Service Pathways of People with LD with offending behaviour

1
Service Pathways of People with LD with offending
behaviour

• Results of a multi-centre study

2
Overview

• Background to Study Nature of Pathway
• Description of Study
• Subject/Participant Characteristics
• Index Behaviour/Setting Characteristics
• Determinants/Predictors of referral destination
  Community or Secure?

3
Introduction

• Study grew out of widespread concern
• Postcode lottery of services for LD offenders
• Vulnerable, socially excluded individuals
• On a pathway to ultimate social exclusion
• Anecdotal evidence of the efficacy of certain
  robust local services
• Even more anecdotal evidence that these are few
  and far between
• DoH Forensic MH programme called for tenders

4
Some critical steps in the offender pathway

• Event
• Recording/local recognition reporting
• Police/statutory involvement
• (Local) clinical assessment
• Statutory Measure instigated or not
• Referral
• Disposal
• Non-disposal

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Elements of a Service

• Legislation which enables treatment
• Effective Communication and Referral Links
• Multidisciplinary diagnostic assessment
• Expertise Appropriate Resources
• Appropriate Treatment Setting(s)
• Appropriate Treatment Approach(es)
• Academic Programme

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Multi-Centre Study

• Commissioned by DoH

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Flow Diagram of Study

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The Subjects

• The 477 adults who were referred to any statutory
  service in the three geographical areas for
  offendingtype behaviour over 2003
• (2002-2003 for high secure referrals)
• Mean Age 33 years (SD 12.4 range 16-84)

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Index Offending-type behaviours ( subjects)
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Subject/Participant Characteristics
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Subjects Level of Learning Disability

• Note the number of high IQ subjects
• Vast majority 50-79
• In 12 the LD level was unknown at time of
  referral

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Documented Psychiatric Diagnoses

• Childhood
• ASD - 4710
• ADHD/Conduct 7315
• Emotional - 51
• Other - 296
• At least one diagnosis in 29 (N137)

• Adulthood
• Major Psychoses (Schiz/paranoid) -84 18
• Mood -89 20
• PD -50 10
• Other - 8016
• At least one diagnosis in 42 (N102)

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Documented Physical Health Diagnoses N

• Epilepsy 90 19
• Diabetes 19 4
• Major neurological problem in 35 7
• Other major physical problem requiring ongoing
  medical care in 100 21
• Overall, at least one of these in 42 cases
  (N199)
• The same as in adult psychiatric diagnoses

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Subjects History of extreme adversity in
Childhood (minimal rates positive evidence
required)
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Multiple I.B.s

• More than 5 Index Behaviours
• 177 subjects 37

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Index Behaviour Setting Characteristics
17
Employment status ( subjects)
18
Living Situation at time of referral
19
Living Arrangements of Day of Index
Behaviour Living Arrangements Freq
of Cases Homeless 5 1 Own
Home 73 15 Family Home 120 25 Shelt
ered Accommodation 16 3 Community Group
Home 106 22 Hostel 11 2 General
Psychiatric Hospital 11 2 LD Hospital Open
Ward 24 6 LD Hospital Locked
Ward 33 7 Medium Secure Unit 17 4
Special Hospital (High Secure) 4
1 Prison 6 1 Special Residential
School 4 1 Other 33 7 Not Known
14 3 Note Living arrangements
in italics were classified as living in
the community. e.g. living in friends home
etc
20
Police Action
21
Statutory Status at Referral ()
22
Referral Source ()
23
Service/Destination of Referral
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Determinants of Referral Destination

• Community or Secure?

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Referred to Community or secure?

• 236 (70) to Community
• 141 (30) to Secure

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Statistical Analysis 1 Test of all key
variables by simple tests of association
(Chi-square / t test) The variables that were
shown to be associated positively or negatively
with community based referrals now follow The
strength of the association between the variables
was categorized as weak, moderate, strong or
very strong Based on the interpretation of the
Cramers V statistic strength of association of
chi-square
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  Fig 1 The proportion of referrals to
Community and Secure Levels of service fulfilling
the criteria for the 16 dichotomous predictor
variables.  
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  The proportion of cases belonging to the
variable category and which level of service they
were referred to.
29
    Mean scores for continuous variables. (s.d.
in parenthesis) Community
referrals Secure referrals   Age at IB
33.9 years (13.0) 31.0 years (10.5)   Age at
first recorded problem behaviour. 16.6 years
(11.9) 12.4 years (7.4)   Number of
different types of problematic behaviour.
2.6 (1.8) 4.6 (2.1)    
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Variables shown to have no significant
relationship with community referrals or not
included     If the IB included verbal
aggression If the IB included stalking
behaviour If the IB included an inappropriate
non-contact sexual behaviour If the IB included
theft If the IB included some sort of fraud If
the IB involved a traffic related offence If
there were multiple incidents of the IB If the
person had a psychiatric disorder as a child If
the person had a physical disability If there
was any evidence of a birth problem associated
with their developmental disability If they were
engaged in any formal daytime activity in and
around the day of the IB.
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Statistical Analysis 2 Binary Logistic
regression Predicting Community Referrals  The 19
variables initially identified as associated with
community referrals were analysed using
multivariate logistic regression (Enter Method)
in an attempt to identify those variables that
best account for the variance between those
referred to this type of service and those
referred to a secure service.
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The 6 key variables

• 6 key variables were found to account for 85 of
  the story, in that, together, they accurately
  predict the referral destination of 85 of cases.
• This held up, however comparison was made
  (multinomial logistic regression) among the
  categories community vs low, medium, high

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The 6 key variables which separate
community/secure

• More to Community
• More Severe Learning disability
• Community living at I.B.
• More to Secure
• If I.B. resulted in police charge
• Higher Number of types of index Problem Behaviour
• If referred from tertiary Health Care
• I.B includes physical aggression

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Key Variables effect strengths

• p
• More severe LD .02
• Community living .001
• Physical aggression .014
• Tertiary source .002
• Multiple types behav. .001
• Police Charge .001

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Conclusion

• LD Severity, Multiplicity of behaviours and use
  of aggression were the subject characteristics
  which emerged as predictors
• Living situation, Police action, and referral
  source (3y) were the Setting characteristics
  which emerged as predictors
• These findings are clinically familiar
• The analysis continues

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Research Team

• North East England
• G OBrien
• J Taylor
• C Middleton K Price (RA)
• East Anglia
• A Holland
• M Bambrick
• I Clare
• J Wheeler (RA)

• Eastern Scotland
• W Lindsay
• D Carson
• L Steptoe (Senior RA)
• High Secure Hospitals
• S Johnston
• S Young