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Risk Factors for Violent Offending in Autism Spectrum Disorder

  • Swedish National Police


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 violent 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 individuals with Asperger syndrome.
Risk Factors for Violent
Offending in Autism
Spectrum Disorder
A National Study of Hospitalized
Niklas Långström
Martin Grann
Vladislav Ruchkin
Gabrielle Sjöstedt
Seena Fazel
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;
comorbidity; crime
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
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Month XXXX xx-xx
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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:
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
Study Setting
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).
Statistical Analyses
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
Table 1
Sociodemographic Characteristics
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
Table 2
Associations of Sociodemographic Characteristics and Comorbid
Psychiatric Disorders With Violent Crime Among Individuals
Diagnosed With Autistic Disorder or Asperger Syndrome
Unadjusted Adjusted
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
(1.49-27.01) (1.54-29.18)c
Immigrant status 9 (29.0%) 106 (27.1%) 1.10 1.30
(0.49-2.47) (0.56-3.03)
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
disorder (0.00-4.33)
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)
autistic disorder)
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.
Violent Conviction
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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12 Journal of Interpersonal Violence
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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
... The relationship between ASD and offending behav iour might also be confounded by evidence of cooccur ring mental health difficulties that complicate the clinical picture (Helverschou et al., 2015;Langstrom et al., 2009). For example, a UK clinical sample reported that 58% of an ASD cohort had at least one other psychiatric condition (Russell et al., 2016). ...
... Another factor to consider in ASDassociated offending behaviour is sex, given increasing recognition of differences in both brain (Craig et al., 2007;Lai et al., 2013) and behaviour between males and females with ASD. A National Autistic Society report on secure psychi atric hospital described an ASD offender ratio of 15:1 between male and females (Hare et al., 1999) and male sex has been seen as a strong predictor for violent criminality in individuals with ASD (Heeramun et al., 2017;Langstrom et al., 2009). ...
... Regarding risk factors for the ASD group, the males were significantly more likely to have had contact with the CJS than ASD females. This is consistent with the ASD offender ratio (Hare et al., 1999) and the finding of male sex being a predictor for violence in individuals with ASD (Heeramun et al., 2017;Langstrom et al., 2009). In addi tion, we report that the cooccurrence of ADHD in adults with ASD increased the risk of contact with the CJS by 1.8 times, in line with Heeramun et al. (2017), who found that the association between ASD and violent offending attenu ated when ADHD was accounted for. ...
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Lay abstract: There has been growing interest in offending and contact with the criminal justice system (CJS) by people with autism spectrum disorder (ASD). However, it is not clear whether people with ASD offend more than those without ASD. Studies have started to look at whether there are particular offences people with ASD are more likely to commit and whether there are any factors that can affect whether someone comes into contact with the CJS as a potential suspect. This study looked at the patients who attended an ASD diagnostic service over a 17-year period to see the rate of contact with the CJS of those who were diagnosed with ASD and whether there were any particular factors that might increase the risk of CJS contact. Nearly a quarter of the ASD group had some contact with the CJS as a potential suspect. Factors that seemed to increase whether someone with ASD was more likely to have contact with the CJS were being male, being diagnosed with ADHD, and being diagnosed with psychosis. This study is one of the largest studies to investigate the rate of CJS contact as a potential suspect in a sample of adults with ASD in an attempt to give a clearer picture of what might influence someone with ASD to engage in offending behaviour in order to try to see what mental health services can offer to reduce the likelihood of someone with ASD coming into contact with the CJS, for example, treatment for another condition or support.
... Results of research regarding a possible causal relation between ASD and violence are mixed (Mouridsen, 2012;Im, 2016aIm, , 2016bDel Pozzo et al., 2018), and several explanations have been proposed. One explanation is the possible effect of comorbid mental disorders (Långström et al., 2009;Mouridsen, 2012;Im, 2016a;Del Pozzo et al., 2018). Research has indicated that high levels of comorbidity are very common in ASD (Del Pozzo et al., 2018), about 75% (Lever and Geurts, 2016), and are possibly more prevalent in violent offenders with ASD. ...
... For example, individuals with ASD may misinterpret social cues resulting in problematic behavior. Furthermore, because of a heightened influenceability, individuals with ASD could be more prone to be led by others to commit criminal acts (Långström et al., 2009;Mouridsen, 2012;Im, 2016a;Del Pozzo et al., 2018). Finally, childhood trauma or victimization, such as neglect and physical or sexual abuse, have been proposed as risk factors for violent behavior (Im, 2016b;Del Pozzo et al., 2018), just as these factors increase the risk of violent behavior in the general population (OR = 1.8; ...
... High rates of comorbidity were found for disorders that have been previously linked to violent offending. One could argue that violent offending in individuals with ASD is a result of the known risk associated with their comorbid disorders rather than their ASD (Långström et al., 2009), which some researchers have proposed (Newman and Ghaziuddin, 2008). ...
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Background Results of research regarding a possible causal relation between autism spectrum disorders (ASDs) and violence are mixed. Several explanations have been proposed. Aims To assess prevalence rates of comorbid disorders in a large sample of mentally ill offenders diagnosed with ASD. Offenders with and without comorbid mental disorders were compared on several characteristics. To better understand the relationship between ASD and violent criminal behavior, the predictive value of several proposed risk factors (comorbidity, negative social network/influenceability, and childhood trauma/victimization) on violent offending was investigated. Method Data of 394 male offenders with a diagnosis of ASD were included. Prevalence rates of comorbid mental disorders next to ASD were calculated, and characteristics were compared using chi-square or t-tests. The predictive value of the risk factors was assessed using a binary logistic regression (n = 357). Results High rates of comorbidity were found (78.9%), specifically for substance use disorders (39.8%), schizophrenia spectrum disorders (31.7%), and neurodevelopmental disorder other than ASD (24.1%). Offenders with and without comorbidity differed significantly in their criminal and mental health care history. Both comorbidity (OR = 1.68; 95% CI 1.27–2.18) and a negative social network/influenceability (OR = 1.49; 95% CI 1.11–1.99) showed to be significant predictors of violent offending within this sample. Conclusions The highest rates of comorbid disorders found were disorders that have been previously linked to violent offending, and the risk of violent offending could be unrelated to ASD. However, the role of social functioning indicates a risk specific to the symptoms of ASD.
... attention-deficit hyperactivity disorder and substance misuse are also considered important risk factors (Dein and Woodbury-Smith, 2010;Esan et al., 2015;Lå ngströ m et al., 2009;Mouridsen, 2012;Newman and Ghaziuddin, 2008). Haw et al. (2013) reported that 73% of patients with ASD had a comorbid diagnosis, with schizophrenia being the most prevalent. ...
... Although the evidence failed to identify an association between violence and ASD (Im, 2016), a range of factors are thought to increase the risk of this occurring. General criminogenic factors include being male and having low education and intelligence (Esan et al., 2015;Lå ngströ m et al., 2009;Matson and Adams, 2014;Woodbury-Smith et al., 2005). Comorbid disorders, including personality disorder, psychosis, affective disorder, Dr Difficulty coping with change or unexpected events, such as becoming distressed, or aggressive because of something not happening when expected, such as a bus not turning up on time. ...
... Similarly, the presence of a major mental health disorder was very high as rated in the historical and clinical subscales of the HCR20 v3 (100% and 91%, respectively). This result is consistent with a large number of studies that reported a high proportion of comorbid psychiatric disorders in individuals with ASD within secure settings (Esan et al., 2015;Dein et al., 2010;Haw et al., 2013;Girardi et al., 2019;Lå ngströ m et al., 2009;Murphy, 2010;Mouridsen, 2012;Newman and Ghaziuddin, 2008;White et al., 2017). Individuals with ASD are at high risk of experiencing traumatic life events (as was the case in this study), which can contribute to the development of comorbid psychopathology (Mehtar and Mukaddes, 2011;Taylor and Gotham, 2016), often considered a significant risk factor for violence in individuals with ASD (Alexander et al., 2016;Haw et al., 2013;Mouridsen, 2012;Murphy, 2010Murphy, , 2013. ...
Purpose Autism-specific characteristics have been associated with internet criminal activities. Internet and non-internet offenders differ on a series of demographic, psychological and offending variables. However, the clinical and criminal presentation of individuals with autism spectrum disorder (ASD) in forensic secure care settings has been underexplored. This paper aims to explore the profiles of internet offenders with ASD admitted to a secure psychiatric unit. Design/methodology/approach This study provides the results of a service evaluation of individuals with ASD. The demographic, clinical and criminal characteristics of a small sample of internet offenders with ASD admitted to secure care are described and discussed. Findings Internet offenders present in secure care with high rates of comorbid disorders, histories of violence and traumatic experiences, mood disorders and difficulties with relationships. Of the 24 internet offenders discussed, 18 of them committed an offence of a sexual nature involving children. Originality/value This paper highlights the potential risks for individuals with ASD in using the internet and the possible difficulties associated with detecting this because of rapid advancements in technology.
... Arguably, according to some studies, autistic people are no more or less likely to come into contact with the CJS compared to non-autistic people (Brookman-Frazee et al., 2009;Cheely et al., 2012;Hippler et al., 2010;Mourisden et al., 2008;Woodbury-Smith et al., 2006). Where criminal offending does occur, research has suggested autistic people engage in a variety of offence types, including violence (e.g., Barry-Walsh & Mullen 2004;Cheely et al., 2012), arson (Woodbury-Smith et al., 2010), sexual offending (e.g., Mouridsen et al., 2008;Långström et al., 2008;Søndenaa et al., 2014), and stalking (e.g., Stokes & Newton, 2004;Stokes et al., 2007). King & Murphy (2014) sought to explore these issues further by conducting a systematic review of the evidence pertaining to autistic people within the CJS, which focused on summarising research conducted up to January 2013. ...
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The purpose of this paper was to determine whether recommendations made by King & Murphy (Journal of Autism and Developmental Disorders 44:2717–2733, 2014) in their review of the evidence on autistic people in contact with the criminal justice system (CJS) have been addressed. Research published since 2013 was systematically examined and synthesised. The quality of 47 papers was assessed using the Mixed Methods Appraisal Tool. Findings suggest a limited amount of good quality research has been conducted that has focused on improving our understanding of autistic people in contact with the CJS since 2013. Methodological limitations make direct comparisons between autistic and non-autistic offenders difficult. Autistic people commit a range of crimes and appear to have unique characteristics that warrant further exploration (i.e., vulnerabilities, motivations for offending).
... Проблемы выросших детей с диагнозом «аутизм» еще только ждут получения научного интереса [8]. По данным немногочисленных работ, агрессия связана с плохим исходом аутистического расстройства, а ее частота колеблется от 7,3% для насильственных действий до 26% для противоправного поведения [7]. По наблюдениям G. Bronsard с соавт. ...
In this study, 64 adults originally (in their childhood) diagnosed with autism were examined for hetero-aggression and its character. Physical hetero-aggression was present in roughly one third of the subjects and, at the same time, it turned out to be dependent on the functional and psychopathological levels of the patients. Occurring only occasionally in high and middle functioning adults as part of a psychopathy-like syndrome, aggression was present in most low functioning patients with catatonic symptoms. These motives for aggressive actions have been revealed: gratifying one's aggressive-sadistic impulses, reaction to one's psychological discomfort, provoking a predictable response. In addition to psychological causes of aggression, the parabulia-related component of autistic adults' aggression is discussed together with the relationship between aggression and dysphoric episodes. Families with an aggressive autistic adult were under significant distress. Quite often the aggression led to injuries of the victims, but the families' need for rehabilitation and psychological counselling wasn't satisfied.
... In addition, low cognitive functioning, poor adaptive skills, and internalizing symptoms (i.e., anxiety, depression) have also been linked with aggressive and disruptive behaviors in this population [24]. As is the case with neurotypical youths, youths with ASD who are aggressive have been shown to have higher rates of substance use, attention deficits, and hyperactivity than do their nonaggressive counterparts [25], [26]. ...
Youths with autism spectrum disorder (ASD) often engage in aggressive and other disruptive behaviors that interfere with important aspects of their lives, such as family, friends, and school. Effective treatments are needed to address the wide variety of risk factors that contribute to disruptive behaviors in this population of youths. Multisystemic therapy (MST) is a comprehensive family- and community-based treatment approach that has been effective in reducing problem behaviors in other challenging clinical populations. In this chapter, we review the broad range of possible contributing factors for disruptive behaviors in youths with ASD and discuss how MST interventions can be adapted to address those factors. We also present a research framework and empirical findings related to the development and evaluation of the MST model for youths with ASD. Implications of those findings and future directions in our continued development of MST for ASD are discussed.
... Il est utile de repérer, chez les patients agités, les signes précurseurs d'une agitation incontrôlable (Tableau 2). En effet, le repérage précoce est une urgence, car la non-prise en charge rapide du patient peut entraîner la mise en danger de celui-ci, mais aussi des professionnels de santé [55][56][57]. ...
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De nombreux patients consultant aux urgences souffrent de pathologies psychiatriques préexistantes ou ont une symptomatologie évocatrice d’une pathologie psychiatrique. En effet, les troubles psychiatriques touchent un adulte sur quatre, et 75%des affections psychiatriques débutent avant l’âge de 25 ans. Le parcours de soins d’un patient adulte à présentation psychiatrique dans les structures d’urgences concerne de multiples intervenants. La complexité inhérente à ces patients complexes ainsi qu’à l’interdisciplinarité induite dans la prise en charge impose un cadre de prise en charge clair et consensuel. Des experts de la psychiatrie, de la gérontopsychiatrie et de la médecine d’urgence se sont réunis pour émettre ces recommandations de bonnes pratiques. Le choix de présenter des recommandations de bonnes pratiques et non des recommandations formalisées d’experts a été fait devant l’insuffisance de littérature de fort niveau de preuve dans certaines thématiques et de l’existence de controverses. À travers ces recommandations de bonnes pratiques cliniques, ils se sont attachés à décrire la prise en charge de ses patients aussi bien en préqu’en intrahospitalier. Les objectifs de ces recommandations sont de présenter les éléments indispensables à l’organisation du parcours de soins de ces patients, la gestion de l’agitation ainsi que la prise en charge pharmacologique ou non. Une partie spécifique est consacrée aux aspects réglementaires.
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Introduction: Risk assessment is integral to forensic psychiatry. Previous work has highlighted the benefits of using scalable and evidence-based actuarial risk tools developed within forensic populations, such as the online Forensic Psychiatry and Violence Oxford (FoVOx) violence risk assessment tool. We examined the feasibility of using FoVOx in a Swedish forensic cohort and tested whether adding modifiable (dynamic) factors would increase its useability to clinicians. Methods: We completed FoVOx assessments on all patients discharged from forensic psychiatric hospitals in Stockholm County, Sweden, between 2012 and 2017 and investigated recidivism rates. In addition, interviews were conducted with the clinicians responsible for each patient on the perceived accuracy, usefulness, and impact of FoVOx, which was examined using thematic analysis. Results: Ninety-five discharges from forensic psychiatric hospitals were followed up. The median FoVOx score was a 7% likelihood of violent reoffending in two years after discharge. Six discharged patients (6%) were confirmed as violent recidivists using official records with a similar distribution of FoVOx risk categories as the rest of the sample. FoVOx was considered accurate by clinicians in more than half of cases, who suggested that modifiable risk factors could be added to increase acceptability. All clinicians thought that FoVOx was useful, and in 20% of discharges, it would have materially altered patient care. Overall, FoVOx was thought to impact decision-making and risk management, was practical to use, and could be completed without reference to written case material. Conclusion: Completing FoVOx in forensic psychiatric hospitals can complement current approaches to clinical decision-making on violence risk assessment and management.
Autistic female offenders represent an extreme intersection of under researched populations. While a developing body of evidence has focused on autistic females, including recognition, presentation, diagnosis, clinical characteristics and support needs, this has not been applied to female offenders. While there is a developing literature focused on autistic offenders, this has largely concentrated on males, and little is theoretically driven. There is limited evidence to guide prevalence estimates of autistic women within forensic settings, or their clinical characteristics. There are minimal descriptions of treatment and management programmes for this group, or studies describing their outcomes following involvement within the criminal justice system. This chapter reviews the available literature pertaining to the female autistic profile, the general female offender population, and studies which have included female autistic offenders. A fictional case study is presented to illustrate key clinical and forensic issues. Practical suggestions for the management and treatment of female autistic offenders within forensic settings are provided, alongside recommendations for future research.
An autist refers to a person who suffers from Autism Spectrum Disorder (ASD), a complex disorder of mental development, causing the person to be adversely affected, especially in social and behavioral aspects of life. Prior to the introduction of a specific Standard Operating Procedure (SOP) for the arrest and detention of autists, the Royal Malaysia Police applied the same standard operating procedure in the Criminal Procedure Code for typical individuals, to autists suspected of criminal offences. However, the issue arising is the legal rights of people with disabilities whereby this SOP is seen as inappropriate and unsuitable to be applied to cases involving autists. As a result, the authorities and parties involved in handling autists came up with the idea of the need for a specific SOP applicable for their arrest and detention. Finally, in the year 2019, the Royal Malaysia Police, in cooperation with NGOs directly involved with autist, successfully launched a specific SOP for autists. The objectives of this article are to study the significance of the specific SOP for autists, and analyse and compare it with the usual SOP for typical people. The methodology of this research is qualitative. Collection of research data used document analysis. Data obtained was thematically and comparatively analysed. Research results find that there are differences between the specific SOP for autists and standard SOP for typical suspects. The differences lie in the legal rights of the autists in Malaysia, namely, in the aspects of arrest and detention of autistic suspects.
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Asperger's Syndrome is a pervasive developmental disorder on the Autistic spectrum. Antisocial behaviour is frequently described as an accompaniment of Asperger's Syndrome although the strength of any association between Asperger's Syndrome and offending remains uncertain. This paper presents five patients with Asperger's Syndrome with a history of offending. For each of them the offending is understandable in the context of the disorder. The specific and general issues raised by these cases in relation to Fitness to Plead and Legal Insanity are considered. Offenders with Asperger's Syndrome have deficits that raise the likelihood that their disorder will render them unfit or be of exculpatory value.
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The prevalence and pattern of offending and other law-breaking among groups of men and women with High Functioning Autism/Asperger Syndrome (ASDs) living in the community has not, so far, been examined empirically. In this study, the illegal behaviours of a small sample (N = 25) of people with ASDs were investigated. Unexpectedly, both self-report and 'official' data indicated that the rate of law-breaking, including offending, was very low. Indeed, it was significantly (p<0.05) lower than that of a stringent non-ASD comparison group (N = 20). Despite similarities, however, there were some striking differences between the patterns of illegal behaviours in the two groups. The participants with a diagnosis of an ASD significantly (p<0.01) less likely to report that they had engaged in illici drugtaking; in contrast, they were significantly more likely (p<0.05) to report activities which could be categorised as 'criminal damage'. Moreover, they tended to have a greater history of violent behaviours. The methodological limitations of this study, particularly the difficulties of recruiting an adequate community sample of people with ASDs, are discussed, together with the implications for the development of services for the small minority of men and women with this diagnosis who are involved in criminal offending and other law-breaking.
Objective: This study aimed to determine the population impact of patients with severe mental illness on violent crime. Method: Sweden possesses high-quality national registers for all hospital admissions and criminal convictions. All individuals discharged from the hospital with ICD diagnoses of schizophrenia and other psychoses (N=98,082) were linked to the crime register to determine the population-attributable risk of patients with severe mental illness to violent crime. The attributable risk was calculated by gender, three age bands (15-24, 25-39, and 40 years and over), and offense type. Results: Over a 13-year period, there were 45 violent crimes committed per 1,000 inhabitants. Of these, 2.4 were attributable to patients with severe mental illness. This corresponds to a population-attributable risk fraction of 5.2%. This attributable risk fraction was higher in women than men across all age bands. In women ages 25-39, it was 14.0%, and in women over 40, it was 19.0%. The attributable risk fractions were lowest in those ages 15-24 (2.3% for male patients and 2.9% for female patients). Conclusions: The population impact of patients with severe mental illness on violent crime, estimated by calculating the population-attributable risk, varies by gender and age. Overall, the population-attributable risk fraction of patients was 5%, suggesting that patients with severe mental illness commit one in 20 violent crimes.
Background: Because most individuals with mental illness are not hospitalized and most violent individuals are not convicted of crimes, hospital-and prison-based research underestimates the rates of mental illness and violence found in the general population. This study examined the overlap of mental disorders and violence in a birth cohort. Method: A total of 961 individuals born in Dunedin, New Zealand, from April 1, 1972, through March 31, 1973, (i.e., 94% of the total city birth cohort) were studied. DSM-III-R interviews were used to identify pastyear prevalence of mental disorders, and self-report of criminal offense and search of official conviction records were employed to measure past-year violence. The variables of substance use before the violent offense, excessive threat perception, and adolescent conduct disorder were studied as possible explanations for the link between mental disorders and violence. Results: Individuals with DSM-III-R alcohol dependence were 1.9 times (95% confidence interval [CI] = 1.0 to 3.5), those with marijuana dependence were 3.8 times (95% CI = 2.2 to 6.8), and those with schizophrenia-spectrum disorder were 2.5 times (95% CI = 1.1 to 5.7) more likely to be violent than individuals without a psychiatric disorder. Although individuals with at least 1 of these disorders committed half of the violent crimes reported in this study (one tenth of the violence accounted uniquely for by patients with schizophrenia-spectrum disorder), they constituted only one fifth of the study cohort. Substance use before the violent event accounted for the violence in individuals with alcohol dependence. Adolescent history of conduct disorder best explained violence in individuals with marijuana dependence. Both excessive threat perception and adolescent history of conduct disorder accounted for violence in individuals with schizophrenia-spectrum disorder. Conclusions: Individuals with mental illness were responsible for a substantial percentage of the violent acts committed by persons within their age group. Because the explanations for violence varied between groups of individuals with different mental disorders, multiple treatment and intervention strategies may be necessary to prevent the occurrence of violent acts.
A consistent relationship between mental disorders and violence has been found repeatedly in forensic psychiatric literature. This article aims at raising awareness of this issue by describing relevant mental disorders and their relationship with specific violent acts. Alcohol and drug abuse are often underestimated as very influential factors in the occurrence of violence. With regard to schizophrenia and psychoses, it has to be said that particularly, non-delusional suspiciousness and the presence of other emotions associated with delusions (and to a lesser extent hallucinations), as for instance anger and anxiety, and the general propensity to act on delusions (and again to a lesser extent on hallucinations) have demonstrated a significant association with a tendency to commit violent acts. There is also a relationship between command hallucinations to commit violence and actual violence. Antisocial and Borderline Personality Disorder are, by definition, often associated with violent acting out. A distinction has to be made between Antisocial Personality Disorder and Psychopathy (the latter as measured by the Psychopathy Checklist-Revised). Affective disorders, mild and moderate Mental Retardation and Organic Brain Disorder are other mental disorders, which are less commonly, but yet weakly, associated with violence. Stalking is a separate topic deserving special attention because of it high rates of violence. In general, violence needs to be interpreted as a dynamic interplay between perpetrator, victim and circumstances. The importance of a good therapeutic relationship and alliance cannot be overvalued.
Asperger’s syndrome (AS) is a pervasive developmental disorder that may be unrecognized, especially if signs of other psychiatric disorders coexist. The objectives of this paper are: 1) to ascertain the prevalence of AS in the emergency psychiatric setting; and 2) to describe features of AS which may help to differentiate these patients from patients with psychotic disorders. Among 2500 patients admitted to a psychiatric intensive care unit, 5 (0.2%) received a diagnosis of AS, for the first time. Besides impairment of social interaction, common features were the following: male gender, left handedness, obsessive-compulsive symptoms, cognitive hyper-abilities, violent behavior, sense of humor, low WAIS total score, high WAIS verbal/performance score ratio, unusual, restricted interest and clumsiness. Comorbid schizophrenia is difficult to rule out in these patients. Psychotic symptoms should not be overvalued in making the diagnosis when specific features of AS are present.
This study examined whether male patients with Asperger's Syndrome detained in a high-security psychiatric hospital could be distinguished from patients with schizophrenia or with personality disorder on the basis of selected admission and neuropsychological details. Exploratory comparisons found that those patients with Asperger's Syndrome were less likely to have a history of alcohol or illicit substance abuse and had lower index offence violence ratings than the other patient groups. Age at admission was less discriminating and Mental Health Act 1983 section information did not suggest any bias. However, within the Asperger's Syndrome group approximately half had received either a mental illness classification or a psychopathic disorder classification respectively. Within the neuropsychological measures patients with Asperger's Syndrome displayed in performance both similarities to and differences from the other patient groups. Tentative conclusions and implications for assessment and treatment are highlighted, along with the methodological limitations.