Care and Treatment of Offenders with Learning Disability

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Care and Treatment of Offenders with Learning
Disability
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Services for People with Special Needs

• 1960s and before
• Large institutions (5000 people and more)
• Little concern regarding the rights of the people
  served.
• Atrocities in the name of behavior management.

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• 1970s
• Greater awareness of rights of people with
  special needs.
• Landmark legislation
• Continued reports of rights violations (Sunland
  Center)

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• Late 1970s and 1980s a plethora so service
  options begin to appear group homes,
  independent living, parent training, respite
  services, supported living, supported work, etc.
• Cherry picking
• People with few behavior challenges
• Noncompliance
• Tantrums

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• Late 1980s and 1990s
• Big push to depopulate institutions (largely cost
  cutting)
• People with behavior challenges move into
  community
• 50 leave and 70 return (Personal communication)
• Community not prepared for people with behavior
  challenges I told you so!!!

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• Late 1990s 2000s
• Those remaining in institutions
• People with serious medical problems
• People with severe behavior challenges
• People with special needs and forensic
  backgrounds assault, theft, Pedophilia.
• People determined to be a danger to self and
  others.
• People who refuse to show remorse.
• People who refuse to learn from the consequences.

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Linear Model

• Many attempts to move people with severe behavior
  challenges / forensic backgrounds into the
  community.
• Many failures (Lack of commitment.)
• The problem!!!!
• Linear Model to Services
• A------?B-----?C
• Overreliance on consequences
• Dont believe it will work!!!

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Person Centered Behavioral Supports
BEHAVIORAL ASSESSMENT
Process
Content
Materials
MULTI-ELEMENT SUPPORT PLAN
PROACTIVE STRATEGIES
REACTIVE
Focused Support Strategies
Ecological Changes
Positive Programming
Situational Management
MEDIATION
TRAINING
CHANGE AGENTS
General
Natural
Specialized
Professional
Specific
Compliance
OUTCOME MEASURES
Speed Degree Of Effects
Clinical / Educational Validity
Generalization Of Effects
Social Validity
Durability Of effects
Side Effects
Over Time
Episodic Severity
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TJ A Brief Case Study

• 23 Years Old
• Diagnoses
• Attention Deficit Disorder
• Tourettes Syndrome
• Fetal Alcohol Syndrome
• Obsessive Compulsive Disorder (OCD)
• Touching, spitting
• Autism
• Pervasive Developmental Disorder

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• Cognitive Domain
• Average Intellectual Functioning
• WAIS (FS 91)
• Problems concentrating
• Problems with comprehension of social rules
• Problems understanding social nuances
• Doesnt understand WHY? people dont like what he
  does.
• Doesnt understand WHY? people dont like to be
  touched the way he touches.

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• Language / Communication Domain
• Good receptive, but gets confused easily
• Can express needs
• Poor word retrieval (easily frustrated)
• Special words and names for people, places and
  functions
• Ya Ya
• Captain
• Ass hole
• Dirt bag

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Living Arrangements

• From 1992 to 1999
• 26 different living arrangements
• Group homes
• Psychiatric hospitals
• Respite
• Crisis homes

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• From 1999 to 2003
• Forensic unit
• Physical aggression
• Sexual touching of roommate
• Arrested and placed because of Breach of Peace
• Three staff with him 24-hours-a-day
• 4-point restrain, 24 hours a day.
• Turned down by all services for placement in the
  community
• Accepted to IABA supported living

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Start IABA Services

• Transition period
• Transported in private plan in restraint
• Supported living

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Ecological Strategies

• Two story house no staff goes upstairs
• Damage protocol
• 31 staffing ratio during waking hours
• 1 staff member on break each hour
• Ratio NOT for purpose of restraint
• Community Rules for staff
• Dos and Donts
• Therapist for Sexual Difficulties
• Interactional Guidelines
• No good-looking staff
• Thick-skinned staff

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Positive Programming

• Prep for community activities
• Set order and expectations
• PET
• Relaxation
• Compliment Board
• Holiday protocol
• Grocery shopping protocol
• Healthy Living protocol
• Alt-R for Good Will (tickets)
• Alt-R for Self Control
• Daily Schedule
• Stimulus Control for Touching

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Focused Support Strategies

• Driving in private vehicles (Earns additional
  drives)
• Alt-R for working phone
• DRO for ISB and IT (Road worth up to 150.00
  toward item of choice (prespecified.)
• DROP for PA (Road worth up to 150.00 toward
  trips)
• DRO for PA (consecutive days- 3 days in a row
  with no PA extra pick a card )
• DRO for PD (1.00 per day box toward pick a
  card)
• DROP for PT, AT, Stealing, and relaxation (Pt
  chart which leads to signatures toward fun
  activities.)

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Reactive Strategies

• Active Listening
• Stimulus Change
• Remind TJ of Natural Consequences
• When it is OK to Leave the House - Staff
• Strategic Capitulation
• Emergency Protocol
• Run
• Transport to hospital
• Etc.

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Administration / Management

• Critical incident debriefing protocol
• Administering medication
• Staff room protocol
• Staff break protocol
• Clinical PSR

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Summary of Progress

• Quality of Life
• Living in own home (3rd Home)
• Environmental modifications and repair
• Family contact Communication/Visits
• Get-a-ways e.g., Solvang, Santa Barbara, etc.
• Pending
• Pet (cat)
• More visits home
• Intimate relationship
• Starting to define his sexuality / Openness
• Community Activities (100 Self Choice)
• Animal Shelter Volunteer (2-4 hours/week)
• Clubs (4-8 Times a month)
• Restraint Free

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The survey carried out by the Department of
Health and Human Services, Centers for Medicare
and Medicaid Services (formerly Health Care
Financing Administration (HCFA)), in their report
dated October 4, 2001, stated that TJ was
restrained 600 out of 720 hours (83) during
September 2001, 344 out of 744 hours (46) in
August 2001 and 368.5 out of 744 hours (50) in
July 2001.
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In March of 2002, virtually all of TJs time was
spent in 4-point mechanical restraints.
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Behavioral Outcomes
Summary of Progress

• Physical Aggression

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Observational Reliability 11/05 93 12/05
100 2/06 75 4/06 89 6/06 94 8/06
100 12/06 100 2/07 74 4/07 98 4/07
71 (new staff) 5/07 95 9/07 96
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Levels of Episodic Severity
6-Criminal charges filed 5-Loss of
work 4-Medical treatment 3-First aide 2-Attack
on private body part(s) 1-Other
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From Prior State Records
One male staff has missed 259 days of work
secondary to a knee injury and surgery. He still
is unable to bear weight on his injured leg.
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From Prior State Records
One female staff had her thumb grabbed and
twisted. She was thrown to the floor and
sustained a knee injury. Surgery has been
unsuccessful. She has missed 87 days of work and
cannot yet bear weight on her injured leg
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From Prior State Records
Multiple female staff have threatened with having
their breasts bitten off. One female staff had
her sweater pulled off. Another female staff was
kicked in the breast. Three others were grabbed
in the breast. Staff had to pry TJ off two of
these women. One of these women suffers from
PTSD as a result of the assault. Although she
has returned to work, she has been unable to work
on her assigned ward as TJ continues to be
treated there.
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From Prior State Records
Multiple male staff have been kicked or grabbed
in the groin. One man sustained a hernia as a
result of TJs pulling on his scrotum. This man
had to undergo surgical repair In the January
30, 2002 incident he pulled a handful of hair out
of the head of a female staff member before other
staff could get him to release his grip.
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Behavioral Outcomes

• Inappropriate Sexual Behaviors

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Behavioral Outcomes

• Other

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(No Transcript)
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Social Validity
Summary of Progress

• Staff turnover (staff initiative)
• 18 in first 12 months
• 0 in last 12 months

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Social Validity
Summary of Progress

• Consumer Satisfaction
• Family Satisfaction - Letter

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Social Validity
Summary of Progress

• Department Manager

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Generalization
Summary of Progress

• 24-hour data
• Home visit
• Honeymoon periods
• Cycles

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Durability
Summary of Progress

• Prosthetic support
• Rapport
• Ecological strategies
• Lack of restraint - consequences
• Use of hospitalization (ask vs. hurt)

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Side Effects
Summary of Progress

• Most behaviors are directly measured
• Restricted access to knives, daggers guns
• Distance from family

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Contributions to Success

• Non-linear, multi-element plan
• Positive plan (absence of restraints)
• Staff characteristics
• Attitude Dont take it personally.
• Available mental health hospital
• Good quality psychiatric consultation

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Hospitalizations
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Current Medications(Dr. Reyes)
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What Hasnt Worked

• Formal positive programming
• Use of mental health facility
• Participation in some programs
• Increasing social opportunities
• Overreliance on paid staff
• Continued presence of three staff
• Reduction has begun cautiously
• Continued need for prosthetics
• May be required for some time to come

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TJA Person In The ProcessOfBecoming