Care Pathways for the Learning Disabled Offender

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Care Pathways Should be. InclusiveEquitable (O'Brien Principles, etc)RationalFairAuditableCost EfficientSocially ResponsibleInformed by an Evidence Base . Oh, Yeah?. . Plan of Talk. 1 Setting the Scene2 Looking Forwards Some Pointers in Prevention3 Looking Back In-Patient Studies4 Path

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Care Pathways for the Learning Disabled Offender

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1. Care Pathways for the Learning Disabled Offender 0r “Investigating Pathways to Ultimate Social Exclusion”

2. Care Pathways Should be Inclusive Equitable (O’Brien Principles, etc) Rational Fair Auditable Cost Efficient Socially Responsible Informed by an Evidence Base

3. Oh, Yeah?

4. 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 didn’t happen: Section 60 of the Health and Social Care Act (England and Wales), 2001 and PIAG

5. 1 Setting the Scene

6. 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

7. 2 Looking Forwards: Developmental Trajectories and their Implications

8. Children with Learning Disability and Adult Capacity for Independence A Cohort Study of the Adult Outcome of Childhood Learning Disability

9. 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?

10. Case Note Trawl and Interviews Study of school health records of all 33,800 Cambridge HA Children born 1967-73. Identified 326 with iq<80, who had received special schooling Of 228 still living locally, 148 agreed to participate

11. Adult Abilities and Skills : Relationship with Child IQ

12. Child IQ and Adult Vineland

13. Adult Vineland Social Score by Child History

14. Psychiatric Disorders

15. Child Learning Disability and Adult Autism (%)

16. Child Learning Disability Adult Psychiatric Diagnoses (%)

17. 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

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

19. 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

20. 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 person’s education

21. What to do about it 2 Aggression resulting from disturbance of routines or preoccupations Don’t do it suddenly Employ Limit-setting, Shaping, Reverse-Chaining Respect the person’s need for Order and Predictability (But remember that things can be changed)

22. 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 Adolescent’s Social Education

23. 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

24. 3 Looking Back Clinical Correlates of Service Pathways: Insights from In-Patient Studies

25. Northgate Hospital In-Patient Services for LD Offenders and Psychiatric Disorders Can we Discern any Diagnostic or Aetiological Differences?

26. 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?

27. 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

28. 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

29. 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

30. Severity of Learning Disability LD Psychiatry Unit (n=109) and LD Offenders Unit (n=119)

31. Psychiatric Diagnoses (%): Psychiatric and Offenders Units

32. Psychiatric vs. Offenders Units: Patterns 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

33. Psychiatric vs. Offenders Units: Childhood Brain Damage (%)

34. 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

35. 4 Pathways Through Care

36. 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

37. Retrospective Survey - Medium Secure Services Admission and discharge patterns between August 1995 and August 1998. Total Admissions = 59 Source of Admission Age on Admission. < 20 [11] = 18% 21-30 [30] = 51% 31-40 [14] = 24% > 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.

38. 5 Investigating Care Pathways

39. Multi-Centre Study Commissioned by DoH

41. The problem “Case Note Study” Requires Patient Consent Patient Contact Difficult: Consent Moreso MREC Recommends Section 60 Application

42. Section 60 Health 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

44. 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

45. Principles to Follow in Research Personal/Clinical Relevance Highest Ethical Standards Multidisciplinary Clinical-Scientific Collaboration Multi-Agency Subject/Service User+Advocacy Involvement Keep it Feasible

46. Core Team G O’Brien J Taylor North East England A Holland M Bambrick East Anglia W Lindsay D Carson East Scotland S Johnson S Young High Secure Sector

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