Verity Chester

The Clinical, Forensic and Treatment Outcome Factors of Patients with Autism Spectrum Disorder Treated in a Forensic Intellectual Disability Service

BACKGROUND To describe the characteristics of those with autism spectrum disorder (ASD) treated within a forensic intellectual disability hospital and to compare them with those without ASD. METHOD Service evaluation of a cohort of 138 patients treated over a 6-year period. RESULTS Of the 138, 42 had an ASD. Personality disorders and harmful use or dependence on drugs were significantly lower in the ASD group. The ASD group was less likely to be subject to criminal sections or restriction orders. Self-harm was significantly higher in the ASD group. There were no differences in the length of stay and direction of care pathway. CONCLUSIONS Although the ASD and non-ASD groups differ on clinical and forensic characteristics, their treatment outcomes appear similar. This suggests that the diagnostic category of ASD alone may be inadequate in predicting the treatment outcome. There is a case to identify distinct typologies within the ASD group.

“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...

The Essen Climate Evaluation Schema measure of social climate in a secure service for people with intellectual disabilities

Purpose – The aim of the present study is to explore the psychometric properties of the EssenCES measure (patient report) of social climate in a secure service for people with intellectual disabilities.Design/methodology/approach – Patients (37 men, 14 women, Mean age=33.24 years, SD=11.29, age range: 18‐71 years) residing in a secure intellectual disabilities service completed the EssenCES as part of routine clinical practice.Findings – Reliability analysis revealed acceptable reliability for all three subscales (α=0.76‐0.88). In order to consider one aspect of the construct validity of this measure, a predicted group difference regarding the impact of security level on ratings of social climate was investigated. Analysis revealed that social climate ratings were more positive on low secure wards than medium secure wards as measured by the combined EssenCES subscales F(3, 31)=4.71, p=0.008; Λ=0.69; η2=0.31, and the Experienced Safety subscale, F(1, 33)=7.41, p=0.01.Research limitations/implications – Fut...

Arson or fire setting in offenders with intellectual disability: Clinical characteristics, forensic histories, and treatment outcomes

Abstract Background Although many with intellectual disability come to the attention of services for fire setting, research in this area is scarce, which poses challenges for management. Method In this paper we examined those with a fire-setting history (n = 30), identified from a sample of 138 patients treated in a UK forensic intellectual disability service. Those with a fire-setting history were compared to those without this history on various clinical, forensic, and treatment outcome variables. Results Fire-setting was associated with significant psychopathology, including psychosis and personality disorders. Only half of the fire setters had a formal arson conviction. Fire setters were more likely to have a violence conviction and criminal sections/restriction orders. Conclusions Half of those with fire-setting histories did not have formal arson convictions, highlighting the need for thorough history taking. Prevalent comorbidity suggests interventions should focus on treating psychopathology before commencing offence-specific arson therapies.

Management of aggression care plans in a forensic intellectual disability service: a ten-year progress update

Purpose – Standardised approaches to the management of aggression and violence are critical for all stakeholders of intellectual disability services. The purpose of this paper is to describe the Management of Aggression Care Plan (MoACP). The care plan aims to reduce levels of restrictive interventions, to ensure any interventions relative to aggression and violence are the least restrictive possible, and to promote adaptive behaviours and support life enriching opportunities, in a manner which is personalised to the unique profiles of every patient. Design/methodology/approach – The MoACP was first described by Thomas et al. (2005). This paper describes the rationale, theoretical basis, structure and benefits of the care plan, and provides details of revisions made to the plan in response to evidence-based practice recommendations. Findings – The value of implementing a structured approach to the care planning of management of aggression and violence, in reducing the frequency and impact of restrictive p...

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.

Heterogeneity within Autism Spectrum Disorder in Forensic Mental Health: The Introduction of Typologies

Individuals with diagnoses of autism spectrum disorder (ASD) within criminal justice settings are a highly heterogeneous group. Although studies have examined differences between those with and without ASD in such settings, there has been no examination of differences within the ASD group. The paper aims to discuss these issues.,Drawing on the findings of a service evaluation project, this paper introduces a typology of ASD within forensic mental health and intellectual disability settings.,The eight subtypes that are described draw on clinical variables including psychopathy, psychosis and intensity/frequency of problem behaviours that co-occur with the ASD. The initial assessment of inter-rater reliability on the current version of the typology revealed excellent agreement, multirater Kfree =0.90.,The proposed typology could improve understanding of the relationship between ASD and forensic risk, identify the most appropriate interventions and provide prognostic information about length of stay. Further research to refine and validate the typology is ongoing.,This paper introduces a novel, typology-based approach which aims to better serve people with ASD within criminal justice settings.

Clinician experiences of administering the Essen Climate Evaluation Schema (EssenCES) in a forensic intellectual disability service

Purpose – Social climate (ward atmosphere) affects numerous treatment outcomes. The most commonly used measure is the Essen Climate Evaluation Schema (EssenCES) (Schalast et al., 2008). Though studies have investigated the psychometric properties of EssenCES in intellectual disability populations, few have focused on the clinical utility, or accessibility of the measure. The purpose of this paper is to examine clinicians experiences of using this measure with this population. Design/methodology/approach – Clinicians experienced in administering EssenCES with forensic intellectual disability patients completed an open-ended questionnaire, which sought qualitative data on their experiences of using EssenCES with this population. Data were analysed using thematic analysis. Findings – A number of issues were raised regarding use of EssenCES with patients with intellectual disability. Four overarching themes arose: Understanding of Language, Commenting on Others, Understanding of Likert Scale, and Scale Posit...

Traumatic brain injury in a forensic intellectual disability population

ABSTRACT Traumatic brain injury (TBI) screening in forensic populations has been recommended, due to a high prevalence, links to specific offence profiles and poorer outcomes, such as higher rates of psychiatric disturbance, longer stays in prison, and reoffending. Research focusing on TBI among offenders with intellectual disability (ID) is lacking. This study therefore describes the implementation of TBI screening using the Brain Injury Screening Index (BISI©), TBI prevalence and correlates in a forensic ID service. TBI appeared under recorded in case notes, with considerably more patients self-reporting TBI. Reported causes of TBI differed somewhat to the general population, including childhood physical abuse, self-harming behaviour, and assault. Approximately one-third of injuries did not receive any treatment. Though further adaptations may be required on current screening measures for TBI in offenders with ID, screening can provide valuable information, contributing positively to individual patient therapeutic and risk formulations.

Adapting measures of social climate for use with individuals with intellectual developmental disability in forensic settings

ABSTRACT The social climate of forensic settings is thought to impact on a number of important clinical and organisational outcomes and is, therefore, an important construct in relation to the successful functioning of forensic units. A variety of self-report questionnaires have been developed to objectively measure the social climate of forensic settings (e.g. the Correctional Institutions Environment Scale and the Essen Climate Evaluation Schema), however these questionnaires have not been validated for individuals with intellectual developmental disabilities (IDD). Given the prevalence of IDD in prison and forensic psychiatric settings and the potential impact of such cognitive deficits on the ability to complete a range of self-report questionnaires, it is important to consider the potential reliability and validity of existing social climate measures in IDD populations. This article will, therefore: (1) examine the cognitive, linguistic and response format difficulties that may arise when administering self-report measures of social climate in IDD populations; (2) consider potential adaptations to existing measures of social climate that might make them more suitable for use with IDD populations; and (3) identify important directions for future research in the area.