institutet, Sweden.
Seena Fazel, MD, MBChB, MRCPsych, is a clinical senior lecturer at the department of psy-
chiatry, University of Oxford, Oxford, United Kingdom, and is also affiliated with the Centre
for Violence Prevention, Karolinska Institutet, Sweden. He is interested in the connection
between mental disorder and violent and sexual crime.
Långström et al. / Violent Offending in Autism Spectrum Disorder 13