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Purpose
Down syndrome is one of the common genetic causes of intellectual disability. Adult with Down syndrome may have many psychiatric comorbidities. Therefore, their mental health status should be considered in legal proceedings such as criminal responsibility and legal capacity where they are involved. This study aims to highlight that individuals with Down syndrome are often referred directly to forensic psychiatry without undergoing an interview, despite the fact that this is a group with varied mental statuses.
Design/methodology/approach
This study analysed the socio-demographic, clinical and forensic characteristics of eight adult individuals with Down syndrome for whom the Council of Forensic Medicine (CFM) requested an opinion on criminal liability and other legal situations between 2018 and 2022. The CFM is an authoritative institution to which cases from all areas of Türkiye are referred.
Findings
The mean age of the individuals with Down syndrome for whom a forensic psychiatric opinion was requested was 24.63 (±7.95) and the mean IQ level was 54.13 (±13.38). All cases were male, 6 / 8 were referred for assessment of criminal responsibility and 4 / 6 of those referred for assessment of criminal responsibility were referred for sexual offences. It was found that 5 / 8 of the cases had moderate intellectual disability and 3 / 8 of the cases had mild intellectual disability.
Research limitations/implications
Regarding the limitations of this study, the first one is the small sample size. Nevertheless, due to the low prevalence of people with Down syndrome in society, it is plausible that their stigmatization may not be reflected in the judicial system, even in cases involving violent behaviour. The second limitation is that the reports lack all psychiatric medical documents, including forensic psychiatric evaluations of individuals with Down syndrome. Additionally, additional diseases were recorded based on familial anamnesis. The third limitation is that this study is the first publication to investigate Down syndrome from a forensic psychiatric perspective. Thus, there is a lack of literature to make direct comparisons and references in the discussion section.
Social implications
This is the first study about forensic psychiatric aspects for people with Down syndrome. The aim of this study was to examine the forensic psychiatric approach in Down syndrome, one of the most common genetic causes of intellectual disability, the situations in which forensic psychiatric assessment is required and the issues that might be considered important in this regard. Although there are various publications in the literature on the psychiatric conditions of individuals with Down syndrome, to our knowledge, this is the first study to evaluate individuals with Down syndrome in terms of forensic psychiatric evaluation. People with Down syndrome are known to have varying degrees of intellectual disability and different types of psychiatric comorbidity.
Originality/value
People with Down syndrome are a heterogeneous group in terms of intellectual disability. The criminal responsibility and legal capacity of individuals may vary according to the legal situation. When requesting forensic psychiatric evaluation of these patients with psychiatric co-morbidity, patients should not be prejudged in terms of their level of mental competence and each case should be assessed individually.
1. Introduction
Down syndrome, resulting from 21st chromosome trisomy is one of the common genetic causes of intellectual disability. The Down syndrome phenotype includes symptoms affecting multiple body systems, particularly the musculoskeletal, neurological and cardiovascular systems. People with Down syndrome usually have short stature, muscular hypotonia, atlantoaxial instability, decreased neuronal density, cerebellar hypoplasia, intellectual disability and congenital heart defects, especially atrioventricular septal defect (Antonarakis et al., 2020). The life expectancy of people with Down syndrome is increasing over time due to increased access to treatments (Chua et al., 2020; Hughes-McCormack et al., 2020). With increased life expectancy, the number of adults with Down’s syndrome has increased, as has the frequency of their contact with the justice system.
The majority of people with Down syndrome are classified as having mild to moderate mental disabilities. Their cognitive profile shows that they have strong visual learning skills, but weaknesses in verbal working memory and episodic memory (Liogier d'Ardhuy et al., 2015). However, if differences in IQ, language, attention, memory and functional abilities are analysed, a wide range of cognitive qualification will be encountered.
To summarize the key findings on the mental and cognitive characteristics of people with Down syndrome, these individuals generally have variable intellectual disability and multiple health and psychiatric comorbidities. Down syndrome is associated with psychiatric comorbidities in 28.9% of cases. The most common conditions in individuals with Down syndrome include general anxiety disorder, obsessive-compulsive behaviours, neurodevelopmental disorders, depression and sleep disorders (Dalrymple et al., 2022; Startin et al., 2020). Compared to the general population, people with intellectual disabilities are at much higher risk of behavioural, emotional and psychiatric problems. In this respect, while bipolar disorder and schizophrenia are reported to be relatively less common in adults with Down syndrome, depressive mood, anxiety disorders and Alzheimer’s disease are suggested to be more common in people with Down syndrome than in the general population and people with intellectual disabilities with an aetiology other than Down syndrome (Brizard et al., 2021; Chicoine et al., 2021; Hussain et al., 2020; Santoro et al., 2021).
People with Down’s syndrome are often not treated with the same level of seriousness as other individuals when they are involved as victims or suspects within the legal system, as they are regarded as (or assumed to be) mentally incompetent. Consequently, stigmatization becomes a significant issue for people with Down’s syndrome. The literature discusses these individuals in terms of stigma and social vulnerability (Fisher et al., 2013). People with Down syndrome are often directly stereotyped as having intellectual disabilities or autism due to their specific facial appearance. Stigmatization exists both in society and among legal personnel. In current judicial proceedings involving people with Down syndrome, relevant institutions such as the prosecutor and police refer them directly to forensic psychiatric evaluation without taking their statements or conducting a preliminary evaluation. This situation is a consequence of the stigmatization of individuals with Down syndrome. Despite society and legal professionals holding prejudiced views, the cognitive abilities of individuals with Down syndrome exhibit heterogeneity.
This study comprises a descriptive examination of a case series, encompassing the clinical and legal attributes of individuals diagnosed with Down syndrome. These individuals have been subjects of forensic psychiatric assessments solicited by judicial entities in response to diverse legal contexts. The principal objectives of this study are to enhance recognition of the psychological diversity inherent within the Down syndrome population and to underscore the cognitive and legal prejudicial attitudes directed towards these individuals. The study aims to substantiate the assertion that such perspectives are fundamentally flawed. Although the rate of intellectual disability is high in people with Down syndrome, this condition is heterogeneously distributed and there are no serious problems with integration into the judicial system in mild forms of disability.
1.1 Background
The judicial system in Türkiye generally consists of three steps. These steps can be categorized as Courts of First Instance, Regional Courts of Justice and higher courts such as the Court of Cassation/Court of Appeal. At the top, as a separate classification, there is the Constitutional Court, which monitors the constitutionality of laws. Civil and criminal courts of first instance conduct first instance proceedings and hear cases. The Regional Courts of Appeal conduct appellate reviews and have supervisory jurisdiction over the decisions of the courts of first instance. The Court of Cassation conducts the final examination of legal disputes and sets an example in terms of legal standards. The Constitutional Court considers applications concerning constitutional violations and has the power to annul laws that are incompatible with the constitution. Courts may seek expert opinion at any stage (Kılınç, 2016).
In Türkiye, the Council of Forensic Medicine was established under the Ministry of Justice to act as an expert witness in justice affairs, to organize symposiums, conferences and similar events in the fields of forensic medicine specialization and sub-specialization programmes and other forensic sciences on issues falling within its field of duty, and to implement training programmes related to these. The duties of the Council can be summarized as; to provide scientific and technical opinions on issues related to forensic medicine sent by courts, judgeships and prosecutor’s offices and public institutions and organizations in areas deemed appropriate by the Council, to provide forensic medicine specialization and sub-specialization training in accordance with the legislation on specialization in medicine, to organize seminars, symposiums, conferences and similar events to carry out studies in the fields of forensic medicine and forensic sciences, to implement training programmes related to these and to assist in the preparation and execution of training programmes related to forensic medicine to be prepared by relevant institutions, organizations and boards (Doğan et al., 2022).
While the 4th Specialized Board of the Council of Forensic Medicine is a board where outpatient examinations are carried out and a report is issued on the relevant cases, the Expertise Department of Psychiatric Observation is an institutional body where the relevant cases are hospitalized and observed for up to three weeks and a report is issued according to the decision as a result of this observation:
TPC 32/1
“A penalty shall not be imposed on a person who, due to mental disorder, cannot comprehend the legal meaning and consequences of the act he has committed, or if, in respect of such act, his ability to control his behavior was significantly diminished. However, security measures shall be imposed for such persons.”
"Turkish Penal Code, 2004"
In Turkish law, the assessment of criminal responsibility is based on the legal provisions set out in Articles 31 and 32 of the Turkish Penal Code (TPC). In particular, the assessment of criminal responsibility of individuals between the ages of 12 and 15 is carried out in accordance with the scope described in Article 31 / 2 of the TPC (Turkish Penal Code, 2004). Meanwhile, cases involving allegations of mental disorder and mental weakness are examined in accordance with Article 32 (Turkish Penal Code, 2004). In Türkiye, the assessment of criminal liability in the case of intellectual disability is evaluated within the framework of the concept of “mental weakness” mentioned in the relevant article:
TPC 31/2
[…] where a minor is older than twelve, but younger than fifteen, at the time of an offence, and he is either incapable of appreciating the legal meaning and consequences of his act or his capability to control his behavior is underdeveloped then he is shall be exempt from criminal liability. However, such minors may be subject to security measures specific to children. Where the minor has the capability to comprehend the legal meaning and result of the act and to control his behaviors in respective of his act, for offences requiring a penalty of aggravated life imprisonment, a term of twelve to fifteen years of imprisonment shall be imposed and for offences that require a penalty of life imprisonment […]
"Turkish Penal Code, 2004"
In this context, it is noteworthy that, although criminal sanctions are not imposed in cases of alleged mental illness, a number of protective measures are put in place. Among these measures, the referral of individuals to specialized forensic psychiatric facilities for comprehensive monitoring and therapeutic intervention is a prominent aspect of the safeguards in place.
Disability rate was evaluated within the scope of the “Regulation on Disability Assessment for Adults” dated 20.02.2019 issued by the Presidency of the Republic of Türkiye. According to this regulation, if there is no other additional disease, 50% disability rate is given for mild intellectual disability, while 70% disability rate is given for moderate intellectual disability. Various calculations are made based on these rates and disabled people are paid a salary and various social rights are granted (Çankaya and Kahraman, 2024).
In Türkiye nowadays, there is no separate legal regulation for people with Down syndrome, but there are legal regulations for people with intellectual disabilities. The State is obliged to provide education to every child with special educational needs (intellectual disability, autism spectrum disorder, specific learning disability, etc.) in accordance with the principle of the social state. At present, the cost of up to 12 h of education per month is covered by the State (Tonbul and Çalışkan, 2021). Nevertheless, intensive efforts are being made to increase this to 40 h per month.
The aim of this study was to examine the forensic psychiatric approach in Down syndrome, one of the most common genetic causes of intellectual disability, the situations in which forensic psychiatric assessment is required and the issues that might be considered important in this regard. Although there are various publications in the literature on the psychiatric conditions of individuals with Down syndrome, to our knowledge, this is the first study to evaluate individuals with Down syndrome in terms of forensic psychiatric evaluation. People with Down syndrome are known to have varying degrees of intellectual disability and different types of psychiatric comorbidity (Startin et al., 2020). Due to associated behavioural problems and psychiatric disorders, individuals with Down syndrome may also be subject to legal mechanisms for various reasons (Tassé et al., 2016).
We present this study to highlight that individuals with Down syndrome are often referred directly to forensic psychiatry without undergoing an interview, despite the fact that this is a group with varied mental statuses.
2. Methods
2.1 Sample and data collection
Between 01.01.2018 and 31.12.2022, eight cases with Down syndrome, for which an opinion was requested from the 4th Specialized Board and Expertise Department of Psychiatric Observation of the Council of Forensic Medicine, were accessed through the electronic archive system. As the Council of Forensic Medicine allowed a five-year retrospective file search, we were able to access cases between these dates. During the period from 01.01.2018 to 31.12.2022, the 4th Specialized Board was requested to evaluate a total of 22,543 cases, while the Expertise Department of Psychiatric Observation was requested to evaluate 6,390 cases. Of these cases, only the eight people discussed in this article were found to have Down syndrome. The inclusion criteria require requesting an opinion from the Council of Forensic Medicine within the relevant dates and obtaining a definitive diagnosis of Down syndrome.
2.2 Procedure
In the study, data were obtained by determining the sociodemographic characteristics of the case, the reason for the request for forensic psychiatric evaluation, the relevant forensic case and the relevant decision, the mental status of the case, IQ score and disability rate, if any; the sociodemographic characteristics of the victim, mental status, proximity to the relevant case and the place where the incident occurred.
The data of the cases in question were obtained from the files of the Observation Specialized Department and the 4th Specialized Board through the National Judicial Network Project (UYAP) software. UYAP is a software programme that operates in all Ministry of Justice organizations and judicial units in Türkiye and all judicial, administrative and audit activities of these units are carried out electronically through this system (Çam, 2014).
While determining the level of intellectual disability, the clinical judgement of 12 psychiatry consultants working in the Council of Forensic Medicine in two separate committees (4th Specialized Board and Expertise Department of Psychiatric Observation) and was taken into consideration in addition to the clinically applied Kent and Porteus IQ tests.
In the seventh person, the continuation of the security measure was asked and it was decided that social recovery was revealed. This implies that individuals without criminal responsibility would be admitted to psychiatric hospitals for treatment instead of being incarcerated. Clinicians would then determine their discharge after achieving a state of well-being (TPC 57).
2.3 Assessment
The Expertise Department of Psychiatric Observation Evaluation Committee consisted of five professors of psychiatry and four expert doctors specialized in forensic psychiatry. The 4th Specialized Board comprises two professors of psychiatry, two psychiatry specialists, two associate professors of forensic medicine and an associate professor of neurology. This expert team is responsible for conducting forensic psychiatric evaluations of the cases. The expert team, which is the author of the article, conducted a comprehensive review of the relevant literature and developed a three-stage data form. Sociodemographic, clinical and forensic psychiatric data were collected. The questionnaire included general sociodemographic information such as age, gender, education, employment status and living arrangements for each individual. Forensic information included the type of offence, the place of offence, the victim of the offence, the victim’s gender, age and level of intimacy.
2.4 Data analyses
The cases included in the study were numbered sequentially. The data obtained at the end of this process was handled as a series of cases. The relevant statistical data were analysed using Microsoft Excel Office Software 2016.
2.5 Ethical approvement
To obtain and publish the necessary data in the relevant study, approval was obtained from the Scientific Research Commission of the Council of Forensic Medicine (Approve Number: 21589509 / 2022/1059).
3. Results
Between 2018 and 2022, the number of Down syndrome cases for whom an opinion was requested from the Council of Forensic Medicine in Türkiye (4th Specialized Board and the Expertise Department of Psychiatric Observation of the Forensic Medicine) in terms of criminal responsibility and legal capacity was determined as eight. The mean age of these cases was 24.63 years (±7.95) and the oldest of the cases was 39 years old and the youngest was 13 years old. It was observed that all of the individuals with Down syndrome were male. Mild intellectual disability was found in 3 / 8 and moderate intellectual disability in 5 / 8 of the cases. None of the patients exhibited alcohol and substance abuse (Table 1).
The average IQ level was found to be 54.13 (± 13.38), and it is seen that the IQ levels of the related cases ranged between 35 and 73. Two of the cases were given a 50% disability rate, and six of them received a 70% disability rate. Since the case with mild intellectual disability had additional neurological diseases, it was thought that this rate was given as 70%.
Of the cases for which legal opinion was requested, a report was requested in terms of criminal liability for 6 / 8 cases, for the continuation of security measures for one and for the necessity of guardianship for one. It was seen that four of the six cases for which opinion was requested due to criminal responsibility, the related crime was child abuse; one of them is deliberate injury and another one is intentionally endangering public safety. Details are given in Table 2.
Of the six cases, only one case, aged between 12 and 15, was evaluated by the Observation Department and was evaluated in accordance with the second paragraph of Article 31 of the TPC, and it was concluded that the ability to perceive the legal meaning and consequences of the act committed and to direct his/her behaviour was not fully developed. In the other five cases, criminal responsibility was removed and an assessment was made under Article 32 / 1 of the TPC. In seven of these eight cases, no statement was taken from the persons concerned by the judicial authorities and no statement of these persons was included in the case file. In the only judicial case related to guardianship, the statements of the person concerned were included.
Considering the six cases that came to be consulted due to the crime they have committed; two of the crimes were committed at the workplace (2 / 6 for criminal responsibility and 2 / 8 for total cases), one at a special education centre (1 / 6 criminal responsibility and 1 / 8 for total cases), one at home (1 / 6 criminal responsibility and 1 / 8 for total cases), another in the residential garden (1 / 6 criminal responsibility and 1 / 8 for total cases) and the last one in the public WC (1 / 6 criminal responsibility and 1 / 8 for total cases) was found to be processed.
When an examination is made in terms of the crimes that are the victims, it is seen that the victim of the crime of intentional injury has normal mental capacity and is a friend of the case. In the other four cases, opinions were requested due to sexual crime and it was seen that two victims were female and two were male children. One victim had intellectual disability and the incident occurred in a special education centre. The ages of the victims are listed as 15, 17, 7 and 8, respectively. Further details presented in Table 3.
Considering the closeness and relations of the victims to the cases, it is noteworthy that two of them are friends of the case, two of them are neighbours of the case and one of them is the nephew of the case.
4. Discussion
While individuals with Down syndrome have heterogeneous intellectual abilities, judicial authorities often seek forensic psychiatric opinions during legal proceedings without making any effort to interview them themselves. This suggests that people with Down syndrome face stigma based on their mental status. While Down syndrome is often stigmatized negatively, it is also perceived differently from other types of intellectual disabilities when viewed from a different perspective. Studies have shown that parents of children with Down syndrome, particularly those with positive personality traits, maintain positive perceptions of their children’s abilities through adolescence (Burke et al., 2012).
People with Down syndrome may have various psychiatric comorbidities (Startin et al., 2020). There are studies showing that these individuals have more behavioural and psychiatric problems compared to other children, as well as studies showing that people with Down syndrome have less social adaptation and forensic problems compared to other individuals with intellectual disabilities (Baumer et al., 2022). In the group included in our study, when we retrospectively scanned the files in the system, there were no medical records of additional psychiatric comorbidities in the file, so we identified additional psychiatric disorders based on the anamnesis obtained from the relatives of the individuals. However, mild or moderate intellectual disability was detected in all of our current cases.
In our study, we see that views on people with Down syndrome are mostly sought in terms of criminal responsibility. Sexual offences are at the top of the list. If we look at the content of these offences, we see that they remain at the level of simple sexual assault and there is no qualified situation. These are crimes committed in a way that is generally thought to be related to impulsivity. Other types of offences are seen as crimes that disturb the peace of society by shooting with a gun and deliberately injuring others. These are also considered to be impulsive crimes. There are studies in the literature that show that the risk of sexual assault increases in people with IQ scores of 71–84 (Vinkers, 2013). In this regard, our sample aligns with the existing literature regarding the type of crime. Providing treatment to control impulsivity in cases of high intellectual disability will have a positive effect on criminal behaviour.
Approximately 88.3% of individuals with Down syndrome are intellectually disabled (Ashraf et al., 2022). Moreover, the prevalence of Down syndrome in individuals with intellectual disability is approximately 2.5% (Emerson et al., 2012). As seen in our study, the presence of intellectual disability is important in the forensic psychiatric assessment of individuals with Down syndrome. It is known that individuals with intellectual disability have higher rates of aggressive behaviour in forensic psychiatric settings compared to individuals without intellectual disability (Chester et al., 2018). Serious mental illness has been found to be more prevalent among people with intellectual disabilities compared to their peers without intellectual disabilities (Perera et al., 2020). Nevertheless, some authors argue that the risk of mental illness is not increased in people with mild intellectual disabilities (Perera et al., 2020). The sample cases included people with mild to moderate intellectual disability, so the fact that an additional psychiatric disorder was observed less frequently supports the second view. Of course, the lack of access to medical reports, which will be discussed later, is a limiting factor for this interpretation.
In the field of forensic psychiatry, it can be stated that intellectual disability (ID) plays a significant role in cases where criminal responsibility is being evaluated due to criminal behaviour. A recent study conducted in Türkiye revealed that ID has a high prevalence rate of 20.2% among all cases labelled as perpetrators (Ersolak et al., 2023). In other studies conducted in Turkey, rates of mental deficiency in forensic psychiatry cases were reported as 11%–16% (Bolu et al., 2014; Çöpoğlu et al., 2014). It is therefore important to study ID in terms of its potential to cause criminal behaviour and to implement various programmes to prevent these individuals from becoming perpetrators or victims. The prevalence of attention deficit/hyperactivity disorder (ADHD) in individuals with Down syndrome varies, with one study reporting a 33% prevalence of ADHD symptoms in adults based on health records, while another study found a 30% prevalence in Down syndrome children aged 2 to 4 years (Ekstein et al., 2011). Two cases in our study were found to have ADHD according to information provided by their relatives. One person committed sexual assault, and the other individual intentionally endangered public safety. Impulsivity, a component of ADHD, can be linked to both of these offences. It is noteworthy that treating impulsivity in these cases could help in preventing individuals from engaging in acts defined as offences.
Over a quarter of adults with Down syndrome are believed to be affected by a psychiatric disorder, and major depressive disorder is the most frequent one among them (Visootsak and Sherman, 2007). In terms of intellectual disability, some studies have reported similar rates of depression in individuals with Down syndrome and intellectual disability (Mantry et al., 2008). Nevertheless, previous studies have discovered elevated levels of depression or depressive symptoms in elderly individuals with Down syndrome (Dykens et al., 2015). On the other hand, one study found that the prevalence of anxiety and depression was lower in the Down syndrome population compared with controls, and the difference between these groups increased with age. For individuals above the age of 30 years, those with Down syndrome had lower depression and anxiety rates when compared to the control group (Alexander et al., 2016). Regarding OCD, the prevalence of obsessive-compulsive disorder in people with Down syndrome is unclear. However, some studies suggest that individuals with Down syndrome are susceptible to OCD (Sclanavo and Sebes, 2020). The literature presents inconsistent data on the prevalence of depression, anxiety and OCD in people with Down syndrome. Our study investigating the relationship between psychiatric conditions and the legal system in people with Down syndrome observed the presence of one case of anxiety disorder and one case of OCD. It is worth noting that these diagnoses were observed in individuals with relatively higher intellectual capacity. This observation might be explained by the possibility that anxiety and depression diagnoses might be overlooked in people with lower intellectual functioning due to more severe behavioural problems, or by the lack of access to sound information about these diagnoses.
The prevalence of autism in people with Down syndrome varies between 5% and 42% in different studies (Diniz et al., 2022). Although there is no specific literature on Down syndrome and criminal behaviour, it is known that additional psychiatric disorders commonly seen in adults with autism spectrum disorder are risk factors for criminal behaviour (Buck et al., 2014; Helverschou et al., 2015). It has been suggested that criminal behaviour in people with autism spectrum disorder (ASD) is associated with comorbid diagnoses (e.g. psychosis and/or personality disorders) rather than with ASD (Grant et al., 2018). However, these studies are usually based on selected samples, such as psychiatric hospitals or forensic psychiatric units, where higher rates of psychopathology might be expected. As a result of the assessments made in relation to the offences involved, it was decided that the offenders were not criminally responsible. The assessment of criminal responsibility was carried out under Articles 31 and 32 of the Turkish Penal Code (Yenisey, 2021). When assessing criminal responsibility in individuals with autism spectrum disorder, it is important to evaluate their ability to understand the legal implications and consequences of their actions as well as their ability to exercise control over their behaviour. To achieve this, the level of autism, awareness and impulsivity must be examined meticulously.
For the first of the two cases other than the cases where criminal responsibility was questioned, an opinion was received on the necessity of the continuation of the security measure decision. In the evaluation made here, it was stated that the current situation of the case does not require a security measure and that social recovery has been realized, provided that outpatient psychiatric follow-up continues. In the other case, the restriction and guardianship of a person with Down syndrome diagnosed with mild intellectual disability was asked and it was decided that there was no need for guardianship of the person as a result of the mental status examination. As can be seen, the criminal or legal capacity of persons with Down syndrome may differ in each case. Therefore, each case should be evaluated separately. People with Down syndrome are a heterogeneous group in terms of intellectual disability. Therefore, cases cannot be classified into a single group in terms of both criminal and civil liability. Each case and legal situation will need to be evaluated separately.
When the places where Down syndrome people who are asked about criminal responsibility have committed the alleged crimes are evaluated, it is seen that there are places such as houses, schools and gardens where most of their lives are spent. It is seen that people who are victims of crime are mostly people who have a close relationship with them. In only one case, the victim was found to have an intellectual disability, and in all other cases, the victims were people with normal mental capacity. All these show that, as expected, in cases where the psychiatric follow-up of the syndromic people is done regularly, the caregivers themselves and their environment can suffer the most from this situation.
In the case of the seventh individual, the question was posed as to whether the security measure should be continued. It was determined that social improvement had occurred, which signifies that individuals who are not criminally responsible will be hospitalized in psychiatric hospitals for treatment instead of being imprisoned. The fundamental rationale behind protection treatment, which is one of the security measures, is to control the disorder that causes the relevant offence by treating it. In cases such as ID, where there is no absolute treatment, protection treatment can be continued in the form of outpatient clinic controls after a standard treatment routine has been established. This routine is generally symptom-oriented and aims to reduce impulsivity, as well as controlling irritability and anxiety.
People with Down syndrome do not all have the same intellectual ability. As previously mentioned, individuals with Down syndrome exhibit intellectual diversity. Direct communication between judicial authorities and the individuals involved in legal proceedings is essential. Nevertheless, people with Down syndrome can have varying degrees of intellectual disability. Regarding forensic psychiatric assessment, it is essential to take into account the possible presence of intellectual disability and evaluate their capacity to comprehend the pertinent event and regulate their conduct. Moreover, these individuals may suffer from psychiatric comorbidities. Individuals with these comorbidities should undergo an evaluation that considers not only intellectual disability but also the appropriate clinical context, including the clinical features of the disease.
4.1 Limitations
Regarding the limitations of our study, the first one is the small sample size. Nevertheless, due to the low prevalence of people with Down syndrome in society, it is plausible that their stigmatization may not be reflected in the judicial system, even in cases involving violent behaviour. The second limitation is that the reports lack all psychiatric medical documents, including forensic psychiatric evaluations of individuals with Down syndrome. Additionally, additional diseases were recorded based on familial anamnesis. The third limitation is that this study is the first publication to investigate Down syndrome from a forensic psychiatric perspective. At last, the study is limited to a country where the continental European legal system is valid. It is important to note that the assessment of criminal responsibility may differ in the Anglo-American legal system. Thus, there is a lack of literature to make direct comparisons and references in the discussion section. To maintain the anonymity and confidentiality of the individuals involved, the sociodemographic information was not provided in detail. This may be considered a limitation in terms of sociodemographic information.
5. Conclusion
Down syndrome is a common genetic cause of intellectual disability and may also be associated with psychiatric comorbidities. Hence, regular psychiatric follow-up is necessary. People with Down syndrome have varying degrees of intellectual disability and hence cannot be considered as a homogeneous group. The legal capacity and criminal responsibility of individuals with Down syndrome may vary depending on the relevant legal situation. Although intellectual disability is an important factor in the evaluation of these individuals, they should not be pre-judged based on their competence level. Each case should be evaluated individually. People with Down syndrome and psychiatric comorbidity should undergo forensic psychiatric evaluation, taking into account the relevant comorbid disorder. Conducting studies to determine the forensic psychiatric and psychiatric needs of individuals with Down syndrome and to increase awareness will be helpful in addressing the deficiency in this field. The stigmatization of individuals with Down syndrome may also result in them being victims in prosecution and forensic psychiatric evaluation processes. Although ID is accompanied by a high rate of stigmatization, it should be kept in mind that not all individuals with ID have the same level of impairment and that they can perceive the attitudes towards them. Furthermore, it should be kept in mind that these individuals are individuals with high social vulnerability. It is recommended that future studies examine the clinical and criminal characteristics of individuals with Down syndrome in a cross-sectional and prospective manner. Furthermore, it is important to increase social awareness about people with Down syndrome.
The authors declare that there are no acknowledgements.
Conflict of interest: The authors declare that there is no conflict of interest.
Funding: The authors received no funding from an external source.
Sociodemographic and mental status of the cases
| Case | Age | Gender | Level of intellectual disability5 | IQ Score1 | Disability %2 | Is there a comorbid psychiatric disorder?3 |
|---|---|---|---|---|---|---|
| 1 | 13 | M | Mild intellectual disability | 64 | 50 | ADHD4 |
| 2 | 31 | M | Moderate intellectual disability | 35 | 70 | Not known |
| 3 | 39 | M | Moderate intellectual disability | 45 | 70 | Not known |
| 4 | 25 | M | Mild intellectual disability | 70 | 70 | Anxiety disorder |
| 5 | 26 | M | Moderate intellectual disability | 50 | 70 | Not known |
| 6 | 21 | M | Moderate intellectual disability | 50 | 70 | ADHD4 |
| 7 | 18 | M | Moderate intellectual disability | 46 | 70 | Not known |
| 8 | 24 | M | Mild intellectual disability | 73 | 50 | Obsessive-compulsive disorder |
Notes: 1Kent and/or Porteus IQ Tests;
2It was evaluated within the scope of the “Regulation on disability assessment for adults” dated 20.02.2019 issued by the Presidency of the Republic of Türkiye;
3There are no relevant medical documents in the file of the court case. Nevertheless, the absence of a psychiatric comorbidity in the record does not necessarily mean that these individuals do not have a psychiatric comorbidity. In cases 1, 4, 6 and 8, the psychiatric disorders were not on the basis of medical records, but on the basis of the statements of the persons’ relatives;
4Attention-Deficit/Hyperactivity Disorder;
5The decision is based on IQ tests and clinical assessment
Source: Table by authors
Legal issue and decision
| Case | Legal issue | Reason for requesting opinion | Decision | Statement taken?* |
|---|---|---|---|---|
| 1 | Criminal responsibility | Sexual crime | No aware of the action | No |
| 2 | Criminal responsibility | Sexual crime | No criminal responsibility | No |
| 3 | Criminal responsibility | Sexual crime | No criminal responsibility | No |
| 4 | Criminal responsibility | Intentional injury | No criminal responsibility | No |
| 5 | Criminal responsibility | Sexual crime | No criminal responsibility | No |
| 6 | Criminal responsibility | Intentionally endangering public safety | No criminal responsibility | No |
| 7 | Security measures | Continuation status of the security measure | Social healing had revealed | No |
| 8 | Capacity to act | Guardianship | Full legal capacity and guardianship not approved | Yes |
Note: *Has a statement been taken by the judicial authorities?
Source: Table by authors
Crime and characteristics of the victim
| Case | Crime | Case place | Victim situation | Victim’s gender | Victim’s age | Victim’s relation |
|---|---|---|---|---|---|---|
| 1 | Sexual crime | Special education centre | Intellectual disability |
F | 15 | Friend |
| 2 | Sexual crime | House | Normal intelligence | F | 17 | Nephew |
| 3 | Sexual crime | Residential garden | Normal intelligence | M | 7 | Neighbour |
| 4 | Intentional injury | Workplace | Normal intelligence | M | * | Friend |
| 5 | Sexual crime | Public WC | Normal intelligence | M | 8 | Neighbour |
| 6 | Intentionally endangering |
Workplace | * | * | * | * |
Notes: * No information was found in the case file; ** He took his father’s licensed gun and fired it around
Source: Table by authors
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