Treatment of Individuals with Autism Spectrum Disorders who Display Sexual Offending Behaviours.

Most individuals with autism spectrum disorders (ASD) do not display criminal behaviours, and a penchant for adherence to rules may in fact act as a protective factor against breaking the law in those with ASD . It has however been suggested that the cognitive and behavioural features of ASD such as atypical communication and social interaction styles, difficulties with theory of mind and empathy, inflexibility of thought and repetitive interests, have the potential to leave an individual vulnerable to committing offences, including sexual crimes. The Autism Act (2009) and later changes in social policy have led to increased recognition and support for autistic offenders, both in the community and those detained at her Majesty's pleasure or under the Mental Health Act. This includes the need for evidenced-based treatment and as such, research has continued to speculate over the presence of ASD in sexual offenders and any potential impact of the clinical features on positive treatment outcomes. It has thus been suggested that the cognitive and behavioural profile referred to above may result in barriers to treatment, particularly in programmes for sexual offending. Sexual offending treatment is typically delivered in groups and includes therapeutic objectives to increase victim empathy and address cognitive distortions to reduce 'pro-offence thinking styles' and attitudes conducive to offending. While many have supposed the ASD phenotype as challenging within treatment programmes, this has not been subjected to rigorous empirical investigation, with autistic offenders frequently being studied within intellectual disability or neurotypical samples rather than as a distinct population. Three studies have therefore been undertaken to begin to address this gap in the evidence based regarding sexual offending treatment for individuals with ASD. It is widely acknowledged that many adult sexual offenders displayed inappropriate or abusive sexual behaviours during childhood and adolescence, with many missed opportunities for intervention. This pattern also appears to be present in adult autistic sexual offenders, therefore an online prevalence survey (Chapter Five) was undertaken to identify children and young people with ASD who display risky sexual behaviours within services across the UK, and explore current assessment and treatment provisions. Response rate to the survey was low however the data attained illustrated inconsistency in practice across services for both assessment and treatment, with little use of tools or measures adapted specifically for intellectual or developmental disability. A second study (Chapter Six) provided empirical evidence for sexual offending treatment for individuals with ASD. This was done through interviews with thirteen men with ASD who had completed an adapted sex offender treatment programme and twelve clinicians who facilitated said treatment programmes. The study recorded the collective views and experiences of service users and group facilitators, exploring whether they felt treatment was helpful in reducing risk of re-offending. The findings provided some support for existing propositions regarding the features of ASD and their potential impact on positive treatment outcomes. However, they also illustrated that adapted group sexual offending treatment groups can be beneficial to men with ASD despite potential social or communication difficulties. Challenges remain in shifting cognitive distortions and increasing theory of mind, with changes in affective empathy being a particular caveat in treatment. To explore empathy in a non-forensic sample (due to challenges in accessing a youth forensic sample) , a final study piloted an adapted empathy course for adolescents with intellectual and developmental disabilities (Chapter Seven). This study examined empathy amongst autistic adolescents, particularly in relation to those with ASD who display challenging or offending behaviours and those who do not, and to those without ASD. A six-week empathy course was run with sixteen students (mean=17.3yrs; SD=11.42). Measures of empathy were taken at (i) baseline, (ii) following a six-week control period, and (iii) after completion of the empathy course. Whilst the measures did not yield any significant increases in empathy, qualitative data from staff and students highlighted improvements in social skills, including increased understanding and awareness of the thoughts and feelings of others. This study illustrated that a short empathy course can be of benefit to adolescents with and without ASD, however for those with more complex needs further input is required to impact behaviour change. These three studies contribute to the developing body of literature on sexual offending treatment for autistic offenders, providing empirical support to some of the existing suggestions in the literature. The findings from the three studies illustrate the need for appropriate and effective treatment for autistic sexual offenders, and that there are benefits to completing an adapted sex offender treatment programme. Many of these benefits are implicit and relate to improvements in identity, self-esteem and quality of life, with reduction of risk stemming from external or indirect treatment outcomes (e.g. development of external management strategies such as staffing levels, or increased monitoring opportunities) rather than internal change (e.g. shift in cognitive distortions or increases in victim empathy). The empathy profile seen in autistic sexual offenders was echoed in a non-forensic sample of autistic adolescents and further investigation is required into the role of empathy in the development pro-social behaviours and risk of sexual offending

'They’re the hardest group to treat, that changes the least.' Adapted sex offender treatment programmes for individuals with Autism Spectrum Disorders: Clinician Views and Experiences

Aims: Clinicians working with individuals with autism spectrum disorders (ASD) who display sexual offending behaviours may face challenges during treatment, as a result of the cognitive and behavioural profile associated with ASD. This research explored the views and experiences of those running adapted sex offender treatment groups with men with ASD. Method: Semi-structured interviews with group facilitators (n=12) focused on service user engagement and response to the core components of the treatment programme (e.g. increasing victim empathy, addressing cognitive distortions, etc.), and gathered the experiences of those working with men with ASD who display sexual offending behaviours. Results: Grounded Theory was used to develop a model conceptualising the potential impact of ASD on treatment outcomes, and this emerged predominantly through clinician’s views of risk of re-offending. Benefits of attending a group included: the presence of other group members, a forum to develop pro-social roles and relationships, and increased opportunity for monitoring. Challenges regarding empathy, specifically emotional empathy, and shifts in cognitive distortions were felt particularly pertinent to those with ASD, as well as questions over internalisation of therapy. Conclusion: Despite identification of a number of challenges, adapted sex offender treatment programmes were considered beneficial for men with ASD, especially in light of a dearth of evidenced-based alternatives

Modulation of surface CD11/CD18 glycoproteins (Mo1, LFA-1, p150,95) by human mononuclear phagocytes

Mo1, LFA-1, and p150,95 are structurally related glycoproteins of the CD11/CD18 complex that are expressed on the membrane of human leukocytes. In the neutrophil, the surface expression of the CD11/CD18 complex is up-modulated (Mo1 > p150,95 >> LFA-1) by stimulatory factors that include calcium ionophore A23187, phorbol myristate acetate (PMA), and N--formyl--leucyl--phenylalanine (fMLP). Here, in an immunofluorescence analysis, we have examined CD11/CD18 glycoprotein expression by human monocytes, pulmonary alveolar macrophages (PAM, obtained by bronchoalveolar lavage), and breast milk macrophages (BMM) as compared to neutrophils before and after exposure to A23187 (1 [mu]M), fMLP (0.1 [mu]M), or PMA (0.1 [mu]g/ml) ft 37[deg]C. Unstimulated monocytes within unfractionated blood mononuclear cells kept at 4[deg]C (n = 13) expressed all three CD11/CD18 glycoproteins, and exposure to A23187 resulted in significant increases in the surface expression of Mol (median of 5.7-fold), LFA-1 (median of 2.1-fold), and p150,95 (median of 7.2-fold). Exposure to fMLP- or PMA-stimulated increases of lesser magnitude. CD11/CD18 expression by PAM (n = 9) was barely detectable and was unaffected by exposure to A23187. In contrast, BMM (n = 11) expressed all three CD11/CD18 glycoproteins (with considerable variability among specimens), but no increase was stimulated by A23187. These results demonstrate that monocytes, like neutrophils, have the capacity to respond to activating factors with an increase in CD11/CD18 glycoprotein expression; macrophage differentiation is accompanied by a loss (PAM) or retention (BMM) of CD11/CD18 expression that is unmodulated in response to activation.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/27416/1/0000453.pd

Psychiatric inpatient admissions and discharges of people with intellectual disabilities: a time series analysis of English national data

Background. We examined whether a series of variables were related to the number of psychiatric inpatients using publicly available data about English psychiatric bed utilisation and NHS workforce. Method. Using linear regression, with auto-regressive errors, we examined relationships between variables over time using data from December 2013 to March 2021. Results. Over time, the number of inpatients reduced by either 6.58 or 8.07 per month depending upon the dataset utilised, and the number of community nurses and community nursing support staff reduced by 7.43 and 2.14 nurses per month, respectively. Increasing numbers of consultant psychiatrists were associated with fewer inpatients over time. More Care and Treatment Reviews (CTRs) were associated with more admissions over time, while more post-admission CTRs were associated with increased discharges over time. Conclusions. Future studies should examine whether psychiatric bed utilisation elsewhere within the NHS by people with intellectual disabilities has increased

Psychiatric inpatient admissions and discharges of people with intellectual disabilities: a time series analysis of English national data

Background. We examined whether a series of variables were related to the number of psychiatric inpatients using publicly available data about English psychiatric bed utilisation and NHS workforce. Method. Using linear regression, with auto-regressive errors, we examined relationships between variables over time using data from December 2013 to March 2021. Results. Over time, the number of inpatients reduced by either 6.58 or 8.07 per month depending upon the dataset utilised, and the number of community nurses and community nursing support staff reduced by 7.43 and 2.14 nurses per month, respectively. Increasing numbers of consultant psychiatrists were associated with fewer inpatients over time. More Care and Treatment Reviews (CTRs) were associated with more admissions over time, while more post-admission CTRs were associated with increased discharges over time. Conclusions. Future studies should examine whether psychiatric bed utilisation elsewhere within the NHS by people with intellectual disabilities has increased

Risk factors for postoperative complications after adrenalectomy for phaeochromocytoma: multicentre cohort study

Background: To determine the incidence and risk factors for postoperative complications and prolonged hospital stay after adrenalectomy for phaeochromocytoma. Methods: Demographics, perioperative outcomes and complications were evaluated for consecutive patients who underwent adrenalectomy for phaeochromocytoma from 2012 to 2020 in nine high-volume UK centres. Odds ratios were calculated using multivariable models. The primary outcome was postoperative complications according to the Clavien–­­Dindo classification and secondary outcome was duration of hospital stay. Results: Data were available for 406 patients (female n = 221, 54.4 per cent). Two patients (0.5 per cent) had perioperative death, whilst 148 complications were recorded in 109 (26.8 per cent) patients. On adjusted analysis, the age-adjusted Charlson Co-morbidity Index ≥3 (OR 8.09, 95 per cent c.i. 2.31 to 29.63, P = 0.001), laparoscopic converted to open (OR 10.34, 95 per cent c.i. 3.24 to 36.23,

Treatment Effectiveness for Offenders with Autism Spectrum Conditions: A Systematic Review

Theoretical suppositions suggest a potential vulnerability in some individuals with autism spectrum conditions (ASCs) to displaying offending behaviours. Additionally, it is recognised that the features of ASCs may result in possible barriers to treatment. A systematic review was undertaken to identify empirical evidence examining the effectiveness of treatment programmes for offenders with ASCs and to explore the potential impact of ASC symptoms on treatment outcomes. The studies identified consisted of a small number of case series and a collection of case reports with little or no direct comparisons to offenders without ASCs. A synthesis of the findings highlighted variability in treatment approach and impact. Effectiveness was primarily defined by reduction in further offending behaviours and was found to be variable across the data. The potential relationship between the symptoms of ASCs and treatment outcome was explored with all case reports identifying the need for adaptations to treatment programmes, necessitated by the symptoms of ASCs. This systematic review joins an existing body of literature emphasising need for more controlled research into the effectiveness of offending behaviour treatment programmes for individuals with ASCs, and for further investigation into the impact of the clinical features of ASCs on treatment outcomes

Renal artery sympathetic denervation:observations from the UK experience

Background: Renal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response—particularly in those prescribed aldosterone antagonists at the time of RDN. Methods: We examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres. Results: Results from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively (p < 0.001 for trend). Use of aldosterone antagonist did not predict response (p < 0.2). Conclusion: In 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication