The Psychopathy Checklist Short Version (PCL:SV) is a brief measure of psychopathy. This study aimed to assess the reliability and validity of the PCL:SV with autistic adults detained in inpatient psychiatric care. Data were collected from 282 autistic adults at two time points separated by 12-months. Reliability and validity were investigated using omega, regression, receiver operating characteristic curves, and correlational analysis. PCL:SV Total, Factor 1, and Factor 2 had satisfactory to high reliability and construct validity. Higher PCL:SV scores were associated with poorer treatment progress, a longer length of stay, and previous criminal offending. Factor 1 was associated with a forensic history, detention under Part III of the Mental Health Act, and a personality disorder diagnosis, while Factor 2 was also associated with the absence of a forensic history, detention under Part II of the Mental Health Act, but not a personality disorder diagnosis. It was thought that Factor 2 most likely captured data associated with autism and/or intellectual disabilities (e.g., behaviors that challenge). Those with intellectual disabilities were less likely to have convictions, a history of violent offending, or a forensic history. They were also more likely to be detained under Part II of the Mental Health Act, and were more likely to have had a positive transfer 12-months later to a ward with lesser security. The PCL-SV correlated as expected with the HCR-20 and the START. This study provides preliminary evidence to support the use of the PCL:SV with autistic adults, including those with intellectual disabilities, within inpatient psychiatric hospitals.

This chapter describes the development and delivery of hospital inpatient services and community services for those with neurodevelopmental disorders with a focus on services for those with intellectual disability in England. The tired model of service provision is described with Tier 1 to Tier 3 being community-based services and Tier 4 as all types of specialist inpatient services. Within Tier 4 services, there are six categories of services that ranging from high secure to long-term rehabilitation inpatient units or to highly specialised units provided at a national level such as those for autistic people. Autistic patients admitted to forensic in-patient care are a heterogenous group with complex needs. Developing forensic services for people with neurodevelopment disorders requires all relevant stakeholders to be involved using a care pathway-based approach addressing key elements such as the environmentand be person centred so that treatments are tailored to the individual needs of the patient. Future services both in the community and within hospital setting will need to be flexible to meet changing needs and demands.

Background An increasing number of children, adolescents and adults with intellectual disabilities and/or autism are being admitted to general psychiatric wards and cared for by general psychiatrists. Aims The aim of this systematic review was to consider the likely effectiveness of in-patient treatment for this population, and compare and contrast differing models of in-patient care. Method A systematic search was completed to identify papers where authors had reported data about the effectiveness of in-patient admissions with reference to one of three domains: treatment effect (e.g. length of stay, clinical outcome, readmission), patient safety (e.g. restrictive practices) and patient experience (e.g. patient or family satisfaction). Where possible, outcomes associated with admission were considered further within the context of differing models of in-patient care (e.g. specialist in-patient services versus general mental health in-patient services). Results A total of 106 studies were included and there was evidence that improvements in mental health, social functioning, behaviour and forensic risk were associated with in-patient admission. There were two main models of in-patient psychiatric care described within the literature: admission to a specialist intellectual disability or general mental health in-patient service. Patients admitted to specialist intellectual disability in-patient services had greater complexity, but there were additional benefits, including fewer out-of-area discharges and lower seclusion rates. Conclusions There was evidence that admission to in-patient services was associated with improvements in mental health for this population. There was some evidence indicating better outcomes for those admitted to specialist services.

BACKGROUND:We examined whether a series of variables were related to the number of psychiatric inpatients using publicly available data about English psychiatric bed utilisation and NHS workforce.METHOD:Using linear regression, with auto-regressive errors, we examined relationships between variables over time using data from December 2013 to March 2021.RESULTS:Over time, the number of inpatients reduced by either 6.58 or 8.07 per month depending upon the dataset utilised, and the number of community nurses and community nursing support staff reduced by 7.43 and 2.14 nurses per month, respectively. Increasing numbers of consultant psychiatrists were associated with fewer inpatients over time. More care and treatment reviews (CTRs) were associated with more admissions over time, while more post-admission CTRs were associated with increased discharges over time.CONCLUSIONS:Future studies should examine whether psychiatric bed utilisation elsewhere within the NHS by people with intellectual disabilities has increased.

Offending behaviour and intellectual disability has long been—erroneously—associated in the literature and this misattribution has shaped services for this population. In this chapter, the relationship between intellectual disability and criminality is described along with the impact on the care and treatment of people in this population. Developments in the assessment of risk are outlined and clinical interventions for fire setting, sexually aggressive and violent behaviour are detailed, along with consideration of service level outcomes. Over the last 20 years or so there have been significant developments in clinical assessment and treatment approaches for people with intellectual disabilities who offend, however more rigorous and larger scale research is required to support further advances.

Rehabilitation services for people with mental illnesses have been extensively researched. However, services with similar aims and specifications for patients with intellectual disabilities (IDs) have had little focus. This study describes the characteristics and outcomes of 21 patients admitted to a specialist ID rehabilitation service over an 8-year time frame. Rather that solely accepting 'step-down' referrals, some patients were referred from community settings. During the study, 20 patients were discharged, 80% to lower levels of service restriction, while 14.3% to higher levels. The study suggested that rehabilitation services have an important role within the wider service model for people with ID. Within the service studied, patients were referred from both higher and lower levels of restriction, suggesting the rehabilitation service 'bridged the gap' between inpatient and community settings, supporting the aim of caring for patients in the least restrictive setting for their needs.

Purpose: People with Intellectual Disability (ID) and epilepsy are more likely to experience psychiatric conditions, challenging behaviour (CB), treatment resistance and adverse effects of anti-seizure medications (ASM) than those without. This population receives care from various professionals, depending on local care pathways. This study evaluates the training status, confidence, reported assessment and management practices of different professional groups involved in caring for people with ID, epilepsy and CB. Methods: A cross sectional survey using a questionnaire developed by expert consensus which measured self-reported training status, confidence, and approaches to assessment and management of CB in people with ID and epilepsy was distributed to practitioners involved in epilepsy and/or ID. Results: Of the 83 respondents, the majority had either a psychiatry/ID (n = 39), or Neurology/epileptology background (n = 31). Psychiatry/ID and Neurology/epileptology had similar confidence in assessing CB in ID-epilepsy cases, but Psychiatry/ID exhibited higher self-rated confidence in the management of these cases. While assessing and managing CB, Psychiatry/ID appeared more likely to consider mental health aspects, while Neurology/epileptology typically focused on ASM. Conclusion: Psychiatry/ID and Neurology/epileptology professionals had varying training levels in epilepsy, ID and CB, had differing confidence levels in managing this patient population, and considered different factors when approaching assessment and management. As such, training opportunities in ID should be offered to neurology professionals, and vice versa. Based on the findings, a best practice checklist is presented, which aims to provide clinicians with a structured framework to consider causal explanations for CB in this population.

It is important to ensure that people with intellectual disability (ID) have access to high quality healthcare services. There is a wide variation in the availability of services and service delivery models globally for people with ID. Reasons for these variations are examined including availability of workforce resources and the development and availability of specialist resources. Tracing the development of services across the world, the chapter goes on to review the ongoing debate on access to generalized healthcare services versus the role of specialist services. We review advantages and disadvantages of different service delivery models. While these models have evolved in response to the political, cultural, and economic environment, it is important that any development of service delivery model signs up to basic underlying principles of person-centred, right-based, and outcome-focused approach. This should be undertaken in partnership with service users and carers in the spirit of co-production and with the underlying principles of choice, inclusion, rights, and independence. Any service development should also ensure that it would meet the complex health needs of people with ID as described in the tiered model of services with an efficient use of available resources. It should be sustainable through development of skills, competencies, and capabilities of the workforce and agencies that work with people with ID. There are number of examples across countries of innovative service provisions by public, private, and voluntary sectors as described in the chapter and it is important that we learn from those models. Advocating should be an integral aspect of any service delivery; we should be constantly advocating globally for high quality healthcare based on the best available evidence for people with ID.

This report is concerned with the standards of recording, monitoring, and regulation of restrictive interventions involving people with intellectual disabilities with mental health and/or behaviour that challenges within inpatient services. Restrictive interventions, a central concern for all stakeholders of intellectual disability services, has come under increased scrutiny following the abuse scandal at Winterbourne View. Current efforts to monitor them rely almost exclusively on the numbers of such incidents. This approach is fundamentally flawed because numbers alone do not assess the quality of a services’ overall restrictive interventions practice and cannot be used to infer good or poor standards of practice and abuse. Further, there are problems with the variable use of definitions, the failure to distinguish between various degrees of physical restraint, the impact of outliers, the failure to capture individual patient progress and the absence of meaningful benchmarking. Service providers and regulators must therefore rely on other methods to evaluate the use of restrictive interventions and move from basing their conclusions on just the total number of restrictive interventions to one of examining a wider range of quality parameters. With representative examples, this document makes recommendations on how restrictive interventions should be recorded, monitored, regulated and published.

BACKGROUNDProblem behaviours (PBs) are a common cause for clinician contact in people with disorders of intellectual development and may be a common cause for the prescription of psychotropic medication. We aimed to use a large, multinational sample to define the prevalence of PBs, the associations with psychotropic medication use, and to assess for any potential 'diagnostic overshadowing' by the label of PBs in a population of people with disorders of intellectual development.METHODA multinational, multi-setting, cross-sectional service evaluation and baseline audit was completed. Data were collected from UK hospitals, UK community settings, Sri Lanka and Hong Kong. A semi-structured questionnaire was completed by treating clinicians, capturing demographic details, prevalence rates of intellectual disability and psychotropic medication use, alongside psychiatric co-morbidity.RESULTSA sample size of 358 was obtained, with 65% of included participants treated in an inpatient setting. Psychotropic use was prevalent (90%) in our sample, particularly antipsychotics (74%). The prevalence of PB was high (83%). There was no statistically significant association between psychotropic prescription and recorded psychiatric co-morbidity, suggesting prevalent 'off-label' use for PBs, or poor recording of psychiatric co-morbidity. There was some evidence of possible diagnostic overshadowing due to the PB classification. A higher dose of psychotropic medication was associated with aggression toward others (P = 0.03).CONCLUSIONSWe found evidence of prevalent potential 'off-label' use for psychotropic medication, which may be due to PBs. We also found evidence of potential diagnostic-overshadowing, where symptoms of psychiatric co-morbidity may have been attributed to PBs. Our findings provide renewed importance, across borders and health systems, for clinicians to consider a holistic approach to treating PBs, and attempting to best understand the precipitants and predisposing factors before psychotropic prescribing.

Autistic adults who have a history of committing crimes present a major problem for providers of services in terms of legal disposal options and possible interventions, and greater understanding of this group and their associated needs is required. For this reason, we aimed to investigate the face validity of a proposed sub-typology of autistic adults detained in secure psychiatric hospitals in the United Kingdom. Initially, a focus group was completed with psychiatrists, clinical psychologists, healthcare workers, family members and autistic adults who had been detained in hospital, leading to revisions of the sub-typology. Following this, a consensus rating exercise of 10 clinical vignettes based on this sub-typology with three rounds was completed with 15 psychiatrists and clinical psychologists; revisions to the vignettes to improve clarity were made following each round. The findings indicated that these subtypes possess face validity and raters were able to classify all 10 clinical case vignettes into the sub-typology, and percentage of agreement ranged from 96% to 100% for overall subtype classification. This study suggests that the further validity of the sub-typology should be investigated within a larger study, as these subtypes have the potential to directly inform the hospital care pathway such that length of stay can be minimised. Lay abstract Autistic adults who have a history of committing crimes pose challenges for the criminal justice system in terms of disposal and treatment. For this reason, we investigated the validity of a proposed sub-typology of autistic adults detained in secure psychiatric hospitals. Initially, we ran a focus group with psychiatrists, clinical psychologists, healthcare workers, family members and autistic adults who had been detained in hospital to consider a sub-typology of autistic adults who may come into contact with secure psychiatric hospitals. We asked 15 psychiatrists and clinical psychologists to rate 10 clinical vignettes based on our sub-typology with three rounds; revisions to the vignettes to improve clarity were made following each round. The findings indicated that these subtypes possess face validity and raters were able to classify all 10 clinical case vignettes into the sub-typology and percentage of agreement ranged from 96% to 100% for overall subtype classification. The findings suggested that the further validity of the sub-typology should be investigated within a larger study using a clinical sample. These subtypes may help inform treatment and care pathways within hospital.

Purpose There is increasing emphasis on caring for people with intellectual disabilities in the least restrictive, ideally community settings. Therefore, the purpose of this paper is to explore the risk factors considered by clinicians involved in discharging people from secure services. Design/methodology/approach The views of five senior clinicians were sought in semi structured interviews. Data were analysed thematically. Findings Themes related to risk assessment, risk management, and multidisciplinary and multiagency working. Illustrative quotes are used to evidence themes. Practical implications This study described the risk assessment and management factors considered during the discharge of patients from secure to community services, which are of direct relevance to multiple stakeholders post-Winterbourne. Originality/value Challenges when facilitating discharge were highlighted, such as ongoing risk management issues, or unexpected discharge from tribunals, and how these were addressed, via the development of extensive risk assessment and management processes, and interdisciplinary and interagency working.

Background: Inpatient services for people with intellectual and other types of developmental disabilities (IDD) who also have forensic or risk issues are largely provided in secure hospitals. Although this is a health service sector with high levels of expenditure, there is limited empirical information on patient outcomes from such services. In order for a future substantive longitudinal outcomes study in forensic IDD services to be informed and feasible, more needs to be understood about the outcome domains that are of relevance and importance and how they should be measured. A preliminary series of studies was therefore undertaken. Objectives: To synthesise evidence in relation to the outcome domains that have been researched in the existing literature from hospital and community forensic services for people with IDD, within the broad domains of service effectiveness, patient safety and patient experience. To identify a definitive framework of outcome domains (and associated measures and indicators) based both on this research evidence and on the views of patients, carers and clinicians. To synthesise the information gathered in order to inform design of future multisite longitudinal research in the sector. Design: Three linked studies were conducted. Stage 1 was a systematic review and evidence synthesis of outcome domains and measures as found within the forensic IDD literature. Stage 2 was a consultation exercise with 15 patients with IDD and six carers. Stage 3 was a modified Delphi consensus exercise with 15 clinicians and experts using the information gathered at stages 1 and 2. Results: At stage 1, 60 studies that researched a range of outcomes in forensic IDD services were identified from the literature. This resulted in the construction of an initial framework of outcome domains. The consultation with patients and carers at stage 2 added to these framework domains that related particularly to carer experience and the level of support post discharge in the community. The Delphi process at stage 3 confirmed the validity of the resulting framework for clinician. This survey also identified the outcome measures preferred by clinicians and those that are currently utilised in services. Thus, indicators of appropriate measures in some important domains were identified, although there was a paucity of measures in other domains. Conclusions: Together, these three linked studies led to the development of an evidence-based framework of key outcome domains and subdomains. A provisional list of associated measures and indicators was developed, although with the paucity of measures in some domains development of specific indicators may be required. With further refinement this could eventually be utilised by services and commissioners for comparative purposes, and in future empirical research on outcomes in forensic IDD services. An outline research proposal closely linked to recent policy initiatives was proposed. Limitations of the study include the relatively small number of carers and patients and range of experts consulted. Future work: This would comprise a national longitudinal study tracking IDD in patients through hospitalisation and discharge. Study registration: This study is registered as PROSPERO CRD42015016941. Funding: The National Institute for Health Research Health Services and Delivery Research programme.

IntroductionConstituting 2% of the population, PWDID are a vulnerable group with a higher prevalence of mental disorders than the general population. ICD diagnostic criteria often rely on adequate cognitive functioning and hence diagnosis of mental disorders in PWDID can be difficult, consequently leading to inequity of treatment, prognosis and stigma. Our study critically analysed the available evidence base and explored the feasibility of applying modified diagnostic criteria within the context of cumulative iterative iteration. We present the outcome using diagnosis of DID and anxiety disorder as examples.AimsAddress current shortcomings in ICD classification regarding PWDID by contributing effectively to the WHO ICD-11 consultation process in collaboration with international stakeholders.ObjectivesFacilitate accessibility of ICD-11 criteria for diagnosis of mental disorders capable of engendering robust evidence based epidemiological data and healthcare in PWDID.MethodsWe evaluated current evidence via a systematic literature search utilising PRISMA guidelines and developed pragmatic guidelines to adapt ICD diagnostic criteria in PWDID. A brief screener [Glasgow Level of Ability and Development Scale (GLADs)] for detecting DID was also studied internationally within the context of clinical utility (n = 136).ResultsThe evidence base relating to mental disorders in PWDID is poor, significantly hampered by difficulties in applicability of diagnostic criteria. The GLADs appears to be a promising screening tool with good clinical utility for detecting disorders of intellectual development (DID) particularly where resources are scarce.ConclusionsPragmatic modifications to ICD-11 diagnostic criteria and the GLADS tool facilitates its clinical utility for PWDID and contributes significantly to enhancing research based evidence, and, ultimately their health access and well-being.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Persons with intellectual disabilities are likely to be misdiagnosed and end up in prisons for petty offences. The rates of criminal behaviours will be influenced by social and cultural factors. What is seen as illegal behaviour in one society may not be so in another. Cultures also play a major and significant role in defining deviant behaviour and defining what is abnormal. Thus relationship between intellectual disability and criminal behaviour deserves better understanding and research. In hospital or care settings as well as in prisons, clinicians must be sensitive to the role intellectual disability may play in contributing to mental ill-health and behavioural problems. Clinicians must have the skills to identify intellectual disability and its consequences. Wherever possible, depending upon local needs, court diversion schemes and pathways be identified and developed through all agencies who may be involved in caring for persons with intellectual disability.

BACKGROUND AND PURPOSE:About a quarter of people with epilepsy have intellectual disability (ID). This group has communication issues, premature mortality, more treatment resistance, difficulties in making informed choices and greater risks of physical and mental health comorbidities. There is no specific prescribing guidance for this large and vulnerable group. The literature on prescribing for epilepsy in this group was reviewed, in particular examining how antiepileptic drugs (AEDs) work regarding their side effect profiles, effects on specific epilepsy syndromes associated with ID and their individual strengths and weaknesses based on the nature and degree of ID.METHOD:This is a narrative review for which a comprehensive search was conducted to identify evidence for prescribing commonly used AEDs to people with ID including genetic syndromes specifically associated with epilepsy.RESULTS:A detailed analysis of the results has highlighted the urgent requirement for suitable and reliable evidence in AED prescribing amongst adults with epilepsy and ID as no studies taking account of the response to AEDs of the ID populations based on the WHO Diagnostic and Statistical Manual of Mental Disorders criteria of clinical severity of ID were identified.CONCLUSION:There is a significant shortfall in suitably powered studies to provide sufficient evidence for safe prescribing of AEDs to people with ID.