Overview This thesis reviewed forensic aspects of Intellectual Disabilities (ID) and Autism Spectrum Disorder (ASD). Chapter two was a case study where an individual with ID and ASD who exhibited forensic/Challenging Behaviour (CB) was assessed and intervention offered. Chapter three then focussed on the assessment of people with ID and ASD by critiquing the Wechsler Adult Intelligence Scale (WAIS), version 3 and 4 (WAIS-III & WAIS-IV) (Wechsler, 1997; Wechsler, 2008a, 2008b, 2008c) and discussed application issues for people with ID and ASD. Chapter 4 and 5 examined intervention in more depth. Chapter 4 applied Weiner’s (1985, 1993) theory of achievement, motivation and emotion as a way of understanding contextual intervention and Chapter 5 examined the effect of psychotherapeutic interventions on CB. Chapter Two The case study discussed in chapter two examined explanations of violence and diagnoses. ASD and an ID were identified as useful neurodevelopmental diagnoses that could be used as a framework to understand the individual’s needs. Some explanations of violence were related to features of these diagnoses. Social factors were also identified as increasing risk. Violence was modelled by a key male figure during childhood development which appeared to have been retained as a template of acceptable behaviour, supporting the work of Bandura on social learning (1973). This, and the experience of being a victim of this violence, also supported the work of Douglas, Hart, Webster and Belfrage (2013) who indicated that social factors can increase the risk of violence. In turn this affected attachment supporting the work of Bowlby (1980). The behavioural approach (Cipani & Schock, 2010) was also applied to identify functions of violence. A psychotherapeutic intervention was offered to improve one aspect of emotional recognition, face perception, with the aim of enabling him to comprehend visual feedback from the environment, make interpretations about the emotions experienced by others, and modify his behaviour accordingly. There was little difference to his level of skills following the intervention. It was concluded that particular skills development may be difficult for someone with a neurodevelopmental difficulty if the biological structures are not there to support that skill, or skills may take a long time to develop. In this case it was concluded that the best intervention was to consider a placement for him in an appropriate environment that would cater for his ASD and ID related needs. Comments were made about the quality of assessments and for improvements to be considered to formulation and intervention. Chapter Three Chapter three was a critique of the WAIS, a tool widely used as part of the process to identify whether someone has an ID. This may determine if an individual may be unfit to plead in court or to determine the services appropriate for that individual’s needs. The review focussed on the most recent version, WAIS-IV (Wechsler, 2008a, 2008b, 2008c) but also referred to other versions in particular the WAIS-III (Wechsler, 1997). The conclusion was there were some flaws to the assessments that required further research and also some omissions in the epistemology. The critique examined different aspects of validity and reliability. The examination of convergent validity yielded mixed results with some positive correlations with other tests and some weak correlations. This difference could be caused by some tests measuring different aspects of ‘g’. The consequences of differences can be significant, for example the scores of the Wechsler Intelligence Scale for Children, version 4 (WISC-IV) (Wechsler, 2003) and the WAIS-IV scores could differ by up to 10 points and could mean individuals moving from a children’s to an adult service could become ineligible for the same levels of support. The results for test-retest reliability were good in the short term but more research was recommended to determine if the latest version of the WAIS would be reliable in the long term. The ‘Flynn effect’ (Flynn, 2007) indicated that levels of intelligence were rising so the WAIS-IV compensated for this and currently measures intelligence at around 3 points lower than the WAIS-III. The stability of this effect was unclear. The results for internal reliability were good although more research independent of the WAIS was recommended. The application of the WAIS for individuals with an ASD and ID was considered with the WAIS being found to be a limited tool for discriminating between categories of ASD, although what can be expected is an uneven profile. It was also unclear how useful the WAIS was to discriminate between individuals with a substance misuse/abuse disorder and normal controls. There were also difficulties with the application of the WAIS to individuals with ID. Difficulties measuring intelligence at lower levels were identified as scores can be unstable. Research was also recommended to provide a comprehensive view of the effect upon results of variables such as nationality, gender and age. Chapter Four Chapter four was an empirical research project investigating Weiner’s (1985, 1993) theory of achievement, motivation and emotion as a means of understanding the responses of unqualified nursing staff to clients with ASD exhibiting CB. One hundred and twenty seven unqualified nursing staff responded to an Attributional Style Questionnaire (ASQ) (Dagnan & Cairns, 2004) and questions based on a vignette. The quantitative results found weak support for Weiner’s model. There was weak evidence for the effect of demographic variables and the type of client (ASD or ID) and the type of service (ASD or Mental Health/ID) did not affect the results. Qualitative data was themed and coded according to Braun and Clarke (2006) and Boyatzis (1998) and provided an insight into the psychological processes influencing staff responses to CB. The results suggested that intervention was influenced by staff, patient and contextual variables. A recommendation was made for a contemporary exploration of the topic and to improve the validity and reliability of the ASQ. Chapter Five Chapter five was a systematic review of psychotherapeutic interventions aimed at reducing the CB exhibited by people with ID only due to a paucity of research using people with ASD as participants. A systematic literature search was conducted using 5 databases, a search of relevant journals and contact made with experts. From this 8 papers met the inclusion/exclusion criteria and these were analysed qualitatively. Three types of psychotherapeutic intervention were used within the ten papers, Cognitive Behavioural Therapy (CBT), “Soles of the Feet” meditation and Solution-Focussed Brief Therapy. All types of psychotherapeutic intervention reduced CB although the results of studies using CBT were mixed. There were shortcomings to these conclusions; these were methodological issues such as a need to ensure the consistency of outcome measures and the types of CB used to measure change. The effect of intervention may have been modified by variables such as length of treatment, the context and intrapersonal variables. Conclusions The chapters of this research thesis indicated that neurodevelopmental factors influenced forensic/CB, although social role models, attachment and trauma were also significant. Assessments were important as they may affect fitness to plead and services/treatment offered. Assessments such as the WAIS are supported by research although further research has been recommended. The use of the WAIS with people with ASD and ID was limited as people with ASD appear to exhibit uneven profiles when completing the WAIS and there were inaccuracies when using the WAIS with people with lower levels of intelligence. The difficulties people with ASD have with social communication skills can also affect performance and support is needed when administering assessments. Intervention for people with a neurodevelopmental difficulty can also be successful. Consideration is needed regarding appropriate intervention for each individual, how long before the intervention is effective, the context including the type of support offered and how that affects outcomes, intrapersonal variables such as intelligence, and whether the treatment includes one to one support. More research of an improved quality is required to determine the effectiveness of both assessment and treatment including contextual based treatment such as the interaction between staff and patients within an institutional setting. Considering these further would improve the service for this client group and contribute to a reduction of risk.

Valid and reliable measures of Acceptance and Commitment Therapy's (ACT) purported mechanism(s) of change are paramount in establishing its incremental validity above other extant psychological therapies. However, the most widely used general measure of psychological flexibility and the six ACT processes of which it is composed of, the Acceptance and Action Questionnaire (AAQ-II), has been significantly criticised, principally in terms of being a conflated distress measure due to having items with poor face and content validity. Theoretically, there has also been debate about whether ACT's 'hexaflex' model, which conceptually underpins the AAQ-II and other ACT process measures, is comprised of fewer than six distinct processes as per current ACT theory. The overall aim of our study was therefore to: 1) develop a new general measure of ACT processes; 2) test the measure's validity and reliability; and 3) establish whether the measure's factor structure accords with Hayes et al.'s (2011) clustering of ACT's six processes into three dyadic processes. The measure was named the Comprehensive assessment of ACT processes ('CompACT'). Using a Delphi-consensus methodology, ACT experts (N= 10) rated the face and content validity of 106 items. Items were taken from existing ACT process measures and two mindfulness measures, as well as generated by ourselves and the ACT experts within our study. Items which failed to reach pre-defined ratings thresholds were removed and remaining items were re-rated until a pre-defined consensus threshold was reached. After three rounds, an initial 37-item version of the CompACT was produced. The CompACT was then disseminated to a non-clinical sample of participants (N = 377) mainly via social media. Participants also completed other measures to assess different aspects of the CompACT's validity. A three-factor structure was found to be the most stable for a 30-itemed version of the CompACT. An examination of the distribution and contents of item loadings also confirmed that the CompACT's three factors could be defined in accordance with Hayes et al's. (2011) three dyadic ACT processes. The CompACT performed in theoretically predicted ways against measures of other related and distinct constructs, and was mostly comparable to the AAQ-II in terms of its magnitude of associations with these other measures, with the exception of a distress measure. The CompACT's associations with these measures also supported ACT's central hypothesis: higher levels of psychological inflexibility are associated with higher levels of distress and lower levels of health and wellbeing. Overall, the CompACT shows initial promise as a comprehensive measure of ACT processes, and more generally as a measure of psychological flexibility. The psychometrically viability of Hayes et al.'s (2011) three dyadic ACT processes as a conceptual model for the CompACT further strengthens previous suggestions that ACT's clinical model may be composed of fewer than six distinct processes. The CompACT was adjudged by ACT experts to possess items with better face and content validity than the AAQ-II. However, in order to be considered as a viable alternative measure to the AAQ-II, further testing of the CompACT's psychometric properties is needed.

Introduction: The concept of pornography addiction, although widely accepted, continues to be debated, and as such no diagnostic criteria exist. Opponents and proponents of pornography continue to cite evidence that supports the claim that pornography is either harmful or beneficial, respectively. However, a review of the literature pertaining to pornography use revealed conceptual and methodological shortcomings which limit the conclusions made in the existing literature base. Without adequate research to further our understanding of the complex relationship individuals have with pornography, we risk pathologising or condoning behaviours that are legal and consensual, which may cause distress for some individuals, or even divert attention from deeper issues, such as an individual’s thinking styles and feelings of shame. Researchers acknowledge that people’s relationship with pornography is complex (Hardy, 1998) and individuals experience it in different ways, for example the time spent viewing pornography, the environment in which they view it, who they view it with, and the genre of pornography they watch (Attwood, 2005; Hald & Malamuth, 2008; Malamuth, Addison, & Koss, 2000; Poulsen, Busby, & Galovan, 2013; Reid, Li, Gilliland, Stein, & Fong, 2011). Given that additional variables may be involved when people pathologise their pornography use, particularly rigidity of thinking (Reid et al., 2009), it is worth investigating such variables further to help discern differences between those who pathologise their pornography use and those who do not. Aims: The overall aim of this study was to explore whether thinking styles impact on the meaning given to pornography use. The primary objective was to compare participants who perceived their pornography use to be problematic (porn addict) with individuals who did not (non-addict) on the following dependent variables: thinking styles, shame, levels of desirability responding, levels of religiosity, and perceived effects of pornography use. As this was an exploratory approach a two-tailed hypothesis was employed. The secondary objective was to capture in-depth qualitative experiences participants had with pornography, and pornography addiction. Design: This study used a mixed-method sequential explanatory design (MMSE), using questionnaires to collect quantitative data and interviews to collect qualitative data. Method: Participants (n=265) were recruited from both UK National Health Service (NHS) and non-NHS sites. For non-NHS participants, the questionnaires were made available online and advertised through social media. NHS recruitment occurred at a specialist sexual health clinic and was advertised using posters displayed in relevant clinical areas. The study predominantly employed a maximum-variation sampling technique. This is a purposive sampling technique used for this research to ensure that an eclectic sample of diverse demographics was captured. Quantitative data was collected using a demographic questionnaire and four validated measures; the Inventory of Cognitive Distortions (Yurica & DiTomasso, 2001), the Test of Self-Conscious Affect-3 (Tangney, Dearing, Wagner, & Gramzow, 2000), the Balanced Inventory of Desirable Responding (Paulhus, 1991; 1998), and the Pornography Consumption Effects Scale (Hald & Malamuth, 2008). All interviews were conducted either through the audio function on Skype© or over the telephone. Results: Participants reported themselves as belonging to one of three groups; addicts, somewhat addicts, or non-addicts. MANOVA analyses revealed that groups significantly differed in their propensity for cognitive distortions, reported effects of their pornography use, the impact of their religious beliefs, and time spent viewing pornography. Significant differences were not found for the shame scales, or for social desirability. Multinomial logistical regression revealed that negative impact of pornography on participants’ lives in general, on their sex life, dysfunctional thinking styles (overall and externalisation of self-worth, magnification and fortune telling, minimisation and arbitrary inferences, and perfectionism), and impact of religious beliefs significantly predicted group membership. Furthermore, regression analysis supported the hypothesis that thinking styles mediated the relationship between time spent viewing pornography and the overall negative impact of pornography. Qualitative results supported these findings, and thinking styles were revealed to influence the discourses participants had regarding pornography. Primary themes identified were participants’ relationship with pornography and perceived causation of pornography addiction, significance of social norms, and impact of expert opinion. Furthermore, although absent in the quantitative findings, the concept of shame was raised as an influential factor in the pathologising of pornography use, thus supporting the notion that a conflict in values, paired with a relatively inflexible cognitive style, may lead to pathologising, and shame will be a product of that process. Discussion: This study demonstrates the role thinking styles play in how people evaluate their pornography use. Thinking styles both predict whether an individual perceives their pornography use to be problematic or not, and are evident in the discourses people use when discussing their pornography use and the concept of pornography addiction. Specifically, individuals with a propensity for rigid thinking styles are more likely to negatively evaluate their pornography use. Furthermore, the similarities and differences apparent in group comparisons can be understood within a values theoretical framework; it may be that individuals with rigid thinking styles are more likely to endorse particular values that are incongruent with their pornography use behaviours. Conversely, individuals with more flexible thinking styles may be more likely to endorse values which are not incongruent with their pornography use behaviours. This is important from a research and treatment perspective, as it may not be the behaviour itself (pornography use) that is problematic and the target for intervention, but the cognitive framework individuals use in relation to the behaviour. Current treatment offered to those who self-report as pornography addicts often ignore the role of thinking styles and values. In light of this study’s findings, thinking styles should be a focus in future research and treatment as it may help to reduce cognitive dissonance and engender agency.

Objective This study aims to compare the outcome and psychiatric morbidity of the forensic mental observation referrals, in the two legally created groups of awaiting trial detainees – the ‘singles’ representing the minor violent and non-violent offenders versus the ‘panels’, representing the seriously violent offenders. Method A cross-sectional, retrospective record review of 200 cases, spanning from January 2010 to August 2010, of all individuals admitted to the Forensic unit of Sterkfontein Hospital, for 30 days psychiatric observation. The Pearson’s Chi squared test for categorical data was used to determine statistical significance. Results Of 110 ‘singles’ 49 (44.55%) were found fit for trial and 40 (40.4%) criminally responsible, whereas of the 90 ‘panel’ cases 60 (66.67%) were fit for trial and 57 (64.77%) were criminally responsible. (p = 0.002 and 0.001 respectively) Conclusion Those charged with seriously violent offences appear to be more likely to be found both fit and responsible, compared to those charged with less serious offences.

Ph.D., Faculty of Health Sciences, University of the Witwatersrand, 2011 / Introduction: An increasingly important role for spirituality has been observed in health, mental health and psychiatry. In South Africa it has become particularly apparent in how the Western scientific biomedical model has increasingly been regarded as only one approach in parallel to local African traditional faith and healing practices. It is currently important for local psychiatrists themselves to consider from within the discipline, as to what they would judge the role of spirituality to be in specialist psychiatric practice and teaching. Methods: This study is an explorative, descriptive, contextual, phenomenological and theorygenerating qualitative investigation. In-depth, semi-structured interviews with individual academic specialist psychiatrists affiliated to a local South African university were conducted as primary data source. Considering selected journal articles from a review of the international literature as secondary data items, the content of the conducted interviews was subsequently compared and integrated with the content of the literature on the subject. A layered grounded analysis was made of the interview and literature content. Final categories of concepts were identified from the integrated content, as well as one single core concept for model construction. The elements of the core concept were defined by determining their dictionary (denotative) and subject (connotative) meaning. Essential and related criteria were established for the definition of each element. A practice-orientated model was developed based on the defined single core concept. The steps adopted for the construction of the model referred in particular to the methodology for nursing theory development. Results: The local interviews and the international literature revealed a strong consensus that the role of spirituality should be incorporated into the current approach to local specialist psychiatry, mainly because of its important role in the lives of people in general. Incorporation of this role should, however, only be considered within the parameters of the professional and ethical scope of the discipline, and with all faith traditions and belief systems accommodated equally. The model accounted for the two-fold nature of this central core concept, by drawing an analogy with the comparable counterbalanced two-directional transportation systems of large trees, to describe the structure and relationships of the elements of the concept. The model was operationalised, providing guidelines for its implementation in different practice and training scenarios. Discussion: The model may contribute to the acknowledgement of, and participation in, the discourse on the place of spirituality in local psychiatry, clinical medicine, health and mental health. Defining terminology, specifically what exactly “spirituality” and “religion” would mean in a particular scenario and for the study, proved to be one of the most critical elements of this investigation. Appropriate guidelines for clinical care, for ethical practice and training, and for the referral of patients to relevant spiritual professionals are necessary. Academic institutions in South Africa may have to reconsider their approach to the training of specialist psychiatry and of clinical medicine in general, in order to account for the currently increasingly important role of defined spirituality in local practice and training.

A dissertation submitted to the Faculty of Medicine in Part Fulfilment of the Requirements for the Degree of Master of Medicine in Psychiatry at the University of the Witwatersrand / Ninety-one patients referred for observation were evaluated by means of a data sheet which covered demographic, forensic and psychiatric data, as well as special investigations performed during the admission period. A significant number of patients (P = 0,005) involved in crimes of theft were found to be psychotic. A significant number of patients (P = 0,(24) involved in murder/attempted murder/culpable homicide were found to be apsychotic. None of the special investigations had a significant bearing on the diagnosis or legal destiny of the patient. it is clear that we should have a high index of suspicion towards psychosis in those patients who were allegedly involved in crimes against property and in particular crimes of theft. Special investigations should only be performed where there is a clear clinical indication. This approach wiII save considerable time and money without compromising the assessment. / Andrew Chakane 2019

Aims: The aim of this thesis was firstly, to prospectively examine cognitive function in relation to epilepsy, with event-related potential (ERP) and neuropsychological assessments, over a one year period. Secondly, to investigate whether electrophysiological measures have some predictive value for behavioural outcomes. Methods: A methodology development study investigated optimal stimulus and recording parameters for the mismatch negativity (MMN). A prospective epilepsy study included investigation of a healthy control group, groups of patients with: primary generalised seizures (PGS), focal with secondary generalised seizures (FSG) or focal seizures (FS) and a chronic pain group undergoing anti-epileptic drug (AED) therapy. Assessments were conducted over the course of 12 months: at baseline (session 1), 6-months follow-up (session 2) and 12- months follow-up (session 3). ERP measures included the MMN, P3b and P3a. Neuropsychology measures were obtained using visual reaction time, spatial working memory, planning, word list learning, perseverative function, story recall memory and word list learning tests. Cross-sectional analyses of data obtained at sessions 1 and 2 were carried out to investigate group differences at the different time points. Longitudinal analyses were carried out to investigate the effect of time on behavioural and ERP changes in relation to the different groups. Finally, the predictive value of baseline ERPs for behavioural outcomes at one year follow-up was explored. Results: The methodology development study demonstrated that a reading task with duration increment tones yielded the most replicable MMNs in healthy controls. The clinical study demonstrated significant changes in some ERP components obtained from standard oddball, dual target oddball and novel sounds tasks, between controls and seizure groups -some of which were only apparent at session 3. Although the seizure groups showed evidence of significant impairments in aspects of behavioural performance, there was no significant progressive deterioration over time. Moreover, although the pain group showed similar behavioural impairments, in contrast to the seizure groups, they showed significant improvements in some aspects of performance over time. Conclusion: An MMN recording protocol was established for use with the subsequent prospective clinical study. The prospective epilepsy study revealed functional cognitive changes that may be linked to the nature of pathophysiology underlying different seizure types.

The aim of the current thesis was to explore sexual knowledge and risk in the assessment and treatment of adolescent males with intellectual developmental disorders (IDD), who display harmful sexual behaviour (HSB). A variety of methods were used in this undertaking, including a systematic review, a single case study, a critique of a psychometric measure and two empirical studies. The findings of the systematic review indicated that although the identified/assessed risk variables related to recidivism were found to be similar in cases and controls, some were found to be more prevalent for sexual offenders with IDD. However, it was difficult to draw any firm conclusions due to inconsistencies in findings and limitations in the methodological quality of included studies. The case study detailed the assessment and treatment of an adolescent male with limited cognitive ability and a history of harmful sexual behaviour. The assessment highlighted the utility of the integrated theories of sexual offending, and how his adverse early life experiences and developmental trauma disorder may have negatively impacted on his attachments, social and self-regulation skills, low-self-esteem and the development of his harmful sexual behaviour. The post-intervention assessment highlighted the client had made some positive shifts within his identified treatment targets, although there was still room for improvement with regards to his level of socio-sexual knowledge, his ability to self-regulate and his tendency to engage in aggressive and rule-breaking behaviours. In the critique of the Knowledge Test and Quick Quiz components of the Assessment of Sexual Knowledge –ASK (Butler, Leighton & Galea, 2003) the Knowledge Test measure demonstrated some good psychometric properties and had undergone extensive research and robust testing with individuals with IDD during its development. However, weaknesses of the measure considered were its lack of normative data, the ambiguous wording of some items, and limited empirical research regarding the tool’s effectiveness in measuring sexual knowledge across different populations of individuals with IDD. The empirical research consisted of two studies. In the first study a questionnaire adapted from the Knowledge Test of the Assessment of Sexual Knowledge – ASK, was tested for its ability to accurately measure sexual knowledge in adolescent males with and without IDD and their counterparts who display harmful sexual behaviour. Tests examining both the reliability and validity of the adapted measure suggested its psychometric properties were promising. The second study sought to explore whether there were differences in sexual knowledge in adolescents with and without IDD and their counterparts who display harmful sexual behaviour (HSB). Significant differences were observed between groups. In the HSB groups, adolescents with IDD experienced significantly higher rates of sexual victimisation than No IDD adolescents. For those with IDD the HSB group were 12 times more likely to view sexually explicit material than the Non HSB group. The findings suggested that a lack of sexual knowledge might not be a contributory factor in why some young people with IDD go on to display harmful sexual behaviour.

This thesis aims to provide a broad overview of contemporary challenges in relation to sexual offending, with specific focus being placed on the need to balance the public’s perceptions of those convicted of sexual offences with the reality of their offence patterns, to determine what risk society really faces from these individuals. In doing this, it incorporates diverse methods, including a systematic review, an empirical research study, an individual case study and a critique of a psychometric measure. Following a general introduction in Chapter 1, Chapter 2 presents a systematic evaluation of 13 studies investigating public perceptions of sexual offenders, with specific focus on comparing public demographic variables as predictors of these attitudes. It was found that overall; the public’s perceptions were negative, with beliefs about high recidivism rates amongst other misperceptions. Demographic characteristics were shown to be inconsistent in predicting punitive judgments. Level of educational attainment was the only demographic variable investigated that was consistently associated, with higher levels of education resulting in more positive perceptions. In Chapter 3, the offence patterns of repeat sexual offenders are investigated, including an analysis of whether this population escalate, de-escalate or remain stable over time. The results indicate an overall pattern of stability, indicating that sexual recidivists commit the same category of offence from one offence to the next. However, escalation was also common, a finding that warrants further exploration. Chapter 4 explores the factors that contribute to the onset and escalation of the offence behaviours of a repeat sexual offender, through the use of psychological formulation. Results indicated that a different set of risk factors contributed to the onset of the client’s offending compared to those that contributed to escalation. Chapter 5 evaluates the Community Attitudes Toward Sex Offenders (CATSO) scale (Church, Wakeman, Miller, Clements, & Sun, 2008), an assessment measure used in Chapter 2. Finally, Chapter 6 provides a discussion and conclusion to the thesis, drawing together the implications of the research.

The role of violent video games (VVG) in increasing levels of aggression in players is a topic that has been debated for decades. While a simple cause and effect relationship is not present, it is apparent from the literature that VVGs do have a relationship with elevated levels of aggression within some players. The first chapter of this Thesis presents a systematic review of the literature focusing on additional factors included in the research to explain this finding. However, a lack of standardisation in both measurement and reporting of results making interpretation difficult. The second chapter provides a critique of the non-experimental methods used within video game (VG) research. The third chapter focuses on a non-experimental study which highlighted the differences in aggression, motivations for playing, empathy, and personality in a group of VVG players. The final chapter presents the results of a service evaluation of the management of VGs within a high secure psychiatric hospital, which highlighted the real-world implication of an unclear literature base. The conclusions of this thesis highlight the variation in the quality of the literature available and stresses the need to conduct research with targeted populations, both VG players and clinically populations, to fully understand the relationship between engaging in VVG and increased aggression.