John Devapriam

Brief report: Aggressive challenging behaviour in adults with intellectual disability following community resettlement

BACKGROUND Aggressive challenging behaviour is common in adults with intellectual disability (ID) in long-term care facilities. The governments commitment to the closure of all facilities in England has led to concerns over how to manage this behaviour in the community. The aim of this study was to assess changes in aggressive challenging behaviour and psychotropic drug use in adults with ID following resettlement using a person-centred approach. METHOD The Modified Overt Aggression Scale was administered to carers of 49 adults with ID prior to discharge from a long-stay hospital and 6 months and 1 year after community resettlement. RESULTS All areas of aggressive challenging behaviour reduced significantly between baseline and 6 months following resettlement (P < 0.001). This reduction remained (but did not decrease further) at 1-year follow-up. CONCLUSIONS Further work is needed to evaluate the role of environmental setting on aggressive challenging behaviour in adults with ID.

Arson: characteristics and predisposing factors in offenders with intellectual disabilities

The prevalence rate of arson in offenders with intellectual disabilities (ID) has been reported to be higher than that in the general population. This retrospective study focuses on examining the characteristics of offenders with ID and the range of identified reasons for the index offence. The findings indicate a higher prevalence of arson in this population, along with the fact that the majority of people with ID who have committed arson tend to bypass the Criminal Justice System. A significant number are likely to repeat the behaviour and will also commit other offences. The most common reason for arson appears to be revenge, closely followed by suggestibility. The majority had an associated diagnosis of personality disorders along with an Axis 1 psychiatric diagnosis. Other factors include large family size, history of childhood psychiatric disorders, abuse, homelessness, unemployment and relationship difficulties.

“Why can’t they be in the community?” A policy and practice analysis of transforming care for offenders with intellectual disability

Purpose – The purpose of this paper is to describe key policy and practice issues regarding a significant subgroup of people with intellectual disability – those with offending behaviour being treated in forensic hospitals. Design/methodology/approach – The reasons why psychiatrists continue to be involved in the treatment of people with intellectual disability and mental health or behavioural problems and the factors that may lead to patients needing hospital admission are examined. Using two illustrative examples, three key questions – containment vs treatment, hospital care vs conditional discharge and hospital treatment vs using deprivation of liberty safeguards usage in the community are explored. Findings – Patients with intellectual disability, mental health problems and offending behaviours who are treated within forensic inpatient units tend to have long lengths of stay. The key variable that mediates this length of stay is the risk that they pose to themselves or others. Clinicians work within t...

Managing anti‐epileptic drug treatment in adult patients with intellectual disability: a serious conundrum

About a quarter of people with epilepsy have intellectual disability (ID). This group has communication issues, premature mortality, more treatment resistance, difficulties in making informed choices and greater risks of physical and mental health comorbidities. There is no specific prescribing guidance for this large and vulnerable group. The literature on prescribing for epilepsy in this group was reviewed, in particular examining how antiepileptic drugs (AEDs) work regarding their side effect profiles, effects on specific epilepsy syndromes associated with ID and their individual strengths and weaknesses based on the nature and degree of ID.

Delayed discharge from intellectual disability in-patient units

Aims and method We undertook a cross-sectional service evaluation of the reasons and extent of delay in the discharge process in an intellectual disability hospital over a 12-month period. Delays at each stage of the discharge process are also quantified in this study. Results We found that discharge was delayed for 29% of patients during the study period. The majority (78.5%) was due to awaiting completion of assessment of future care needs and waiting for public funding. Clinical implications Commissioners (health and social), provider trusts, regulators and community providers should consider the reasons for delay in the discharge process and adopt a whole systems approach to discharge planning. This is highly relevant in light of recommendations by the Department of Health following the Winterbourne View scandal, which has raised concern about patients staying in intellectual disability in-patient units too long and for the wrong reasons.

Tiered model of learning disability forensic service provision

Purpose – Traditionally, services for people with learning disabilities (LD) and forensic needs are underdeveloped. This paper aims to describe the setting up of a tiered model of LD forensic service provision in Leicester, Leicestershire and Rutland, facilitated and driven by a core team of professionals who have the skills and expertise in this area.Design/methodology/approach – With no dedicated funding, this team is virtual in nature and provides support for the community and in‐patient teams in the assessment and management of offenders with LD. A care pathway including a process map is included to represent a visual idea of the referral, assessment, intervention and disposal strategies across the four tiers of service delivery. The service has a unique partnership arrangement with the independent sector that allows for staff training in order to deliver quality outcomes. The virtual team can support patients with learning disabilities and forensic needs in the community and in‐patient settings, both...

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities

Background There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals. Aims This study identified and developed the domains that should be used to measure treatment outcomes for this population. Method A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts. Results The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction. Conclusions To index recovery, services need to measure treatment outcomes using this framework. Declaration of interest None. Copyright and usage

Impact of care pathway-based approach on outcomes in a specialist intellectual disability inpatient unit

Specialist intellectual disability inpatient units have come under increased scrutiny, leading to questions about the quality of service provision in this sector. A care pathway-based approach was implemented in such a unit and its impact on outcome variables was measured. The care pathway-based approach resulted in the turnover of more patients, increased capacity for admissions to the unit, reduced lengths of stay in hospital, timely assessments and treatments, which resulted in better outcomes in patients. Care pathway-based approach to service provision provides not only better outcomes in patients but also a reliable way of ensuring true multi-agency working and accountability. If used widely, it can reduce the variability in the quality of current service provision.

Discharging inpatients with intellectual disability from secure to community services: risk assessment and management considerations

There is increasing emphasis on caring for people with intellectual disabilities in the least restrictive, ideally community settings. Therefore, the purpose of this paper is to explore the risk factors considered by clinicians involved in discharging people from secure services.,The views of five senior clinicians were sought in semi structured interviews. Data were analysed thematically.,Themes related to risk assessment, risk management, and multidisciplinary and multiagency working. Illustrative quotes are used to evidence themes.,This study described the risk assessment and management factors considered during the discharge of patients from secure to community services, which are of direct relevance to multiple stakeholders post-Winterbourne.,Challenges when facilitating discharge were highlighted, such as ongoing risk management issues, or unexpected discharge from tribunals, and how these were addressed, via the development of extensive risk assessment and management processes, and interdisciplinary and interagency working.

Intellectual disability and the ICD-11: towards clinical utility?

Purpose – The 11th revision of the International Classification of diseases which sets global standards for defining, reporting and managing health conditions is under way. The International Classification of Diseases (ICD) underpinning principle of clinical utility is currently poor for persons with Disorders of Intellectual Development (DID) and mental disorders. This impedes access to healthcare resources; services and social inclusion thereby further aggravating their vulnerability. The purpose of this paper is to present a critical overview and evidence informed recommendations within the context of an international collaborative programme, undertaken by the Faculty of Psychiatry of Intellectual Disability, Royal College of Psychiatrists, UK with support from the World Health Organisation (WHO). Design/methodology/approach – The authors carried out: first, a systematic review (SR) of literature, using PRISMA guidelines regarding the reliability, validity and utility of the ICD-10/Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnostic criteria in people with DID (PWDID); second, a national and international consultation exercise with partners, stakeholders and experts; third, a multicentric survey of problem behaviours in PWDID; and finally, information dissemination/dialogues including presentations and workshops at key scientific events, consultation networking, data gathering and consensus building. Findings – The SR revealed a dearth of robust studies – most consisting of weak research methodologies. Significant difficulties were highlighted regarding the application of diagnostic criteria in the current classificatory systems – particularly in people with severe/moderate DID. Recommendations supported the introduction WHERE APPROPRIATE of modifications based on observed phenomena (signs) in PWDID in lieu of reported symptoms to facilitate DIAGNOSIS AND better access to healthcare and the community. Heterogeneity precluded quantitative pooling and meta-analysis. The consensus building exercise globally revealed that problem behaviours were the commonest reasons for referral to healthcare services with significant numbers without a diagnosed mental disorder being prescribed psychoactive medication. Research limitations/implications – The consensus gathering exercise WAS SELECTIVE AND did not cover all of the 194 member states of WHO due to resource and time constraints and this constitutes the main limitation of our study. Based on the SR and expert consensus, the authors submitted evidence informed pragmatic proposals to the WHO aimed at addressing the shortcomings of the ICD-10. The key recommendations focused on improving clinical utility within the context of epistemic iteration which would consolidate and strengthen the future evidence base. It was also recommended that self-injurious behaviour should form a standalone sub category in view of its relevance for healthcare services and resources which underpin clinical utility. Practical implications – The ICD-11 is a global, multidisciplinary and multilingual development for public health benefit with 70 per cent of the worlds health expenditures assigned using this system for resource allocation. Currently mental disorders in PWDID can be misinterpreted, unrecognised and under reported resulting in barriers to access to treatment and healthcare resources. Conversely disorders may be over diagnosed when the inherent discrepancies between the chronological age and the developmental level of functioning are not considered. Conclusions and recommendations from this study will result in better diagnosis of mental disorders and healthcare resources in this population. Social implications – PWDID are a vulnerable sector of the population with an increased prevalence of mental health problems who are marginalised and discriminated by society. Early detection, treatment and management of these conditions will prevent further decompensation and stigmatisation. Originality/value – To the best of the authors knowledge this is the first comprehensive, large-scale study which evaluates the ICD classificatory system within the context of clinical utility for PWDID, including experts and stakeholders from both lower/middle- and high-income countries. The international consultation/consensus building process culminating in the formulation of evidence informed recommendations, aimed at improving the clinical utility of the ICD-11 for this population, has the potential to improve access to appropriate healthcare and treatment and consequent enhancement of their quality of life.