Forensic care pathways
for adults with intellectual
disability involved with the
criminal justice system
Faculty Report FR/ID/04
February 2014
Royal College of Psychiatrists’
Faculty of Psychiatry of Intellectual Disability
and Faculty of Forensic Psychiatry
London
© 2014 Royal College of Psychiatrists
The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in
Scotland (SC038369).
Contents
Joint working and consultative groups
4
Foreword
7
Preface
8
Executive summary and recommendations
9
Intellectual disability and offending behaviour
15
Intellectual (learning) disability v. learning dificulties
15
Offending behaviour
16
Care pathway for offenders with intellectual disability
18
The criminal justice system
23
Police
23
Courts and court diversions
26
Prisons
28
Community disposals and hospital treatment
31
Community disposals
31
Hospital treatment
35
References
Royal College of Psychiatrists
39
3
Joint working and consultative
groups
Joint
working group
Chair
Dr Harm Boer
Past Vice Chair, Faculty of Psychiatry of
Intellectual Disability, Royal College of
Psychiatrists, and Consultant Forensic
Psychiatrist for people with intellectual disability,
Forensic Service, Brooklands, Birmingham
Dr Regi T. Alexander
Faculty of Psychiatry of Intellectual Disability,
Royal College of Psychiatrists, Honorary
Senior Lecturer, University of East Anglia, and
Consultant Psychiatrist, Partnerships in Care
Learning Disability Services, Diss, Norfolk
Editor
SECrEtary
Dr Elizabeth Beber
Faculty of Psychiatry of Intellectual Disability,
Royal College of Psychiatrists, and Consultant
Psychiatrist, St Andrew’s Healthcare,
Northampton
Dr John Devapriam
Faculty of Psychiatry of Intellectual Disability,
Royal College of Psychiatrists, and Consultant
Psychiatrist in Intellectual Disability,
Leicestershire Partnership NHS Trust
Dr Andrew Forrester
Faculty of Forensic Psychiatry, Royal College
of Psychiatrists, Honorary Senior Lecturer,
Institute of Psychiatry, King’s College London,
and Consultant Forensic Psychiatrist, Healthcare
Department, HMP Brixton, London
Dr Glyn Jones
Faculty of Psychiatry of Intellectual Disability,
Royal College of Psychiatrists, Honorary
MEMbErS
4
http://www.rcpsych.ac.uk
Joint working and consultative groups
Senior Lecturer, Department of Psychological
Medicine and Neurology, Cardiff University, and
Consultant Psychiatrist in Intellectual Disability,
Abertawe Bro Morgannwg University Health
Board, NHS Wales
Dr Nicola Phillips
Faculty of Psychiatry of Intellectual Disability,
Royal College of Psychiatrists, and Consultant
in Forensic Intellectual Disability Psychiatry,
Northumberland, Tyne and Wear NHS
Foundation Trust
Dr Dominic de Souza
Faculty of Forensic Psychiatry, Royal College
of Psychiatrists and Consultant Forensic
Psychiatrist, West London Mental Health NHS
Trust
Dr Seema Sukhwal
Faculty of Forensic Psychiatry, Royal College of
Psychiatrists and Specialist Registrar in Forensic
Psychiatry, West London Mental Health NHS
Trust
Consultative
group
Of the 30 consultative group members, the following is a list of those who
commented on the draft report and are happy to have their names appear
in the document.
Dr F. Ahmad
Consultant Psychiatrist, Birmingham Forensic
Intellectual Disability Service
Dr B. S. Arackal
Consultant and Lead Psychiatrist in Learning
Disabilities, Sussex Partnership NHS Foundation
Trust
Professor S. Bhaumik
Medical Director, Leicestershire Partnership NHS
Trust
Dr S. Cooray
Honorary Lecturer, Imperial College London
Dr D. Dalton
Consultant Forensic Psychiatrist, Hertfordshire
Partnership University NHS Foundation Trust
Dr S. Dinani
Consultant Psychiatrist, Avon and Wiltshire
Mental Health Partnership NHS Trust
Professor C. Duggan
Emeritus Professor Forensic Mental Health,
University of Nottingham
Dr F. Esan
Consultant Psychiatrist, Partnerships in Care
Learning Disability Services, Diss, Norfolk
Royal College of Psychiatrists
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Faculty Report FR/ID/04
6
Dr B. Fitzgerald
Consultant Psychiatrist, Central and North West
London NHS Foundation Trust, and University
College London Hospital
Dr S. Gangadharan
Consultant Psychiatrist, Leicestershire
Partnership NHS Trust
Ms W. Goodman
Forensic Nurse, Avon and Wiltshire Mental
Health Partnership NHS Trust
Dr I. Gunaratna
Consultant Psychiatrist, Partnerships in Care
Learning Disability Services, Diss, Norfolk
Dr A. Hiremath
Consultant Psychiatrist, Leicestershire
Partnership NHS Trust
Dr S. Hoare
Clinical Director, Partnerships in Care Learning
Disability Services, Diss, Norfolk
Dr P. Langdon
Clinical Senior Lecturer, University of East
Anglia and Honorary Consultant Forensic and
Clinical Psychologist, Hertfordshire Partnership
University NHS Foundation Trust
Professor W. Lindsay
Professor of Learning Disabilities and Forensic
Psychology, University of Abertay, Dundee, UK;
Honorary Professor, Bangor University, Wales,
UK; Consultant Clinical Forensic Psychologist,
Castlebeck, UK; and Honorary Professor, Deakin
University, Melbourne, Australia
Dr E. Machiwenyika
ST5 in Psychiatry of Intellectual Disability,
Oxford Health NHS Foundation Trust
Dr A. Michael
Consultant Psychiatrist, Norfolk and Suffolk NHS
Foundation Trust
Dr D. M. Michael
Consultant Psychiatrist, Humber NHS
Foundation Trust
Dr C. Morgan
Consultant Forensic Psychiatrist for people
with intellectual disability, Forensic Service,
Brooklands, Birmingham
Dr R. A. Naseem
ST4 in Psychiatry of Intellectual Disability,
Colchester, Hertfordshire Partnership NHS
Foundation Trust
Dr K. Purandare
Consultant Psychiatrist, Central and North West
London NHS Foundation Trust
Dr A. Shaikh
Locum Consultant Psychiatrist, Low Secure
Intellectual Disability Unit, The Wells Road
Centre, Nottingham
http://www.rcpsych.ac.uk
Foreword
This Faculty Report sets out how people with intellectual disability can
interact with the criminal justice system. This is of crucial importance to
people with intellectual disability, who may encounter dificulties and a lack
of understanding about their needs at different stages of the criminal justice
process. Many people they encounter will not have specialist expertise in
supporting people with intellectual disability, but this report really helps to
enable non-specialists to have a better understanding of the needs of this
vulnerable patient group and how they can best support them, including
when community options are appropriate and when to get more specialist
services involved. It also makes clear recommendations about how, for
example, the police and prison services can develop skills by including
information about people with intellectual disability in induction programmes.
Good commissioning of specialist forensic services for people with
intellectual disability is essential, especially in the light of the poor practice
exposed at Winterbourne View hospital and the relative lack of monitoring
by commissioners and regulatory bodies. Often commissioners may have
to take up a brief at short notice, so this report will be invaluable to them.
It is essential that there is proper strategic commissioning, especially for
services working with prisoners, and to ensure there is a proper range of
secure in-patient services so that those who require in-patient treatment can
be treated in the least restrictive setting and as close to home as possible.
The report also makes clear that proper outcome-based research
is required, including an economic analysis, to ensure that we make the
optimum use of resources to provide services that give the best chance
for people with intellectual disability to successfully address their offending
behaviour.
Dr Ian Hall
Chair of the Faculty of Psychiatry of Intellectual Disability
Royal College of Psychiatrists
Royal College of Psychiatrists
7
Preface
This document aims to highlight good practice guidelines for pathways of
care for people with intellectual disability involved in the criminal justice
system.
Its objective is a description of a care pathway that involves the
criminal justice system (including police, courts, prisons and probation),
specialist intellectual disability services, adult mental health services, forensic
services and Social Services in England and Wales. It identiies the key roles
and responsibilities of professional input (including triggers of involvement)
and provides good practice guidance on multi-agency and holistic approaches
in the management of offenders with intellectual disability.
Although the report touches on speciic subgroups (e.g. people with
autism spectrum disorder, women, children, adolescents and people with
sensory impairments), there are no speciic chapters on these areas, and
readers are advised to seek specialist advice in those ields.
All chapters in this document end with key recommendations to
relevant stakeholders.
The target audience is psychiatrists, psychologists, nurses and allied
health professionals working in specialist intellectual disability, forensic
mental health, and adult mental health services. This report is also highly
relevant to commissioners (health and local authority) and criminal justice
system professionals.
This document was drafted by a joint working group of nine members
drawn from the Faculties of Forensic Psychiatry and Psychiatry of Intellectual
Disability of the Royal College of Psychiatrists. The inal version, including
recommendations, emerged after discussions with a wider consultative group
and we thank all those who contributed to this effort.
We are very grateful to Ms Verity Chester, research assistant to Dr Regi
T. Alexander, for her help with the relevant literature searches.
Dr Regi T. Alexander
Editor of the joint working group
Dr Harm Boer
Chair of the joint working group
8
http://www.rcpsych.ac.uk
Executive summary
and recommendations
This document has been produced by members of the Faculties of Psychiatry
of Intellectual Disability and Forensic Psychiatry of the Royal College of
Psychiatrists. It describes the key stages of the care pathway for people
with intellectual disability who have been charged with committing, or are
suspected to have committed, offences.
There is some confusion as to whether people with intellectual
disability who offend should be dealt with by health or criminal justice
systems (or both). A failure to report, and therefore to prosecute, episodes
of serious challenging behaviour may lead to an individual believing that
such behaviour is acceptable, leading to further and potentially more
serious acts. However, an assumption that forensic psychiatry services offer
the way forward for everyone with an intellectual disability and offending
behaviour could also be potentially reductionist and simplistic. Whether these
patients access services through forensic services or through ‘non-forensic’
community and hospital services, what is most important is that their needs
are identiied in a timely manner and that they receive the appropriate
therapeutic input.
When people with intellectual disability do access the criminal justice
system there are signiicant dangers that their speciic needs will not be
recognised and therefore not met. Even when professionals within the
criminal justice system do recognise a person’s intellectual disability, they
may not be aware of their statutory responsibilities or of how to access
appropriate support services. Intellectual disability services in turn frequently
lack knowledge of the criminal justice system and, in contrast to mental
health services, are rarely party to local health and criminal justice policy
and service planning.
There is a larger group of offenders with learning dificulties (as
opposed to intellectual disability) who may be less visible but are,
nonetheless, vulnerable. In contrast to individuals with intellectual disability,
there will often be no statutory services designated to address their speciic
needs.
Intellectual disability services have rarely been party to the increasing
collaborative arrangements between mental health and criminal justice
services; therefore ‘diversion’ between specialist intellectual disability and
criminal justice services may represent an ofloading of an individual with
complex problems rather than an opportunity for collaborative working
between partner agencies.
Professionals, particularly those with no knowledge, experience or
expertise in working with people with intellectual disability, can sometimes
express the view that nothing can be done under the Mental Health Act 1983
because the person is not ‘mentally ill’. It is important for professionals to
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Faculty Report FR/ID/04
be aware that intellectual disability associated with abnormally aggressive
or seriously irresponsible behaviour could potentially be a mental disorder,
even if the person does not have a mental illness, and that a referral to
psychiatric services for people with intellectual disability may be appropriate.
In addition, many people with intellectual disability may have other mental
health problems. In police stations, appropriate adults (National Appropriate
Adult Network, 2001) and medical opinions should be sought.
All courts need access to a court diversion scheme that has links with
people experienced in assessing people with intellectual disability. Psychiatric
trainees gaining a Certiicate of Completion of Training (CCT) in intellectual
disability psychiatry should be competent in applying those parts of mental
health legislation relating to people concerned in criminal proceedings and
in providing reports to the court. Psychiatric reports for the court on people
with intellectual disability should routinely contain recommendations to
the court on necessary adaptations to the court process. In order for some
accused people to have a fair trial, the Witness Intermediary Scheme should
be available to vulnerable defendants.
There is a balance to be struck between diverting people with
intellectual disability and signiicant mental health problems from the
criminal justice system and those factors favouring prosecution and
safeguarding the public. Wherever possible, the aim is to maximise the use
of community disposals. A large range of community disposals are open to
courts at the sentencing stage. Ongoing specialist professional support is
crucial to the implementation and success of these community disposals.
Courts, probation services and youth offending teams in each locality
should have access to intellectual disability services as a irst point of
contact. This should ideally be a dedicated community forensic intellectual
disability team, of which there are a few examples. If that is not available,
the function can be carried out by a community intellectual disability team
or, depending on local protocols, an appropriately skilled mainstream mental
health or forensic mental health team.
Protocols for joint working between community forensic intellectual
disability, community intellectual disability, community forensic and community mental health teams should be developed locally and opportunities
for pooling resources and sharing skills should be explored. Community intellectual disability teams and professionals need structured training on risk
and related forensic issues, whereas those from mainstream mental health
or forensic services need training in intellectual disability.
There is still a limited understanding of the prevalence and needs of
people with intellectual disability in prisons, who probably receive insuficient
support and treatment. They are likely to experience greater dificulty
coping in custody and to be vulnerable to bullying, and they are less likely
to participate in or beneit from prison treatment programmes.
It is estimated that there are about 48 high, 604 medium and 1741
low secure beds in addition to 345 forensic rehabilitation beds for people
with intellectual disability in England. These are very unevenly distributed,
causing some people to be placed far away from home. These units treat a
group of people with intellectual disability and very high rates of comorbidity
including personality disorder, substance misuse, autism spectrum and other
developmental disorders.
The nature of treatments available in secure units for intellectual
disability has not been described precisely, although there are some broad
frameworks that are now available. There is a paucity of outcome studies in
this area and none examining costs.
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Executive summary and recommendations
reCommendations
1
There should be national standards on health and social care
provision for offenders with intellectual disability, with clear lines of
accountability and explicit mechanisms for addressing any apparent
gaps in service provision. Particular attention should be paid to the
commissioning of a range of in-patient and community services that
will allow people with intellectual disability who offend to be managed
safely in the least restrictive setting.
2
There also needs to be greater clarity in the use of terminology (e.g.
intellectual or learning disability, learning dificulties, etc.) both within
and between health, social care and criminal justice systems.
3
Local multi-agency strategic planning groups must be developed
between intellectual disability and criminal justice services, with the
aim of preventing offending and reoffending. These do not necessarily
need to be distinct from existing mental health arrangements, but
must include speciic arrangements for joint training and collaborative
working in relation to people with intellectual disability.
4
All police oficers, in particular custody oficers and community support
oficers, need to have intellectual disability awareness training as part
of their induction process. This training should be provided with input
from health professionals.
5
Custody suite staff should be able to recognise whether someone has
intellectual disability and know who to contact about this in order to
ensure the person receives the necessary support.
6
Appropriate adults should follow the same individual throughout their
contact with the criminal justice system to ensure continuity for the
detainee.
7
There needs to be an identiied link police oficer at every police station
who should attend the police liaison group which occurs with the local
health service, and work collaboratively with local mental health and
intellectual disability services. Good links with the local community
support team must be available, so that they can access advice,
assessment, treatment, court reports and joint work for individuals in
their service, and also more general advice and training in intellectual
disability.
8
People with intellectual disability should have equitable legal and civil
rights to other people. Those who are at risk of offending should also
have a right to be held accountable for intentional actions, to have
fair boundaries set and to have the full range of sentencing options
available to them, if convicted. In view of their vulnerability and limited
understanding, they may have dificulty in exercising their rights within
the criminal justice system. Consequently, they may need support
when they enter the criminal justice system.
9
All courts should have access to a court diversion scheme and all such
schemes should have input from health professionals trained to work
with people with intellectual disability.
10
Members of the judiciary and the probation service should be trained
in mental health and intellectual disability awareness.
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11
Psychiatric reports on people with intellectual disability for the courts
should be provided by professionals who are both experienced in
working with this group and appropriately trained to provide advice to
the courts.
12
Psychiatrists and trainees gaining a specialist qualiication in intellectual
disability psychiatry should be competent in applying those parts of
the relevant mental health legislation relating to this population and
should be competent in preparing a psychiatric report for the court,
particularly in the areas of itness to plead and appropriate disposal
options (how the court deals with the case).
13
Psychiatrists and trainees gaining a specialist qualiication in intellectual
disability psychiatry should be fully aware of the provisions of the
criminal justice system with regard to the provisions for vulnerable
defendants, including knowledge of appropriate disposal options if
found guilty.
14
Psychiatrists and trainees gaining a specialist qualiication in forensic
psychiatry should ideally have obtained some experience in working
with offenders with intellectual disability and competencies should be
identiied with regard to this.
15
Psychiatric reports on people with intellectual disability for the court
should routinely contain recommendations to the court on necessary
adaptations to the court process.
16
Courts, probation services and youth offending teams in each locality
should have access to intellectual disability services as a irst point
of contact. This should ideally be a dedicated community forensic
intellectual disability team or a specialist function within the intellectual
disability team. If that is not available, the function can be carried
out by a community intellectual disability team. Depending on local
protocols, this function may also be carried out by mainstream mental
health or forensic mental teams provided they have the appropriate
skills.
17
Protocols for joint working between community forensic intellectual
disability, community intellectual disability, community forensic and
community mental health teams should be developed locally and
opportunities for pooling resources/sharing skills should be explored.
Local pathways should be developed in conjunction with other agencies
involved in the management of an offender with intellectual disability.
18
Community intellectual disability teams should receive further training
to manage less serious offending and to provide input where speciic
community forensic intellectual disability teams are not feasible or
where the case-load demands it. Likewise, in areas where they carry
out this function, community forensic and mental health services will
need training on issues of intellectual disability.
19
Training of the members of the intellectual disability teams could
include input from psychiatry, nursing and psychology, with the
team accepting referrals from existing National Health Service (NHS)
services and the criminal justice system. The team should provide
expertise to the criminal justice system and make recommendations
for community disposals where appropriate.
http://www.rcpsych.ac.uk
Executive summary and recommendations
20
In order to recommend community disposals, the appropriate
treatments should be available (from community forensic intellectual
disability teams or from specialists within generic intellectual disability
teams) in the form of adapted programmes for substances misuse,
sex offender treatment, ire-setting and violent offending; preferably
in collaboration with mainstream services as outlined in Valuing People
(Department of Health, 2001). Such programmes may need to be
lexible so as to not exclude those with borderline intellectual disability.
21
Based on existing Department of Health work, all prisons in England
and Wales should include proper and full reception screening for
intellectual disability as part of routine screening procedures (currently
done in accordance with the Grubin tool; Grubin et al, 2002). As
mentioned in ‘The criminal justice system’, the recently developed
Learning Disability Screening Questionnaire (LDSQ) can be a suitable
tool (www.gcmrecords.co.uk/gcm_records_007.htm).
22
All prison healthcare providers should work with local community
intellectual disability service providers to assist in ensuring that
local team expertise is incorporated within the prison. This could, for
example, involve visiting sessions from an intellectual disability/dually
trained psychiatrist or regular attendance by a community psychiatric
nurse who has training in intellectual disability.
23
In order for such services to work, they will require full integration with
existing prison mental health services (including primary care services)
to ensure joint working, learning from experience and education.
24
Intellectual disability referral pathways need to be clearly mapped in
agreement with local intellectual disability services, with the following
questions in mind, and recognising that most individuals can be
supported within the prison system:
a
Who should be referred?
b
When should they be referred?
c
What response can be expected following referral?
25
Local initiatives in respect of joint working with other agencies
(including the voluntary service) should be encouraged. Commissioners
of services should be integral to this process.
26
Inside prisons, joint working between existing mental health providers,
primary care and other multi-agency partners is recommended. This
may require a joint vehicle for the discussion of complex cases, and
arranging a meeting to determine which agencies should be involved
in each particular case is recommended. This meeting will resemble
an ‘internal’ Multi-Agency Public Protection Arrangements (MAPPA)
meeting, but, unlike MAPPA, will not be restricted to high-risk
individuals.
27
Particular attention should be paid to the commissioning of a range
of in-patient and community services that will allow these patients
to be managed safely in the least restrictive setting. Offenders with
intellectual disability should be treated as near as possible to their
home area.
28
Reliable data on the number of offenders with intellectual disability in
secure units should continue to be actively collected.
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29
14
The nature of treatments offered should be clearly described and a
common data-set of short-term and long-term outcome variables
collected through a nationwide audit. This should include information
about the cost of placements. Such information should be used to
identify predictors of length of hospital stay and successful treatment
outcomes.
http://www.rcpsych.ac.uk
Intellectual disability and offending
behaviour
intelleCtual (learning)
disability v. learning
diffiCulties
By deinition, the term intellectual disability or learning disability refers to a
person with:
signiicant impairment of intellectual functioning (IQ <70 on an
established IQ test such as the Wechsler Adult Intelligence Scale,
WAIS-IV; Wechsler, 2008)
signiicant impairment of social functioning (there is no gold standard
test to measure this at present; clinicians tend to use adaptive
behaviour assessment scales such as the Vineland Adaptive Behavior
Scales (Sparrow et al, 1984) or the Adaptive Behavior Assessment
System (Harrison & Oakland, 2003))
signiicant impairment which has been present from childhood (onset
during the developmental period).
In contrast, the term learning dificulties (used by the UK Department
for Education) can cover a range of conditions including speciic learning
disabilities or dyslexia, dyspraxia, speech, language and communication
problems, sensory impairments, attention-deicit hyperactivity disorder
(ADHD), autism spectrum disorder (ASD) as well as individuals functioning
in the borderlines between normal and impaired intellectual functioning.
In the recent past there have been other deinitions such as that provided
by the Mental Health Act 1983 for ‘mental impairment’ under the deinition
of ‘Mental Disorders’: some patients detained under these categories did
not have intellectual disability in the stricter sense but were more likely to
have had borderline intellectual functioning. Even in the strictest possible
deinition, people with intellectual disability are a heterogeneous group with
different degrees of ability, comorbidities and other confounding factors
including those relating to communication, sensory impairments, mobility
and other health problems.
Inconsistent application of deinitions and terminology – especially
between intellectual disability, learning disability and learning dificulties –
has led to considerable confusion in both research and clinical practice. The
category of borderline intellectual functioning becomes relevant here and
is deined in DSM-IV-TR (American Psychiatric Association, 2000) as an IQ
range of between one and two standard deviations below the mean (70–84).
Using this deinition, 12.3% of a UK-wide cross-sectional sample of 8450
adults living in private households have borderline intelligence (Hassiotis
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Faculty Report FR/ID/04
et al, 2008). Those with borderline intellectual functioning do not have an
intellectual disability in the strict diagnostic sense (Langdon et al, 2010).
However, some people within this IQ range may have other developmental
disabilities (e.g. ASD, other genetic disorders) that result in signiicant
impairments of social and adaptive functioning. It has been recommended
that patients with borderline intellectual disability (e.g. IQ 70–75) can be
classiied as having a mental disorder as deined in the Mental Health Act
(amended in 2007), particularly if they have additional disabilities such as
severe social deicits, genetic abnormalities, autism, cerebral palsy and
brain injury. Forensic services for people with intellectual disability may
have specialist skills in treating those with borderline intellectual disability
because of psychological therapies available for people with reduced
cognitive abilities. The needs of individuals with borderline intellectual
disability who have offended can remain largely similar to those who have
mild intellectual disability. Many forensic intellectual disability services
admit people with borderline intellectual disability and even low average
IQ. However, this service provision is patchy. Halstead (1996) noted that,
‘forensic intellectual disability practice quickly reveals the phenomenon of
the person who its so many borderlines that no service is willing to take
them on’. Specialist forensic facilities are required for persons with mild and
borderline intellectual disability and serious offending behaviour to ensure
an adequate period of specialist assessment and treatment. Historically,
prison and probation services explicitly excluded men with a full-scale IQ
<80 from offence-speciic treatment (Langdon, 2010). Therefore there was
a cohort of men with ‘borderline’ intellectual disability who did not receive
treatment. Many studies from forensic intellectual disability services also
include people with borderline intellectual disability and low average IQ (Torr,
2008). Generally, no distinction is made between the intellectual disability
and borderline intellectual disability groups.
It is generally accepted that approximately 2% of the UK general
population have intellectual disability (Loucks, 2007), and about 17%
will have an IQ <85. The rate of social and intellectual impairments rises
considerably among offenders. If both intellectual disability and learning
dificulties are considered together, about 20–30% will fall into that category
(Talbot, 2008a). These individuals are likely to struggle with standard
methods of communication and are likely to require considerable additional
support if they are to safely and effectively negotiate the various elements
of the criminal justice system.
People with speciic learning dificulties as opposed to intellectual
disability therefore represent a signiicantly larger and more functionally
able group of patients than are typically cared for in conventional intellectual
disability services, and they may feel that services lack the specialist
resources to meet their complex needs. Similarly, mental health services are
frequently restricted to the care of individuals with severe mental illness and
this leaves many individuals with learning dificulties outside conventional
statutory support services.
offending
behaviour
The term offending behaviour is problematic when used in relation to
people with intellectual disability. Under English law (England and Wales),
a crime is deined by two components: actus reus (the act of crime) and
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Intellectual disability and offending behaviour
mens rea (the intent to commit that crime). The latter is dificult to elicit
in people with intellectual disability (especially in those with moderate to
profound intellectual disability) and is a key issue when it comes to legal
perception of the difference between challenging behaviour and criminal
behaviour. Similarly, these factors inluence police decisions to caution or
to arrest and convict an individual with intellectual disability. Thus when a
person has moderate to severe intellectual disability, unless the criminal
act is very serious, they are unlikely to be dealt with through the criminal
justice system. However, the issue becomes far less clear for those with
mild intellectual disability where both their understanding of the offence and
the appropriateness of them being dealt with through either the health or
criminal justice system requires specialist evaluation.
Some believe that the involvement of the criminal justice system
in cases of offending by people with intellectual disability is punitive and
draconian. A review by McBrien & Murphy (2006) identiied that some
carers stated that they would not even report serious crimes such as rape if
committed by a person with intellectual disability. It may be argued that a
failure to report, and therefore to prosecute, episodes of serious challenging
behaviour may lead to an individual believing that such behaviour is
acceptable, leading to further and potentially more serious acts (Murphy
& Mason, 2007). Moreover, the Crown Prosecution Service’s decision to
prosecute depends on the perceived likelihood of conviction and the extent to
which this course of action is considered to be in the public interest (Holland
et al, 2002). On the other hand, the assumption that forensic psychiatry
services offer the way forward for everyone with intellectual disability and
offending behaviour could be potentially reductionist and simplistic (B.
Fitzgerald, personal communication, 2012).
There has been a general shift from custodial sentencing to an
approach to rehabilitate offenders with intellectual disability either in
hospital or in community settings. This in turn has an effect on prevalence
studies of offending in this population as these are usually conducted in
prisons or secure hospital settings where there would inevitably be an
overrepresentation of people with intellectual disability who are more able
(with mild/borderline levels of intelligence) and who have committed serious
offences necessitating remand to prison or secure hospital settings.
Many specialist intellectual disability services in the community
have developed extensive ‘challenging behaviour’ resources, within which
signiicant behaviour which might otherwise be deemed a criminal offence is
likely to be dealt with either through use of the Mental Health Act or outside
statutory frameworks. Whether these patients access services through
forensic services or through ‘non-forensic’ community and hospital services,
the most important factor is that their needs are identiied in a timely
manner and that they receive the appropriate therapeutic input.
Royal College of Psychiatrists
17
Care pathway for offenders
with intellectual disability
The journey of an offender (without intellectual disability) from index
offence through the various stages of the criminal justice system process,
including arrest, charging, conviction and potentially custodial sentence,
may appear relatively straightforward. However, for a person with
intellectual disability this can represent a bewildering sequence of events,
as shown in Fig. 1.
Voluntary treatment
Voluntary treatment
Health
service
improvement
(primary
care)
Specialist
intellectual
disability
services
Index
event
S2, 3
Hospital
care:
formal/
informal/
voluntary
Discharge
planning
Not
reported
S47, 49
S135, 136
S37, CPIA (both
+/– restriction
order)
S35, 36, 38, 48/49
Police
involvement
Verbal warning?
Arrest (and
caution) +
interviewa
Courtb
Disposalc
Absolute
discharge
Prison
Discharge
planning
Orders
including
probation
and/or health
service
Fig. 1 Pathway of an offender with intellectual disability through the criminal justice system. S, Section (of the
Mental Health Act 1983).
a. Appropriate adult (Police and Criminal Evidence Act 1984).
b. Special measures (Youth Justice and Criminal Evidence Act 1999).
c. Criminal Procedure (Insanity) Act 1964, Criminal Procedure (Insanity and Unfitness to Plead) Act 1991 (CPIA).
18
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Care pathway for offenders with intellectual disability
Home Ofice policy, as far back as 1990 (Home Ofice, 1990), stated
that wherever possible, mentally disordered offenders should receive care
and treatment from health and social services rather than be dealt with via
the criminal justice system.
The Reed report (Department of Health & Home Ofice, 1992) in turn
called for ‘closer working between the Police, Health and Social Services to
avoid unnecessary prosecution of mentally disordered offenders’, and it set
clear principles of care for people with intellectual disability who offend. It
advocates a tailored approach to the individual, with care and treatment
provided in the community, close to home and support networks.
These principles were supported by the Bradley report (Department
of Health, 2009a), which recommends early identiication of people with
intellectual disability when they come into contact with the criminal justice
system, clear referral protocols, appropriate training for those working within
the criminal justice system and appropriate community-based treatment
and care packages for those at risk. If criminal justice professionals are
unaware that the person has intellectual disability or lack knowledge of
the support needs of this population and the statutory safeguards which
should be available to protect them, then there is a likelihood of signiicant
disadvantage and potential miscarriage of justice (Loucks, 2007; Talbot,
2007, 2008a). Similar problems exist for people with a variety of dificulties,
including dyslexia, dyspraxia, speech, language and communication
problems, sensory impairments, ADHD and ASD.
In his review (Department of Health, 2009a), Lord Bradley notes that
different agencies had very different views of diversion and what it meant.
In recognising a range of options on the appropriate interpretation, he
attempted to reach a consensus which strikes a balance between the rights
of the offender, the rights of any victim and the protection of the public. He
described diversion as:
‘a process whereby people are assessed and their needs identiied as
early as possible in the offender pathway (including prevention and
early intervention), thus informing subsequent decisions about where an
individual is best placed to receive treatment, taking into account public
safety, safety of the individual and punishment of an offence.’ (p. 16)
He also commented on how policy in these areas had developed in
a piecemeal fashion, with many governmental departments, agencies and
organisations ‘working independently of one another, developing policies and
practice in isolation, addressing one problem or are part of the system at
a time’ (p. 123). In other words, ‘working in silos’. Lord Bradley recognised
that robust governmental arrangements at a national, regional and local
level were the key to implementation of effective change and made national
accountability a key recommendation of his report.
system
response to offenders with intelleCtual
disability
In the past decade, the criminal justice system has made signiicant efforts
to identify individuals with intellectual disability in the system, understand
the needs of these individuals and develop care pathways that facilitate the
diversion of these individuals into systems of care that are more suitable
and appropriate.
Royal College of Psychiatrists
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Faculty Report FR/ID/04
no one knows
The No One Knows programme was undertaken by the Prison Reform Trust
to address concerns raised by prison staff, prisoners and their families
regarding the unmet needs of people with intellectual disability and learning
dificulties within the wider interface of prisons, the criminal justice system,
specialist health and social services. The review (Talbot, 2008a) found that
decision-making by the police on enforcement, diversion and disposal for
people with intellectual disability is inconsistent. The use of appropriate
adults during police interviews is patchy because the need is not identiied
or because there are not enough individuals to perform this role. People with
intellectual disability and their carers are often bafled by court proceedings,
which are rarely adapted to enable them to participate appropriately (Talbot,
2008a). It was apparent that there was lack of adequate staff skills to
identify intellectual disability and even if they did, a perverse disincentive
to do so as this would bring statutory responsibilities which staff felt unable
to fulil (Loucks, 2007; Talbot, 2007, 2008a). There is a scarcity of adapted
treatment programmes for people with intellectual disability in prison, which
has been raised as a human rights issue (Joint Committee on Human Rights,
2008).
laCk
of Joined-up working between Criminal
and intelleCtual disability serviCes
The problem is that there is no joined-up approach between the criminal
justice system and health and social care systems in dealing with these
issues, and even the effectiveness and quality of court diversion schemes
vary in different regions. Awareness among police forces and prison
oficers across the UK is crucial for this pathway to be eficient, effective
and useful for people with intellectual disability. Unfortunately, despite
good local initiatives, most regions do not have a training programme
in place for all staff concerned, and support for training and liaison work
through the commissioning route is at times missing. When compared
with the reasonably well-established networks between specialist forensic
mental health services and various elements of the criminal justice system,
collaborative working between intellectual disability and criminal justice
professionals is typically piecemeal or absent. They often appear unaware
of each other’s roles, responsibilities or potential collaborative solutions
to address potentially offending behaviour by people with intellectual
disability. Even when individual professionals from the relevant services
are working together to establish an effective outcome in an individual
case, this is rarely generalised across services. There is clearly a need
for a more open debate on this interface between services and a greater
commitment to collaborative working (Department of Health, 2009a;
Jones & Talbot, 2010). Some people with mild intellectual disability state
that they would prefer a ixed prison sentence than the uncertain and
potentially far longer detention under a section of the Mental Health Act.
This situation has been complicated further by the introduction of the
indeterminate prison sentence for ‘public protection’ (Prison Reform Trust,
2007).
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Care pathway for offenders with intellectual disability
offending
pathway
The offending pathway will often be cyclical rather than linear. That is, many
individuals who have already passed through the criminal justice system
will reoffend unless their patterns of offending behaviour are addressed.
Unfortunately, few of the programmes designed to address recidivism within
prison or probation services are modiied to make them accessible for
people with intellectual disability (Talbot, 2007). In contrast, individuals with
intellectual disability who enter the health system are more likely to access
input from specialist services designed to address recidivism.
Although the UK has a long history of specialised service provision for
people with intellectual disability and mental health problems, over recent
years the political emphasis has been very much on people with intellectual
disability accessing ‘mainstream’ services – i.e. those set up for people with
‘normal’ intelligence, albeit with some input from professionals in intellectual
disability (Department of Health, 2009b; National Institute for Health and
Clinical Excellence, 2009). However, in relation to the treatment of recidivism
in those with intellectual disability, the beneit of separate specialist services
appears to continue to exist.
This creates an interesting dynamic for offenders with intellectual
disability treated in specialist forensic intellectual disability units, who
often have a mild intellectual disability or an IQ score in the borderline
range of intellectual functioning. They often fall between the boundaries
of ‘mainstream’ mental health and intellectual disability services in the
community – too disabled for one and too able for the other.
Discussing this issue in the context of offenders with intellectual
disability and personality disorder, Alexander et al (2010) suggest that
although being admitted to mainstream units may achieve the aim of equity
of access, achievement is meaningless in the absence of equity of outcome.
A low IQ may often exclude people from treatment programmes (Beech
et al, 1998; Talbot, 2007; Tyrer et al, 2007). This happens not necessarily
because these mainstream units are overcome by prejudice, but because the
treatment content needs to be delivered for people with intellectual disability
in a way that is appropriate for their developmental and intellectual level.
Economies of scale, as well as availability of a critical mass of expertise may
mean that these developmental-level-speciic treatment programmes are best
delivered in specialised intellectual disability units (Alexander et al, 2010).
However, these in-patients will be able to make effective transition
to the community only if relevant expertise and resources exist within
intellectual disability services. It has been consistently found that this is
a group who even after discharge from hospital will need high levels of
continuing professional input for many years (Naik et al, 2002; Alexander et
al, 2006).
The following chapters will outline in detail the pathway followed by an
offender with intellectual disability through the criminal justice system, health
and social care settings.
reCommendations
1
There should be national standards on health and social care
provision for offenders with intellectual disability, with clear lines of
Royal College of Psychiatrists
21
Faculty Report FR/ID/04
accountability and explicit mechanisms for addressing any apparent
gaps in service provision. Particular attention should be paid to the
commissioning of a range of in-patient and community services that
will allow people with intellectual disability who offend to be managed
safely in the least restrictive setting.
22
2
There also needs to be greater clarity in the use of terminology (e.g.
intellectual or learning disability, learning dificulties) both within and
between health and criminal justice services.
3
Local multi-agency strategic planning groups must be established
between intellectual disability and criminal justice services, with the
aim of preventing offending and reoffending. These do not necessarily
need to be distinct from existing mental health arrangements, but
must include speciic arrangements for joint training and collaborative
working in relation to people with intellectual disability.
4
Psychiatrists in the ield of intellectual disability need to be competent
in the relevant mental health legislation and know how to apply it
when faced with offending behaviour. In addition, a detailed knowledge
of relevant mental health, criminal and equality legislation and an
understanding of their potential application in proceedings throughout
the various stages of the offender’s journey is required.
5
Forensic psychiatrists need to have a good understanding of the needs
of patients with intellectual disability and learning dificulties, and of
the role and structure of specialist intellectual disability services.
http://www.rcpsych.ac.uk
The criminal justice system
poliCe
Contact with the criminal justice system can be both daunting and confusing.
This is magniied when a person has an intellectual disability. People with
intellectual disability can come into contact with the police either following
behaviour that concerns the public or an alleged offence. If arrested following
after an alleged offence, issues such as whether the person is it to be
detained or interviewed need to be considered.
People with intellectual disability can vary widely as to their level
of functioning and ability, which can further complicate things. They may
have little long-term perspective and limited ability to understand the
consequences of their actions. They may be easily manipulated. They often
make no attempt to disguise what they have done. In trying hard to please
authority igures, they may confess to what they have not done and may
show evidence of increased acquiescence (Finlay & Lyons, 2002).
SCrEEning
for intEllECtual diSability and MEntal diSordErS
All people in police custody need to be assessed in order to determine
whether they are likely to present any particular risks either to themselves
or other people. This role is undertaken by the custody oficer. Research
has raised concerns about the screening processes used in police custody
to detect people who may have a psychiatric or medical problem. It is
suggested that some people with intellectual disability are not being detected
(McKinnon & Grubin, 2010).
Screening should include questions to establish the presence of
intellectual disability and, if used consistently, will help to ensure that
individuals with health needs are identiied early and receive the help
which they require (Jacobson, 2008; Talbot, 2008a). The Grubin screening
tool (Grubin et al, 2002) used in prisons may identify some people with
intellectual disability and mental health problems. More recently, the
Learning Disability Screening Questionnaire (LDSQ; www.gcmrecords.co.uk/
gcm_records_007.htm) has been suggested as being suitable. It should be
noted that such instruments can be over-inclusive, and can also identify
people who do not have intellectual disability. It is therefore essential that
such tools are not the sole sources of indication of any intellectual disability
and are followed up with in-depth assessments.
It is important to note that many people with intellectual disability,
particularly those who come into contact with the criminal justice system,
may have additional mental health problems including other developmental
Royal College of Psychiatrists
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Faculty Report FR/ID/04
disabilities, mental illnesses (e.g. psychosis, personality disorder) and
substance use disorders (Alexander et al, 2011). When a person in police
custody appears to have a mental disorder or looks like they need clinical
attention, then appropriate help must be sought as soon as possible.
The police surgeon (who is also known as the forensic medical
examiner or forensic physician) is asked to assess the detainee in this
situation. It is usually the police surgeon who assesses whether the detainee
is ‘it to be interviewed’, although sometimes psychiatrists can be asked to
provide an opinion. It is also known that ‘upon this assessment (of whether
someone is it to be interviewed) may hinge the decision of the court to
convict the guilty or acquit the innocent’ (Rix, 1997).
appropriatE
adult
In England and Wales, the Police and Criminal Evidence Act 1984 helps to
provide special protection to people at police stations who could have a
mental disorder or are mentally vulnerable. This is partly done by ensuring
that they have an appropriate adult with them while they are in police
custody (Perks, 2010), and it is important to do this as soon as possible
(Association of Chief Police Oficers, 2012). An appropriate adult is required,
as detainees ‘may need the support of an adult presence; of someone
to befriend, advise and assist them to make their decisions’ (The Royal
Commission on Criminal Procedure, 1981). Research has shown that the
number of instances of police requesting an appropriate adult was much
less compared with when the researchers felt that this should have occurred
(Hodgson, 1997). To ensure continuity, the appropriate adult appointed at the
time of the initial interview should follow the person throughout their entire
contact with the criminal justice system. The importance of the detainee
knowing the appropriate adult and being able to trust them has previously
been emphasised by people with intellectual disability (Leggett et al, 2007).
SECtion 136
and pEoplE with intEllECtual diSability
In England and Wales, people with intellectual disability can also come into
contact with the police if they are detained under Section 136 of the Mental
Health Act (removal of a person with a mental disorder in immediate need
of care or control found in a public place to a place of safety) for a mental
health assessment. On assessment, some professionals can sometimes
express the view that nothing can be done under mental health legislation
because the person is not ‘mentally ill’. This is especially the case when the
assessing professionals do not have expertise or experience in working with
people who have intellectual disability. It is important to note that intellectual
disability associated with abnormally aggressive or seriously irresponsible
behaviour could potentially be a mental disorder warranting treatment under
the Mental Health Act, even if the person does not have a mental illness. In
addition, many people with intellectual disability, particularly those who come
into contact with the criminal justice system, may indeed have mental health
problems – including other developmental disabilities, substance misuse,
personality disorders – and this complexity highlights the importance of a
careful mental health assessment and, if necessary, referral for admission
to hospital.
24
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The criminal justice system
To ensure good continuity of care, it is important to nurture good links
between the police and the local community mental health, intellectual
disability and hospital services. As part of this, it is important that psychiatric
trainees have the opportunity to attend police stations and undertake
psychiatric assessments on detainees when these are required. Research
has shown that certain routes of referrals are underused, such as from the
criminal justice system into community intellectual disability teams (Wheeler
et al, 2009). A police liaison group could also help with this and should be
in place in order to provide a forum where overlapping issues involving both
services can be discussed. To encourage good links between the services,
there should be a named oficer at every police station who works with the
local health services.
It is crucial that police oficers have received the necessary awareness
training so that they can detect individuals who may have a mental disorder
or who are mentally vulnerable and know who to contact in order that the
individual receives the support and treatment which they require. Forensic
liaison services need to be aware of the issues of intellectual disability and
the criminal justice system.
rECoMMEndationS
1
All police oficers, in particular custody oficers and community support
oficers, need to have intellectual disability awareness training as part
of their induction process. This training should be provided with input
from health professionals.
2
Custody suite staff need to be able to recognise whether someone has
intellectual disability and know who to contact about this to ensure the
person receives the necessary support.
3
Appropriate adults should follow the same individual throughout their
contact with the criminal justice system to ensure continuity for the
detainee.
4
There needs to be an identiied link police oficer at every police
station. They should attend the police liaison group which occurs
with local health services, and work collaboratively with local mental
health and intellectual disability services. Good links with the local
community support team must be available, so that they can access
advice, assessment, treatment, court reports, and jointly work for
individuals in their services, and also more general advice and training
in intellectual disability.
5
People with intellectual disability should have equitable legal and civil
rights, just as people without intellectual disability do. Those who are
at risk of offending should also have a right to be held accountable
for intentional actions, to have fair boundaries set and to have the
full range of sentencing options available to them, if convicted. In
view of their vulnerability and limited understanding, they may have
dificulty in exercising their rights within the criminal justice system.
Consequently, they may need support when they enter the system.
Royal College of Psychiatrists
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Faculty Report FR/ID/04
Courts
and Court diversions
A court appearance, be it in the lower or higher courts, is a daunting
experience at the best of times for most people. An offender or suspected
offender with any degree of intellectual disability may be further
disadvantaged as a result of their cognitive deicits and life experience. In
England and Wales this has been recognised by the criminal justice system
in The Criminal Procedure (Amendment No. 2) Rules 2013, which set out
provisions for those people classiied as ‘vulnerable defendants’. This group
includes people with intellectual disability.
The Consolidated Criminal Practice Direction states that all possible
steps should be taken to assist a vulnerable defendant to understand and
participate in court proceedings and that the court process should be adapted
as far as necessary (para. 3D.2). These adaptations include the defendant
having a chance to visit the court room out of hours to familiarise themselves
with the environment, having the proceedings and possible outcomes
explained in advance in understandable language, being free to sit with
family or a supporting adult during the proceedings, having frequent breaks
to aid concentration and having the trial (including cross-examination)
conducted in simple, clear language. There is also provision for evidence to
be given by video link and for restrictions on who can be in attendance in
the court room.
Early
rECognition of intEllECtual diSability
For these provisions to have any effect, it is vital that defendants with
intellectual disability are recognised as such early on in the process. Court
diversion schemes play an important role in the recognition of mental
disorder in defendants but there is often little expertise in intellectual
disability in these teams. Nacro (2005) noted that most diversion schemes
were focused on offenders with mental illness and that there were only three
such schemes in England and Wales that had either intellectual disability
practitioners or links with intellectual disability services. This is despite
the recommendations of the Reed report (Department of Health & Home
Ofice, 1992) that ‘court diversion and assessment schemes should develop
effective links with local intellectual disability teams, and where possible,
team members should be encouraged to contribute to teams’ (p. 52, para.
11.120). Not all the courts in England and Wales are served by a diversion
scheme and many of these schemes only work a limited number of days per
week.
The Bradley report (Department of Health, 2009a) recognised the
dificulties inherent in the diversion schemes and the problems resulting
from the non-recognition of intellectual disability at the court stage. It was
recognised that the most likely people to have contact with individuals
with intellectual disability were professionals working in the criminal justice
system, and recommended that the probation service and the judiciary
should receive mental health and intellectual disability awareness training.
The Department of Health (2010) has produced a booklet aimed at
professionals working in the criminal justice system that highlights the
needs of people with intellectual disability. The booklet contains a section
for court professionals and includes advice on communication and rights and
responsibilities when dealing with people with intellectual disability.
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The criminal justice system
Non-recognition of intellectual disability at the early court stage
can have an adverse effect on a number of issues including the failure to
assess itness to plead, the failure to make the necessary adjustment to
the process, the failure to consider alternative sentencing options and the
failure to use the provisions of mental health legislation appropriately if this
is applicable; for example, in England and Wales the use of Sections 35 and
36 of the Mental Health Act for assessment/treatment as an alternative to
remand in prison or the use of Section 37 hospital or guardianship orders as
a means of disposal.
pSyChiatriC
rEportS
A further area of concern highlighted in the Bradley report was the dificulties
courts faced in obtaining timely and good-quality psychiatric reports
(Department of Health, 2009a). It was noted that the courts rely on a limited
number of psychiatrists who are willing to undertake such work outside of
their NHS duties. There are only a limited number of intellectual disability
psychiatrists who have experience in forensic psychiatry across England
and Wales, compounding the problem in this particular area. This situation
may be further worsened by the ruling that expert witnesses will no longer
be immune from suit (Jones v. Kaney [2011]). Assessment of people with
intellectual disability by practitioners with little or no experience of working
with this group can lead to problems with diagnosis or assessment of itness
to plead and there may be confusion about how the Mental Health Act applies
to them. Conversely, generic intellectual disability psychiatrists may feel that
they do not possess the necessary skills to undertake forensic assessments.
witnESS intErMEdiary SChEME
The Witness Intermediary Scheme was introduced in 2004 to help vulnerable
witnesses to give evidence. The Witness Intermediary Scheme national
matching service can be accessed by contacting SOCA (Serious Organised
Crime Agency) and aims to match vulnerable witnesses to a suitable
professional in their area. These registered intermediaries are professionals
from different backgrounds, all of whom have experience in working with
people with communication dificulties and have received specialist training
from the Ministry of Justice to work in this area. The police and Crown
Prosecution Service are able to draw on this resource to aid a vulnerable
witness through the criminal justice process. The Coroners and Justice Act
2009 opened the scheme up to vulnerable defendants; however, this section
of the Act has not yet been implemented.
nECESSary
ChangES
For the current situation to improve, it will be necessary to ensure that
trainee psychiatrists in intellectual disability psychiatry gain competencies
in working within the forensic arena, particularly in regard to understanding
court processes, the range of offending behaviour present in this population,
the out-patient and in-patient treatment options available and how to
assess offenders, particularly with reference to itness to plead and for
recommending appropriate disposal options. Consideration should also be
Royal College of Psychiatrists
27
Faculty Report FR/ID/04
given to what competencies a forensic psychiatry trainee should have in this
area given that general forensic psychiatrists are often the irst contact that
offenders with intellectual disability have with psychiatric services.
Court diversion schemes need to improve their links with local
professionals working with people with intellectual disability. A formal
link and service-level agreement would allow for rapid assessment of
the offender and timely advice to the court as to who to approach for a
formal opinion on crucial issues such as assessment of itness to plead,
what adaptations to the normal court process would be necessary, suitable
disposal options and other related issues. A further potential beneit from
those local links could be the provision of experienced staff to support those
going through the court process.
rECoMMEndationS
1
All courts should have access to a court diversion scheme and all such
schemes should have input from health professionals trained to work
with people with intellectual disability.
2
Members of the judiciary and the probation service should be trained
in mental health and intellectual disability awareness.
3
Psychiatric reports for the courts on people with intellectual disability
should be provided by professionals who are both experienced in
working with this group and appropriately trained to provide advice to
the courts.
4
Psychiatric trainees gaining a specialist qualiication in intellectual
disability psychiatry should be competent in applying those parts of
the relevant mental health legislation relating to this population and
should be competent in preparing a psychiatric report for the court,
particularly in the areas of itness to plead and appropriate disposal
options (how the court deals with the case).
5
Psychiatric trainees gaining a specialist qualiication in intellectual
disability psychiatry should be fully aware of the provisions of the
criminal justice system for vulnerable defendants, including knowledge
of appropriate disposal options if found guilty.
6
Psychiatric trainees gaining a specialist qualiication in forensic
psychiatry should ideally have gained some experience in working
with offenders with intellectual disability and competencies should be
identiied in regard to this.
7
Psychiatric reports for the court on people with intellectual disability
should routinely contain recommendations to the court on necessary
adaptations to the court process.
prisons
Much has been written about mental health morbidity in prisons both
nationally (e.g. Singleton et al, 1998) and internationally (e.g. Fazel &
Danesh, 2002), and in the past few decades this has contributed greatly to
a better understanding of the needs of the prison population.
28
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The criminal justice system
In England and Wales, following a series of documents in the late
1990s in which existing prison healthcare services were criticised, mental
health in-reach teams were commissioned. The idea was that they would
function like community mental health teams inside prisons, with the
understanding that the prison was part of the community. Since then, more
has been learned about the nature of prison mental health in-reach teams
and prison healthcare wings (e.g. Forrester et al, 2010).
However, there is still a limited understanding of the prevalence
and needs of individuals with intellectual disability (deined as signiicant
impairment of intellectual functioning and adaptive behaviour originating
before the age of 18) or of the larger group referred to as having learning
dificulties (Talbot, 2008a). A range of developmental conditions such as
ADHD and ASD as well as individuals functioning within the borderline range
of intellectual functioning is often considered along with this group.
In one of the largest studies of its kind, looking at 10 prison surveys
across 4 countries involving almost 12 000 inmates, Fazel et al (2008) found
substantial heterogeneity and did not undertake a summary estimate of
prevalence. The results suggested that typically 0.5–1.5% of prisoners were
diagnosed with intellectual disability (range 0 to 2.8% across studies).
In the UK, igures from No One Knows (Talbot, 2008a) suggest that
assuming a prison population of 82 000, there will be around 5740 people
with an IQ <70 and about 20 500 with an IQ 71–80. Elsewhere, it has been
suggested that up to 11% of remand and 5–7% of sentenced prisoners have
intellectual disability, although there appears to be a problem identifying this
group because of insuficient screening (Singleton et al, 1998). It is therefore
thought that people with intellectual disability probably receive insuficient
support and treatment presently, although they are known to present with
multiple comorbid problems (including physical problems, autism, ADHD and
substance misuse) more often than the general population.
When compared with controls within the prison population, individuals
with intellectual disability/learning dificulties were, before arrest, more
likely to have been homeless, to have had contact with formal support
agencies, to have attended a special school which they are less likely to
have enjoyed and from which they were more likely to have both played
truant and been excluded. They were also more likely to have been ‘looked
after’ in childhood, to have been employed and to have lived with a partner
or children (Talbot, 2008b). The information on schooling is particularly
poignant and one can only relect that for many, patterns of maladaptive
behaviour – which are deeply ingrained by the time they enter adult services
– may have been amenable to more intensive interventions in childhood.
Here, the paucity of specialist child and adolescent mental health services for
young people with intellectual disability may be particularly relevant.
Petersilia (1997) has commented that those with intellectual disability
are likely to experience greater dificulty coping in prison custody and to be
vulnerable to bullying, and there are likely to be issues in respect of prison
treatment programmes, court attendance and parole hearings. He also noted
that people with intellectual disability are more likely to respond to bullying
with physical aggression, which could result in transfer to more restrictive
secure settings (S. Cooray, personal communication, 2012).
Conventional offending behaviour programmes are not generally
accessible for those with an IQ <80 (Talbot, 2008a), as they are deemed
ineligible for such programmes and this is especially problematic for people
who are serving an Indeterminate Sentence for Public Protection (IPP).
Royal College of Psychiatrists
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Faculty Report FR/ID/04
rECoMMEndationS
30
1
Based on existing Department of Health work, all prisons in England
and Wales should include proper and full reception screening for
intellectual disability as part of routine screening procedures (currently
done in accordance with the Grubin tool; Grubin et al, 2002). As
mentioned in this chapter, the LDSQ can be a suitable tool (www.
gcmrecords.co.uk/gcm_records_007.htm).
2
All prison healthcare providers should work with local community
intellectual disability service providers to assist in ensuring that
local team expertise is incorporated within the prison. This could, for
example, involve visiting sessions from an intellectual disability/dually
trained psychiatrist or regular attendance by a community psychiatric
nurse who has training in intellectual disability.
3
For such services to work, they will require full integration with existing
prison mental health services (including primary care services) to
ensure joint working, learning from experience and education.
4
Intellectual disability referral pathways need to be clearly mapped in
agreement with local intellectual disability services, with the following
questions in mind, and recognising that most individuals can be
supported within the prison system:
a
Who should be referred?
b
When should they be referred?
c
What response can be expected following referral?
5
Local initiatives in respect of joint working with other agencies
(including the voluntary service) should be considered and encouraged.
Commissioners of services should be integral to this process.
6
Inside prisons, joint working between existing mental health providers,
primary care and other multi-agency partners is recommended. This
may require a joint vehicle for the discussion of complex cases, and
the development of a meeting to determine which agencies should be
involved in each particular case is recommended. This meeting will
resemble an ‘internal’ MAPPA meeting, but, unlike MAPPA, will not be
restricted to high-risk individuals.
http://www.rcpsych.ac.uk
Community disposals and hospital
treatment
Community
disposals
The Reed report (Department of Health & Home Ofice, 1992) set clear
principles of care for people with intellectual disability who offend. It
advocates a tailored approach to the individual, with care and treatment
provided in the community, close to home and support networks rather than
in hospital settings. This is supported by the Bradley report (Department
of Health, 2009a), which recommends early identiication of people with
intellectual disability when they come into contact with the criminal justice
system, clear referral protocols, appropriate training for those working within
the criminal justice system and appropriate community-based treatment and
care packages for those at risk. The report states that ‘community sentences
can provide safe and positive opportunities for offenders with mental health
problems or learning disabilities to progress with their lives, as well as
receiving a proportionate sanction from the court’ (p. 91). This move to
increasing use of community disposals is also advocated in the White Paper
Breaking the Cycle (Ministry of Justice, 2010).
There is of course a balance to be struck between public interests
of diverting those with signiicant mental health problems and intellectual
disability from the criminal justice system and those factors favouring
prosecution and safeguarding the public. The approach to sentencing in
England and Wales is set out in R v. Birch [1990] (Fig. 2(a)).
For offenders with comorbid mental disorder and intellectual disability,
there are a number of factors that would determine whether a community
disposal is appropriate. These would not only include the nature of the
offence, history of offending, the presence of mental illness, comorbid
substance misuse, capacity to consent and the need for public protection, but
also issues of vulnerability in prison settings and the availability of adapted
treatment programmes.
At the time of sentencing, there are a number of disposals currently
available (Fig. 2(b)). Some of these options may overlap for those individuals
with intellectual disability who are found unit to plead and it is established
that they did the act or made the omission charged against them (Fig. 2(c)).
If found unit to plead, an individual with intellectual disability (in
England and Wales) can be treated in the community via a guardianship
order or a supervision and treatment order. A guardianship order can help
in establishing boundaries and can include a requirement for the person
to allow access to professionals and to attend for speciic activities such
as medical treatment, and in the right case can prevent more restrictive
options being used. However, guardianship does not provide legal authority
Royal College of Psychiatrists
31
Faculty Report FR/ID/04
(a) Approach to sentencing
(b) Sentencing options
•
•
•
•
•
•
•
•
Is compulsory detention in
prison or a community sentence
appropriate?
Are conditions for a hospital order
satisfied and is it the most suitable
way of disposing this case?
Are the conditions for a restriction
order satisfied?
Consideration should be made to
a hospital and limitation direction
(Sections 45a and 45b of the
Mental Health Act 1983)
Custodial sentence
Diversion to hospital
Guardianship order
Community/
suspended sentence
(c) Unfitness to plead
disposals
•
•
•
•
Hospital order +/–
restriction order
Guardianship order
Supervision and
treatment order
Absolute discharge
Fig. 2 Sentencing in England and Wales.
to detain a person physically in accommodation or to remove them against
their wishes, and should never be used solely for the purposes of transferring
any unwilling person into residential care. Nor does it allow for force to be
used to secure attendance at speciied places for medical treatment to be
administered without the person’s consent. Even if granted an absolute
discharge, it is recommended that appropriate follow-up by specialist
services is organised with use of the care programme approach structure.
For offenders with intellectual disability, if they are able to consent, the
Criminal Justice Act 2003 introduced a community order/suspended sentence
order, with 12 different requirements that an offender can be ordered to
complete – see Table 1.
A Missed Opportunity? (Khanom et al, 2009) advocates increased and
more creative use of the community order with greater use of the Mental
Health Treatment Requirement (MHTR) option. To facilitate this, practical
guidance should be available on how to construct and manage MHTRs for
those with intellectual disability. In England, general practice consortia
should commission services to enable courts to use MHTRs via interagency
protocols.
Recommendations for community disposals require early identiication
of those offenders with intellectual disability and professionals with the
appropriate expertise to assess these individuals and make recommendations
for treatment. Screening tools and suggested assessment formats are
discussed here and in ‘The criminal justice system’.
Services responsible for treatment provision need to be identiied early
to ensure the legal process is not unnecessarily delayed. Within community
settings, this can be provided by community intellectual disability teams,
community forensic teams, community mental health teams or specialist
forensic intellectual disability teams (very rare in the country). This will
depend on availability of services as well as the unique needs of the
individual.
The model of a community forensic intellectual disability team is
available in Birmingham, Avon and Somerset (Benton & Roy, 2008; Dinani
et al, 2010), and Leicester operates a virtual community forensic intellectual
disability team within a tiered model of service provision (Devapriam &
Alexander, 2012). These teams assess individuals who fall in the range
of intellectual disability or are eligible for input from intellectual disability
services. They provide points of contact at all stages of the criminal justice
32
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Community disposals and hospital treatment
Table 1 Criminal Justice Act 2003 requirements for offenders with intellectual disability
Requirements for community orders
Level of
seriousness
Length
Main purpose(s)
Unpaid work
Low
Medium
High
40–80 h
80–150 h
150–300 h
Punishment
Reparation
Rehabilitation
Supervision
Low
Medium
High
Up to 12 months
12–18 months
12–36 months
Rehabilitation
Programme (accredited)
Medium
High
Stated number (or
range) of sessions
Rehabilitation
Drug rehabilitation (offender must consent)
Low
Medium
High
6 months
6–12 months
12–36 months
Rehabilitation
Alcohol treatment (offender must consent)
Low
Medium
High
6 months
6–12 months
12–36 months
Rehabilitation
Mental health treatment (offender must
consent)
Medium
High
Up to 36 months
Rehabilitation
Residence
Medium
High
Up to 36 months
Rehabilitation
Protection
Speciied activity
Medium
High
20–30 days
Up to 60 days
Rehabilitation
Reparation
Prohibited activity
Low
Medium
High
Up to 24/36
months for
suspended
sentence order/
community order
Punishment
Protection
Exclusion
Low
Medium
High
Up to 2 months
Up to 6 months
Up to 12 months
Punishment
Protection
Curfew (typically up to 12 h a day)
Low
Medium
High
Up to 2 months
2–3 months
4–6 months
Punishment
Protection
Attendance centre
Low
12–36 h
Punishment
process, allowing for those never known to services being identiied as well
as providing nurses trained in the area of intellectual disability to participate
in local court diversion schemes. They provide specialist treatment packages
and where appropriate liaise with other mainstream mental health services.
It is noted that there is a huge unmet need for those falling just outside the
eligibility criteria for intellectual disability services but have similar support
and treatment needs. Data from these areas suggest that community
forensic intellectual disability services can manage risk and provide a goodquality service at a reduced cost by averting the need for expensive secure
hospital admission often far from the home of the offender. This is also the
least restrictive alternative.
The treatment options available for offenders in hospital under the
Mental Health Act (England and Wales) are outlined in Table 2. These hospital
orders can be to either specialist forensic intellectual disability hospitals or
in some cases mainstream forensic psychiatry facilities.
Royal College of Psychiatrists
33
Faculty Report FR/ID/04
Table 2 Treatment options for offenders under the Mental Health Act 1983
Section
Function
Section 35
The accused is remanded to hospital for a psychiatric report. Evidence from one
doctor is required. The order is for 28 days and renewable up to a maximum of 12
weeks.
Section 36
The accused is remanded to hospital for psychiatric treatment. Evidence is required
from two doctors. The order is for 28 days and renewable up to a maximum of 12
weeks.
Section 38
Interim hospital order. Evidence is required from two doctors. The order is for 12
weeks and renewable up to a maximum of 12 months. Applies to offenders already
convicted.
Section 37
Hospital order following conviction. Evidence required from two doctors. The order is
for 6 months and renewable for 6 months, yearly thereafter.
Section 37/41
Hospital order with restrictions. This is issued when there are concerns around public
protection. Evidence from two doctors required, with oral evidence from one doctor.
Section 45a
Hospital and limitation directions allow the Crown Court to authorise the detention
of offenders in hospital for treatment at the same time as passing a prison sentence.
Evidence is required from two doctors.
rECoMMEndationS
34
1
Court and probation staff need to have intellectual disability awareness
training as recommended in the Bradley report to allow early
identiication of offenders with intellectual disability.
2
Courts, probation services and youth offending teams in each locality
should have access to intellectual disability services as a irst point
of contact. This should ideally be a dedicated community forensic
intellectual disability team or a specialist function within the intellectual
disability team. If that is not available, the function can be carried
out by a community intellectual disability team. Depending on local
protocols, this function may also be carried out by mainstream mental
health or forensic mental health teams, provided they have the
appropriate skills.
3
Protocols for joint working between community forensic intellectual
disability, community intellectual disability, community forensic and
community mental health teams should be developed locally and
opportunities for pooling resources/sharing skills should be explored.
Local pathways should be developed in conjunction with other agencies
involved in the management of an offender with intellectual disability.
4
Community intellectual disability teams should receive further training
to manage less serious offending and to provide input where speciic
community forensic intellectual disability teams are not feasible or
where the case-load demands it. Likewise, in areas where they carry
out this function, community forensic and mental health services will
need training on issues of intellectual disability.
5
Training members of the intellectual disability team could include input
from psychiatry, nursing and psychology, with the team accepting
referrals from existing NHS services and the criminal justice system.
The team should provide expertise to the criminal justice system and
make recommendations for community disposals where appropriate.
http://www.rcpsych.ac.uk
Community disposals and hospital treatment
6
In order to recommend community disposals, the appropriate
treatments should be available (from community forensic intellectual
disability teams or from specialists within generic intellectual disability
teams) in the form of adapted programmes for substance misuse, sex
offender treatment, ire-setting and violent offending, preferably in
collaboration with mainstream services as outlined in Valuing People
(Department of Health, 2001). Such programmes may need to be
lexible so as not to exclude those with borderline intellectual disability.
7
Higher trainees in both forensic psychiatry and psychiatry of intellectual
disability should obtain experience of both specialties with basic
competencies described. The training needs of other disciplines in this
ield should also be considered, especially when plans are in place to
adapt existing teams.
8
Commissioners of services should be integral to the process of
purchasing appropriate services.
hospital
treatment
There have been specialist secure beds for people with intellectual disability
from as far back as 1920 when Rampton Hospital became the state
institution for ‘defectives’.
Currently in the UK, there are forensic intellectual disability hospital
beds at three levels of security – high, medium and low. Reliable information
about the number of these beds and the occupancy rates was lacking,
although some projections could be made using data from the Count Me In
census (Care Quality Commission, 2005) and the Ministry of Justice data
on restricted patients (Ministry of Justice, 2009). In addition, there is also
an unknown number of locked units – mental impairment units, locked
rehabilitation units and step-down units – that are not formally classiied
as low secure units. There are few services speciically for women offenders
with intellectual disability, although high secure hospitals have always
operated strict segregation policies, where women make up about 10% of
the population (Beber & Boer, 2004). This group of patients have high levels
of mental illness, are more likely to have suffered from sexual abuse, and
may be more challenging to manage.
An earlier survey of forensic intellectual disability beds estimated that
there were 48 high, 414 medium and 1356 low secure beds for people with
intellectual disability in 2009 within the 10 strategic health authority regions
of England (Alexander et al, 2011). In a recent report, the Royal College of
Psychiatrists identiied six categories of in-patient beds within a four-tiered
model of service provision (Royal College of Psychiatrists, 2013) (Fig. 3 and
Box 1). Within this categorisation there were 2393 category 1 beds (made
up of 48 high, 604 medium and 1741 low secure beds) and 345 category 4
(forensic rehabilitation) beds.
Both these surveys showed a very uneven distribution of beds, with
some regions not having any medium or low secure units within their
borders. It is this uneven distribution that has led to some offenders with
intellectual disability often being placed in units far away from their families
because suitable local units are not available (Yacoub et al, 2008). On the
other hand, some authors (Barron et al, 2004) have discussed the economies
of scale and commented about how it is unrealistic to have very specialised
Royal College of Psychiatrists
35
Faculty Report FR/ID/04
Category 1
Category 2/3
Tier 4
In-patient
services
Category 4/5
Category 6
Tier 3
Highly specialised
element of community
intellectual disability services
Tier 2
General community intellectual
disability services
Tier 1
Primary care and other mainstream
services
Tier 1 encompasses primary care and other mainstream services. It is the tier of service provision that serves the general
health, social care and educational needs of people with intellectual disability and their families. The community intellectual
disabilities team and the psychiatrist have limited direct clinical contact in this tier. Nevertheless, they are involved in activities
which may influence patients’ care and interacting with this tier is essential to the training of intellectual disability psychiatrists.
Tier 2 is general community intellectual disability services. At this level the person with intellectual disability starts to use
specialist intellectual disability services. Most specialist services are provided jointly between health and social services or are
moving towards such a model.
Tier 3 is a highly specialised element of community intellectual disability service. This includes areas of specialised needs
such as epilepsy, dementia, challenging behaviour, pervasive developmental disorders and out-patient forensic services.
Tier 4 is specialist in-patient services. It includes all specialist in-patient services for people with intellectual disabilities,
ranging from local assessment and treatment services to high secure forensic services.
Fig. 3 Tiered/stepped model of care for intellectual disability services (adapted from Royal College of Psychiatrists,
2011).
box 1 Categories
of in-patient beds within
tier 4
for people with intelleCtual disability
and mental health and/or severe behavioural problems
•
Category 1: high, medium and low secure forensic beds
•
Category 2: acute admission beds within specialised intellectual disability units
•
Category 3: acute admission beds within generic mental health settings
•
Category 4: forensic rehabilitation beds
•
Category 5: complex continuing care and rehabilitation beds
•
Category 6: other beds including those for specialist neuropsychiatric conditions
For deinitions and illustrative case examples, please refer to Royal College of Psychiatrists
(2013).
36
http://www.rcpsych.ac.uk
Community disposals and hospital treatment
services of this nature in every district. On balance, it is fair to expect that
offenders with intellectual disability should be treated as near as possible to
their home area.
Patients referred or admitted to these units have a high rate of
psychiatric and developmental morbidity. Most have histories of early
deprivation and abuse, about half have personality disorder, the same
proportion have substance misuse, a third have mental illnesses and about
a third to a quarter have ASD (Alexander et al, 2003; Hogue et al, 2006).
They also have extensive histories of offending behaviour, with risk proiles
that are as serious as in those detained in generic forensic units (Hogue et
al, 2006).
Based on the available bed numbers in 2009, the cost of this provision
was estimated at £258–323 million per year, and for an area with spending
at this level, there was a surprising paucity of outcome studies (Alexander
et al, 2011). Over the past 30 years, there were a total of two outcome
studies from low, four from medium and two from high secure hospitals in
this category (Day, 1988; Butwell et al, 2000; Halstead et al, 2001; Reed
et al, 2004; Alexander et al, 2006; Gray et al, 2007; Morrissey et al, 2007;
Alexander et al, 2011). The most common outcome variable described was
duration of stay. Others included direction of care pathway, institutional
aggression, reoffending, reconviction and readmission to hospital. None of
the outcome studies have looked at the cost of placements and this means
that discourse about costs in this area is often based on anecdote and
opinion rather than objective evidence.
Likewise, the nature of treatments has not been described in any detail
except in a couple of studies (Day, 1988; Alexander et al, 2011) and this ties
in with the view that intervention and care packages are still relatively nonspeciic and unfocused (Barron et al, 2004). The four-stage model proposed
by Johnston (2008) that includes assessment and motivational work,
interventions including foundation treatments, offence-speciic treatments
and personality disorder symptom reduction treatments, consolidation or
relapse prevention, and discharge, offers a broad framework that can be
used to describe the nature of interventions.
A number of studies have, however, described in detail the process
and outcome of speciic psychological, offence-focused therapies such as
anger (Taylor & Novaco, 2005) and sexual offending (Lindsay, 2005; Large
& Thomas, 2011).
Based on a review of outcome literature, the report People with
Intellectual Disability and Mental Health, Behavioural or Forensic Problems
(Royal College of Psychiatrists, 2013) sets out a minimum data-set of
outcome variables divided into the categories of measures of treatment
effectiveness, patient safety and patient experience (Table 3).
rECoMMEndationS
1
Particular attention should be paid to the commissioning of a range
of in-patient and community services that will allow these patients
to be managed safely in the least restrictive setting. Offenders with
intellectual disability should be treated as near as possible to their
home area.
2
Reliable data on the number of offenders with intellectual disability in
secure units should continue to be actively collected.
Royal College of Psychiatrists
37
Faculty Report FR/ID/04
3
The nature of treatments offered should be clearly described and a
common data-set of short-term and long-term outcome variables
collected through a nationwide audit. This should include information
about the cost of placements. Such information should be used to
identify predictors of length of hospital stay and successful treatment
outcomes.
Table 3 Minimum data-set of outcome variables for in-patient beds in categories 1 and 4
Measures at baseline
Essential
Desirable
Diagnoses on ICD-10 criteria or equivalent: include degree of intellectual
disability, pervasive developmental and other developmental disorders,
personality disorders, mental illnesses, substance misuse or dependence and
physical disorders (Gray et al, 2007; Alexander et al, 2011)
IQ score on WAIS-IV or equivalent (Wechsler, 2008)
Coded forensic history: index offence, nature of detention, past convictions
for offences of violence, sex, arson and other offences, history of aggression
towards other people, property and self (Alexander et al, 2006, 2011; Gray et
al, 2007)
HoNOS secure score (Dickens et al, 2007)
PCL:SV score (Hart et al, 1995; Morrissey, 2003, 2007, 2011; Gray et al,
2007; Fitzgerald et al, 2011)
HCR-20 (Webster et al, 1995; Gray et al, 2007; Fitzgerald et al, 2011)
VRAG score (Gray et al, 2007; Quinsey et al, 2006; Fitzgerald et al, 2011)
START score (Webster et al, 2004)
Measures of effectiveness
Essential
Desirable
Global measures or measures of symptom severity: HoNOS secure, yearly and
at discharge (Dickens et al, 2007)
Progress measures: community leave status (no leave/escorted leave/
unescorted leave)
Progress measures: length of stay
Progress measures: direction of care pathway (whether moved to a less
restrictive setting)
Symptom-speciic assessment scales (e.g. measures of anger, depression/
anxiety, other psychopathology)
HCR-20: yearly and at discharge
START score: regular intervals (e.g. 2-monthly and at discharge)
CGI scale (Guy, 1976)
Measures of patient safety
Essential
Proxy measures of aggression: index of the number of restraints and seclusions
(total number divided by length of stay) (Alexander et al, 2010)
Proxy measures of self-injury/self-harm: index of the number of incidents
(total number divided by length of stay)
Number of alerts regarding patient safety
Any ‘never’ incidents: escapes, suicide
Measures of patient experience
Essential
Desirable
Evidence of patient participation in treatment planning: My Shared Pathway
(NHS Networks; Esan et al, 2012)
Patient satisfaction surveys
Evidence of carer/family participation in treatment
Measures of social climate: Essen Climate Evaluation Schema or equivalent
(Schalast et al, 2008)
Quality of Life measure: EQ-5D-3L or equivalent, yearly and at discharge
(EuroQol Group, 1990)
CGI, Clinical Global Impression scale; HoNOS, Health of the Nation Outcome Scales; HCR-20, Historical, Clinical, Risk
Management-20; ICD-10, International Classification of Diseases (10th edn); PCL:SV, Psychopathy Checklist: Screening
Version; START, Short-Term Assessment of Risk and Treatability; VRAG, Violence Risk Appraisal Guide; WAIS-IV, Wechsler
Adult Intelligent Scale, Fourth Edition.
38
http://www.rcpsych.ac.uk
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