Personality disorders in people with learning disabilities: follow-up of a community survey

Background A sample of community-based service users with intellectual disability (ID) was re-examined after 5 years to determine the impact of a diagnosis of personality disorder (PD). Methods Seventy-five of the original 101 participants were followed up. Of these, 21 people had a PD identified during the original study. Results Compared with controls, people with a PD were significantly more likely to receive central nervous system (CNS) drugs, have more contact with psychiatric services, show increased offending behaviour, score higher on the Aberrant Behaviour Checklist and score above the threshold on the Psychiatric Assessment Schedule for Adults with Developmental Disability (PAS-ADD). Participants with PD recorded were more likely to have a recorded psychiatric disorder, have contact with specialist teams, and have more hospital admissions. Conclusion People with ID and PD are able to live in the community with specialist support but improved assessment, diagnosis and support services need to be targeted more effectively to them.     

Service utilisation by children with conduct disorders

Background: Children with conduct disorders and their families come into contact with a range of community and specialist agencies.Methods: The aim of this study was to establish the lifetime service utilisation rates among children with conduct disorders from the Great Britain National Study (N=10,438), and to examine the association between comorbid disorders, family and social factors, and service utilisation. The Development and Well-Being Assessment, a service checklist, and a battery of family and social functioning measures were used.Results: The weighted prevalence of oppositional and conduct disorders was 5.4%. Within this group (N=403), 241 (59.8 %) had conduct disorder only, 79 (19.6 %) comorbid emotional, 72 (17.9 %) comorbid hyperkinetic, and 11 (2.7 %) comorbid emotional and hyperkinetic disorders. These subgroups were compared on service utilisation with children with other psychiatric disorders (N=351). Children with conduct disorders had significantly higher lifetime rates of utilisation of social and educational services than children with other psychiatric disorders. Contact with primary health, specialist health, and educational services was significantly associated with comorbid physical and psychiatric disorders. In contrast, contact with social services was associated with family discord and social sector tenancy.Conclusions: The findings are discussed in the context of organisation and co-ordination of health, other statutory, and nonstatutory services, also taking into account previous research on interventions for children with conduct disorders and their families.     

A Comparison of Referrals With and Without Autism Spectrum Disorder to Forensic Intellectual Disability Services

Although some authors have suggested that there are higher rates of people with Autism Spectrum Disorder (ASD) in forensic and offending groups, systematic studies have not supported the hypothesis. The present study reviewed 477 referrals made to forensic intellectual disability (ID) services in one calendar year. It was found that 10% of referrals had ASD, a figure similar to the general population of people with ID. Those with ASD had similar patterns of offending to those without but they showed a lower prevalence of contact sexual offences and fewer had been previously charged. We concluded that there is no persuasive evidence that ASD is a risk factor for offending or for any particular type of offending.     

Characteristics of patients presenting for emergency psychiatric assessment at an English hospital

OBJECTIVE: The needs and characteristics of patients who are referred for psychiatric emergency services vary by the source of referral. Such differences have wider implications for the functioning of the mental health care system as a whole. This study compared three groups of patients in a two-month cohort of 189 patients who were referred for emergency psychiatric assessment at a hospital in England: those who were referred by general practitioners (family physicians), those who were receiving specialist services from community mental health teams, and those who arrived at the hospital from the broader community. METHODS: The three groups were compared on demographic characteristics, clinical and service use variables, risk to self or others, factors that contributed to the emergency presentation, and ratings on standardized scales of functioning. RESULTS: The patients who were receiving specialist services from community mental health teams had high rates of psychosis, often relapsed, and had a history of contact with a psychiatrist. These patients were the most likely to be admitted to the hospital after emergency assessment. The patients who had been referred by general practitioners tended to have fewer indicators of social problems and were more likely to be experiencing a new episode of mental illness. Their referral to the emergency department was most likely to be deemed inappropriate by emergency department clinicians. The patients who came from the broader community were more likely to be male and to exhibit self-harming behavior, substance misuse, and behavioral difficulties. CONCLUSIONS: The rate of emergency referral is one indicator of the functioning of the service system as a whole. Improvements to the system should include better access to community mental health team services and a greater capacity of the primary care system to manage mental health crises. Services need to be developed that are acceptable to male patients who are experiencing social and behavioral problems.     

Epilepsy and intellectual disability: Does epilepsy increase the likelihood of co-morbid psychopathology?

Although epilepsy is particularly common among people with intellectual disability (ID) it remains unclear whether it is associated with an increased likelihood of co-morbid psychopathology. We therefore investigated rates of mental health problems and other clinical characteristics in patients with ID and epilepsy (N = 156) as compared to patients with ID but no epilepsy (N = 596). All participants were consecutive referrals to specialist mental heath services. Specialist clinicians agreed on the mental health diagnoses by applying ICD-10 clinical criteria using information gained from interviews with key informants and the patients. Bivariate and multivariate analyses showed that patients with epilepsy were more likely to live in residential housing and have severe ID in line with previous evidence. However, the presence of epilepsy was not associated with an increased likelihood of co-morbid psychopathology. On the contrary, rates of mental health problems, including schizophrenia spectrum, personality and anxiety disorders, were significantly lower among patients with epilepsy. The results are discussed in the context of mood-stabilizing and other psychotropic effects of anti-epileptic drugs in adults with ID and epilepsy, as well as possible diagnostic overshadowing.     

Recreational substance use patterns and co-morbid psychopathology in adults with intellectual disability

There is very limited evidence on the patterns of recreational substance use among adults with Intellectual Disabilities (ID) who have co-morbid mental health problems. In this study we collected clinical and socio-demographic information as well as data on substance use patterns for consecutive new referrals (N = 115) to specialist mental health services for adults with ID in South-East London. The data were recorded from active clinical case notes. About 15% of patients had a history of substance use, however only 8% were currently using substances. Alcohol was the most frequently used substance (80%) followed by cannabis (28%) and cocaine (12%). Overall, substance use was significantly more likely among male patients, those with a mild level of ID and those with a forensic history. Substance use was less likely among patients with autism and more likely among those with schizophrenia spectrum disorders. Logistic regression analyses revealed that those with a forensic history were about five times more likely to have current substance use problems. Male gender was the only predictor for legal substance (alcohol) use. Illicit substance use was about three times more likely among patients with schizophrenia spectrum disorders. The present results highlight the role of illicit substance use as a health risk factor for adults with ID as well as the need to increase awareness within specialist mental health services.     

Psychiatric inpatient care for adults with intellectual disabilities: generic or specialist units?

BACKGROUND: When adults with intellectual disabilities (ID) require a psychiatric admission, general adult mental health units are often used. Specialist units have emerged recently as a care option but there is only limited evidence of their effectiveness. Thus this study aims to describe and evaluate the effectiveness of a specialist inpatient unit and report on the utilization of generic and specialist inpatient services. METHOD: All patients admitted to a specialist ID psychiatric unit were evaluated on admission and immediately after discharge on a number of outcome measures. In addition, they were compared with those admitted to general adult mental health units covering the same catchment area. RESULTS: Significant improvements were demonstrated within the specialist unit cohort on measures including psychopathology, global level of functioning, behavioural impairment and severity of mental illness. The specialist unit patients had a longer length of inpatient stay but were less likely to be discharged to out-of-area residential placement. CONCLUSIONS: Specialist units are an effective care option for this group of people.     

Emotional and behavioural problems in children and young people with autism spectrum disorder in specialist autism schools

We investigated emotional and behavioural problems in a sample (N = 615) of children and young people with autism spectrum disorders (ASD), most of whom also had intellectual disability (ID), attending specialist autism schools. High rates of parent- and teacher-reported problems were recorded. Teacher-reported levels of hyperactivity were higher in younger children. Teacher- but not parent-reported levels of conduct problems and hyperactivity were highest in children without phrase speech. Greater use of mental health services was associated with higher levels of emotional and behavioural problems, but only a minority of participants had accessed mental health services in the previous 6 months.     

Criminal offending and distinguishing features of offenders among persons experiencing a first episode of psychosis

Aims: Persons with severe mental illness (SMI) are at increased risk of criminal offending, particularly violent offending, as compared with the general population. Most offenders with SMI acquire convictions prior to contact with mental health services. This study examined offending among 301 individuals experiencing their first episode of psychosis. Methods: Patients provided information on sociodemographic and clinical variables and completed a neurological soft sign examination and neuropsychological tests. Additional information was extracted from clinical files and official criminal records. Results: The results show that 33.9% of the men and 10.0% of the women had a record of criminal convictions, and 19.9% of the men and 4.6% of the women had been convicted of at least one violent crime. Proportionately more male and female patients than men and women in the general UK population had prior convictions for violent crimes. In a multivariate model including background and clinical variables, only one variable distinguished the male offenders. African‐Caribbean ethnicity was associated with a threefold increase in the odds of offending (odds ratio = 3.84, 95% confidence interval 1.03–14.37). Offenders, as compared with non‐offenders, obtained significantly lower premorbid and current intelligence quotient scores and similar scores on tests of neurological soft signs, working memory and executive functions. Conclusions: At contact with mental health services for a first episode of psychosis, significant numbers of patients have records of criminal convictions and thereby a high risk for future violent behaviour. These patients require specific interventions, in addition to medication, to reduce offending and aggressive behaviour.     

What Are The Factors Associated With Criminal Behaviour For Young People With Mental Health Problems?

Rates of offending peak in adolescence and associations between mental ill health and criminal behaviour have been well documented. Despite this, few studies have examined the nature or correlates of offending behaviours in young people with mental health problems, particularly in community settings. This study examined salient risk markers associated with police contact in a cohort of 802 young people (aged 12–25 years) seeking help from youth mental health services in Australia. Explanatory factors for analysis were obtained using validated clinical and psychosocial measures that participants completed via both interview and self-report. Regression analyses were conducted to determine which factors demonstrated the strongest associations with self-reported criminal charges. The results indicated that male gender, not being engaged in education, employment or training, frequent drug use and having experienced multiple adverse life events were related to police contact. This study indicates that the risk factors for offending commonly found in the general criminological literature are also those associated with offending in young people with mental health problems. The findings denote the need for a comprehensive therapeutic approach for such patients that accommodate both their clinical as well as criminogenic needs.     

A Scoping Study of a Tertiary Intellectual Disability Mental Health Service: A Family Member and Support Person Perspective

ABSTRACT

Introduction: People with intellectual disability (ID) experience barriers in accessing mental health care. Recommendations have been made to implement specialist intellectual disability mental health (IDMH) services in Australia. However, there is limited evidence to inform service development.

Method: Family members and support persons of people with ID (n = 42) completed an on-line survey about support for, and operation of, a tertiary IDMH service in New South Wales, Australia.

Results: Participants agreed that a tertiary IDMH service would assist in meeting the needs of people with ID. Key service features included that it be delivered within the public health system, by psychiatrists and psychologists, provide face-to-face clinical contact and advice. Key service areas included behaviors of concern, self-harm, assessments, and interventions.

Conclusion: These findings suggest support for a tertiary IDMH service and how it could be delivered. Further research is required from the perspective of people with ID, mental health staff, and clinical experts.     

Offending by adults with learning disabilities and the attitudes of staff to offending behaviour: implications for service development

The aims of this study were: (I) to identify all adults with learning disabilities living in residential homes or attending day services in the Cambridge Health District in contact with the criminal justice system during 1992; (2) to evaluate the responses of services involved; and (3) to investigate the attitudes of staff and the policies of the services to ‘offending behaviour'. Details of offences committed and the response of the police, health and social services, and other agencies were obtained by direct interview with the senior staff and through examination of case records. The attitudes of staff to offending behaviour was investigated by the use of a semi-structured questionnaire. Seven (2%) out of 358 adults with learning disabilities were reported to have had contact with the police during 1992. The eight offences allegedly committed by the seven people were two acquisitive offences, two sexual offences, one assault, one wasting of police time, one offence against the Public Order Act and one traffic offence. One offender was cautioned after the Crown Prosecution Service discontinued the case because of lack of evidence, while the other alleged offenders received informal warnings. None of the seven alleged offenders were prosecuted. Three alleged offenders lived in hostel accommodation, yet hostel accommodation only accounts for 7.8% of adults with learning disabilities living in the Cambridge Health District. Because of a lack of operational policies on offending behaviour, there were no existing referral structures for people who might need specialist health service support. Referrals tended to be inconsistent, with a considerable time-lag between offence and referral. Tolerance levels towards offending behaviour were extremely high in the two hostels, 20 group homes and day centres which were included in this study. Theft and criminal damage was hardly ever reported. Thirty establishments were visited during the course of this study. Of these establishments, staff in 12 said they would ahvays report a major assault. In only three would a sexual assault or indecent exposure always be reported if it was to occur. Staff at one residential establishment said they would hesitate to report rape and the staff in another two would consider the circumstances before reporting it to the police.     

Young people at risk of offending: their views on a specialist mental health service in south east London

This article explores the views of young people regarding their involvement with a specialist mental health service for adolescents who offend or are at risk of offending. The main aims are to shed light on means of engaging this group in therapeutic work, and to illustrate the use of qualitative techniques in the evaluation of health services. Twenty clients and ex-clients were interviewed using a semistructured schedule. Responses were analysed using a thematic indexing technique. Findings show that the majority felt the service had helped them to some extent, despite initial resistance to referral. Five factors which helped practitioners overcome this resistance were identified: (1) A manner which demonstrates respect and commitment; (2) being able to operate flexibly and offer outreach appointments; (3) clinical effectiveness; (4) making therapeutic sessions seem personally relevant; and (5) explaining clearly the role of the service. Attention should be paid to these areas if mental health services are to support this challenging client group.     

Staff attributions towards men with intellectual disability who have a history of sexual offending and challenging behaviour

Background   Staff working within secure services for people with intellectual disabilities (ID) are likely to work with sexual offenders, but very little attention has been paid to how they think about this sexual offending behaviour.
Method   Forty-eight staff working within secure services for people with ID were recruited and completed the Attribution Style Questionnaire in relation to the sexual offending behaviour and challenging behaviour of men with mild ID. Attributions towards challenging behaviour and sexual offending were compared and relationships between level of ID and seriousness of the sexual offence were explored.
Results   The results indicated that staff attributed sexual offending as more external to the staff group than they did for challenging behaviour. Sexual offending behaviour was also seen as more stable, and less controllable by people with ID than was challenging behaviour. Sexual offending was also attributed as more uncontrollable by the staff group than challenging behaviour. There was a significant negative correlation between general intellectual functioning and several attributional dimensions regarding sexual offending, but not challenging behaviour. Sexual offending that was coded as more serious was attributed as universal and uncontrollable by the staff group.
Conclusions   The differences between staff attributions regarding challenging behaviour and sexual offending potentially relate to the decision-making processes involved in deciding whether or not to involve criminal justice agencies when someone with ID commits a sexual offence. Further research within this area is warranted.     

Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health Surveys

Method:  A third of the children from the 1999 British Child and Adolescent Mental Health Survey were followed up over 3 years. Parents provided summary information on service contacts for emotional, behavioural and concentration difficulties, with more detailed information being obtained by telephone interview for selected subgroups.
Results:  Having a psychiatric disorder predicted substantially increased contact with social services, special educational needs resources, the youth justice system and mental health services (district CAMHS and tier four, but not tier two). Of those children with psychiatric disorders, 58% had been in contact with at least one of these services for help with emotional, behavioural or concentration difficulties, including 23% who had been in contact with mental health services.
Conclusions:  British children attend a wide variety of services for help with emotional, behavioural and concentration difficulties. The proportion seeing specialist mental health services is higher than that generally reported in the research literature.     

Health professionals' attitudes and emotions towards working with adults with intellectual disability (ID) and mental ill health

Objectives Mainstream mental health services are providing more care for individuals with an intellectual disability (ID); this has implications for staff and service users. Attitudes of staff towards people with ID in mental health services may be negative and negative staff attitudes may have a detrimental impact on service provision. Design A cross‐sectional design was used. Methods A questionnaire designed to investigate the attitudes and emotions of staff towards delivering mental health care to adults with ID was completed by 84 staff from mainstream and specialist ID services. Results Staff in both services experienced more positive emotions when working with clients whom they are currently employed to work with. When the frequency of contact with adults with ID, the number of individuals worked with and the amount of formal ID training received were considered, there was no significant difference between the attitudes of staff in both services. Positive correlations were found between attitude scores and positive emotional experiences in both services. Conclusions The research suggests that numerous factors, including the role of emotional experience and a number of environmental aspects, need to be considered in the context of providing mental health services to adults with ID to ensure the highest quality. Research limitations and clinical implications of the study are also considered.     

Prior Service Utilization in Detained Youth with Mental Health Needs

This study examined the prevalence of mental health needs and rates of service utilization among youth detained in a metropolitan juvenile justice system in California. Of the 345 youth in the sample, 265 (76.8 %) qualified for high or acute mental health need and 210 (60.9 %) had at least one prior contact with mental health services. No differences in mental health need were found across ethnicities; however rates of prior service utilization significantly differed (χ² = 19.18, p < 0.001). Asian and Pacific Islander participants were less likely to have had prior contact with county services than any other ethnic group.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.     

Alcohol and its relationship to offence variables in a cohort of offenders with intellectual disability

Abstract

Background Alcohol use and misuse may be lower in people with intellectual disability (ID) than in the general population but may be related to offending.

Method Alcohol-related crime and history of alcohol use was recorded in 477 participants with ID referred to forensic ID services and related to offending.

Results Level of alcohol-related crime and history of alcohol misuse was lower than in some previous studies at 5.9% and 20.8%, respectively. History of alcohol abuse was associated with alcohol-related offences and theft. Higher rates of alcohol problem history were associated with histories of a number of offences, psychiatric disturbance in adulthood, psychiatric disturbance in childhood, and experiences of childhood adversity. Most effect sizes were weak or moderate.

Conclusions The convergence of childhood adversity, psychiatric problems in childhood and adulthood, and alcohol abuse is consistent with studies that have found these as risk markers for offending.