Transcript Slide 1
Challenging behaviour and offenders with learning disabilities Isabel Clare Consultant Clinical & Forensic Psychologist Cambridge Intellectual and Developmental Disabilities Research Group, Department of Psychiatry Challenging behaviour culturally abnormal behaviour(s) of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit use of, or result in the person being denied access to, ordinary community facilities Emerson, 1995 The Bradley Report 2009- Review of People with Mental Health or Learning Disabilities in the CJS Agenda in terms of community treatment and support • Multi-agency • Using a range of services offering different levels of support • Person-centred, maximising rehabilitation and the prevention of further offending • As near to ‘home’ as possible • Involving the person and others who care about him/her as much as possible Prevalence Addressed in 2 ways: a) How many people in the CJS have LD? UK estimates vary wildly: 0 – 85% - depends on site, who measures, what measure etc. b) How many people with LD have contact with the CJS? UK estimates vary: best study: McBrien et al. (2003) N=1326 • 0.8% currently sentenced and in custody • 3% past or current conviction • Further 7% contact as suspect - no conviction • Additional 17% had challenging behaviour that could have been offence SO: Around 10% Assessment Task is to find out what the behaviour ‘means’ for the person in the context of his or her life. Influenced by research and clinical literature and developing knowledge of the person and his/her situation. • The behaviour(s) • The physical social and emotional context in which the person lives • The individual The behaviours • • • • • • What is the behaviour/s? What is the frequency/duration? What is the severity? If it involves others, who is most likely to be affected? When is it more or less likely to happen? What is the outcome? The physical, social and emotional environment • How is the person likely to experience the environment? Consider: choice, inclusion, rights, and participation and other experiences that may be important to him/her • What is likely to be his/her experience? Measures of the environment What’s it like? Where is it geographically? How many of the staff are regular? What does a ‘typical day’ look like for the person? Are care plans for individuals, linked with guidelines, in place? • What do staff/carers think and feel about the person and his or her difficulties? • What supervision and support do staff or other carers have? • • • • • Assessing individuals Developmental history Socio-emotional history Medical and psychiatric history Forensic history Current medical and psychiatric problems Cognitive and everyday skills, interests, dreams Verbal and non-verbal perceptual and communication skills and difficulties Thoughts and feelings about their past experiences, the present, future Perceived availability of practical and emotional support Formulations Provisional summary - integrating all the information to provide an: • Understanding of how the behaviour(s) developed and maintained; • Rationale for interventions A treatment framework LaVigna et al. 1989 Proactive strategies • Ecological manipulations • Positive programming • Direct treatment Reactive strategies Evaluating progress Meaningful outcomes are socially valid: • address a socially significant problem • result in socially important outcomes or effects Evaluation in offending by people with LDs Increase in group evaluations – including in community settings • Sex offenders • Violence and aggression • Fire-setting But Remains very limited Components often similar but other aspects are not Clearer that change can be obtained in terms of clinical than of social outcomes Mr J case study Mr. J was brought up by his mother on her own. She found him hard to manage: his development was delayed, he was over-active, had little interest in other children, resisted any changes to his routine, and had unusual interests. He could not keep up with the work at a ‘mainstream’ school and staff were unable to manage his behaviour so he was sent to a residential school for children with emotional and behavioural problems. He settled better there but made no friends. Just as he was leaving school, his mother died, so he moved to a hostel for people with mild learning disabilities, where he became friendly with an older woman who was a member of staff. She offered to let him live as a tenant in her house. With his landlady’s help, Mr. J obtained a job in a supermarket canteen, where he helped with the washing-up. For a couple of weeks, things went well but when his supervisor suggested a change in his hours, he started shouting, threw crockery at other staff, and was dismissed. He would not participate in attempts to find him other activities. He stayed at home. He was irritable and occasionally was physically aggressive to his landlady. One day, he made a serious suicide attempt and spent some time in hospital. After his discharge, he moved to a hostel for a short time but managed to persuade his landlady to let him live with her again. At first, things were settled but gradually, he again became unable to leave home unless he was with his landlady. She was resentful and there were many arguments. Finally, it was agreed that he would leave and move to a group home for people with learning disabilities. At the last moment, though, he would not go. Shortly after, when his landlady was going out, Mr. J asked to come with her. She refused and left the house. He followed and they had an argument. She tried to persuade him he was unwell and to go with her to his G.P. As they were going up the steps to the surgery, he lifted her off her feet and threw her down. She suffered very serious injuries. Mr J was convicted of Grievous Bodily Harm, and admitted to hospital under s.37 of the Mental Health Act 1983. Formulation of Mr J’s aggressive behaviour The formulation, or understanding, is shown by the boxes and arrows; the italics show the interventions and their intended effects. Interventions with Mr. J Summary of the interventions which were carried out during Mr. J’s admission. In terms of LaVigna et al.’s (1989) framework, they included: Proactive strategies Ecological manipulations helping him find enjoyable supported employment; identifying a structured, residential placement postdischarge in his local area; negotiating changes with him to help him feel more in control; information to staff in new residential placement about mood disorders; training for staff at his work and new residential placement about autistic spectrum disorders and preparing for change Positive Programming information about his autism and mood disorder; individual and group social skills training to help him cope with everyday social situations; help in negotiating change; help to identify and describe about his own feelings; anger diary to help him manage angry feelings; simple self-statements to help him cope with feelings of anger and rejection; help to understand the feelings of his former landlady, who did not wish ever to see him again; extending his social network through joining a social group for people with autistic spectrum disorders Reactive strategies Direct Treatment anti-depressant medication to treat his mood disorder support to go to his room to calm after verbal or physical aggression and then carry on with any previously agreed changes Formulation of Mr J’s aggressive behaviour The formulation, or understanding, is shown by the boxes and arrows; the italics show the interventions and their intended effects.