Defendants with intellectual disability and autism spectrum conditions: the perspective of clinicians working across three jurisdictions.

The treatment of vulnerable defendants by criminal justice systems or correctional systems varies within and between countries. The purpose of this paper is to examine three legal jurisdictions - New South Wales in Australia; Norway; England and Wales - to understand the extent of variation in practice within the court systems for defendants with intellectual disabilities (ID) and/or autism spectrum conditions (ASC). Two of the jurisdictions had a process for screening in place, either in police custody or at court, but this was not universally implemented across each jurisdiction. All three jurisdictions had a process for supporting vulnerable defendants through the legal system. Across the three jurisdictions, there was variation in disposal options from a mandatory care setting to hospital treatment to a custodial sentence for serious offences. This variation requires further international exploration to ensure the rights of defendants with ID or ASC are understood and safeguarded.

Treatment outcomes from forensic intellectual disability services: The perspectives of patients and their family/carers.

INTRODUCTION: Research investigating the treatment outcomes of forensic intellectual and developmental disability (FIDD) services has largely focused on the perspectives of clinicians and researchers. This study sought the perspectives of patients and family/carers on the outcomes important to them. METHODS: Semi-structured consultation groups were conducted with patients in FIDD services (n = 21) and family carers (n = 6). Interview data were content analysed, and outcomes identified fell into three main domains (effectiveness, safety and patient experience). RESULTS: The consultations identified outcome domains not considered in the published literature. Patients and carers also had differential perspectives on treatment outcomes commonly reported within literature. Illustrative quotes are used to evidence the domains. DISCUSSION: This study is the first to investigate the outcomes of relevance to patients and their families. These views have been incorporated into an outcomes framework which will form the foundation of future prospective outcome studies.

A systematic review and synthesis of outcome domains for use within forensic services for people with intellectual disabilities.

BACKGROUND: There is limited empirical information on service-level outcome domains and indicators for the large number of people with intellectual disabilities being treated in forensic psychiatric hospitals. AIMS: This study identified and developed the domains that should be used to measure treatment outcomes for this population. METHOD: A systematic review of the literature highlighted 60 studies which met eligibility criteria; they were synthesised using content analysis. The findings were refined within a consultation and consensus exercises with carers, patients and experts. RESULTS: The final framework encompassed three a priori superordinate domains: (a) effectiveness, (b) patient safety and (c) patient and carer experience. Within each of these, further sub-domains emerged from our systematic review and consultation exercises. These included severity of clinical symptoms, offending behaviours, reactive and restrictive interventions, quality of life and patient satisfaction. CONCLUSIONS: To index recovery, services need to measure treatment outcomes using this framework. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Attribution (CC BY) licence.

Longitudinal HCR-20 scores in a high-secure psychiatric hospital.

BACKGROUND: The HCR-20 is a widely used 20 item structured professional judgement aid to risk assessment and management, but longitudinal studies of its value are rare, particularly with people at high risk of reoffending. AIMS: To investigate whether the HCR-20 discriminates between patient subgroups in one high-security hospital in England, whether scores reduce with hospital treatment and whether lower scores predict discharge. METHODS: Repeated HCR-20 ratings were made by clinical teams across five services within the hospital, two of them (women and men with intellectual disability) national services. A database of 3337 HCR-20 ratings, from 532 patients over a period of 5 years, was examined using mixed effects models. RESULTS: As expected, HCR-20 scores were high overall, but there were differences between services in the ratings obtained. Female patients and men with intellectual disability had the highest total score. There was a significant relationship between discharge and lower clinical risk score, but not between total and risk scale scores and discharge. There were significant changes in scores over time, although these were small and may not be clinically meaningful. Differences between services were observed, with women evidencing greater change. CONCLUSIONS: It is unsurprising that patients in two national services (for men with intellectual disability and women) have the highest HCR-20 scores; however, the finding of relatively greater risk reduction in women needs further investigation. Although we did not find ceiling effects in this sample, the clinical value of frequently repeated HCR-20 ratings may be limited for high-risk populations where any change is likely to be slow.

Structural, item, and test generalizability of the psychopathy checklist--revised to offenders with intellectual disabilities.

The Psychopathy Checklist-Revised (PCL-R) is the most widely used measure of psychopathy in forensic clinical practice, but the generalizability of the measure to offenders with intellectual disabilities (ID) has not been clearly established. This study examined the structural equivalence and scalar equivalence of the PCL-R in a sample of 185 male offenders with ID in forensic mental health settings, as compared with a sample of 1,212 male prisoners without ID. Three models of the PCL-R's factor structure were evaluated with confirmatory factor analysis. The 3-factor hierarchical model of psychopathy was found to be a good fit to the ID PCL-R data, whereas neither the 4-factor model nor the traditional 2-factor model fitted. There were no cross-group differences in the factor structure, providing evidence of structural equivalence. However, item response theory analyses indicated metric differences in the ratings of psychopathy symptoms between the ID group and the comparison prisoner group. This finding has potential implications for the interpretation of PCL-R scores obtained with people with ID in forensic psychiatric settings.

Predictive validity of the PCL-R for offenders with intellectual disability in a high security hospital: treatment progress.

BACKGROUND: Among mainstream offenders, the severe personality disorder of psychopathy has considerable importance as a construct. The disorder has long been associated with failure to make treatment progress. Previous work has identified that psychopathy as a disorder occurs in samples of offenders with intellectual disability (ID), and suggests that the Psychopathy Checklist - Revised (PCL-R: Hare, 1991, 2003) as a measure of the disorder has adequate reliability and validity (Morrissey et al., 2005). The present study aimed to compare the predictive power of the PCL-R in relation to treatment progress with a more general assessment of violence risk, the HCR-20 (Webster, Douglas, Eaves, & Hart, 1997). METHOD: A sample of 73 residents in a high security intellectual disability service, who had previously been assessed using the PCL-R and the HCR-20, were followed up at 2 years post-assessment, and their outcome determined in terms of two distinct dichotomous variables reflecting definite positive treatment progress and definite negative treatment progress respectively. RESULTS: In line with predictions, the PCL-R Total score and Factor 1 score (Interpersonal and Affective aspects of psychopathy) and the HCR-20 Total score were significantly inversely associated with a positive move from high to medium security hospital conditions within 2 years of assessment. However against prediction, the PCL-R Total score had incremental validity over the HCR-20. The PCL-R Total and Factor 1, but not the HCR-20 Total score, were also significantly associated with negative treatment progress in terms of a move to more restricted treatment conditions. CONCLUSION: Psychopathy, and in particular its interpersonal and affective manifestations, is a construct which appears to be associated with indirect measures of treatment progress in this high security ID group. However, caution should be applied in the use of a construct with potentially negative connotations in an already devalued population.