Maudsley Centre for Behavioural Disorders, South London and Maudsley NHS Trust, and Health Services Research Department, Institute of Psychiatry
Maudsley Centre for Behavioural Disorders, South London and Maudsley NHS Trust, and Department of Psychological Medicine, Institute of Psychiatry, London, UK
Correspondence: Suzie Reed, Research Nurse, Institute of Psychiatry, The David Goldberg Centre for Health Services Research, Section of Psychiatric Nursing, Box PO30, De Crespigny Park, London SE5 8AF, UK. E-mail: S.Reed{at}iop.kcl.ac.uk
Declaration of interest The authors are or have been part of the clinical team at the specialist unit evaluated.
![]() |
ABSTRACT |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Aims To test between-group differences in aggression and treatment outcome in people with learning disability and challenging behaviour, with and without a forensic history.
Method Clinical records of 86 former in-patients (45 offenders and 41 non-offenders) of a specialist unit were compared on measures of behavioural disturbance and placement outcome.
Results People in the offenders group were significantly less likely to be aggressive to others and to use weapons, but significantly more likely to harm themselves compared with the non-offenders group. Both groups had a significant reduction in their challenging behaviour during admission, and there was no significant difference in treatment outcome.
Conclusions The negative reputation of people with learning disabilities who offend needs to be reconsidered.
![]() |
INTRODUCTION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
METHOD |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The sample
The target population consisted of all patients with learning disability
and challenging behaviour admitted to the unit since its opening and prior to
31 January 2001 (n=121). In the unit's 14-year period of service
there has been no significant difference in the proportions of offenders and
non-offenders admitted. We excluded from the study people whose admission did
not proceed beyond an 8-week assessment phase or who were not discharged at
the time of data collection. Eighty-six people with learning disability and
challenging behaviour were included in the final sample and assigned to two
study groups. The offenders' group (n=45) consisted of those
receiving treatment under terms of a forensic order (defined as sections 35,
37, 37/41 or 38 of the Mental Health Act 1983, or probation order) during
their admission. The non-offenders' group (n=41) excluded
people who were currently the subject of a forensic order, or who had a known
history of custodial sentencing, a forensic order under the Mental Health Act
or a past admission to a special hospital.
The people we included (Table 1) were predominantly young (mean age 28 years, s.d.=8), White and male, with a mean full-scale IQ of 66 (s.d.=8.07). Approximately 20% of the sample had an IQ above the accepted upper limit of 70 for the category of mild learning disability. This is because the service receives a number of referrals from general adult psychiatry and operates wider eligibility criteria for learning disability. Length of admission ranged from 12 weeks to 185 weeks (mean 69, s.d.=37.68). Those excluded were not significantly different from the final sample in demographic or clinical variables. In the offenders group aggressive behaviours were implicated in the majority of index offences (physical assault in 36% of cases and criminal damage in 20%); the remaining offences were arson (27%), sexual offences (16) and theft (13%). Custodial sentences had been served by 16%, and 27% had previously been admitted to a special hospital.
|
Procedure
A retrospective survey was conducted. We examined case notes for:
Outcome measures
Challenging behaviour was quantified using hospital untoward incident
records, completed according to standard hospital policy. Three outcome
measures were selected to compare challenging behaviour treatment outcome
between the two groups.
Frequency of challenging behaviour
Total number of incidents of each challenging behaviour type recorded
during the admission were used as indicators of behavioural disturbance, and
frequency rates (incidents per month) were calculated to control for length of
admission. Reduction in frequency of challenging behaviour during admission
was defined as change in rate of the behaviour, per person per week, from
baseline (the 4-week period during weeks 610 after admission, to allow
for a honeymoon' period) to end of stay (last 4 weeks of
admission).
Severity of challenging behaviour
Type of staff intervention (e.g. restraint, relocation or seclusion) was
used as a proxy measure for severity of challenging behaviour. Monthly rates
were calculated to control for length of admission and a change in
severity' effect was defined as change in rates of seclusion from baseline to
end of stay.
Placement outcome
A binary outcome variable (good or poor outcome) was generated by comparing
accommodation status on admission and discharge. Good outcome was defined as
discharge to a less restrictive placement than the place of origin (e.g. from
prison to hospital, or from hospital to community home). Poor outcome was
defined as no change in restriction level or discharge to a more restricted
setting (e.g. from community home to hospital).
Analysis
Data were analysed using the Statistical Package for the Social Sciences
(SPSS), version 8 (SPSS,
1999). Normality of distribution was determined using
F-tests, and level of statistical significance was defined as
P<0.05 (two-tailed). Between-group difference in length of stay
was tested using an independent t-test and we applied
2-tests for independence to test categorical variables
relating to patient characteristics. Group differences in type, frequency and
severity of challenging behaviour were tested using MannWhitney
U-tests. Data pertaining to change in challenging behaviour were
analysed using the STATA package
(StataCorp, 2001), and
reductions in frequency and severity of this behaviour were compared using
Poisson regression analysis of covariance, adjusted for the difference in
rates at baseline. Finally, the significance of between-group differences in
placement outcome was examined using
2-tests. In all tests,
participants with missing values were excluded from the analysis of that
variable.
![]() |
RESULTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Frequency of challenging behaviour
Behavioural data were available for 85 people (99%) of the total sample
(Table 2). There was no
significant between-group difference in the in-patient rates of total
incidents of challenging behaviour, violence towards property, sexual assault
and fire-setting. However, the non-offenders group was significantly more
assaultive to staff (P<0.01) and to other patients
(P=0.01), and used weapons significantly more frequently
(P<0.01). In contrast, the offenders group had a significantly
higher rate of self-injurious behaviour (P=0.02). Because inspection
of the data revealed potential effects from outliers, analysis of rate data
was repeated with extreme values (scores indicated by SPSS to extend more than
3 box lengths from the edge of the box-plot distribution) removed; the
significant differences remained.
|
Analysis of between-group differences in treatment effect on frequency of challenging behaviour revealed a baseline to end of stay decrease from 0.79 to 0.36 incidents per person per week in the offenders group, compared with a decrease from 0.23 to 0.11 incidents per person per week in the non-offenders group. Thus there was a trend (P=0.08, 95% CI 0.161.10) for reduction in challenging behaviour to be greater among offenders than non-offenders, but the difference was not statistically significant.
Severity of challenging behaviour
The non-offenders group required restraint and relocation significantly
more frequently than the offenders group
(Table 3). Again, this finding
remained significant after removal of potential outliers. There was no
significant between-group difference in rate of seclusion or change in rate of
seclusion during admission.
|
Placement outcome
There was an expected difference between the groups in place of origin,
with a greater frequency of people in the offenders group being admitted from
non-community settings (e.g. hospital, special hospital or prison) and people
in the non-offenders group being admitted from community settings
(2(1,86)=8.88; P<0.01). Data on discharge
placement were available for 78 people (91% of the total sample;
Table 4). As expected, there
was a significant association between forensic status and discharge setting,
with a greater proportion of the offenders group being discharged to
non-community settings (
2(1,78)=5.00; P=0.03). When
place of discharge was compared with place of origin, the offenders group
tended towards a better outcome, with 71% achieving discharge to a placement
less restrictive than the placement of origin, compared with 59% of the
non-offenders group. However, the difference was not statistically
significant.
|
![]() |
DISCUSSION |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Study design limitations
We assigned people to the offender group by using Mental Health Act status
as an indicator of offending. However, this may not be a reliable marker in
people with learning disability and challenging behaviour, because in learning
disability services tolerance of offences even those as serious as
rape is high (Lyall et
al, 1995; Hakeem &
Fitzgerald, 2002). This reluctance to proceed with criminal action
may arise from beliefs that prosecution is oppressive or will fail, or because
such behaviour is seen as challenging but not legally culpable
(Kearns, 2001). Thus there are
a number of extraneous factors that may determine whether offending behaviour
is labelled as challenging in one person with learning disability yet treated
as forensic in another. However, comparing people on the basis of this
definition allows us to question whether difference in legal status (and thus
reputation') can be explained by difference in behaviour or treatment
outcome.
As the study sample was exclusively in-patient no conclusion can be drawn about patients in non-hospital settings. We are also limited by reliance on retrospectively collected data, and so although our database was compiled from standardised incident forms these might be inaccurate. Underreporting of violence is high in retrospective research and incident records may underestimate the occurrence of certain types of incidents (Silver & Yudofsky, 1987; Aquilina, 1991). However, this bias should have affected each group equally. Also, there were relatively low frequencies of challenging behaviour other than aggression, and so we combined all types of challenging behaviour to calculate the behaviour change score; we therefore cannot comment on group differences in change of each behaviour type. Further, we used type of intervention as a proxy measure of behaviour severity, and although incident severity is one factor that may produce a specific staff intervention, other factors include staffing levels, ward characteristics and environmental variables (Rangecroft et al, 1997).
Our analysis of placement outcome aimed to test between-group differences in change of level of restriction in the placement discharged to (compared with place admitted from) and showed a trend for greater improvement in the offenders group, but because of the small numbers within that group admitted from less restrictive settings, this result is likely to be a ceiling effect and must be treated with caution. Finally, we did not address whether there is a difference in the success of community placements after discharge, and consequently the stability of outcome over time is unknown. Future evaluation of treatment effectiveness should follow people through services and into the community in order to map out the pathways followed in cases of both successes and failures of current practice (Badger et al, 1999). Recidivism rates would be an informative long-term outcome measure.
Clinical and behavioural differences
Despite these limitations, our findings suggest that there are clinical
differences in people with learning disability and challenging behaviour
between those who are labelled as offenders and those who do not offend. A
smaller proportion of people in the offenders group were diagnosed as having
pervasive developmental disorder (autistic-spectrum disorder). This is
surprising, since the triad of impairments associated with autistic-spectrum
disorders might be expected to generate more socially unacceptable behaviours
and hence offence statistics. Also, others have reported a relatively high
prevalence of people with autistic-spectrum disorders in prison
(Department of Health & Home Office,
1992). It may be that carer tolerance of offending is increased by
the visibility of impaired functioning in people with autism and learning
disability and so they are less likely to be entered into the court system.
However, once in the court system people with autistic-spectrum disorders may
not easily be clinically recognised, and so they may be less likely to be
diverted into the health and social services. The trend for a greater
prevalence of personality disorder in the offenders group is consistent with
epidemiological surveys of people with learning disabilities that have
reported an association between personality disorder and aggressive or
offending behaviours (Linaker,
1994; Vaughan et al,
2000).
A significant difference in type of behavioural disturbance indicated that where learning disability and a forensic order coexisted in our service there was an increased risk of self-injurious behaviour. The reason for this is unknown. However, a high prevalence of self-injury has previously been noted in people with learning disability, people with personality disorder and in forensic populations (Winchel & Stanley, 1991; Hillbrand et al, 1996; Haw et al, 2001). Hence a combination of these individual factors may have a cumulative effect on risk of self-injury in the offenders group. Alternatively, as the majority of the people in this group were admitted from institutional care settings, it might be that their prior environment exacerbated their self-injurious behaviour, or that those who are already the subject of forensic proceedings have more motivation to avoid further trouble and therefore direct aggression towards themselves rather than towards others.
The non-offenders group had a significantly higher frequency than the offenders group of assault on others and use of weapons. Similar differences between civil and forensic patients have been observed in a generic psychiatric in-patient sample (Agarwal & Roberts, 1996). Again, this could imply that people without forensic restrictions have less to lose than offenders by directing their aggression towards others. We also found a significant difference in severity of incidents, with the probability of physical restraint or relocation to another room being higher for those in the non-offenders group. Gudjonsson et al (2000) reported a similar disparity between psychiatric in-patients detained on civil and forensic sections in a medium secure unit. This suggests that, contrary to popular image, people with learning disabilities who offend may be less dangerous than those who exhibit challenging behaviour but have no recognised forensic history. Nevertheless, this hypothesis should be treated with caution, because it might be staff management strategies rather than severity of behaviours that differ between the groups. Staff may be especially vigilant with patients with a known forensic history, and this might result in less opportunity for their challenging behaviour to escalate because of better risk management. Whatever the cause of violent behaviour in people with learning disabilities, our data suggest that in mainstream NHS services, staff care plans for aggression need to take account of forensic status.
Treatment outcome
Lelliot et al
(1994) reported that 43% of
long-stay psychiatric in-patients had a history of serious violence, dangerous
behaviour or admission to special hospital. Prolonged detention has negative
implications and is inversely correlated with discharge into the community
(Watts et al, 2000).
This is of particular concern in the population with learning disabilities,
for whom community living has long been hindered by segregated care systems
and institutionalisation. Our study does not support the theory that forensic
status is associated with protracted admission, or that people with learning
disability who have committed offences are less likely to move on'.
Despite having lower levels of aggression towards others than the
non-offenders group, a significantly greater proportion of the offenders group
were discharged to non-community settings. Nevertheless, our findings
demonstrate positive treatment outcomes among offenders and a trend for
greater reduction in challenging behaviour compared with their non-offending
counterparts. Although the latter trend did not reach statistical
significance, it confirms that offenders and non-offenders may benefit equally
from treatment in a specialist service.
Implications of the study
We found significant clinical and behavioural differences between people
with learning disability and challenging behaviour as defined by their legal
status. People with learning disability detained on a forensic order for
treatment in hospital present less risk to others but are more likely to harm
themselves, compared with in-patients with learning disability who have
challenging behaviours not recognised as forensic; and they are more likely to
have a diagnosis of personality disorder. Those who are referred to specialist
in-patient services for challenging behaviours and/or mental health needs and
are diagnosed with an autistic-spectrum disorder are significantly less likely
to have been admitted to hospital as a consequence of criminal
proceedings.
We demonstrated clinical improvement in both groups of people with learning disability. Also, those offenders in the group had a trend for greater reduction in challenging behaviour, and forensic section was not associated with prolonged admission. The findings demonstrate that people with learning disability who offend can reduce the frequency of their challenging behaviour and achieve community resettlement. There is no room for therapeutic nihilism in this neglected group of people. Further research is needed to investigate the long-term outcomes of this service for people with these complex needs, and a follow-up study of this cohort is currently under way.
![]() |
Clinical Implications and Limitations |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
LIMITATIONS
![]() |
ACKNOWLEDGMENTS |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
![]() |
REFERENCES |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Alborz, A. (2003) Transitions: placing a son or daughter with intellectual disability and challenging behaviour in alternative residential accommodation. Journal of Applied Research in Intellectual Disabilities, 16, 75 -88.[CrossRef]
Aquilina, C. (1991) Violence by psychiatric inpatients. Medicine, Science and the Law, 31, 306 -312.
Badger, D., Nursten, J., Williams, P., et al (1999) Systematic Review of the International Literature on the Epidemiology of Mentally Disordered Offenders. CRD Report 15. Executive Summary. York: NHS Centre for Reviews and Dissemination.
Clare, I. & Murphy, G. (1993) MIETS: a service option for people with mild mental handicaps and challenging behaviour and/or psychiatric problems, III. Follow-up of the first six clients to be discharged: diverse measures of the effectiveness of the service. Mental Handicap Research, 6, 70-91.
Department of Health (1993) The Mansell Report: Services for People with Learning Difficulties and Challenging Behaviours or Mental Health Needs. London: HMSO.
Department of Health (2001) Valuing People: A New Strategy for Learning Disability for the 21st Century. CM 5086. London: Stationery Office.
Department of Health (2003) Fulfilling Lives: Inspection of Social Care Services for People with Learning Disabilities. London: Stationery Office.
Department of Health & Home Office (1992) Review of Health and Social Services for Mentally Disordered Offenders and Others Requiring Similar Services. Final Summary Report (the Reed Report). Cmnd 2088. London: HMSO.
Gaskell, G., Dockrell, J. & Rehman, H. (1995) Community care for people with challenging behaviours and mild learning disability: an evaluation of an assessment and treatment unit. British Journal of Clinical Psychology, 34, 383 -395.[Medline]
Gudjonsson, G. H., Rabe-Hesketh, S. & Wilson, C. (2000) Violent incidents on a medium secure unit: the targets of assault and the management of incidents. Journal of Forensic Psychiatry, 11, 105 -118.[CrossRef]
Hakeem, A. & Fitzgerald, B. (2002) A survey
of violent and threatening behaviours within an in-patient learning disability
unit. Psychiatric Bulletin,
26, 424
-427.
Haw, C., Hawton, K., Houston, K., et al
(2001) Psychiatric and personality disorders in deliberate
self-harm patients. British Journal of Psychiatry,
178, 48-54.
Hillbrand, M., Young, J. & Krsytal, J. (1996) Recurrent self-injurious behaviour. Psychiatric Quarterly, 67, 33-45.[Medline]
Holland, T., Clare, I. C. H. & Mukhopadhyay, T. (2002) Prevalence of criminal offending' by men and women with intellectual disability and the characteristics of offenders': implications for research and service development. Journal of Intellectual Disability Research, 46 (suppl. 1), 6 -20.
Home Office (1990) Provision for Mentally Disordered Offenders. Home Office Circular 66/90. London: Home Office.
Home Office (1995) Provision for Mentally Disordered Offenders. Home Office Circular 12/95. London: Home Office.
Kearns, A. (2001) Forensic services and people with learning disability: in the shadow of the Reed Report. Journal of Forensic Psychiatry, 12, 8 -12.
Lelliot, P., Wing, J. & Clifford, P. (1994) A national audit of new long-stay patients. I: Method and description of the cohort. British Journal of Psychiatry, 165, 160 -169.[Abstract]
Linaker, O. M. (1994) Assaultiveness among institutionalised adults with mental retardation. British Journal of Psychiatry, 164, 62 -68.[Abstract]
Lyall, I., Holland, A. J. & Collins, S. (1995) Offending by adults with learning disabilities and the attitudes of staff to offending behaviour: implications for service development. Journal of Intellectual Disability Research, 39, 501 -508.[Medline]
Murphy, G. & Clare, I. (1991) MIETS: a service option for people with mild mental handicaps and challenging behaviour or psychiatric problems, III. Assessment, treatment, and outcome for service users and service effectiveness. Mental Handicap Research, 4, 180 -206.
Murphy, G., Holland, A., Fowler, P., et al (1991) MIETS: a service option for people with mild mental handicaps and challenging behaviour or psychiatric problems, I. Philosophy, service, and service users. Mental Handicap Research, 4, 41-66.
Netten, A. P., Rees, T. & Harrison, G. (2001) Unit Costs of Health and Social Care 2001. Canterbury: Personal Social Services Research Unit (PSSRU).
Rangecroft, M. E. H., Tyrer, S. P. & Berney, T. P. (1997) The use of seclusion and emergency medication in a hospital for people with learning disability. British Journal of Psychiatry, 170, 273 -277.[Abstract]
Silver, J. M. & Yudofsky, S. C. (1987) Documentation of aggression in the assessment of the violent patient. Psychiatric Annals, 17, 375 -384.
SPSS (1999) Statistical Package for the Social Sciences, version 8.0 (19891999). Chicago, IL: SPSS Inc.
StataCorp (2001) STATA 7.0 for Windows (19842001). College Station, TX: Stata Corp.
Vaughan, P. J. (1999) A consortium approach to commissioning services for mentally disordered offenders. Journal of Forensic Psychiatry, 10, 553 -566.
Vaughan, P. J., Pullen, N. & Kelly, M. (2000) Services for mentally disordered offenders in community psychiatry teams. Journal of Forensic Psychiatry, 11, 571 -586.[CrossRef]
Watts, R. V., Richold, P. & Berney, T. P.
(2000) Delay in the discharge of psychiatric in-patients with
learning disabilities. Psychiatric Bulletin,
24, 179
-181.
Winchel, R. M. & Stanley, M. (1991) Self-injurious behavior: a review of the behavior and biology of self-mutilation. American Journal of Psychiatry, 148, 306 -317.[Abstract]
World Health Organization (1992) International Statistical Classification of Diseases and Related Health Problems (ICD10) . Geneva: WHO
Xenitidis, K., Henry, J., Russell, A., et al (1999) An inpatient treatment model for adults with mild intellectual disability and challenging behaviour. Journal of Intellectual Disability Research, 43, 128 -134.[CrossRef][Medline]
Received for publication September 29, 2003. Revision received July 2, 2004. Accepted for publication July 9, 2004.