The Future of Learning Disability Inpatient Secure Services

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The Future of Learning Disability Inpatient
Secure Services
Dr Ernest Gralton Forensic Psychiatrist in
Developmental Disabilities Malcolm Arnold
House St Andrews Healthcare
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Key issues- we need to adapt to new evidence

• Complex co-morbidities
• Head injury
• Complex co-morbid Autism/DAMP
• Developmental Traumatology
• Rehabilitation systems/philosophy
• Right brain treatments
• Diet
• Touch
• Exercise
• Pharmacology

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Complex and Diverse population

• Autistic Spectrum Disorders
• DAMP
• Tourettes Disorder
• PTSD Developmental Trauma
• Affective Disorders (atypical)
• Schizophrenia/Schizoaffective
• Attachment disorders
• Paraphillias
• Brain injury/Executive function deficits
• Conduct Disorder
• Substance misuse

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Head injury

• Head injury amongst referral population common
• In a significant minority- developmentally normal
  prior to serious head injury
• Often complicated by other psychiatric disorders
• Requires neuro-psychology input with brain injury
  expertise
• Can lead to a range of offending behaviours
  including serious sexual offending- executive
  function deficits

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Attachment issues/Developmental Traumatology

• High levels of disordered attachment
• Increased levels of neglect and abuse
• Early entry into care
• Multiple short term failed placements

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Animal models

• Seligman
• Learned Helplessness 1967
• Beagles rats exposed to electric shock without
  chance to escape
• Originally considered a model for depression now
  more likely for PTSD (especially Chronic PTSD)
• Massive outpourings of stress neurohormones
• Animals exposed to varieties of chronic stress
  (including primates)- demonstrate impairments in
  learning and memory
• Associated with alterations in structure-
  temporal lobe, amygdala and hippocampus

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Anxiety Bell Curve

• Anxiety increases to a level where performance
  decreases
• Speech centres shut down, increased blood flow
  motor areas
• Over-arousal can quickly lead to aggression

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Stress Plasticity in Limbic System (Sapolsky
2003)

• Damage by Glucocorticoids-
• Decrease in length retraction of dendritic
  processes
• Loss of branch points, neuronal atrophy/death
• Growth is promoted (rodents/primates)
• a) Reduction in glucocorticoids (stress)
• b) Environmental enrichment
• c) Exercise

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Autism

• A high proportion of young people with LD
  requiring inpatient care have co-morbid autism
• Dislike change, find transitions very difficult

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Mixed Disorders

• Symptoms of ADHD 1846
• Comorbid disorders
• DAMP syndrome

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Sensory Sensitivities

• Significant proportion of autistic patients have
  sensory sensitivities- that may adversely
  influence behaviour

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Robert

• 17 year old adolescent in mild LD range
• Developmental History consistent with PDD/ADHD/
  Developmental dyspraxia
• Aggressive toward sibs- punitive parenting
  strategies
• Multiple foster care placements from age 4
• Sexual abuse history from age 7, head injury aged
  8
• Erratic education/ no peer relationships bullied
• Multiple childrens homes from age 9
• Arson and sexual offending against younger
  children
• Social Services Secure Accommodation-
  consistently aggressive, needing continuous
  restraint

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Care Pathway

• Conventional mental health rehabilitation
  pathway models are often unsuitable

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The developmental perspective

• Young people still rapidly developing
• Challenges- more complex difficult to meet
  needs
• Opportunity- to make a much greater impact on
  their development and outcome
• Unlikely single interventions will be sufficient
• Programme of intervention should be comprehensive
  covering all developmental domains
• Improvements in one area impact on others
• More difficult to distinguish contribution of
  individual interventions

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Hierarchy of interventions

• They need to be safe basic needs met
• Level of arousal/aggression needs to be reduced
• Only then can move on to other interventions
• Every interaction has the potential to be
  therapeutic

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EMDR

• Number of theories as to mechanism of effect
• Difference between hippocampal/amygdala may
  initially worsen PTSD and lead to increased risk
  of self harm
• neocortical memories- conversion one to other
• Good evidence for single trauma PTSD in adults
• Delivering it to patients (especially
  adolescents) with complex PTSD is not straight
  forward
• If dissociate cannot co-operate with procedure
• Highly reliant on feedback of SUD score
• Needs to be supported with other anxiety
  management techniques and medication

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Neurobiology of EMDR

•  EMDR stimulation (visual, auditory and tactile)
  brings about a constant alternating shifting of
  attention- cholinergic surge.
• The cholinergic surge starts the REM processing
  system.
• Pontine Genticulate Occipital (PGO) Waves occur
  in REM EMDR
• The REM system activates areas of the anterior
  cingulate, - link between (cognitive) neocortex
  and (emotional) limbic areas - facilitating the
  integration of traumatic memory into neocortex.
• Inhibition of both hippocampal episodic memories
  amygdaloid mediated negative affect of PTSD.

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Solution Focused Model

• Widely used individual intervention for
  difficult to treat populations -good evidence
  efficacy
• Widened use into a Model of Care
• Crosses multi-professional boundaries
• Simple principles easy to teach- quick to apply
• Integrates with CPA
• Future focussed- acknowledges individual
  preferred future
• Draws on existing strengths
• Avoids confrontational relationships

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Diet
20 of neuronal wall is made up of Essential
Fatty acids DHA is essential for the operation of
ion channels Essential for neuronal growth
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Pharmacotherapy

• Low dose Risperidone for CD/LD/Autism
• SSRI- act via serotonergic mechanisms, can
  trigger rapid cycling affective disorders
• Benzodiazepines- can increase dissociation
• Antiepileptics- Carbemazepine and Valproate open
  label evidence
• Antiadrenergic agents Propranolol Clonidine (NIMH
  CT trial underway)

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Be prepared!

• Young people need lots of preparation to make a
  transition into a new placement