Treatment Approaches in Offenders with Learning Disability: What Works

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Treatment Approaches inOffenders with Learning
DisabilityWhat Works?

• - What Do We Know?- What Do We Need to Know?-
  What Gaps Can We Fill?- What are the Service
  Implications?

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Treatment Approaches

• 1. Learning Disability-Related
• 2. Health/Mental Health-Related
• 3. Offence-Related

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1. Interventions related to Learning Disability
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Learning Disability - Related Issues and
Approaches

• The relevance of severity of learning disability
  
• Relevance of cognitive profile - specific
  deficits
• Relevance of academic attainments

• Relevance of social deficits
• The importance of cause/aetiology of learning
  disability
• The influence of Life experience and personal
  history, especially extreme deprivationabuse

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Severity of LD/Cognitive Profile

• Contributes to understanding of offence
• Frames style/mechanism of therapeutic
  inter-action
• Determines possibilities of modes of inter-action
• Statutory Implications
• Evidence-base empiricalpublished

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Academic Attainments

• Inputs concerning basic literacy and numeracy
  Empiriacl appeal, plus longstanding
  evidence base from which to extrapolate (eg
  Head Start)
• Mode of therapeutic inputs pictorial/new
  technology, etc - emphasis on framing
  intervention to meet individual attainments

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Social deficits

• Long history of social skills based interventions
  in all intervention with people with learning
  disability
• Both in community and hospital-based treatment
  settings
• Here, aims at developing alternative life
  strategies other than offending
• Close attention to self-esteem, attainment and
  positive contribution to society

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Cause of Learning Disability

• Where genetic, evidence contributes to design of
  interventions - Behavioural Phenotypes (e.g.
  Tuberous Sclerosis, XYY, Smith-Magenis,
  Tourrette, Sotos, etc, etc)
• Where acquired, similar considerations apply -
  especially Head Injury/Brain Damage

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Why are Behavioural Phenotypes relevant here?

• Genes code for proteins
• Which design and regulate all body systems
• Including the Brain
• Which controls behaviour
• Learning disability entails disruption of brain
  function
• So, depending on genetic mechanism, behavioural
  phenotypes present
• This informs long-term management

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Life Experience, Deprivation and Abuse

• As cause of learning disability - or a
  compounding factor
• Many general inputs aim to compensate and/or
  ameliorate
• Evidence base mainly in respect of abuse
• Also, in respect of role-modeling limit setting

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2. Health and Mental Health Related Interventions
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Psychopathology in LD Offenders Received Wisdom
RD Issues

• Extent and Nature of Psychopathology in LD
  Offenders Less Clear
• Generic Treatments Employed Empiricism
• Few Naturalistic Outcome Studies
• Fewer Still Controlled Outcome Studies
• RCTs???
• Ethics!

• Extent and Patterns of Psychopathology in
  Learning Disability are Known
• Appropriate Treatments Appear to be Available
• Natural History of Disorders is Largely
  Understood
• Impact of Societal Changes and of New Service
  Patterns?

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Psychiatric Diagnoses ()Psychiatric and
Offenders Units
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Health-Related InterventionsExamples

• 1. Epilepsy-related
• 2. Autism-related

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Epilepsy and Offending Overview of interactive
mechanisms

• (Not including learning, interpersonal,
  experiential, family, and social issues)

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1. Epilepsy and Offending
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2. Seizures and Offending
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3 Peri-ictal Period and Offending
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2. Autistic Spectrum Disorder managing
offending behaviour

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Overview

• Autism and Antisocial Behaviour/Offending - the
  General Issues
• Typology of Offending in Autism
• Implications of the Typology for the Management
  of Aggression/Antisocial Behaviour in Autism

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PDD (Pervasive Developmental Disorder) and
Offending

• PDD over-represented in offender populations
  (Scragg and Shah, 1994)
• Antisocial and Aggressive Behaviour common in
  Asperger Synd. (Tantam, 1988)
• Bizarre patterns of offending reported in PDD
  arson and sex offending (Le Couteur, 1991,
  Cooper, 1993)

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Typology of Offending in Autism(Howlin, 1992)

• Individual led into criminal acts by others,
  through social naivety
• Aggression resulting from disturbance of autistic
  routines or preoccupations
• Social deviance resulting from misunderstanding
  of social cues
• Antisocial behaviour which stems from obsessional
  thinking

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Lessons from the Typology of Offending in
Autism1

• Individual led into criminal acts by others,
  through social naivety
• Make Family, Clinicians and Carers aware
• When it happens, explain
• Consider peer group and socialisation
• Important focus of the person with autisms
  education

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Lessons from the Typology of Offending in
Autism 2

• Aggression resulting from disturbance of autistic
  routines or preoccupations
• Dont do it suddenly
• Employ Limit-setting, Shaping, Reverse-Chaining
• Respect the need for Order
• and Predictability
• (But remember that things can be changed)

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Lessons from the Typology of Offending in
Autism 3

• Social deviance resulting from misunderstanding
  of social cues
• As before, educate Family, Clinicians and carers
  of the possibility
• When it happens, explain
• Important focus of the individuals Social
  Education

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Lessons from the Typology of Offending in
Autism 4

• Antisocial behaviour which stems from obsessional
  thinking
• Important to Detect possibility
• Again, Parents, Carers education
• May require Medication SSRI Risperidone
• Cognitive techniques?
• Educational Interventions more established

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3. Offence-Related Interventions
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Key Focuses in Offence-Related Interventions

• Sex Offending and Sexuality
• Anger and Anger Management
• Aggression
• Fire-setting
• Motivation

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Offence-Related InterventionsA Few Observations

• General Intellectual and Specific Cognitive
  decicits suggest need for specialist evidence
  base
• Evidence base is amassing (cf many presentations
  this conference)
• As with medication - Start low, go slow, avoid
  multiple changes
• Anticipate resurgence of problem/offending over
  course of therapy

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Management Strategies
Offence Specific Treatments
Structured Social Learning
Other Treatments
Structured Week/ Day. Balanced
timetable Occupational Social Recreational Indepe
ndent/ Daily Living Skills A Cautious Approach
to Decision Making Personal Freedom Incentive
Scheme

• Pre-treatment focus groups.
• Offence Related
• Closed Groups
• Individual

• Speech Language Therapy.
• Further Education
• Medication - timing key issue

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Elements of a Service

• Legislation which enables treatment
• Effective Communication and Referral Links
• Multidisciplinary diagnostic assessment
• Expertise Appropriate Resources
• Appropriate Treatment Setting(s)
• Appropriate Treatment Approach(es)
• Academic Programme