Care Pathways for the Learning Disabled Offender

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Care Pathways for the Learning Disabled Offender

• 0r
• Investigating Pathways to
• Ultimate Social Exclusion

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Care Pathways Should be

• Inclusive
• Equitable (OBrien Principles, etc)
• Rational
• Fair
• Auditable
• Cost Efficient
• Socially Responsible
• Informed by an Evidence Base

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Oh, Yeah?
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Plan of Talk

• 1 Setting the Scene
• 2 Looking Forwards Some Pointers in Prevention
• 3 Looking Back In-Patient Studies
• 4 Pathways Through Care
• 5 Multi-Centre Care Pathway Study
• 6 And why it almost didnt happen Section 60 of
  the Health and Social Care Act (England and
  Wales), 2001 and PIAG

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1 Setting the Scene
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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

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2 Looking Forwards Developmental Trajectories
and their Implications
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Children with Learning Disability and Adult
Capacity for Independence

• A Cohort Study of the Adult Outcome of
  Childhood Learning Disability

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How are They Now? Children with Learning
Disability Grown Up

• Identify and Find Adults with History of Child
  Learning Disability
• Not easy - Registers are not maintained
• Measure their Abilities Skills
• Carry out Psychiatric Examination
• Study their Service and Care History
• How does Child Learning Disability relate to
  these Features in Adulthood?
• How much can we plan in advance?

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Case Note Trawl and Interviews

• Study of school health records of all 33,800
  Cambridge HA Children born 1967-73.
• Identified 326 with iqlt80, who had received
  special schooling
• Of 228 still living locally, 148 agreed to
  participate

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Adult Abilities and Skills Relationship with
Child IQ
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Child IQ and Adult Vineland
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Adult Vineland Social Scoreby Child History
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Psychiatric Disorders
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Child Learning Disabilityand Adult Autism ()
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Child Learning Disability Adult Psychiatric
Diagnoses ()
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Child Learning Disability Anticipates Adult
Social Capacity and Psychiatric Conditions

• Argues for More Careful Follow-up
• Especially in More Severe Cases
• Especially for Autism Screening

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Autism and Offending - Some pointers to avoid
the Pathway into Secure Services

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Antisocial Behaviour in Autism Four Common
Scenarios(Howlin, 1992)

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

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What to do about it

• 1 Individual led into antisocial acts by others,
  through social naivety
• Make Parents, Teachers and Carers aware
• When it happens, explain
• Consider peer group and socialisation
• Important focus of the young persons education

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What to do about it

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

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What to do about it

• 3 Antisocial behaviour resulting from
  misunderstanding of social cues
• As before, educate Parents, Teachers and carers
  of the possibility
• When it happens, explain
• Important focus of the Adolescents Social
  Education

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What to do about it

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

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3 Looking Back

• Clinical Correlates of Service Pathways
• Insights from In-Patient Studies

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Northgate Hospital In-Patient Services for LD
Offenders andPsychiatric DisordersCan we
Discern any Diagnostic or Aetiological
Differences?
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Questions

• Which Psychiatric Disorders do we encounter in
  clinical practice with adult learning disabled
  aggressive offenders?
• What were the causes of learning disability among
  these adults?
• How does this compare with clinical practice
  among learning disabled adults with psychiatric
  problems?

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Prospective Clinical Study

• Consecutive admissions over 4 Years to 2
  In-Patient Units of One Hospital for Adults with
  Learning Disabilities
• Severity of Learning Disability
• Psychiatric Diagnoses by ICD-10
• Genetic and Non-Genetic Aetiologies

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In-Patient Service for Offenders with Learning
Disabilities

• 168 beds (32 female 136 male)
• Varying levels of security Medium Low Locked
  Rehabilitation
• All Patients detained mostly from Courts
• Patients from throughout G.B.
• Mostly opened within past ten Years

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In-Patient Unit for Psychiatric Problems in LD
Adults

• 24 Beds
• Open Unit
• Mostly Informal Patients Some Detained
• Three Health Authority Districts Host Population
  1,000,000

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Severity of Learning DisabilityLD Psychiatry
Unit (n109)and LD Offenders Unit (n119)
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Psychiatric Diagnoses ()Psychiatric and
Offenders Units
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Psychiatric vs. Offenders UnitsPatterns of
Psychopathology

• Schizophrenia, Bipolar Disorder and Anxiety
  Neuroses - (Adult Mental Illnesses) more
  prevalent among Psychiatric In-Patients
• ADHD and Autism (Neuropsychiatric Disorders)
  more prevalent among LD In-Patient Offenders

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Psychiatric vs. Offenders UnitsChildhood Brain
Damage ()
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Childhood Brain Damage- as common as all other
causes added together

• Most common cause of LD identified
• Accompanied buy other problems
• Devastating in long term impact

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4 Pathways Through Care
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Aims

• To ensure no person with learning disability is
  in custody unrecognised
• To meet the mental health need of offenders with
  learning disability
• To improve public safety

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Retrospective Survey - Medium Secure
ServicesAdmission and discharge patterns
between August 1995 and August 1998. Total
Admissions 59

• Source of Admission
• Age on Admission.
• lt 20 11 18
• 21-30 30 51
• 31-40 14 24
• gt 40 4 7

• Area of Origin.
• 41 originate from core catchment areas.
• 71 originate from the north of England.
• Evidence suggests that those from outside the
  locality use our service because there is nothing
  available in their own area.

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5 Investigating Care Pathways
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Multi-Centre Study

• Commissioned by DoH

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Flow Diagram of Study

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The problem

• Case Note Study Requires Patient Consent
• Patient Contact Difficult Consent Moreso
• MREC Recommends Section 60 Application

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Section 60Health and Social Care Act 2001

• Act requires that all patient identifiable data
  can only be used for research with Patient
  Consent
• Recognises that in some projects this is
  unfeasible, impossible or undesirable
• Where the project is sufficiently important,
  Exemption under Section 60 may be granted
• PIAG Patient Information Advisory Group meets
  quarterly, and is very conservative on these
  matters
• We were advised by PIAG to to a pilot study

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• Over the three centres of the study, 37 subjects
  were taken for this pilot study being
  approximately 10 of the total sample of 400.
  These were individuals who had been referred to
  the local services in the three areas of the
  study Tayside North East England Eastern
  Region.
•  
•  
• It proved impossible to contact 13 of the 37.
• Of the 24 interviewed, 19 (79) consented.
• We have an overall consent rate of only 51.
• We cannot tell whether the individuals for whom
  we lack consent are representative of the whole.
  
• One feature of those who consented was, that
  these included all but one of those who are in
  in-patient care - all but one of those who could
  not be contacted or who refused were in other
  community facilities
• This demonstrates that the requirement to gain
  patient consent biases the data beyond
  usefulness.

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Result of Application

• Provisional approval
• This means that the study proceeds outwith the
  province of the Ethical Committees
• The application may set a precedent for others

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Principles to Follow in Research

• Personal/Clinical Relevance
• Highest Ethical Standards
• Multidisciplinary
• Clinical-Scientific Collaboration
• Multi-Agency
• Subject/Service UserAdvocacy Involvement
• Keep it Feasible

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Core Team

• G OBrien
• J Taylor North East England
• A Holland
• M Bambrick East Anglia

• W Lindsay
• D Carson East Scotland
• S Johnson
• S Young High Secure Sector