Deconstructing Complex Needs

1

• Deconstructing Complex Needs Risk Appraisal in
  Forensic Developmental Neuropsychiatry
• From Clinical Neuroscience to Multidisciplinary
  Forensic Practice
• Ekkehart F.A. Staufenberg Lead, Broadland Clinic
  Forensic Services-East Anglia,
• Senior Lecturer, School of Medicine, UEA,
  Norwich
• Lead Consultant Neuropsychiatrist, Dpt.
  Neurology, Norwich Epilepsy Clinic,
• Norfolk Norwich University Hospital,
• (ekkehart.staufenberg_at_norwich pct.nhs.uk or
  estaufenberg_at_uea.ac.uk

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Overview
• What this talk is not about !
• AS HFA
• Triad of Impairments in ASDs
• Neurocognitive Models of ASDs Mentalisation
  (ToM) Central Coherence
  Executive Function

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Overview (cont.)
• Risk Appraisal at the BCFS-East Anglia
• standardised
• designated Risk Appraisal related tools -
• HCR20 incl. PCL-SV SWAP200-pilot
• Mental Health Abilities Functioning -
• BADS PAS-ADD GSS12 Vineland OT SALT
• Neurocognitive Functioning
• Index offence related Psychometric Schedules
• clinical structured assessments
• The BCFS - Risk Appraisal Grid

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• What this talk is not about -
• the neurofunctional circuitries or behavioural
  neurology of phenotypy
• arrested development (eg. ABI / TBI -
  Conference UEA, Sept. 2006, Norwich)
• Risk Appraisal in other CNS disorders with high
  risk or offending conduct

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Aspergers Syndrome High Functioning Autism
  in ASDs
• Clinical criteria (cave under review)
• ICD10 F84 - F84.9
• DSMIV 299.00 - 299.80

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Aspergers Syndrome High Functioning Autism
  in ASDs
• Triad of Qualitative Impairments in ASDs
• social reciprocal verbal / non-verbal (not IQ )
• repetitive repertoire
• circumscribed interests (not to fixed.)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Aspergers Syndrome High Functioning Autism
  in ASDs
• Neurocognitive Models of ASDs
• Mentalisation (ToM)
• Central Coherence Executive Function

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Central Coherence Risk Appraisal
• denotes a persons / our Inherent
  Cognitive Style
• defined as ... natural tendency in
  information processing to draw together stimuli
  into coherent wholes (Frith, 1989)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Central Coherence Risk Appraisal
• Weak CC (less integration / fragmentation)
• Strong CC (gist person - overview)
• NB affects all somato-sensory domains!

10
Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Overview
• What this talk is not about !
• AS HFA
• Triad of Impairments in ASDs
• Neurocognitive Models of ASDs Mentalisation
  (ToM) Central Coherence
  Executive Function

11
Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Overview (cont.)
• Risk Appraisal at the BCFS-East Anglia
• standardised
• designated Risk Appraisal related tools -
• HCR20 incl. PCL-SV SWAP200-pilot
• Mental Health Abilities Functioning -
• ADI-R PAS-ADD BADS GSS12 Vineland OT-
  SALT - assessments
• Neurocognitive Functioning
• Index offence related Psychometric Schedules
• clinical structured assessments
• The BCFS - Risk Appraisal Grid

12
Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-East Anglia Risk Appraisal Grid
• Objective 1
• 1. Information Communication
• Provide all colleagues (incl. CJS / HO) with a
  homogeneous practice (reliable /
  understandable / replicable / responsive, and
  specific) in
• Information Recording and Monitoring
• for individual offender / patient

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-East Anglia Risk Appraisal Grid
• Objective 2
• 2. Clinical Management
• To help RMO / multidisciplinary team in making
  decisions about the individual offender /
  patients
• Dynamic Clinical Risk Management

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-East Anglia Risk Appraisal Grid
• Objective 3
• 3. Prediction Prognosis their Review
• To permit Predictive Formulation and Prognosis
• in context of neurodevelopmental functioning /
  trajectory, as well as environmental social /
  psychological / physical
• characteristics and changing circumstances
• (cave Patients Neurocognitive
  Functioning is pivotal!)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-East Anglia Risk Appraisal Grid
• Objective 4
• 4. To aid Risk Appraisal research into the AS /
  HFA end of the ASDs particularly with
  regard to (hypothesised) pivotal role
  of Cognitive Styles (phenotypic expression of
  underlying functional neural circuitries /
  neurotransmissions

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-Risk Appraisal Grid
• Structural Design
• Dimensional not categorical
• Integration of historical with dynamic biological
  / social / psychological patient and team
  variables across the multidisciplinary team
• Plasticity of the Appraisal and Reappraisal
  processes reflective of offender patients
  developmental trajectory
• Qualitative not quantitative (eg. no score)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-Risk Appraisal Grid
• Our Starting Point (1998)
• Ed Mulvey et al. (1995)
• Conditional Prevention
• Adapted from conditional prediction

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-Risk Appraisal Grid
• Our Starting Point (1998)
• RISK (potential) victim
• environmental circumstances
• (putative) perpetrator
• (modified after Dr. Peter Scott, 1976)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• My own cognitive set in Risk Appraisal
• Risk Risk Variables (enhancing or reducing)
• factors Victim Environment Perpetrator
• Biolog.
• Social
• Psychol.

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• RISK VARIABLE 1
• The Potential Victim
• Victim (potential) Roles of Variables
• Variables predisposing precipitating maintaining
• biological
• social
• psychol.

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• RISK VARIABLE 2
• The Environmental Circumstances
• Environment (potential) Roles of Variables
  predispose precipitant maintain
• physical
• social
• emotion (EE)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• RISK VARIABLE 3
• The (potential) Perpetrator Perpetrator
  Roles (potential) of Variables
• Variables predisposing precipitating maintaining
• biological
• social
• psychol.

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Case Vignettes
• Pre-hoc -
• 15 y, AS, specialised (excellent) residential
  school, no antecedents, room search and IT
  search.
• 17 y, challenging behaviour, admitted for
  assessment, family secrets.attempted matricide
  x2 previous 3 yearsGAD Panic Attacks, dog
  died, father died during admission, new maternal
  partner, managements since

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Post-hoc -
• East Street Sniper context Washington
  sniper
• 23y right handed, IQ 148
• Cousin, air gun, moved within maternal
• neighbourhood
• Self-report to psychological support nurse of
  ruminations merging into actions
• I am here because I take responsibility for my
  actions, which are wrong.do not think about my
  cousin

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• Summary
• To date no designated Risk Appraisal Tool for
  this population
• Final Risk Score often becomes a
  Static Variable in its own rights - not
  appropriate in neurodevelopmental /
  neuropsychiatric disorders (?or any other)

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Risk Appraisal in Forensic Developmental
Neuropsychiatry

• The BCFS-East Anglia Risk Appraisal Grid
• complements our other standard processes,
• has face / clinical validity,
• achieves its 4 objectives for the clinical
  forensic team, but
• requires evaluation of reliability / sensitivity
  and subsequent predictive validity studies

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High Risk or Offending Conduct in Aspergers
Syndrome

• Post hoc -
• 38 female, 33/40 gestation prima para, abusive
  alcohol abusing partner, 7/7 post-natal discharge
  to own flat first time ever, SW discontinued,
  supportive parents, 4 weeks post discharge
  infanticide - disposal diminished 3 years PO
  with tx - now 4 years post index - well

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• Deconstructing Complex Needs Risk Appraisal in
  Forensic Developmental Neuropsychiatry
• From Clinical Neuroscience to Multidisciplinary
  Forensic Practice
• Ekkehart F.A. Staufenberg Lead, Broadland Clinic
  Forensic Services-East Anglia,
• Senior Lecturer, School of Medicine, UEA,
  Norwich
• Lead Consultant Neuropsychiatrist, Dpt.
  Neurology, Norwich Epilepsy Clinic,
• Norfolk Norwich University Hospital,
• (ekkehart.staufenberg_at_norwich pct.nhs.uk or
  estaufenberg_at_uea.ac.uk