J Forensic Sci, 2019

doi: 10.1111/1556-4029.14002
CASE REPORT Available online at: onlinelibrary.wiley.com

PSYCHIATRY & BEHAVIORAL SCIENCE

William Frizzell,1 M.D.; Lindsay Howard,1 D.O.; Henry Cameron Norris,2 B.A.; and Joseph Chien,3 D.O.

Homicidal Ideation and Individuals on the

Autism Spectrum†

ABSTRACT: Interest in the relationship between autism and violence has increased in recent years; however, no link has clearly been estab-
lished between them. Researchers remain curious if autistic people with certain traits (e.g., a history of trauma) are at greater risk of violence
than those individuals with autism alone. In this article, we detail two individuals with homicidal ideation (HI) admitted to inpatient psychiatric
units who were found to have a diagnosis of autism without language impairment. These cases illustrate the need for mental health providers to
consider autism in their differential diagnosis when evaluating an individual with HI. Broadly, we consider how an autistic individual could be
susceptible to developing HI and explore treatments specific to autistic individuals that may be helpful in such cases.

KEYWORDS: forensic science, behavioral science, psychiatry, autism spectrum disorder, violence, homicidal ideation

Autism Spectrum Disorder (ASD) is a neurodevelopmental
disorder defined by anomalies in verbal and nonverbal communi-
cation, reciprocity in social interactions, and unusual patterns of
interest and play (1). According to the DSM-5, the diagnosis
may be evident before the age of 3, after which it is a lifelong
disorder (2). The prevalence of ASD has progressively increased
in the past decades, and it is now understood to be a condition
occurring more frequently than once thought (1). Importantly,
there is considerable variability in phenotype. One prominent
subtype of ASD are individuals who communicate with speech
and generally do not use or require developmental disability ser-
vices and might have previously been categorized as having
“High Functioning Autism Spectrum Disorder” or Asperger’s
disorder (3). In this subtype, individuals do not have significant
delay in language and have intellectual functioning in the normal
range; however, they may display atypical development of social
reasoning and intuitions (3). In this paper, we use the term “aut-
ism” or “ASD” to refer to this subtype that in previous times
was termed “high functioning” autism or Asperger’s disorder.
Recently, significant interest has developed regarding the rela-
tionship between ASD and violence; however, this relationship
remains poorly understood. Media representation of recent mass
killers, such as perpetrators of the shootings in Sandy Hook in
2012, Santa Barbara in 2014, and Charleston in 2015, would
1
Department of Psychiatry, Oregon Health and Science University, 3181
SW Sam Jackson Park Road, Portland, OR 97239.
2
Oregon Health and Science University School of Medicine, Oregon
Health and Science University, 3181 SW Sam Jackson Park Road, Portland,
OR 97239.
3
Mental Health and Neurosciences Division, VA Portland Health Care
System, 3710 SW US Veterans Hospital Road, Portland, OR 97239.
*Corresponding author: William Frizzell, M.D. E-mail: frizzelw@ohsu.edu
†
Presented at the 70th Annual Scientific Meeting of the American Academy
of Forensic Sciences, February 19-24, 2018, in Seattle, WA.
Received 27 Sept. 2018; and in revised form 20 Dec. 2018; accepted 31
Dec. 2018.
seem to suggest a link between homicidal violence and individu-
als that either have been diagnosed with ASD or appear to be on
the autism spectrum. Research to date has not supported this
link. Daniel Im reviewed the literature exploring ASD and vio-
lence from 1943 to 2014 and found no conclusive evidence of a
connection (4). In this review, he did identify some risk factors
specific to individuals with ASD which may increase violence
risk among these individuals. These include generative risk fac-
tors, specifically comorbid psychopathology, social-cognition
deficits, and emotion regulation problems, as well as associa-
tional risk factors, specifically younger age, repetitive behaviors,
and “high functioning” ASD. Allely et al. have questioned
whether if a subgroup of individuals with ASD commit more
extreme acts of violence when other risk factors are present (5).
Silva and colleagues, in reviewing the psychiatric literature on
violence and ASD, have suggested the presence of an associa-
tion between ASD and serial homicidal behavior (6).
The link between ASD and violence requires further investiga-
tion, including consideration of the relationship between homici-
dal ideation and ASD. Features of ASD may enable the
development of homicidal ideation; specifically, restricted inter-
ests, lack of social understanding, deficient empathy, and sen-
sory hypersensitivity may cause frustration to the autistic
individual that leads to homicidal thoughts. There have been
numerous reported cases of individuals engaging in violent
behaviors linked to these criteria, outlined thoroughly by Im (4).
Stereotyped interests in individuals with ASD has been described
in murder cases by Schartz-Watts (7) as well as attempted mur-
der by Murrie et al. (8) Schartz-Watts also described two cases
of murder by individuals with ASD where tactile/sensory hyper-
sensitivity was thought to be a significant factor leading to vio-
lence (7). Aggression and violence toward other related to
deficits in social abilities in ASD have been reported exten-
sively, with the first such case being described by Hans Asper-
ger in 1943 (9). More recently, homicide has been reported by
Silva et al., in two individuals with deficits in theory of mind,

© 2019 American Academy of Forensic Sciences 1

2 JOURNAL OF FORENSIC SCIENCES
social reciprocity, and empathy (10,11). Silva and colleagues
also have reported a case of an individual with ASD in which
deficits in theory of mind, empathy, social reciprocity, as well as
restricted interests and paraphilic tendencies were all thought to
be factors in serial homicide (12). A review of typical motives
and triggers of violence in individuals with ASD found that
more than half of cases were motivated by communicative and
social misinterpretation or sensory hypersensitivity (13).
For the mental health provider evaluating an individual with
homicidal ideation, a central concern is assessing for the pres-
ence of psychopathology, whether it be psychosis, mania, or a
personality disorder leading to violent thoughts (14). Determin-
ing the underlying psychopathology is crucial in determining
what interventions are most appropriate in mitigating the individ-
ual’s risk of acting on their thoughts. A mental health provider
may find him or herself in a unique position if they believe an
individual with homicidal ideation is exhibiting signs of ASD
that previously have not been diagnosed. However, the evaluator
may feel less comfortable making this diagnosis if he or she is
uncertain what interventions are appropriate.
In this report, we describe two cases of adult males experienc-
ing homicidal ideation who were found to meet criteria for
ASD. We discuss how in both cases the development of violent
thoughts was related to each individual’s autistic features. In
both cases, we discuss the role of comorbid psychopathology
with ASD and review the literature considering how this relates
to violence. We consider in the initial case how the presence of
psychotic symptoms in conjunction with ASD impacted the nat-
ure of that individual’s HI and review the literature regarding
the relationship between violence in individuals with ASD and
psychosis. In the second case, we consider how a history of
trauma concurrent with ASD resulted in HI and review the liter-
ature regarding violence in individuals with ASD and trauma.
We propose that identification of ASD in an individual experi-
encing homicidal thoughts may assist in preventing violence by
allowing the treatment uniquely tailored to autistic people, which
otherwise might be overlooked if the diagnosis were not consid-
ered. Assessment and treatment strategies for patients with possi-
ble ASD who are at a risk for violence are discussed.
Case 1
Mr. A, a man in his late 30s, was admitted to an acute inpa-
tient psychiatry ward on a voluntary basis with vague symptoms
of anxiety and difficulty controlling his anger, and indirectly
alluding that he was a threat to harm himself or others. Specifi-
cally, Mr. A described receiving messages, which he reported
uncertainty if they were his own thoughts or messages from an
outside source, directing him to threaten and harm individuals
opposing the political organizations he belonged to. He also
described these messages have advocated for cutting off the ears
of such individuals. Six weeks prior to his admission, Mr. A had
seen a psychologist within our hospital system who had diag-
nosed him with ASD, without accompanying intellectual impair-
ment. Mr. A was evaluated by an outpatient psychiatrist within
our hospital system the day prior to his hospitalization who also
diagnosed him with ASD. At that evaluation, he described diffi-
culty understanding social situations, difficulty understanding
nonverbal communication and maintaining eye contact, inability
to maintain relationships. Mr. A also reported a clear history of
restricted and repetitive interests and behaviors, with one consis-
tent interest throughout life being firearms. He recalled that as a
child he would repeatedly arranged his toy cars in a row,
insisted his baseball cards were alphabetized at all times, and lis-
tened to one particular song over and over for hours. Mr. A
recalled being diagnosed with ASD as a child but not receiving
treatment focused on this condition in adulthood. His outpatient
psychiatrist contacted his parents at his appointment, and his par-
ents corroborated Mr. A’s past diagnosis of ASD during child-
hood. Aside from the evaluations conducted in the month prior
to his hospitalization, to our knowledge, Mr. A had not received
a comprehensive autism assessment utilizing standardized diag-
nostic measures during adulthood.
Prior to admission to the hospital, Mr. A reported stress over
the past several months due to increased involvement with orga-
nizations supporting the right to bear arms and opposing
increased gun control policy. Having a lifelong interest in fire-
arms, Mr. A had attempted to start a gunsmithing business sev-
eral years prior. He described that this business had failed after
public outcry against firearms in the wake of a mass shooting.
The failure of his business led to him losing his home and hav-
ing to move in with his parents in a separate city. These difficul-
ties motivated him to become involved with organizations
supporting the Second Amendment. He started to gain increased
prominence in the political organizations, and he was involved
with and caused him to be sought out as a source of leadership.
The stress of his increased prominence, as well as obtaining a
new job that caused him to have an irregular sleep–wake cycle,
caused decline in his mental health. Mr. A described increased
irritability, a 70 pound weight loss over the previous 6 months,
poor appetite, and poor quality of sleep. He also began experi-
encing increased difficulties with reality testing and concerns he
was going to harm himself or harm someone else if provoked.
He described difficulties with reality testing resulting from his
difficulty determining if thoughts he was having were his own
or from an outside force. He was uncertain if he was these
voices were instructing him to harm himself and threaten indi-
viduals involved with his political movements. He expressed
paranoia that people were trying to harm him because of his
political activity. Ultimately, the burden of his symptoms caused
him to seek out psychiatric treatment. At his first appointment
with his psychiatrist, he relayed his symptoms, and his psychia-
trist recommended psychiatric hospitalization.
On admission to the inpatient ward, Mr. A was fixated on
themes of government conspiracies and rights to bear arms, mak-
ing it difficult to have a productive two-way conversation with
him. He again reported his trouble connecting with others as
well as difficulties regulating his anger. He was noted to have
poor social communication, restricted affect, and stereotyped
movements. In conversations, it was noted that he had difficulty
detecting cues to continue or stop talking. He would also make
references in conversation to individuals not known to the per-
son he was conversing with. He described having difficulty mak-
ing eye contact with others. He described becoming a world
expert on a specific type of rifle. Additionally, Mr. A described
a lifelong sensitivity to certain fabrics and food textures.
While hospitalized, Mr. A completed the Autism Spectrum
Quotient (AQ) (15) and scored a 46/50, indicating a high likeli-
hood of being on the autism spectrum. He was treated with a
low dose of risperidone (titrated to 1 mg twice daily) which
resulted in subjectively reported improved mood and less irri-
tability. He no longer reported thoughts or messages to harm
himself or others at the time of discharge, and psychotherapy
aimed at improving social skills was recommended. Mr. A
reported finding it useful to be re-educated on the criteria of
ASD and to consider the impact of autistic traits on his life. He

found it reassuring that there existed forms of therapy he could
try in the outpatient setting for this diagnosis that could help
him with difficulties he had in forming and maintaining interper-
sonal interactions.
Case 2
Mr. B was a middle-aged man voluntarily admitted to an
acute inpatient psychiatry ward with thoughts of self-harm after
not following through with a plan commit mass homicide. At
time of admission, the patient reported developing a plan to
drive cross-country to enact a chemical attack on a government
building. He explained that he became motivated to do this after
finding out the government had garnished his wages to recoup
child care support, 7 days before being hospitalized. He devel-
oped this plan the day of learning about the garnishment of his
wages, which had caused him to not be able to afford his rent.
His anger prompted him to drive cross-country over the course
of 4–5 days to enact his plan.
He initially did not follow through with this plan due to
concerns he had regarding its feasibility. Additionally, his deci-
sion to abort his plan was cemented after observing his
intended victims in front of the targeted building, causing him
to realize he did not want to harm innocent people. He devel-
oped guilt about his homicidal thoughts and developed the plan
to instead kill himself with chemicals. He acted on this by
mixing fluids of ammonia and bleach together in his car, with
the expectation this would create a toxic gas which he would
die of by inhalation in a closed space. However, after mixing
these two fluids, there was no chemical reaction. Mr. B
described that he there was no reaction as he did not have the
correct catalyst to facilitate the chemical reaction. He instead
decided to present to the emergency room for assistance with
his emotional distress.
Mr. B’s mental health team developed concerns for a diagno-
sis of ASD based on deficits observed in social reciprocity and
restricted nonverbal communication, specifically, avoiding eye
contact during interpersonal interaction, a pedantic pattern of
speech, as well as restricted facial expression of emotion. Mr. B
agreed to further exploration of his developmental and social
history with his treatment team. Mr. B described being socially
awkward throughout his life and having little desire to have
close relationships and a general inability to make or maintain
close relationships. He stated he always felt more comfortable
alone and a preference to remain solitary. This included a pref-
erence for abstaining from affection from the opposite sex.
Regarding restricted or repetitive patterns of interests, Mr. B
reported a long-standing fascination with other languages and
said that he had taught himself five foreign languages from
watching videos on the internet, as well as having difficulties
with disruptions in his daily routines. He reported being diag-
nosed with “high functioning depression” at the age of 12 or
13, but that previous psychotherapy and medications were not
effective for him. He also reported that his estranged teenage
son had been diagnosed with autism. Regarding his one previ-
ous relationship with his ex-wife, he described having a limited
desire to have a close relationship with her but that she
“latched” on to him and they cohabitated for 3 years and had a
child, and then separated. Mr. B reported no contact with his
ex-wife and son for about the past decade and a limited desire
to have a relationship with either individual. Mr. B attended
nursing school after his divorce, but was removed from the pro-
gram due to concerns from a patient regarding his “interpersonal
FRIZZELL ET AL. . HOMICIDAL IDEATION AND INDIVIDUALS 3
behaviors.” Mr. B described that a patient had complained of
his behavior, specifically, that he had entered the room without
notifying the patient; however, Mr. B described that he had only
entered the room to do necessary charting and had not per-
ceived the need to communicate with the patient. Mr. B
described having no friends and his only source of support
being his father. He described being abused by his mother at a
young age, both emotionally and physically. He reported his
mother attempted to kill him and a sibling during his childhood
but she was not successful.
While hospitalized, Mr. B was administered the AQ and
received a 23/50, indicating an intermediate level or concern for
being on the autism spectrum. Although this screening tool did
not indicate high concern for being on the autism spectrum, we
believed based on clinical evaluation that Mr. B met criteria for
ASD. However, because this diagnosis was made in the inpatient
psychiatric setting based solely on clinical evaluation, we
believed Mr. B would benefit from receiving a comprehensive,
multidisciplinary evaluation for ASD in the outpatient setting.
For his depressive symptoms, he was started on bupropion,
which he found beneficial, and he was discharged to the care of
his father.
Discussion
Homicidal Ideation and ASD
We have described the two cases above as they illustrate an
area in the relationship between violence and ASD that has not
yet been explored; that is, when an individual with ASD devel-
ops powerful thoughts and ideas of harming others, but ulti-
mately seeks help instead of acting upon them. The question that
stems from these cases is how ASD contributed to the develop-
ment of their homicidal thoughts. In the case of Mr. A, he
described a strong history of preoccupation with firearms that
had persisted for most of his adulthood. His thoughts of aggres-
sion were directed at individuals who he perceived to oppose his
fixation on firearms, which was only further exacerbated by the
failure of his gunsmithing business as well as engagement with
individuals who shared his beliefs. The development of homici-
dal thoughts stemming from Mr. A’s restricted interests relates
to previous literature regarding individuals with ASD committing
murder in deriving from their own stereotyped interests (12).
In the case of Mr. B, his difficulties with social reciprocity
and empathy in combination with intense anger over the garnish-
ment of his wages made the idea of harming government
employees seem, to him, like the only logical way to react.
Autistic individuals who have difficulty in reciprocal communi-
cations, regulating anger, and/or reading the emotional states of
others may struggle with typical means of conflict resolution,
such as expressing their emotions in a socially appropriate man-
ner, or engaging in tactful negotiation (16). Furthermore, Mr.
B’s intense anger in the period preceding hospitalization could
be tied to difficulties with emotional regulation because of ASD;
Samson et al. described how there is increasing evidence that
emotional problems are present in ASD (17). Specifically, prob-
lematic patterns of emotion intensity, duration, frequency, or
type can result from difficulties regulating emotions (18–20). It
has been found that individuals with ASD suffer from emotional
regulation failure, and if there is regulation, it is not as adaptive
(21). Studies have also shown that individuals with ASD use
maladaptive emotion regulation strategies, such as rumination,
more frequently (22).
4 JOURNAL OF FORENSIC SCIENCES
Assessing for Comorbid Psychopathology
If an individual experiencing HI likely meets criteria for ASD,
an appropriate next step in his or her care is to evaluate for
comorbid psychopathology. One review suggests that the pres-
ence of a psychiatric condition raises the risk of violence. New-
man and Ghaziuddin found in a review of 37 violent individuals
with ASD, 31 had evidence of a definite or probable other psy-
chiatric disorder, including obsessive-compulsive disorder,
schizoaffective disorder, conduct disorder, depression, and atten-
tion-deficit hyperactivity disorder (23). They concluded further
research is necessary regarding whether a causal link exists
between individual with ASD and comorbid psychiatric illness
and violent crime.
It is also important to distinguish the diagnosis of ASD from
other disorders for which it can be confused. Consideration should
be made to distinguish features of ASD from diagnoses such as
delusional disorder, narcissistic personality disorder, and schizoid
personality disorder. Along these lines, Bjorkly proposed distinc-
tions between violent behaviors in ASD and psychopathy, noting
incidence of violence in ASD as involving sensory reactivity,
naive interpersonal communication, and reactive violence to nega-
tive environmental stimuli (13). In contrast, violence in psychopa-
thy was noted to be due to a manipulative style of interpersonal
communication, proactive style of typical violence, and low sen-
sory reactivity. Wahlund and Kristiansson found violent criminals
with psychopathy to have predatory violent behaviors whereas this
type of violence is rare in individuals with ASD (24).
Psychosis and ASD
In the case of Mr. A, there was concern for various comorbid
psychiatric diagnoses, with primary concern for a psychotic spec-
trum disorder due to his description of hearing voices or com-
mands as well as paranoia. It has been considered whether there is
a special relationship between psychotic disorders, (specifically
schizophrenia) with ASD, with studies having revealed theory of
mind deficits in both schizophrenia and ASD (25). A recent sys-
tematic review explored the prevalence rates of autistic-like traits
and ASD in populations with a diagnosis of schizophrenia or other
psychotic disorder; they found the point prevalence rates for autis-
tic-like traits ranged from 9.6% to 61% while the prevalence rates
for diagnosed ASD ranged from <1% to 52% across outpatient
and inpatient populations (26). They concluded that their results
demonstrated a higher prevalence of ASD in psychosis popula-
tions in compared to the general population, suggesting that men-
tal health providers should not expect for features of both ASD
and psychosis in an individual to be uncommon (26).
As noted above, researchers have considered whether ASD
and comorbid psychopathology increases an individual’s risk of
violence (23). Watchel and Shorter raised the possibility of
increased risk of violence in individuals with comorbid ASD
and psychosis (27), citing a Swedish national study in 2009 that
found a higher incidence of schizophrenia in violent individuals
with ASD (28). Watchel and Shorter also questioned whether
impairments in theory of mind in individuals with ASD made it
such that individuals with both ASD and psychosis are readier
than others to act on psychotic impulses (27). In the case of Mr.
A, his thoughts of wanting to harm others were psychotic in nat-
ure as he could not discern whether the thoughts were his or
not. The content of these thoughts was derived from his strong
preoccupation with firearms and his perception of opposition to
firearm ownership by political figures. However, for Mr. A, he
harbored good insight into the nature of his psychotic impulses
and refrain from acting on these, as evidenced by him accepting
psychiatric hospitalization.
Assessing for Trauma in ASD
The neurobiology of individuals with ASD and individuals
with a history of trauma has been previously compared and may
offer a neurobiological basis for violence in ASD (29). Multiple
studies support that physical, psychological, and sexual trauma
is associated with chronic neurobiological changes to the brains
of trauma victims that may reduce their ability to cope with
stressors, inhibit impulses, and tolerate emotional dysregulation
(30,31). These factors are thought to contribute to the known
association between trauma and violent behavior in normal indi-
viduals. Several of these observed neurobiological changes may
be inherent to ASD in the absence of trauma, and individuals
with ASD may therefore have a decreased baseline capacity to
cope with stress, negative emotion, and impulses. These changes
have been described as “sensitized prefrontal-cortical-limbic net-
works” and may predispose individuals with ASD to aggressive
or violent behavior (29, pg. 184). As noted above, an association
between ASD and violence has not been definitively demon-
strated (4), which suggests that the presence of ASD alone is
insufficient to produce violence. This may be especially true in
the context of appropriate care for individuals with ASD includ-
ing safe environment, appropriate social support, predictable
daily routines, and treated comorbid disease.
Although violence may not be seen in ASD alone, violence may
be more common in individuals with ASD who have experienced
trauma. The theorized decreased baseline capacity to cope with
stressors may make individuals with ASD particularly vulnerable
to trauma, and therefore, trauma may contribute to violence as
seen in normal individuals (29). During traumatic experiences,
neuronal networks in individuals with ASD may become over-
whelmed. Additionally, core features of ASD including a
decreased ability to regulated, recognized, and attribute the source
of negative emotions and a diminished understanding of others,
context, and alternative behaviors may impede the processing of
trauma and lead to violence. Indeed, several case reports have
found that individuals with ASD and violent behavior have a posi-
tive history of trauma, including one case where an individual with
ASD used arson to avenge school bullying (32). In addition to a
history of trauma, several risk factors for violence in ASD have
been identified, and these include comorbid psychiatric diagnoses
(e.g., attention-deficit hyperactivity disorder, depression, bipolar
disorder, psychotic disorders, and personality disorders), substance
use, repetitive behaviors, and history of neglect (32). Patients with
both a history of trauma and untreated comorbid risk factors may
be at the highest risk of violence. The above informs possibly why
Mr. B may have been more prone to developing homicidal idea-
tion after his experiences of childhood trauma. Had Mr. B’s ASD
and trauma been previously diagnosed, and he had engaged with a
trauma-focused psychotherapist, he may have developed the abil-
ity to work through his life stressor; as such, he was only able to
cope with anger incited by a life stressor through thoughts of
retaliation.
Screening for Features of ASD in an Individual with Homicidal
Ideation
It is worth restating that current literature does not support an
increased risk of violence among individuals with ASDs (4).

However, the literature cited above suggests that in an individual
with homicidal ideation, the presence of the unique features of
ASD may be related to violent thoughts. For the mental health
provider seeking to assess an individual of average intelligence
for traits of autism, the Autism Spectrum Quotient (AQ) may be
a useful tool. Published in 2001 by Baron-Cohen and colleagues
at the Autism Research Center, the AQ tests a dimension of
autistic traits that run through the general population (15). It
consists of 50 questions, rated on degree to which patients
agrees with a statement. People with a clinical diagnosis tend to
score above 32. However, the AQ is a screening tool and not
diagnostic. For the diagnosis of ASD in children, the most com-
monly used instrument is Autism Diagnostic Observation Sched-
ule (ADOS), which can be used for adults (1,33). It is important
to note that ASD is a clinical diagnosis, and therefore, all clini-
cal data should be considered (1).
In addition to their use as screening tools, these instruments
can sometimes be therapeutic in adults as it provides them a
framework of what problems they are experiencing in their daily
life. For Mr. A, he reported finding it useful to be re-educated
on the criteria of ASD and to consider the impact of autistic
traits on his life. Recognizing the time constraints and resource
limitations of the acute psychiatric setting, our recommendation
upon discharge to both patients described here was to undergo
formal multidisciplinary assessments in the outpatient setting to
confirm diagnoses of ASD and more clearly identify areas where
treatment might be focused.
Why are Some Cases of ASD Missed?
Despite the evidence supporting the potential role of ASD in
the development of HI, as well as tools available to assess for
ASD, many cases of ASD are likely being missed (34). In the
cases above, it is possible providers would have presumed the
diagnosis would have been caught in these individuals earlier if
it were present (34). However, current literature on ASD posits
why this diagnosis would feasibly be missed. In 1966, the preva-
lence of ASD was four cases in 10,000 (35), whereas currently
the prevalence is estimated at approximately 1% of the adult
population (36). A debate continues regarding the cause behind
this increase in prevalence and whether it is due to increased
incidence. However, evidence indicates increased awareness of
the diagnosis, increase in service availability, and changes in the
diagnostic criteria have led to increased prevalence (37–39). The
path to early identification of ASD usually begins with concerns
raised by parents, teachers, pediatricians, or early educators. It is
likely for the case of Mr. B, these concerns did not emerge or if
so were attributed to eccentricities in personality. Additionally,
studies have indicated the diagnosis of “high functioning” ASD
is both suspected and confirmed at later ages than that for ASD
(40). It is possible parents without knowledge of “high function-
ing” ASD are less likely to question their child’s development
the longer that development has maintained a normal trajectory
(i.e., excelled in school), especially as engagement of their chil-
dren with healthcare services screening decreases in regularity
with age (41).
For Mr. A, ASD was identified in his development but he did
not receive any counseling or education on how this diagnosis
could impact him as an adult. This omission speaks to the under
recognition of ASD in adults. It is postulated adults who did not
receive a diagnosis in childhood are increasingly being diag-
nosed with ASD with increased public awareness of its features,
although it is unclear in the United States what proportion of
FRIZZELL ET AL. . HOMICIDAL IDEATION AND INDIVIDUALS 5
individuals have received the diagnosis in adulthood compared
to childhood or adolescence. This is all to suggest that psychia-
trists should be not be surprised to make the diagnosis of ASD
in an older individual. Psychiatrists should be extra vigilant in
screening for the presence of ASD in populations where it is less
common or more likely to have not have been diagnosed. In
regard to the former, there is a 4:1 male to female incidence of
ASD (42). In regard to the latter, ASD is likely less recognized
in individuals from developing countries (43).
Treatment of Violent Ideation in ASD
Treating homicidal ideation stemming from anger and irritabil-
ity in ASD follows general treatment recommendations for ASD.
ASD requires a multidisciplinary approach individualized based
on age, needs, and strengths with the goal of reducing the core
symptoms of ASD to improve function, independence, and qual-
ity of life. Although ongoing research efforts have not yet identi-
fied a specific treatment algorithm like that for many other
mental disorders, addressing and target symptoms is the mainstay
in the clinical management of ASD. Early intensive interventions
focused on building skills in socialization, communication, emo-
tional regulation, and cognition while simultaneously decreasing
dysfunctional or negative behaviors have the best outcomes.
Additionally, individuals with ASD benefit from family educa-
tion, structured environments (e.g., scheduled routine, nutrition,
exercise, and sleep), and regular medical care. Cognitive behav-
ioral therapy may be considered but the benefits are currently
unclear (44). Appropriate consideration should be given to
comorbid medical and psychiatric disease, as these may exacer-
bate core symptoms of ASD. Pharmacotherapy for ASD is lim-
ited and should be considered only after the supportive measures
above are in place. Similar to supportive measures, pharmacother-
apy is aimed at ameliorating symptoms of ASD. For treating
symptoms of inattention and hyperactivity in ASD, methylpheni-
date may be useful (45). Additionally, small trials have also
found that agitation in ASD may be improved with risperidone,
aripiprazole, and haloperidol, though risperidone is preferred due
to superior efficacy and lower side effect profile (46). Risperi-
done was useful in the case of Mr. A in alleviating his irritability
as well as his psychotic symptoms. Finally, repetitive behaviors,
which are a risk factor for violence in ASD, may be treated with
SSRIs (47). Practitioners seeking to treat aggression and homici-
dal thoughts in ASD should enact typical supportive measures,
treat comorbid medical and psychiatric disease, and consider
pharmacotherapy only in select cases of inattention and aggres-
sion that is refractory to supportive care.
Assessing Future Risk of Violence
Following stabilization of an individual with a diagnosis of
ASD, a mental health provider may be curious how to best pro-
ceed and assessing future violence risk. To our knowledge, there
are no well-validated assessment tools evaluating future risk of
violence in individuals with ASD. Moreover, the usefulness of
current risk assessment tools for identifying individuals who are
likely to become violent is limited (48). These tools are accurate
at identifying individuals with serious mental illness who are
unlikely to perpetrate violence toward others but far less accurate
regarding which of these individuals will become violent (48).
Fazel et al. conducted a systemic review and meta-analysis
studying the effective of risk assessments in 73 different study
populations (49). They found existing risk assessment tools
6 JOURNAL OF FORENSIC SCIENCES
produced low to moderate positive predictive values for violent
offending (the median was 41%), whereas the negative predic-
tive values for were much higher (with a median of 91%.). Vio-
lence risk assessment is known to be a challenging and
imperfect process, and experts recommend the use of standard,
empirically supported, and structured approaches to violence risk
assessment are appropriate for individuals both with and without
mental illness, despite their limitations (50). For a clinician eval-
uating an individual with ASD and violent thoughts, keeping in
mind the unique clinical risk factors of this diagnosis in conjunc-
tion with his or her standard and structured approach can
strengthen the clinician’s overall risk formulation. Therefore,
mitigating future risk for violence in an autistic individual might
include initiating treatment aimed at alleviating specific autistic
traits, such as improving social communication or treating anger/
irritability.
Conclusion
With the understanding that there are likely many adults in
the general population who meet criteria for ASD but have yet
to receive this diagnosis, mental health providers should be vigi-
lant about screening for autism and considering if features of
autism are causing distress in an individual. Our two cases sug-
gest that features of autism—such as restricted interests, lack of
social understanding, deficient empathy, and sensory hypersensi-
tivity —may drive thoughts of homicide, consistent with find-
ings from prior research on ASD and serial homicidal offending
(6). Identification of previously undiagnosed ASD in a homicidal
individual may open up a variety of effective treatment options
that would not be considered in the non-autistic individual.
Proper identification and treatment of autism may prevent future
violence, either imminently and/or in the long-term. Of equal if
not greater importance, identification can lead to treatment
resulting in an improved quality of life.
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