Forensic Learning Disability

1
Forensic Learning Disability

• Dr Judith McBrien
• Consultant Clinical Psychologist
• Plymouth teaching Primary Care Trust
• Developmental Disability Research Education
  Group

2
What is Learning Disability?

• LD is Mental Impairment within Mental Health
  Act.
• Significantly sub-average intellectual
  functioning (IQ under 70) AND
• Significant impairments in adaptive behaviour AND
• Onset prior to age 18 years

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Prevalence of LD

• Administrative prevalence is considered to be
  0.45 of general population.
• In Plymouth City prevalence of LD amongst adults
  in general population is 0.68.
• Equates to 1,326 adults known to health social
  services LD teams in the City.

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LD and the CJS

• Some people with learning disabilities commit
  offences.
• Low IQ is one of many risk factors for crime.
• People with LD are over-represented at various
  stages of the CJS compared to the general
  population, although in the UK not in prisons.
• Such people pose enormous challenges to local
  services - human financial.
• Most are not prosecuted.

5
Challenges to CJS

• Witnesses/complainants may have LD
• Suspect may not be fit to plead
• Vulnerable to false confessions
• Cope poorly in prison
• CJS often fails to identify LD in a suspect
• Often no community disposal available to the
  Court

6
LD Offenders the NHS

• Of 77 high cost LD placements, 43 are forensic
• Of these 43
• Only 17 are known to CJS.
• 13 are in a secure unit out of the area (3,000
  per week in some cases).
• Only 8 of the13 are receiving tailored treatment.
• 35 are in local homes, highly staffed for public
  protection, but not treated (similar costs to
  SS).

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LD Offenders and NHS/SSKeeping Track

• Some national local providers import adults
  with LD from elsewhere in the country.
• They claim to specialise in high risk behaviour.
• There is no contact with the local LD service
  prior to placement.
• Local Social Services do not monitor them.
• The Health team does not know of them until a
  crisis referral is made.

8
LD Offenders the NHS Current services

• There are no Forensic LD teams in community
  services in Devon (1 million pop) or Cornwall
  (1/2 million pop).
• There is a worryingly low level of Consultant
  Psychiatry provision for LD.
• There are no Medium Secure LD beds in the SW
  Region.

9
Offenders with LDLimited evidence base

• Even UK prevalence studies are hard to interpret
  (McBrien, 2003) - most studies examine prevalence
  of LD amongst CJS populations.
• Predisposing factors poorly researched.
• No offence-specific data for LD groups.
• Limited evidence on treatment effectiveness and
  outcomes (Barron et al 2002).
• No reliable system for assessing risk or
  dangerousness (Fraser, 2004).

10
Plymouth study 1 McBrien, Hodgetts Gregory
2003

• Survey of all 1,326 adults with LD in Plymouth
  City in 2001.
• 348 or 26 were reported as either high risk or
  known offenders.
• Similar findings in replication in Teignbridge
  Torbay 2002.

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Face to face interviews with

• 69 Residential home managers
• 13 Day centre managers
• 2 Respite Units
• 21 Care Managers
• 9 Community Nurses
• 5 Psychologists/Psychiatrists
• Health Authority Representative

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Half or more of the settings cared for clients
who

• Assault others (64).
• Show sexually inappropriate behaviour towards
  others (60).
• Take or damage property (50).

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Settings continued...

• 48 of settings 93 of Care Managers cared for
  clients with a CJS history.
• Carers of 11 people with convictions did not know
  nature of the offence.
• Carers of 5 people with current sentences for
  criminal offences did not know nature of the
  offence.

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Risky/Offending Individuals (n 348)Type of CJS
contact

• CJS Contact N of 1,326
• Contact with CJS as suspect 128 9.7
• Questioned by police 84 6.3
• Police called to disturbance 68 5.1
• Arrested in past 62 4.7
• Convicted in the past 31 2.3
• Currently serving a sentence 11 0.8

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Where are they living?
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Limitations to the study

• Data reliant on informants knowledge.
• Some informants unfamiliar with the past
  histories of their clients.
• Some offenders might have been missed.
• Only captured those known to services.

17
Characteristics of LD offenders

• Most studies have looked at people in custody or
  prison and tried to study those with LD.
• Most of of those found do not have LD.
• E.g. Winter et al 1997
• one of the best studies,
• but, only 2 of sample of 21 had IQ lt70

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Plymouth study 2 characteristicsMcBrien,
Masters Morris 2004

• Four groups
• Convicted
• CJS contact but no convictions
• Risky behaviour but no CJS contact
• Controls no risky behaviour, no CJS contact.

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Variables

• Family background
• Mental health
• Educational background
• Residential day occupation history
• Forensic history
• Services received
• Current care package

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Methods/Measures

• File reviews
• Client assessment
• Carer and Care Manager interviews
• IQ (WASI)
• Adaptive Behaviour (ABS I)
• Challenging behaviour (ABS II)
• Mental health life events (PASS-ADD)

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Sample
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CJS group show differences from Non CJS in these
areas

• Individual differences
• Male and younger
• Higher Full Scale IQ (61 vs 54)
• History of psychiatric disorder
• More life events in last two years
• Family differences
• In care as children
• Physically sexually abused as child
• Parents separated/divorced
• Family history of offending
• Service differences
• Exclusions from residential placements
• No day care placement
• Known to Social Services LD team

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Areas of no difference between CJS Non CJS

• Individual similarities
• Adaptive behaviour (daily living skills)
• Level of risky/challenging behaviour
• Current substance misuse
• Epilepsy or Autistic Spectrum Disorder
• Family similarities
• Family histories of domestic violence or
  substance misuse
• Service similarities
• Living locally or away. Or in secure setting
• Whether placement meets needs or contains risk
• Type of special school attended (MLD or SLD)
• Current contact with LD health team

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Reported risk

• In terms of perceptions of current risk
  presented,
• there are no differences between the CJS groups
• and the Risky Only group.
• High/Medium current risk was reported for
• CJS groups 44
• Risky group 55

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Care Packages
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Sexual risk

• Study on characteristics found sexually
  concerning behaviour occurring in
• CJS groups 47
• Risky group 23
• Controls 0

27
Sex Offending in LD(Thompson Brown 1997 Brown
Stein, 1997)

• High incidence of sexual abuse of people with LD,
  including by men with LD. Peer abuse is
  widespread.
• Men with LD are capable of any type of sexual
  offence, but generally at less serious end.
• Not explained by lack of knowledge or awareness
  of rules.
• Repeat offences and lack of appropriate
  intervention are the norm.
• Sexual offences account for up to half index
  offences of men with LD admitted to specialist
  units/hospitals.

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Current research linked to service development

• Evidence on efficacy of Cognitive-Behaviour
  Therapy group treatment is amassing.
• We have joined a multi-centre outcome trial of
  treatment for sex offenders with LD, providing
  control group data (Murphy Sinclair et al).
• Therefore we are assessing men for risk and
  treatment suitability.
• A Home Office Adapted Sex Offender Treatment
  Programme is planned for the local area.

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Contact details

• Dr Judith McBrien
• Consultant Clinical Psychologist
• LDS, Westbourne Unit
• Scott Business Park
• Plymouth PL2 2PQ
• email judith.mcbrien_at_pcs-tr.swest.nhs.uk
• tel [phone]

31
Case study

• 26 yr old male with LD. Brought up by
  grandparents from 11ms. Entered residential care
  when gran entered nursing home.
• Blossomed in residential home, popular, charming,
  helpful.
• Concerns referred for Personal Relationships
  course.
• 2 female residents complained he had touched
  them. When asked he admitted to rape.
• Moved to respite unit. Adult Protection. Police
  interviewed and Cautioned. Risk assessment. FSIQ
  56.
• Moved to male only residential home. Found
  coming out of a residents bedroom. Buzzer put on
  his door to alert staff.
• Found out of room about to enter anothers had
  disarmed buzzer.
• Told staff he had raped 2 LD men.

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Case study contd

• Adult Protection. Police no action no
  complaint, no witnesses.
• Assessment by NSPCC sex offender expert high
  risk.
• Moved to respite unit, then to singleton
  placement. Staffing costs 2,400 per week. High
  anxiety amongst staff.
• Female with LD complained he touched her. Police
  interviewed her.
• Tried for MHA assessment ASW disagreed
• Referred to 2 Medium Secure Units for Sex
  Offender Treatment Programme one said not able
  enough for treatment other says yes.
• Police interviewed and plan to charge, eventually
  dropped.
• Has now been in MSU for 1 yr receiving treatment
  but will return to Plymouth.