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Disordered, vulnerable – or autistic?

How we should treat people with neurodiverse conditions in police custody

by John Nelson
Chair | National Police Autism Association

Back in October 2017, the government launched a consultation on the Codes of Practice relating to detaining people in police custody in accordance with the Police and Criminal Evidence Act 1984 (PACE), the wide-ranging piece of legislation that governs the fundamental powers and procedures under which the police service operates. The consultation was of particular interest to the NPAA and the autistic community as it included an update to the rules in PACE Code C concerning when a detainee would be provided an appropriate adult (AA), and how autism fitted in with PACE as a condition that might require an AA.

Before we look into the changes made following the consultation, a few words about appropriate adults. When a person is booked into police custody, they are entitled under certain circumstances to be accompanied and represented by another person of adult age. These circumstances are based on vulnerability, most commonly due to age – PACE states that all juvenile detainees (i.e. under the age of 18*) must have an AA in custody. The AA’s role is to facilitate communication with the detainee and ensure that their best interests are represented; they do not have to remain with the detainee during their entire stay in custody, however the AA must be present at certain key times, including the detainee being read their legal rights after being booked in, during a strip search (usually required if the detainee is believed to be concealing drugs), and when the detainee is interviewed. An AA is usually a parent or carer for a child detainee, or a friend or other family member not connected with the matter being investigated – they may also be a social work professional or a trained volunteer.

Prior to July 2018 when the revised Codes of Practice took effect, PACE Code C referred to detainees who were ‘mentally disordered’ or otherwise ‘mentally vulnerable’ as requiring an AA. The term ‘mental disorder’ seems like a throwback to a less enlightened age, and it’s a reflection of how far our understanding of mental illness and neurological conditions has come in the last 30 years that it now seems so archaic and out of place. But language aside, the obvious problem with these terms is how they accommodate neurodiverse conditions such as autism.

Most autistic people would rightly feel that a condition which is part of their identity is not a mental disorder, and would probably hesitate to describe themselves as ‘mentally vulnerable’. And yet, there are sound practical reasons why an autistic person of any standing in life would need an AA in police custody. No matter how intelligent, independent or successful an autistic individual may be, or how well-trained the officers dealing with them, the difficulties with social communication inherent in the condition may lead to a detainee missing the nuance of a question, or feeling obliged to make disclosures which could have far-reaching consequences. For this reason, the NPAA’s position is that all autistic people brought into police custody should be routinely offered an AA.

Following representations made by stakeholders and members of public, the revised Codes of Practice introduced a new description of ‘vulnerable’, linking into the Mental Health Act which in turn lists conditions including autism which may cause a person to require support in a custody setting. Although the term ‘mental disorder’ still exists within the PACE Code C to distinguish from mental health conditions, the new Codes of Practice acknowledge that there are many reasons outside of diagnosed conditions or illnesses that may require a person in custody to have an AA – for example:

  • The behaviour of the detainee
  • The mental health and capacity of the detainee
  • What the detainee says about themselves
  • Information from relatives and friends of the detainee
  • Information from police officers and staff and from police records
  • Information from health and social care, including liaison and diversion services, and other professionals who know or have had previous contact with the individual

Ultimately the decision on whether to provide an AA for a detainee lies with the custody sergeant, and this is where autism-specific training as advocated by the NPAA can help our colleagues to make the right decision every time. The good news is that in addition to providing training to custody staff, several Forces such as Avon & Somerset Police now explicitly ask detainees whether they are on the autism spectrum as part of the booking-in process. These measures will help to ensure that all autistic people held in police custody are treated fairly and given the support they need. ∎

*The requirement for an appropriate adult for juvenile detainees formerly applied to children below the age of 17 – this was raised to 18 in 2013

A question of specifics

Should police officers be provided with condition-specific training in autism? NPAA Head of Policy Adam O’Loughlin considers the arguments for and against

One of things the NPAA is regularly challenged on is why autism should benefit from condition-specific training to frontline police officers. With that in mind a few weeks ago, a lady called Paula McGowan launched a petition online asking for a Parliamentary debate to discuss the merits of providing all police officers with mandatory training on autism and learning difficulties. This follows on from her successful campaign aimed at ensuring that all NHS staff receive training on the same conditions, prompted by the loss of her son Oliver at Southmead Hospital in Bristol.

Reaction to being asked to provide condition-specific training is met by The College of Policing with resistance, and the reasons for this are well-thought-out and well-argued. They tend to go along these lines:

  1. Police officers are not medical professionals
  2. There are so many conditions that police officers ‘need’ to know about that if we trained all our staff to the levels advocates want, we’d spend all our time training and none of our time doing police work
  3. It’s doesn’t actually matter what condition a person has – just do a balanced combination of what the public want and what the officers say they need, in context to ensure people’s safety and fundamental rights

These are all perfectly reasonable, and therefore it stands to reason that we need to have some robust arguments as to why we are doing it. I think it’s worth starting with some clarity about what autism is, and more importantly, what it isn’t. The reason is that autism means different things to different people.

First things first, then: autism is NOT a mental health condition. It is generally accepted that autism is a neurodevelopmental condition. Following on from that some autistic people view themselves as being disabled, others view themselves as simply having a differently wired brain. Many more have comorbid conditions such as dyslexia and dyspraxia, as well as mental illnesses such as depression and anxiety – which isn’t that much of a surprise considering many autistic people suffer from significant amounts of social exclusion. What almost all autistic people have in common however is that we don’t refer to ourselves as mentally disordered. And this is ironic, as legally at least that’s exactly what we are. It states it in the Mental Health Act. What that means in practice is that it is possible for someone on the autistic spectrum to meet the criteria in the Act for detention, even if the autism is not associated with abnormally aggressive or seriously irresponsible behaviour. Now that’s scary enough, but what it also means is that given the powers and responsibilities police officers are conferred with, we absolutely have to be aware of this. And right now most police officers aren’t.

What of the next point, that autism is just one of a number of conditions that interested parties advocate for? It’s a perfectly reasonable perspective. And in order to answer it, it’s helpful to consider whether there are other professional bodies or pieces of legislation that treat autism as a special case. As it happens there are, and ironically one of those is the Mental Health Act. Glance at the table of contents of the Codes of Practice and you’ll see that autism has its own chapter, under the heading “additional considerations for specific patients”. So clearly Mental Health legislators considered that autism was deserving of special consideration.

If that wasn’t enough, then there’s also the fact that autism is the only condition to have its own Act of Parliament; the Autism Act. The first reaction we normally get when we mention it is that many people are surprised that it exists at all. But in this case the facts are quite clear: The Act remains the first and so far the only condition-specific legislation of its type in England. This demonstrates the importance Parliament has attached to ensuring that the needs of people with autism are met. If Parliament consider autism to be important enough to warrant its own legislation, then surely it follows that policing should follow suit by treating it with similar seriousness. Here’s what the Act says about training:

“We recommend that other providers of public services, such as providers of services to support people into employment, police, probation and the criminal justice system look to follow the guidance to help improve the delivery of the services they provide to adults with autism: for example ensuring that staff who provide services to adults with autism have received autism awareness training would clearly be of value across all public services.”

And that’s not all. There’s also this:

“When people with autism come into contact with the criminal justice system it is often up to them, or their carer, to explain what having autism means. In some cases, it can positively change the way that police or courts view a situation. Police, probation services, courts and prisons should be supported so that they are aware of the communication challenges experienced by people with autism. NHS bodies, Foundation Trusts and local authorities should work with the criminal justice system to achieve this.”

And finally, this:

“Local Authorities, NHS bodies and NHS Foundation Trusts should seek to engage with local police forces, criminal justice agencies and prisons to the training on autism that is available in the local area and consider undertaking some joint training with police forces and criminal justice services working with people with autism.”

Moving on again, it’s not just Parliament, and it’s not just recommendations. As part of the Autism Strategy, each Local Authority is required by Public Health England to complete a bi-annual Self-Assessment Return (SAF) to demonstrate compliance with the Act. And it will come as no surprise to learn that there is a specific question about the very topic currently up for discussion. It’s actually question 23, and it looks like this:

Criminal justice services: Do staff in the local police service engage in autism awareness training?

Any police forces out there fancy replying: “No, because the College of Policing don’t think it’s a good idea?” No, us neither.

So we think it’s safe to say that the mandate is there. In fact, we don’t think it could be much clearer. The Mental Health Act treats autism as a special case, there’s a specific Act of Parliament that recommends that police forces should engage with partners to undertake training, and a mandatory self-assessment to inform the Department of Health as to progress.

That’s the why, and we think the case is made. ∎

Follow Adam O’Loughlin on Twitter at @autisticcop

Breaking the cycle

Why do so many ADHD children fail at school and fall foul of the criminal justice system?

by Kaj Bartlett
NPAA ADHD Lead & Sussex Police Deputy Coordinator

Attention Deficit and Hyperactivity Disorder (ADHD) is a neurodevelopmental condition affecting five percent of the UK population. Indications are that it is underdiagnosed. Lack of societal awareness of the condition means that many believe it only affects young boys and they grow out of it during the transition to adulthood. This is a myth. ADHD affects all ages, both genders and across all social classes.

There are many symptoms which affect someone living with ADHD, and like autism, not everyone experiences the condition in the same way. It is now known that there are three sub-types of ADHD: inattentive, hyperactive and combined type. There are screening tools which help signpost if someone has ADHD; however diagnosis is ultimately based on a psychiatric assessment of behavioural traits according to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM5). lt is classed as a ‘hidden disability’, because many of the challenges faced by a person who lives with ADHD aren’t always obvious. There are many positive aspects of living with ADHD, however the purist medical concept of the condition defines it through a ‘double whammy’ of being a deficit and a disorder. Most often it is the negative behavioural traits which are exhibited and observed, which are impatience, impulsivity, hyperactivity, significant emotional dysregulation, and poor executive functioning skills. ADHD is not a behavioural disorder: neuroscience now proves that it is a difference in brain function for those who live with it.

ADHD, like autism, cannot be cured; however there are psychological, behavioural, educational and pharmacological interventions which can transform lives. There is a genetic basis for ADHD being passed down the generations, although there is currently no definitive genomic variance conclusion which determines a predisposition for ADHD. Symptoms present differently in women and girls than they do in men and boys.

ADHD can be comorbid with many other conditions including anxiety and depression, and neurodiverse conditions such as dyslexia, dyspraxia and autism. lt is more often that not the comorbid condition will be the one which is identified first, as they are often easier to diagnose. Whilst treatment steps to manage those other conditions will help, a syndrome mix including ADHD will still mean the individual will struggle in life in many ways. Self-medicating can also take the form of substance and alcohol misuse. Adults living with ADHD are 78 percent more likely to be addicted to tobacco and 58 percent more likely to use illegal drugs than those without ADHD. Even food and purchasing addictions are more prevalent. 38 percent of young adults with unmanaged ADHD have been pregnant or have caused an unwanted pregnancy.

Taking that back a step further, children with neurodiverse conditions and in particular ADHD, will inevitably cause problems in the classroom. They will behave differently to their peer group, because they have a different learning style which is not catered for in schools. ADHD is first often seen through disruptive, challenging behaviour in schools, where there can be a prevalence of fighting, defiance and aggression, and damage being caused. lt can also present in more subtle ways and the individual will be the class chatterbox or clown. Usual ways of managing behaviour do not and will never work to moderate and alter the behaviour of those who live with ADHD. Undiagnosed and unsupported children living with ADHD are losing the opportunity for learning as their behaviour in school becomes the only focus, leading to sanctions and a hundred fold increased likelihood of permanent exclusion. Child and adolescent ADHD is widely, and incorrectly believed to be caused by poor parenting, poor diet, too much screen use and lack of self-control. Society expects individuals to exhibit certain levels of self-control, commensurate with the age of the individual. ADHD affects the neurodevelopmental abilities and pathways needed to acquire those skills in life. Challenging, aggressive behaviour arises through deficits of skill, not will. Unmet educational needs leads to criminality and longer term recidivism.

Academic research has estimated 30 to 40 percent of those incarcerated within the prison system have ADHD. There is a soon to be published piece of academic evidence which reinforces the importance of addressing the critical public health issue of ADHD for people living in detention, through (i) systematically offering initial screening and diagnosis to all individuals entering detention, and (ii) delivering treatment, monitoring and care for ADHD during and after detention. These strategies are believed to reduce recidivism and reincarceration, as well as violence in detention settings, in addition to improving the health and wellbeing of people living in detention.

Stripping that back a layer, another academic research paper concluded that 25 percent of those entering police custody during the study, met the strict assessment criteria to gain an ADHD diagnosis. A further conclusion was that these individuals also needed the most support and care whilst in custody and were the most challenging for custody staff. In these prison and police studies, the vast majority of individuals who fitted the assessment criteria for a diagnosis of ADHD were actually unware that they lived with the condition, meaning they have had no possible opportunity for diagnosis and treatment help. From a policing perspective, those living with ADHD are much more likely to commit impulsive crimes often where a loss of self-control is evident, rather than a pre-planned criminal enterprise. This will be seen in offences such as anti-social behaviour and shoplifting, and opportunist acquisitive crime, public disorder, violent behaviour and criminal damage offences. Driving offences such as speeding and failing to stop for police also feature; driving performance can be affected by ADHD through inattention, impulsiveness and hyperactivity. Seeking risk-taking activities can be a form of self-medicating for unmanaged ADHD to increase the dopamine activity in the frontal lobes of the brain, this being an aspect of the neurochemistry behind ADHD.

The College of Policing Authorised Professional Practice on Detention and Custody covers the risk assessment of police custody detainees. Currently there is no specific reference to adult ADHD, and only a one line reference to it in the Children and Young Persons section of that guidance. Vulnerability is increased through the presence of ADHD, however this vulnerability is not being recognised. In my experience, there is no specific training for our custody officers, nor the wider policing family about ADHD and how to best support and manage those who live with it. Lack of awareness and unconscious bias leads us to focus on the offending and not what could be underpinning it. Our untrained behaviours can and do often lead to compounding the problem as we increase the likelihood of emotional dysregulation, leading to non­compliance from the subject. This often leads to violent behaviour.

ADHD is not an excuse for poor behaviour at any age, yet the negative aspects of its presence leads to poorer social outcomes in life and hidden vulnerability for many. An individual’s social environment does not cause ADHD, yet poor social environment and adverse childhood experiences can exacerbate behavioural symptoms. The neurodevelopmental basis of ADHD creates those skills deficits through biology. Neuroplasticity means ADHD biology can be managed and changed with the right approaches. ∎

Follow Kaj Bartlett on Twitter at @ADHD_InspKaj