Forensic Intellectual Disability Service Research Articles

Trauma and adversity in forensic patients with an intellectual disability: a review of risk assessment reports

Purpose People with intellectual disabilities are at a significantly higher risk than the general population for experiencing a wide range of adverse and potentially traumatic events. This paper aims to explore the incidence of experiences of lifetime trauma across this population in one Forensic Intellectual Disability Service. Risk management recommendations and psychological risk formulations were also examined for their consideration of traumatic experiences. Design/methodology/approach Risk assessment reports (n = 39) were reviewed for evidence of traumatic experiences and the consideration of trauma in patient risk formulations and risk management treatment recommendations. Findings Trauma was rated as present or partially present in 84.6% (n = 33) of risk assessment reports reviewed. None of the patients had received a post-traumatic stress disorder (PTSD) diagnosis. Recommendations regarding trauma were identified in 39.4% (n = 13) of the risk assessment reports where trauma was rated either “present” or “partially present”. Practical implications Findings suggest a need for diagnostic tools to be used to measure trauma symptoms and potential cases of PTSD to best support needs of patients. Trauma-focused interventions should also be considered. Further investigation is needed to clarify the disparity between the consideration of trauma in formulations and treatment recommendations. Originality/value This study highlights the different traumatic experiences that forensic patients across three settings have been exposed to during their lifetimes.

Forensic intellectual disability services: differences in staff perspectives in the Danish and Norwegian systems

PurposePersons with intellectual disabilities (ID) who offend are treated differently depending on the national jurisdiction. Norway and Denmark are two such examples. The differences in care models may also have an impact on staff perspectives. This paper aims to study the differences between Norwegian and Danish staff members within secure forensic ID services.Design/methodology/approachA cross-sectional study involving Norwegian (n= 145) and Danish staff (n= 279) in secure forensic learning disabilities services was conducted. The response rates were 50% in Denmark (n= 147) and 69% in Norway (n= 98), respectively. An electronic survey covering five sets of topics (demographic characteristics, working conditions, workplace culture, work motivation and work resilience) was used. The findings was statistically analysed using SPSS.FindingsThis study confirmed that staff in the two neighbouring countries have common conceptions of their employment. Danish staff were more exposed to violent incidents (t= 4.1(237);p< 0.001). There was greater concern with workplace safety in Denmark (t= 5.2(237);p< 0.001) compared to more team-based and rigid working conditions in Norway (t= −2.6(237);p< 0.01).Originality/valueThese differences are discussed in relation to some important national differences in a professional culture, educational systems, service organisation and legal issues that possibly add realistic explanations to the findings.

Comparing co-production approaches to dynamic risk assessments in a forensic intellectual disability population: outcomes of a clinical pilot

Purpose A co-produced clinical practice that aims to improve outcomes through a partnership with service users is becoming increasingly important in intellectual disability (ID) services, yet these approaches are under-evaluated in forensic settings. This study aims to explore and compare the feasibility of two approaches to co-production in the completion of dynamic risk assessments and management plans in a secure setting. Design/methodology/approach A convenience sample of adults admitted to a secure specialist forensic ID service (N = 54) completed the short dynamic risk scale (SDRS) and drafted risk management plans under one of two conditions. In the first condition, participants rated the SDRS and risk management plan first, separately from the multidisciplinary team (MDT). In the second condition, participants and MDTs rated the SDRS and risk management plan together. Findings In total, 35 (65%) participants rated their risk assessments and 25 (47%) completed their risk management plans. Participants who rated their risk assessments separately from the MDT were significantly more likely to complete the SDRS (p = 0.025) and draft their risk management plans (p = 0.003). When rated separately, MDT scorers recorded significantly higher total SDRS scores compared to participants (p = 0.009). A series of Mann-Whitney U tests revealed significant differences between MDT and participant ratings on questions that required greater skills in abstraction and social reasoning, as well as sexual behaviour and self-harm. Originality/value Detained participants with an ID will engage in their dynamic risk assessment and management plan processes. The study demonstrates the impact of different co-production methodologies on engagement and highlights areas for future research pertaining to co-production.

Self-reported experiences of intimate partner violence in a female forensic intellectual disability population

PurposeIntimate partner violence (IPV) is a complex public health and social issue. Women with an intellectual disability (ID) are at greater risk of experiencing IPV. However, little is known about the IPV experiences of women with an ID and forensic care needs. The purpose of this paper is to explore the history of experienced and perpetrated IPV in women detained to secure specialist ID forensic service.Design/methodology/approachParticipants completed the Conflict Tactics Scale-2 (CTS-2, Straus et al., 1996). The CTS-2 measures experienced and perpetrated relationship tactics of common forms of IPV.FindingsParticipants reported high levels of experiencing and perpetrating IPV across all relationship tactics measured by the CTS-2. Participants reported they engaged in similar levels of experiencing and perpetrating positive and negative relationship tactics. The only significant difference was “minor sexual coercive behavior” where participants were significantly more likely to experience than perpetrate this behaviour.Research limitations/implicationsFurther research exploring the risk factors that contribute to IPV is needed. Shortcomings in the current study are acknowledged.Practical implicationsWomen with an ID and forensic profiles may present with treatment needs as victims and perpetrators of IPV. Clinical activities of women in Forensic ID services should include possible IPV care needs. The importance of developing national guidance and interventions to prevent and manage IPV are discussed.Originality/valueThis is the first paper, to the authors’ knowledge, to explore experiences of IPV in women with an ID and forensic care needs.

The prevention of offending behaviour by people with intellectual disabilities: a case for specialist childhood and adolescent early intervention

PurposeElucidating where antisocial or violent behaviour arises within the life course of individuals with intellectual disability (ID) could improve outcomes within this population, through informing services and interventions which prevent behaviours reaching a forensic threshold. The paper aims to discuss this issue.Design/methodology/approachThe Historical Clinical Risk Management-20, Version 3 assessments of a cohort of 84 inpatients within a forensic ID service were analysed for this study, with a particular emphasis on items concerned with the age at which antisocial or violence first emerged.FindingsFor most participants, violent or antisocial behaviour was first observed in childhood or adolescence. The study also highlighted a smaller subgroup, whose problems with violence or antisocial behaviour were first observed in adulthood.Originality/valueThe study findings suggest that targeted services in childhood and adolescence may have a role in reducing the offending behaviour and forensic involvement of people with ID. This has implications for the service models provided for children and adolescents with ID with challenging or offending behaviour.

Deliberate ingestion of foreign bodies as a form of self-harm among inpatients within forensic mental health and intellectual disability services

ABSTRACTDeliberate foreign body ingestion is a significant issue in prison and psychiatric settings. It is associated with serious physical complications, including bowel obstruction, perforation and haemorrhage. Episodes of deliberate foreign body ingestion were identified retrospectively from 5417 incident records from two inpatient forensic services (one mental health and one intellectual disability) over a one year timeframe, using related search terms. Rates were compared according to gender, diagnosis and level of security. Incidents of deliberate foreign body ingestion were found to occur on average every 2.7 days across the study population, with 133 incidents recorded over a one year period, accounted for by 27 patients. Women and patients in lower levels of security were significantly more likely to engage in deliberate foreign body ingestion. Staff responses to this behaviour were highly variable. Deliberate foreign body ingestion occurs frequently within inpatient forensic services, and can have significantly detrimental physical implications for affected patients. Further research should investigate the psychiatric and intellectual disability profile of such individuals in further detail, as well as exploring patient narratives; both of which will help inform development of treatment strategies.

Outcomes of an inner city forensic intellectual disability service

PurposeNational policy in England is now directed towards keeping patients with intellectual disability (ID) presenting with forensic problems for time-limited treatment. The result is that secure hospital services are expected to work much more proactively to discharge patients to community-based services. However, there is little evidence in recent years on the outcome of discharged patients with ID from secure hospitals. The purpose of this paper is to describe the outcomes of a patient group discharged from a specialist forensic ID service in London, England.Design/methodology/approachThis is a descriptive retrospective case note study of patients with ID admitted to and discharged from a secure service with both low and medium secure wards, over a six-year period from 2009 to 2016. The study examined patient demographic, clinical and outcome variables, including length of stay, pharmacological treatment on admission and discharge, offending history and readmissions to hospital and reoffending following discharge.FindingsThe study identified 40 male patients, 29 of which were admitted to the medium secure ward. In all, 27 patients (67.5 per cent) were discharged into the community with 14 patients having sole support from the community ID services and 4 from the community forensic services. In total, 20 per cent of patients were readmitted within the study period and 22.2 per cent of patients received further convictions via the Criminal Justice System following discharge.Originality/valueThis was a complex group of patients with ID discharged into the community with a number at risk of requiring readmission and of reoffending. Community-based services providing for offenders with ID must have sufficient expertise and resourcing to manage the needs of such a patient group including the ongoing management of risks. The national drive is significantly to reduce the availability of specialist inpatient services for this group of patients but this must occur alongside an increase in both resources and expertise within community services.

Head banging as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Introduction: ‘Head banging’ is a common form of self-harm, linked to numerous negative outcomes including significant brain damage. However, little research has investigated head banging behaviour and its correlates in clinical populations. Method: Head banging episodes were identified from the incident records (n = 5417) of two inpatient forensic services (one intellectual disability and one mental health), using relevant search terms. Rates were compared between individual patients, by gender, diagnosis and level of security. Incident accounts were analysed qualitatively using thematic analysis. Results: Head banging incidents occurred approximately every 3 days in each service, with 229 incidents recorded in 1 year. Individual patient rates varied widely, ranging from 1 to 38 incidents within 1 year. Women, and patients in higher levels of therapeutic security, were significantly more likely to engage in head banging. Qualitative incident reports indicated that head banging was associated with mental distress, anger and psychotic experiences. Discussion: Head banging occurs frequently in forensic services, and has documented associations with traumatic brain injury in affected individuals, thus negatively impacting progress through the care pathway and treatment outcomes. Further research should investigate short- and long-term management strategies and treatment approaches, in order to minimise harm.

Treatment outcomes from forensic intellectual disability services: The perspectives of patients and their family/carers.

Research investigating the treatment outcomes of forensic intellectual and developmental disability (FIDD) services has largely focused on the perspectives of clinicians and researchers. This study sought the perspectives of patients and family/carers on the outcomes important to them. Semi-structured consultation groups were conducted with patients in FIDD services (n = 21) and family carers (n = 6). Interview data were content analysed, and outcomes identified fell into three main domains (effectiveness, safety and patient experience). The consultations identified outcome domains not considered in the published literature. Patients and carers also had differential perspectives on treatment outcomes commonly reported within literature. Illustrative quotes are used to evidence the domains. This study is the first to investigate the outcomes of relevance to patients and their families. These views have been incorporated into an outcomes framework which will form the foundation of future prospective outcome studies.

Head banging as a form of self-harm among inpatients within forensic mental health and intellectual disability services

Introduction“Head banging” is a common form of self-harm, linked to numerous negative outcomes including significant brain damage. However, little research has investigated the prevalence and correlates of head banging behaviour in clinical populations.MethodHead banging episodes were identified from the incident records (n = 5417) of two inpatient forensic services (one intellectual disability and one mental health), using relevant search terms. Rates were compared between individual patients, by gender, diagnosis and level of security. Incident accounts were analysed qualitatively using thematic analysis.ResultsTwo hundred and twenty nine incidents of head banging were recorded, occurring approximately every three days in each service. The prevalence of the behaviour between individual patients varied widely, ranging from one to 38 incidents within one year. Women and patients with intellectual disability appeared more likely to engage in head banging. Qualitative incident reports indicated that head banging was associated with mental distress, anger, and psychotic experiences.DiscussionHead banging occurs frequently in forensic services, and has documented associations with traumatic brain injury in affected individuals, thus negatively impacting progress through the care pathway and treatment outcomes. Further research should investigate short and long term management strategies and treatment approaches, in order to minimise harm.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Traumatic brain injury in a forensic intellectual disability population

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

Vitamin D deficiency in an inpatient forensic intellectual disability service.

No research has examined vitamin D deficiency among inpatients within forensic intellectual disability services, despite their potentially increased risk. Tests of serum 25(OHD) concentration in blood are routinely offered to patients within the service as part of the admission and annual physical health check. Results were classified as deficient <25, insufficient <50, sufficient 50-75 or optimal >75. Deficient or insufficient patients were offered supplement treatment and retested within 6 months. Levels were compared between groups: level of security and gender. At baseline, 87% of patients were deficient or insufficient, whilst 13% were sufficient or optimal. At follow-up, 53% had sufficient or optimal levels. However, some patients remained deficient (13%) or insufficient (34%) due to non-compliance with treatment. Women appeared more likely to be deficient. High levels of vitamin D deficiency were found among this population. Vitamin D screening and treatment is a simple and effective way of improving the physical health of this population.

A national survey of offending behaviour amongst intellectually disabled users of mental health services in Ireland.

Offenders with an intellectual disability pose a major challenge to Intellectual Disability Service providers in the Republic of Ireland. This is especially so as no national Forensic Intellectual Disability Service currently exists. The Forensic Intellectual Disability Working Group of the Irish College of Psychiatrists was established in order to take steps to address this issue by establishing the level of need for a Forensic Intellectual Disability Service in Ireland and developing a college position paper. No previous study has been carried out to measure offending behaviour amongst persons with an intellectual disability attending mental health services in Ireland. A postal survey was undertaken targeting the lead clinicians of all Intellectual Disability Psychiatry, General Adult Psychiatry and Forensic Psychiatry Services in the Republic of Ireland. This survey requested anonymous data regarding service users with an intellectual disability and offending behaviour in this population. Data relating to 431 service users was returned. Those reported to engage in offending behaviour were predominantly young males. Assault was the most common offence type. A significant number of serious offences such as unlawful killing, sexual assault and arson were reported. There is an urgent need for the development of a Forensic Intellectual Disability Service in the Republic of Ireland. The current efforts of the National Forensic Mental Health Service to establish such a service by the creation of a post of Consultant Forensic Psychiatrist (special interest in intellectual disability) are to be welcomed.

Home visits: a reflection on family contact in a specialist forensic intellectual disability service

Purpose – There is little published literature about the number of home visits provided to patients within forensic intellectual disability units, and there is no published data on variables that affect home visits. There is a need for a baseline audit that can formulate standards for future practice. The paper aims to discuss these issues. Design/methodology/approach – This paper describes the home visit programme within a forensic intellectual disability service, and a baseline audit of the programme. The audit measured the number of home visits, any factors that adversely affect home visits, and the extent of family contact. The authors propose audit standards for evaluation of good practice in this area. Findings – The audit involved 63 patients over a one-year period. In total, 81 per cent of patients had some form of family contact and 54 per cent of patients at least one home visit. However, 19 per cent of patients had no contact with their family due to a variety of reasons. There were no significant differences in the number of home visits between men and women, patients on civil vs criminal sections or those treated “within area” or “out of area”. Patients in rehabilitation wards had significantly more visits than those in low or medium secure. Originality/value – Conventional wisdom is that reduced family contact is the direct result of patients being placed “out of area”. The results of this audit suggest that, at least in this group, the reasons may be much more nuanced and that the current definition of “out of area” has to be improved to incorporate the actual distance between the patient’s current family home and the service. Audit standards have been proposed to monitor family contact and home visits. Future work should focus on the relationship between family contact and treatment outcomes.

Outcomes from the National High Secure Learning Disability Service: findings and challenges

Purpose – The “outcomes revolution” in healthcare has yet to impact strongly on secure intellectual disability (ID) services in the UK. The purpose of this paper is to review the service-level outcome studies that exist for this population, and to explore some of the challenges of conducting such research. It further describes some illustrative routine outcome data from the National High Secure Learning Disability Service. Design/methodology/approach – Routinely collected outcome measures (length of stay; violent incidents; Emotional Problem Scale (EPS) Behaviour Rating Scale and EPS Self-Report Inventory) were analysed for two overlapping cohorts of patients resident in the high-secure service between 2008 and 2013. Findings – The median length of stay of those discharged during the study period (n=27) was around 9.9 years (range one to 40 years). A significant proportion (25 per cent) of discharges resulted in an eventual return to high security. There did not appear to be a treatment effect over two to three years using staff-rated global clinical measures, but patient-rated clinical measures did reduce. Violent incidents also reduced significantly over a longer period of four years in treatment. Research limitations/implications – There are identified challenges to research design and outcome measurement which need to be addressed in any future cross-service studies. Originality/value – There are relatively few published outcome studies from forensic ID services. None of the studies have used clinical measures of changes or patient-rated outcome measures.

Job stress, burnout and job satisfaction in staff working with people with intellectual disabilities: community and criminal justice care

Purpose – The purpose of this paper is to examine and compare levels of burnout, traumatic stress and resilience amongst Norwegian nursing care staff in two intellectual disability (ID) services. Design/methodology/approach – This was a cross-sectional survey in which 137 staff completed questionnaires measuring work-related stress, burnout, compassion and resilience. Two groups were compared; staff in the national forensic ID services and staff in the community ID caring services. Findings – Nursing staff in the community ID caring services had significantly more signs of stress and burnout compared to the other group. At the same time they were more compassionate. Originality/value – The different caring cultures examined in this study indicated that the forensic ID staff tended to focus on the physical aspects of the caring role whilst the community ID staff tended to focus on the relational issues. The impact of serious events resulted in a higher level of stress and burnout symptoms, however the community carers showed more compassion to their work.

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

Purpose – Social climate (ward atmosphere) affects numerous treatment outcomes. The most commonly used measure is the Essen Climate Evaluation Schema (EssenCES) (Schalast et al., 2008). Though studies have investigated the psychometric properties of EssenCES in intellectual disability populations, few have focused on the clinical utility, or accessibility of the measure. The purpose of this paper is to examine clinician's experiences of using this measure with this population. Design/methodology/approach – Clinicians experienced in administering EssenCES with forensic intellectual disability patients completed an open-ended questionnaire, which sought qualitative data on their experiences of using EssenCES with this population. Data were analysed using thematic analysis. Findings – A number of issues were raised regarding use of EssenCES with patients with intellectual disability. Four overarching themes arose: Understanding of Language, Commenting on Others, Understanding of Likert Scale, and Scale Positives and Adaptation. Clinicians felt certain items were not uniformly understood by all patients, particularly those that incorporated abstract concepts, double negatives, or complex language. Originality/value – Results suggest forensic intellectual disability patients vary in their ability to understand EssenCES items. This resulted in significant further explanation by the administering clinician, a practice which raised concern regarding reliability. Results provide preliminary evidence to indicate EssenCES use requires further consideration in intellectual disability services, or adaptation for this client group.

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

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

Real Work Opportunities: establishing an accessible vocational rehabilitation programme within a forensic intellectual disability service

Purpose – Patients treated within secure/forensic settings experience numerous barriers to meaningful vocation, including restrictions under the Mental Health Act, which limit community access. The purpose of this paper is to describe the development of Real Work Opportunities, an inclusive and accessible vocational rehabilitation programme within a forensic intellectual disability service. The programme involved setting up employment and interview workshops, interviews, and interview feedback, and job roles within the secure service, to simulate the real work process. Design/methodology/approach – A reflective account of the development and implementation of the Real Work Opportunity programme with a forensic intellectual disability population. Findings – The programme was well received by the patients involved and a high attendance rate was maintained over time despite the demands that were expected. Roles have been advertised for two employment periods and have had two sets of successful candidates. Patients demonstrated skills development throughout the employment process, including general work-based skills, punctuality and time management, managing duties, responsibility, specific role-related skills, interpersonal skills and personal presentation. Research limitations/implications – Despite limited experience of work prior to admission, many patients were enthusiastic and motivated to work. The initial trial of the programme has been well received by both patients and staff. Future developments will include widening the number and types of opportunity offered by the programme. Originality/value – This paper describes a vocational rehabilitation programme for a particularly marginalised population, people with intellectual disabilities within a forensic service. The programme proved highly popular with patients, and enabled them to develop transferable employment skills.

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

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