High Cost Residential Placements for Adults with Intellectual Disabilities

Background Concern has been expressed repeatedly about the cost and quality of residential placements for adults with learning disabilities and additional needs. This study sought to identify characteristics of the highest cost placements in the South‐East of England. Method Lead learning disability commissioners in the South‐East of England were asked to provide information about the five highest cost residential placements that they commissioned for adults with learning disabilities. Results The average placement cost of £172k per annum disguised wide variation. Individuals placed were mainly young and male with high rates of challenging behaviour and/or autism spectrum disorder. Most placements were in out‐of‐area residential care. The highest costs were associated with hospital placements and placements for people presenting challenging behaviour. Conclusions Young, male adults with learning disability, challenging behaviour and/or autism continue to receive very high cost residential support, often in out‐of‐area residential care. There remains limited evidence of plans to redirect resources to more local service developments.     

POLICE INVOLVEMENT WITH CLIENTS HAVING INTELLECTUAL DISABILITIES: A PILOT STUDY IN SOUTH LONDON

Following the increasing trend for de-institutionalisation of people with learning disabilities, community services are increasingly being utilised to support those who also display challenging behaviours. Where severely challenging behaviours are involved community service providers may require additional support from die police service. The authors undertook a retrospective pilot study among two major community care providers in South London, and looked at the reasons for calling the police, the frequency with which die police were called; staff expectations in calling the police and the outcomes for die clients in terms of further involvement with the criminal justice system. The authors note that the police were generally used as additional support when clients became too difficult for the immediate service providers to manage. It is also noted that police action on behalf of victims was generally low and that the police were never called in response to clients with learning disabilities reporting having witnessed crime. The authors note that further research is required.     

Indicators of choking risk in adults with learning disabilities: a questionnaire survey and interview study

Purpose. Feeding and swallowing impairments are key predictors of increased morbidity and mortality in adults with learning disabilities. This postal survey and interview study sought to identify risk factors in adults with learning disabilities who have histories of choking. Method. A total of 2000 questionnaires were sent to carers of all adults with learning disabilities registered as service users by three local health authorities. (A 'service user' may be using any specialist learning disability health or social care facility with day, residential or therapeutic services). Of the 674 service users for whom surveys were returned, 47 were living in hospital, 396 were living in residential or group homes and 208 were living with relatives, or in their own homes. Eighteen subjects who had reported serious or repeated episodes of choking were interviewed in depth in their residences or workplaces. Responses were subjected to frequency analyses. Personal characteristics were analysed. Choking patterns were differentiated by food texture. Results. A total of 34% of questionnaires on 674 service users were returned; 42% of respondents reported one or more choking episodes. There was a significantly greater occurrence of choking among people with more severe learning disability, with Down syndrome, people who had an incomplete dentition or were taking a greater number of psychotropic drugs. Antisocial eating habits learnt in institutional settings presented an additional choking hazard for some individuals. Conclusion. Choking is a serious hazard for many adults with learning disabilities. This study establishes many of the characteristics associated with swallowing problems in this population. Clinicians and carers should benefit from awareness of these predictors, leading to better management of eating behaviours and habits. A choking and swallowing risk assessment should be included in routine health assessments of adults with learning disability, paying especial attention to the condition of a person's teeth; possible side effects from prescribed medication, and abnormal eating behaviour.     

Resident Involvement in Activity in Small Community Homes for People with Learning Disabilities

Background Determining the relative importance of variables including client characteristics, setting features, staffing and care practices on the lives of people with learning disabilities in residential care continues to be a relevant topic for research. Methods Measurements were made of the adaptive and problem behaviour of 343 adults with intellectual disabilities living in 76 residential homes and of various aspects of staffing, care practices (extent of active support) and resident engagement in meaningful activity. Ordinal and logistic regression was used to identify variables best predicting engagement and care practices. Results Only adaptive behaviour and care practices predicted resident engagement in meaningful activity; only age and adaptive behaviour predicted care practices. Conclusions Given the limited scope for changing resident adaptive behaviour, attention should be given to improve active support in residential homes in order to promote greater engagement in meaningful activity by people with learning disabilities.     

Users' views of a dynamic risk assessment system

The assessment and management of risk plays a significant role in the ongoing care and future management of patients with learning disabilities. This article describes the use of the dynamic risk assessment and management system for individuals with learning disabilities and offending behaviour.     

Indicators of choking risk in adults with learning disabilities: A questionnaire survey and interview study

Purpose.?Feeding and swallowing impairments are key predictors of increased morbidity and mortality in adults with learning disabilities. This postal survey and interview study sought to identify risk factors in adults with learning disabilities who have histories of choking.

Method.?A total of 2000 questionnaires were sent to carers of all adults with learning disabilities registered as service users by three local health authorities. (A ‘service user’ may be using any specialist learning disability health or social care facility with day, residential or therapeutic services). Of the 674 service users for whom surveys were returned, 47 were living in hospital, 396 were living in residential or group homes and 208 were living with relatives, or in their own homes. Eighteen subjects who had reported serious or repeated episodes of choking were interviewed in depth in their residences or workplaces. Responses were subjected to frequency analyses. Personal characteristics were analysed. Choking patterns were differentiated by food texture.

Results.?A total of 34% of questionnaires on 674 service users were returned; 42% of respondents reported one or more choking episodes. There was a significantly greater occurrence of choking among people with more severe learning disability, with Down syndrome, people who had an incomplete dentition or were taking a greater number of psychotropic drugs. Antisocial eating habits learnt in institutional settings presented an additional choking hazard for some individuals.

Conclusion.?Choking is a serious hazard for many adults with learning disabilities. This study establishes many of the characteristics associated with swallowing problems in this population. Clinicians and carers should benefit from awareness of these predictors, leading to better management of eating behaviours and habits. A choking and swallowing risk assessment should be included in routine health assessments of adults with learning disability, paying especial attention to the condition of a person's teeth; possible side effects from prescribed medication, and abnormal eating behaviour.     

Quality of life for people with physical disabilities: a new instrument

This article describes the development and validation of the Quality of Life Profile for Adults with Physical Disabilities (QOLP-PD). This new cross-disability instrument is grounded in a well-developed conceptual framework. It reflects the underlying assumption that quality of life issues are the same for people with and without disabilities, although adults living with chronic physical disabilities may address those issues somewhat differently during the course of their daily lives. This instrument was developed on the basis of in-depth interviews, item review and refinement, and pilot testing with adults who have chronic acquired and life-long physical disabilities. Preliminary validation studies were carried out in separate studies with two Canadian samples for which separate results are reported. In Study 1, interviewer-administered items were completed by a cross-disability sample from a large city in Ontario (n = 27). In Study 2, self-administered items were completed by adults with spinal cord injuries from urban and rural Saskatchewan (n = 40). Alpha coefficients for the QOLP-PD ranged from 0.67-0.97 (Ontario sample) and from 0.84-0.98 (Saskatchewan sample). Validation coefficients are also reported. Although the samples were small, the psychometric properties of the instrument are generally sound. Future research directions are discussed.     

Sealing the cracks: Preliminary findings from an inter-ministry initiative to address chronic homelessness in British Columbia

It is well documented that homeless individuals with severe mental illness (SMI) are in frequent contact with multiple public systems including housing, health, criminal justice, income assistance and various community-based programs. However, this subpopulation of the homeless continues to experience significant unmet needs. This report examines preliminary findings from British Columbia's Homeless Intervention Project, an interagency collaboration designed to improve outcomes for adults with SMI who are chronically homeless. Administrative data from three provincial ministries were used to examine a variety of outcomes for 362 participants with histories of criminal justice involvement. Comparisons of the pre-enrollment period (2 years) and post-enrollment period (6 or 12 months) indicate significant improvements in health and social service involvement and reductions in offending. These findings suggest that interagency collaboration, particularly co-location and sharing of information and administrative oversight, can result in better outcomes for this hard-to-serve population than when agencies are working in isolation.     

Sealing the cracks: Preliminary findings from an inter-ministry initiative to address chronic homelessness in British Columbia

It is well documented that homeless individuals with severe mental illness (SMI) are in frequent contact with multiple public systems including housing, health, criminal justice, income assistance and various community-based programs. However, this subpopulation of the homeless continues to experience significant unmet needs. This report examines preliminary findings from British Columbia's Homeless Intervention Project, an interagency collaboration designed to improve outcomes for adults with SMI who are chronically homeless. Administrative data from three provincial ministries were used to examine a variety of outcomes for 362 participants with histories of criminal justice involvement. Comparisons of the pre-enrollment period (2 years) and post-enrollment period (6 or 12 months) indicate significant improvements in health and social service involvement and reductions in offending. These findings suggest that interagency collaboration, particularly co-location and sharing of information and administrative oversight, can result in better outcomes for this hard-to-serve population than when agencies are working in isolation.     

Individual Characteristics and Service Expenditure on Challenging Behaviour for Adults with Intellectual Disabilities

Background English policy argues that people with intellectual disabilities should be supported in their local communities. There is considerable evidence that this aspiration is not being achieved. This paper seeks to look at the subsection of people with intellectual disabilities who have expensive care needs because of challenging behaviour, to identify the decision‐making processes that have led to current service provision and expenditure and to suggest improvements. Materials and Methods We carried out a survey within five North London boroughs to investigate the characteristics of a cohort of people with intellectual disabilities and challenging behaviour in high‐cost accommodation (over £70 000/annum). Postal questionnaires and face‐to‐face interviews were conducted with stakeholders with intellectual disabilities and patterns of current costs were estimated from existing data provided by the commissioning authorities in the five boroughs. Results Two hundred and five individuals with intellectual disabilities and challenging behaviour were identified. They were accommodated in placements provided by 97 separate providers, both in and out‐of‐area. Those more likely to be placed out‐of‐area were younger, had multiple health problems, significant challenging behaviour and mental health problems including autistic spectrum disorders. The local community intellectual disabilities teams identified a number of difficulties in meeting the needs of those service users. Conclusions Expenditure on all placements for service users with intellectual disabilities is significant. There is a notable lack of investment in local service development. A coherent approach is required, often across service boundaries. The authors suggest a model for targeted investment aimed at supporting effective local services, and reducing the need for and expense of out‐of‐area placements.     

A Prospective Longitudinal Study of Sexual Recidivism Among Adolescent Sex Offenders

This paper reports on a follow-up of a sample of 303 adolescent male sex offenders from New South Wales, Australia. Adult rearrest and reconviction data were obtained for 292 of these individuals. The mean observation period between their adjudication as adolescents and their follow-up as adults was 7.3 years. Seventy-five (25%) received further convictions for sexual offenses prior to their 18th birthday. As adults, 25 (9%) came to the attention of police for further alleged sexual offenses, including 14 (5%) who received convictions for these offenses. Of these, 11 (79%) also received new convictions for nonsexual offenses. Overall, 61.3% of subjects received convictions for nonsexual offenses as adults. Results suggest considerable diversity and persistence in delinquent and criminal behavior, and challenge assumptions about high transition rates from adolescent to adult sexual offending.     

Violence: the relation between seriousness of injury and outcome in the criminal justice system.

OBJECTIVE: To investigate the relation between injury severity in assault, offence seriousness, and outcome in the criminal justice system. METHODS: Prospective random sample of 93 assault victims who attended hospital were interviewed and examined and followed through the criminal justice system. Patient and police interviews were carried out at Bristol Royal Infirmary accident and emergency and outpatient departments, wards, and in Avon police stations and criminal courts. Severity of injury (injury severity score [ISS] assessed by the major trauma outcome study group), offence seriousness (Delphi panel of criminologists), and outcome in the criminal justice system were recorded. RESULTS: Median ISS was 4 (range 1-17). There was no significant correlation between ISS and outcome in the CJS (rs = 0.07). There was a weak correlation between offence seriousness and outcome (rs = -0.24, P = 0.019). CONCLUSIONS: Outcome in the criminal justice system was not predictable from injury severity scores and was only weakly linked to offence seriousness. Contacts with medical services are opportunities for protecting those at risk of violence.     

Forensic Risk Assessment in Intellectual Disabilities: The Evidence Base and Current Practice in One English Region

The growing interest in forensic risk assessment in intellectual disability services reflects the perception that deinstitutionalization has exposed more people to a greater risk of offending. However, ‘risk’ and the related idea of ‘dangerousness’ are problematic concepts because of connotations of dichotomous definition, stability and predictability. Assessment instruments in mainstream forensic psychiatry often combine actuarial and clinical data, and increasingly stress the dynamic nature of risk as well as the importance of situational and accidental triggers. Despite this increasing sophistication of research in mainstream forensic psychiatry, the ability to predict future offending behaviour remains very limited. Furthermore, actuarial predictors developed in studies of psychiatric or prison populations may not be valid for individuals with intellectual disabilities. Offending behaviour among people with intellectual disabilities is also hard to circumscribe because it often does not invoke full legal process or even reporting to the police. In order to discover how such problems were reflected in practice, a survey of providers in the North‐west Region of England was undertaken. Seventy out of 106 providers identified as possibly relevant to this inquiry responded to a short postal questionnaire. Twenty‐nine (42%) respondents – mainly in the statutory sector – reported operating a risk assessment policy relating to offending. The number of risk assessments completed in the previous year varied from none to ‘several hundred’. Providers reported three main kinds of problems: (1) resources or service configuration; (2) interagency or interdisciplinary cooperation or coordination; and (3) issues relating to the effectiveness, design and content of assessment.     

Background,Offence Characteristics,and Criminal Outcomes of Aboriginal Youth Who Sexually Offend: A Closer Look at Aboriginal Youth Intervention Needs

Canada's Aboriginal peoples face a number of social and health issues. Research shows that Aboriginal youths are over-represented in the criminal justice system and youth forensic psychiatric programmes. Within the literature on sex offending youth, there appears to be no published data available to inform clinicians working with adjudicated Aboriginal youth. Therefore, the present study examines the background, offence characteristics, and criminal outcomes of Aboriginal (n = 102) and non-Aboriginal (n = 257) youths who engaged in sexual offending behaviour and were ordered to attend a sexual offender treatment programme in British Columbia between 1985 and 2004. Overall, Aboriginal youths were more likely than non-Aboriginal youths to have background histories of fetal alcohol spectrum disorders (FASD), substance abuse, childhood victimization, academic difficulties, and instability in the living environment. Both Aboriginal and non-Aboriginal youths had a tendency to target children under 12-years-old, females, and non-strangers. Aboriginal youths were more likely than non-Aboriginal youths to use substances at the time of their sexual index offence. Outcome data revealed that Aboriginal youths were more likely than their non-Aboriginal counterparts to recidivate sexually, violently, and non-violently during the 10-year follow-up period. Furthermore, the time between discharge and commission of all types of re-offences was significantly shorter for Aboriginal youths than for non-Aboriginal youths. Implications of these findings are discussed with regards to the needs of Aboriginal youth and intervention.     

How tutors assist adults with learning disabilities to use virtual environments

Purpose : To describe strategies used by tutors teaching adults with learning disabilities to use desktop virtual environments and to investigate their effectiveness by examining changes over time in tutor and learner behaviour. Method : Twenty adults with learning disabilities spent 12 sessions with one of four non-disabled tutors learning to use desktop virtual environments designed to teach independent living skills. Sessions were recorded on videotape, categories of behaviour were described and tapes analysed for frequency of tutor behaviours and goals achieved by learners. Results : Tutor strategies were described in terms of whether they aimed to help the learner master the interaction devices or to navigate and achieve goals in the virtual environments and how directive they were. There were some differences between tutors but this did not relate to whether tutors were experienced users themselves of the environments or were initially unfamiliar with them. Goal achievement was maintained at a constant level while help with the interaction devices and specific information about the environment decreased over repeated sessions. Rates of non-specific information did not change. Conclusions : Pretraining with the interaction devices would free both tutor and learner to concentrate on achieving goals in the environments. Much of the specific help given by the tutor could be incorporated into the software.     

Comparing Offenders against Women and Offenders against Children on Treatment Outcome in Offenders with Intellectual Disability

Background Several studies have shown the positive effects of sex offender treatment for men with intellectual disabilities who have perpetrated sex offences or inappropriate sexual behaviour. The present study investigates the process of treatment change and compares two groups of offenders against adults and offenders against children. Method Participants comprised of 15 men who had offended against adult women and 15 who offended against children. All were treated for 36 months. Groups were compared with repeated measures using the Questionnaire on Attitudes Consistent with Sexual Offending. Results At baseline, offenders against women had higher scores than offenders against children on the Rape scale while on the offences against children scale the opposite was the case. Both groups showed significant improvement with scores reducing to levels consistent with non‐offenders by 36 months. Significant improvements were still recorded from 18 to 36 months of treatment. Re‐offending across both groups was 23%. Conclusion Sex offender treatment can produce significant reductions in cognitive distortions in sex offenders with intellectual disabilities. The importance of continuing treatment for longer than 12 months was endorsed by the results.     

Effective Factors on Youth Satisfaction from Public Urban Spaces in Tehran

ABSTRACT

This evaluation study uses multiple methods to examine ways mental health issues are identified in juvenile justice residential placements. The study addresses essential characteristics of young males identified with mental health problems and differences between young people identified with mental health problems and the general residential population in a large, multi-site, nonprofit agency. The evaluation found that young males identified with mental health problems had several contacts with the social service network, the juvenile justice system and the mental health system before placement in the juvenile justice residential care setting. The evaluation raises concerns about identification mechanisms used to determine if residents have mental health problems, the responsiveness of residential program models, the need for post-residential community-based support, the importance of training residential staff, and the integration of mental health professionals into the intervention team.