It is recognised that people with neurodevelopmental disorders (e.g., intellectual disability [ID], autism spectrum disorder [ASD] and communication disorders) are over-represented in juvenile and adult criminal justice systems. The relationship between neurodevelopmental disorders and offending behaviour is likely to be complex, requiring a holistic case conceptualisation of each individual's psychosocial background, criminogenic needs (dynamic risk factors for reoffending) and cognitive-linguistic abilities. People with neurodevelopmental disorders often have difficulty with verbal skills, especially pragmatics (i.e., the social, non-verbal and behavioural aspects of language). Good verbal abilities are important for the development of emotional and behavioural regulation skills. It is perhaps not surprising therefore, that people with neurodevelopmental disorders often lack the inner speech to manage impulsive behaviour. They may also have difficulty accurately reading or responding to social situations, thus increasing their risk of engaging in problematic, at times antisocial, behaviours (LaVigne & Van Rybroek, 2011).
Prevalence of neurodevelopmental disorders in the adult criminal justice system
A review of existing studies reveals a wide range of prevalence rates of neurodevelopmental disorders in the adult criminal justice system, often due to methodological differences. It has been estimated that in forensic mental health settings, approximately 3-50 per cent of patients have ID, compared to the prevalence rate of 1-2 per cent in the general population (Keulen-de Vos & Frijters, 2016). According to King and Murphy's (2014) systematic review, the existing high-quality studies reveal an estimated rate of 1.5 to 5.3 per cent of adults with ASD in the criminal justice system. In a study of 100 young offenders serving a custodial sentence in Victoria, 46 per cent were classified as language impaired (i.e., persistent difficulties in the learning and production of language across modalities), based on their results in formal speech pathology assessment (Snow & Powell, 2011). While there is limited research evidence about the prevalence of language disorders in adults, it seems reasonable to expect a significant proportion of adult offenders to exhibit reduced verbal comprehension and/or expression skills, considering that language development relies on exposure to a nurturing environment and good-quality educational experiences, which tend to be lacking in adult offenders. This is consistent with my clinical experience as a neuropsychologist in a prison setting where the majority of adult male clients demonstrate relative weakness in verbal skills on comprehensive neuropsychological assessment.
Vulnerability and poor coping
Adults with neurodevelopmental disorders in custody are more likely to experience comorbid mental illness or mental impairment (e.g., psychosis, anxiety and mood disorders, personality disorders and substance use disorders), with high rates of attempted suicide and self-harm behaviour (Underwood, Forrester, Chaplin, & McCarthy, 2013). Anecdotally, there are individuals with neurodevelopmental disorders who self-harmed for the first time after coming into custody, at times in response to the lack of opportunity to engage in their previous, also maladaptive, coping responses. These individuals are at a greater risk of being exploited by others in custody, with some presenting a management and placement dilemma, considering their need for protection from other prisoners. Some may even have difficulty understanding their legal rights or providing instructions to their lawyers, thus raising concerns about fitness to plead. Once sentenced and if required to attend offence-specific programs, some of them may appear highly strung or lacking "empathy". For example, imagine a prisoner with ASD who has a flat tone of voice and restricted affect with limited reactivity. It may be challenging to ascertain their level of motivation and engagement in treatment programs, which could then impact on their chance of getting parole. This is particularly true for those who benefit from or enjoy structure as they may be more sensitive to the effects of institutionalisation, which could further reinforce dependency on others and exposure to antisocial peers.
Timely assessment and effective intervention
These vulnerabilities highlight the need for timely assessment and appropriate intervention to protect these individuals’ well-being and human rights. As psychologists we need to maximise their potential to benefit from rehabilitation and reintegration efforts, which in turn can protect the safety of our community (Robertson & McGillivray, 2015). Ideally, a multidisciplinary approach involving psychology, neuropsychology, occupational therapy, social work, speech pathology, psychiatry and nursing can foster a holistic approach, which takes into account the complex array of biological, psychosocial and environmental factors that may impact on the person's presentation. Often psychologists may find that they need to take a leadership as well as an advocacy role in the support and management of these people, as illustrated in the following case study.
Case study
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A young adult client was referred for neuropsychological assessment due to frequent episodes of anxiety, suicidal ideation and aggression towards custodial staff. Available information from his family and medical records suggested delayed language development prior to his arrival in Australia, a history of learning difficulty, having been bullied at school and substance abuse.
The initial neuropsychological assessment raised significant concerns about the validity of his test results, suggesting that the overall highly impaired results were unlikely to be a reliable representation of his true cognitive functioning. Initial intervention efforts focused on providing verbal and written (primarily pictorial) feedback to him about the assessment findings and how others (including the relevant clinical services) could support him to cope better in custody. Our multidisciplinary team also provided assessment of personality functioning and worked with prison staff to help them respond to his need for support appropriately.
Input from other disciplines (e.g., occupational therapy and nursing) was elicited to assess the client’s sensory preferences and gradually facilitate his participation in meaningful occupation in prison. As the frequency of his concerning behaviours gradually reduced, it became possible to facilitate a medical examination to rule out possible health conditions that may impact on his presentation.
Despite resource constraints, we were able to advocate for him to participate in a review neuropsychological assessment. The assessment revealed a valid representation of his cognitive functioning and a significant discrepancy between his extremely low verbal and average non-verbal skills. The results were consistent with the suspected language disorder that was noted in a paediatrician letter more than a decade ago, although the client never had the chance to have speech pathology intervention in early life, partly due to lack of financial resources and conduct problems.
Feedback was provided to the client, his family and other clinicians to highlight his relative cognitive strengths and the relevant functional implications, in order to facilitate future treatment planning.
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The role of psychology
Many people with neurodevelopmental disorders struggle to negotiate their way through various stages of the criminal justice system. Psychologists are increasingly being called on to provide expert assessment to the courts, particularly regarding questions of fitness to plead, mental impairment and implications for sentencing. Careful evaluation using gold-standard assessment tools, wherever possible, is crucial, as well as evaluation of how the defendant’s personality style and biopsychosocial and environmental factors may impact on his or her functioning and presentation. The onus is on psychologists to obtain adequate collateral information (rather than relying on self-report or information supplied by a lawyer), seek reliable information about the person's developmental history, and consider how to best assess symptom and performance validity.
Increasingly, neuropsychologists are also working in forensic mental health and correctional services. For example, the Victorian Institute of Forensic Mental Health (Forensicare) has established a neuropsychology service in parts of the service. This includes having a neuropsychologist as part of the Mobile Forensic Mental Health Service that operates out of the Metropolitan Remand Centre in Melbourne. Neuropsychology is seen as a vital part of the service to assess prisoners, as well as recommending and implementing intervention and management strategies.
It goes without saying that early intervention is the key. For many consumers of a prison mental health service, had they been given the opportunity to access adequate assessment and meaningful interventions early in life, perhaps their outcomes would have been different. The reality is, we have a group of offenders who have been under-served or misunderstood by the system, often not due to deliberate neglect or ignorance, but at times due to a lack of training and support for correctional staff and the relevant support services (McAdam, 2012). The criminal justice system can learn to adapt the perception and management of offenders/prisoners with neurodevelopmental disorders, however, regular reminders and timely education from psychologists and other allied health professionals is crucial.
By definition, neurodevelopmental disorders are lifelong conditions with variable manifestations depending on social and environmental demands. Regardless of our work setting, we are bound to encounter clients who may be at risk of, or already involved with, the criminal justice system. We can take action to help strengthen our clients’ natural support network by teaching their significant others how to seek support for themselves and collaborating with other services (including disability services/NDIS providers, housing, mental health, and drug and alcohol treatment services) to identify the appropriate service pathways. We must strive towards creating a more fair and responsive environment to facilitate better outcomes for this often marginalised group of people in our society.
Acknowledgement
Acknowledgement is provided to the current and past colleagues at Forensicare for their insightful comments about this topic.
The list of references can be accessed from the online version of the article: www.psychology.org.au/inpsych/2017/april/hsieh/.