People with an intellectual disability living in an intentional community.

BACKGROUND: Hospital closure programmes in England have generally sought to attain a fulfilling life for people with an intellectual disability by locating them in domestic-style housing in urban settings. Few have been placed in intentional or 'village' communities. Yet comparative studies of different housing types have found that intentional communities have better or similar outcomes for their residents than dispersed housing or residential clusters on former hospital sites. A possible explanation is the distinctive pattern of social relationships that exist in many intentional communities and the impact this has on the lives of their residents. This paper reports the results of research that explores the perceptions of people with an ID living in an intentional community and the meaning of their community to them. METHODS: The research used an ethnographic approach to interview a sample of 15 residents in a large intentional community (Botton Village), which is part of the Camphill Movement. Interviews used Makaton, pictures and symbols where required. RESULTS: Respondents included 10 men and 5 women aged between 38 and 78 years. Length of residence in Botton Village ranged from 5 to 50 years. All lived with the families of co-workers and valued these relationships. All but one (who had retired) worked in a diverse range of employment in the village. Almost all were positive about their work. Respondents reported that they took part in both individual and communal leisure activities and all but two had a network of friends. Opportunities for friendship were enhanced by proximity to other people with an ID and a sense of personal security in the village. As in many villages and communities in society in general, these advantages were balanced by some loss of privacy. CONCLUSIONS: Results confirm those from earlier studies of intentional communities and suggest that positive outcomes derive from the absence of the overt subordination of residents to staff, the facilitation of friendship with other people with an ID, high levels of meaningful employment and a sense of community. These factors contrast with the experience of living in small homes funded on a contractual basis by public authorities, in which cost pressures reduce wage levels for staff resulting in difficulties in retaining suitable staff and a consequent high staff turnover.

Penile hygiene: puberty, paraphimosis and personal care for men and boys with an intellectual disability.

BACKGROUND: Supporting men and boys with an intellectual disability (ID) to meet their penile hygiene needs is perhaps one of the least acknowledged but most confronting issues facing care staff. The delivery of intimate hygiene can be a challenging topic particularly as it has been drawn into the emerging sexuality discourse and the ongoing abuse narrative. Compounding this challenge is the lack of guidance in intimate care for support staff. In addition, whereas the male with an ID outnumber the female, female care staff greatly outnumber male staff. Whether this situation affects outcomes for men and boys with an ID is unknown but it is an issue which should be examined. METHOD: This paper reports data from two separate studies, one quantitative the other qualitative, which sought to explore penile hygiene as a male health issue. RESULTS: Results show the practice of care staff to be inconsistent, the views and values of care staff to be divergent. Some patterns and contextual differences were identified depending upon the gender of care staff. An emerging dialogue described some of the positive contributions that male staff make to men and boys with an ID. CONCLUSIONS: The penile health needs of men and boys with an ID are being compromised by a lack of guidance, training, knowledge and limited gender-sensitive care.

Magnetic resonance imaging, Down's syndrome and Alzheimer's disease: research and clinical implications.

BACKGROUND: The diagnosis of Alzheimer's disease (AD) remains at times difficult to make using available neuropsychological measures. Neuro-imaging is a relatively new form of detecting the changes associated with dementia. The present study investigated the role of magnetic resonance imaging (MRI) in diagnosing AD in adults with Down's syndrome (DS). METHODS: Subjects with DS and Alzheimer-type dementia were matched to non-demented controls with DS. Magnetic resonance imaging findings (i.e. volumetric and two-dimensional scans) were compared between the two groups in order to show a relationship between the changes of AD and structural MRI abnormalities. RESULTS: Specific structural abnormalities which are seen in non-intellectually disabled subjects with dementia are also found in individuals with both DS and AD. However, such findings cannot be used to diagnose clinical AD with good accuracy in adults with DS. A number of practical issues of patient compliance and over-sedation are demonstrated by the findings. CONCLUSIONS: Magnetic resonance imaging has an important but limited role to play in the management of AD in the population with DS. If intravenous sedation is used, medical support is essential to prevent a serious mishap.

Evaluation of a mental health outreach service for homeless families.

AIMS: To describe the characteristics of homeless children and families seen by the mental health outreach service (MHOS), to evaluate the impact of this service on the short term psychosocial functioning of children and parents, and to establish perceptions of, and satisfaction with, the service. METHODS: Twenty seven children from 23 families who were in receipt of the MHOS and 27 children from 23 families residing in other hostels where no such service was available were studied. The MHOS was delivered by a clinical nurse specialist with expertise in child mental health, who offered the following interventions: assessment and brief treatment of mental health disorders in children; liaison with agencies; and training of homeless centre staff. RESULTS: Children in the experimental group had a significantly higher decrease in Strengths and Difficulties Questionnaire (SDQ) total scores. Having received the intervention was the strongest predictor of improvement in SDQ total scores. There was no significant impact on parental mental health (General Health Questionnaire) scores. Homeless families and staff expressed high satisfaction with the MHOS. CONCLUSION: This MHOS for homeless families is an innovative intervention which meets the complex and multiple needs of a vulnerable population unable to access mainstream mental health services. The primary objective of the service was to improve child mental health problems; however, the service developed in a responsive way by meeting social and practical needs of families in addition to its clinical role.

Mental health problems and social supports among homeless mothers and children victims of domestic and community violence.

BACKGROUND: Children and mothers who have suffered domestic or neighbourhood violence constitute a high risk group, although it has not been clear whether their mental health needs are specifically related to the type of violence. This paper reports on the prevalence of mental health problems in homeless parents and children who have experienced domestic and neighbourhood violence and their access to social support networks. METHODS: Three groups of families who had become homeless were compared: those experiencing domestic violence (48 with 75 children), victims of neighbourhood violence (14 with 29 children), and those who became homeless for other reasons (31 with 54 children). Mothers completed a service use semi-structured interview, the Strengths and Difficulties Questionnaire, the General Health Questionnaire, the Family Support Scales, and the SF-36 Health Status Questionnaire. RESULTS: Levels of psychiatric morbidity were high in the group experiencing domestic violence (35.7% in children and 21.9% in mothers) and higher still in those who were victims of neighbourhood violence (52.2% in children and 50% in mothers). Levels of social support were found to be an important factor, particularly in relation to professional support and support from other family members, as they predicted both child and maternal psychopathology. CONCLUSIONS: Mental health interventions for victims of domestic and neighbourhood violence should be integrated with community programmes of social reintegration. Mental health professionals should work in close collaboration with Housing Departments, Social Services, Education and the Police.

Needs for oral care among people with intellectual disability not in contact with Community Dental Services.

Previous research has found an unmet need for oral care among people with intellectual disability. The key factors which have been indicated are low expectations, fear of treatment, lack of awareness among carers and problems in accessing dental services. The withdrawal of many general dental practitioners (GDPs) from the National Health Service (NHS) may have exacerbated the latter problem in the UK. The aims of the present study were: (1) to assess the extent of unmet clinical needs in a group of adults with intellectual disability living in the community who were not in contact with the Community Dental Service (CDS); and (2) to explore their perceptions of teeth and contact with dentists to identify how oral care can be improved. Interviews were completed with subjects and/or carers and a dental examination was completed. There were higher levels of untreated caries (decay), and gingival or periodontal (gum) problems among the sample than in either the general population, or in a previous survey of CDS users at day centres and residential facilities. The subjects were largely unaware of dental problems, and used the appearance and absence of pain to judge the condition of their teeth. They depended greatly on their carers for decision-making and support with regard to visiting the dentist and tooth-brushing. Carers requested training in oral care and the use of dental services, and support in dealing with clients who have problems tolerating tooth-brushing. The subjects had experienced a wide variation in the treatment provided by dentists, but had not found it difficult to access a dentist despite recent reductions in the availability of NHS dental care. They expressed a particular need for a good relationship with their dentist and for their dentist to have personal skills in relating to people with an intellectual disability. Dental screening checks and oral care training for carers should be made easily available. Care plans should include tooth-brushing and dietary issues for all clients who have their own natural teeth. There are significant training issues for dentists in developing personal skills in total communication, disability awareness and attitudes which value people with intellectual disability.

A follow-up study of mentally disordered offenders after a court diversion scheme: six-month and one-year comparison.

The aim of this study was to investigate offenders' living patterns, quality of life, types of aftercare received and psychological well-being, following their diversion from one court diversion scheme in England. Sixty-five offenders were followed up after six months, 22 of whom were also followed up after one year. Their transient living patterns throughout these two periods were described. Their quality of life was found to be poor in that most did not have an occupation, nor did they receive education, and the life experiences during both periods were lower than that of standardized urban samples. There were no significant changes in their poor life experiences over the two periods. Over 55% of the 22 offenders still contacted their GPs regularly but there was a significant drop in those consulting hospital doctors. Only a small number of offenders had contact with the social services in these two periods and no significant differences were found between them. Their GHQ total scores went above cutoff point and the level of psychiatric conditions was similar in both periods.

A description of a forensic diversion service in one city in the United Kingdom.

This paper describes some recent research on forensic diversion services and the application of such services in Birmingham, UK. Key components include the diversion scheme in court, diversion at point of arrest, and the remand prison liaison scheme. Various community facilities, such as a specialized bail hostel and landlady schemes to which offenders are possibly referred, are also briefly described. We advocate the need for further research in order to examine the effectiveness of the services in Birmingham.

Mental health problems of homeless children and families: longitudinal study.

OBJECTIVE: To establish the mental health needs of homeless children and families before and after rehousing. DESIGN: Cross sectional, longitudinal study. SETTING: City of Birmingham. SUBJECTS: 58 rehoused families with 103 children aged 2-16 years and 21 comparison families of low socioeconomic status in stable housing, with 54 children. MAIN OUTCOME MEASURES: Children's mental health problems and level of communication; mothers' mental health problems and social support one year after rehousing. RESULTS: Mental health problems remained significantly higher in rehoused mothers and their children than in the comparison group (mothers 26% v 5%, P = 0.04; children 39% v 11%, P = 0.0003). Homeless mothers continued to have significantly less social support at follow up. Mothers with a history of abuse and poor social integration were more likely to have children with persistent mental health problems. CONCLUSIONS: Homeless families have a high level of complex needs that cannot be met by conventional health services and arrangements. Local strategies for rapid rehousing into permanent accommodation, effective social support and health care for parents and children, and protection from violence and intimidation should be developed and implemented.

Psychosocial functioning of homeless children.

OBJECTIVE: To investigate the psychosocial characteristics of homeless children and their parents. METHOD: Homeless families were assessed within 2 weeks of admission to seven hostels and were compared with a group of housed families matched for socioeconomic status. Measures included a semistructured interview, the General Health Questionnaire (GHQ), the interview Schedule for Social Interaction, the Child Behavior Checklist (CBCL), the Communication domain of the Vineland Adaptive Behavior Scales, and height and weight percentiles. The sample consisted of 113 homeless families (249 children aged 2 through 16 years) and 29 comparison families (83 children). RESULTS: Homeless families primarily consisted of single mothers and an average of two children, who had become homeless because of domestic violence (56%) or violence from neighbors (29%). Homeless mothers reported high rates of previous abuse (45%) and current psychiatric morbidity (49% caseness on the GHQ) and poor social support networks compared with housed controls. Homeless children were more likely to have histories of abuse, living in care, and being on the at-risk child protection register and less likely to have attended school or a preschool/day-care center since admission to the hostel. They also had delayed communication and higher CBCL scores. Maternal GHQ scores best predicted CBCL caseness. CONCLUSIONS: Homeless mothers and children have high rates of psychosocial morbidity, which are related to multiple risk factors and chronic adversities. Their complex needs should be best met by specialized and coordinated health, social, and educational services.

Assessing the need for challenging behaviour services in an English health district.

The aim of the present study was to assess the health care needs for people with learning difficulties who display challenging behaviour in a newly established health district. Ninety-eight clients were studied, using Disability Assessment Schedule (DAS), Aberrant Behaviour Checklist (ABC) and The Psychopathology Inventory for Mentally Retarded Adults (PIMRA). The results showed that a large proportion of them were mobile, continent and able to feed themselves. Almost half had no problems in communication but less than half were sociable. On the whole, they did not have adequate skills. A large proportion of them did not present severe challenging behaviour and did not suffer from psychiatric illnesses, apart from inappropriate adjustment disorder. Correlation coefficients showed that there were relationships between challenging behaviours and some of clients' disabilities and inappropriate adjustment disorder.

A preliminary study on the prevalence of challenging behaviours.

The purpose of this study was to estimate the prevalence of challenging behaviour among subjects with learning disabilities in an English health district. Subjects' disabilities included incontinence, lack of communication skills, and need of assistance with domestic activities, feeding, washing, and dressing. Some also had physical impairments. The most common behaviours were hyperactivity and irritability and the most common psychiatric disorders included severe anxiety, affective disorder, and adjustment disorder.

Mental impairment in the West Midlands.

The case records of 55 people from the West Midlands (UK) fulfilling the Mental Health Act 1983 criteria for mental impairment or severe mental impairment, were studied. Most were young men with mild mental retardation. 73 per cent were resident in (or on leave from) mental handicap hospitals, and 27 per cent resident in special hospitals. 29 per cent were subject to a Restriction Order. Most had lived in hospital for more than six years. The commonest problem behaviours were aggression, property offences and inappropriate or offending sexual behaviour. 31 per cent were mentally ill or had a past history of mental illness. A diverse range of services appears necessary to meet the needs of this group of people.

To market to market....

There are clear parallels between the problems of industrial firms in eastern Europe and those faced by NHS managers in meeting the challenge posed by the internal market. Stuart Cumella looks at the ever-changing rules of the game.

A study of the accumulation of long-stay patients in a general hospital psychiatric department.

A survey of all admissions of patients under the age of 65 years during the first 6 years of a General Hospital Psychiatric Department identified 16 'long-stay' patients (a year or more of continuous inpatient care) and 8 'medium-stay' patients (at least 6 months inpatient care in any period of a year). The most common diagnoses were organic brain disorders among long-stay patients, and affective disorders among medium-stay patients. There was no consistent accumulation of long-stay patients: those with functional disorders were usually discharged to hostel accommodation, while those with organic brain disorders died or were transferred to inpatient care in other hospitals.

Patterns of care in a district general hospital psychiatric department.

A survey of all admissions of patients under the age of 65 during the first 6 years of a District General Psychiatric Department without mental-hospital support is reported. Three high-uptake groups of in-patients were defined; the long-stay (12 months or more), the medium-stay (6-12 months), and the revolving-door group (more than three admissions in any period of 12 months). Identifying characteristics which distinguish between these groups were examined. During a 7-year period there was no accumulation of long-stay patients, and a striking lack of schizophrenic patients who remained in hospital for more than 6 months or who had more than three admissions in any twelve-month period. This was not accounted for by drift of the high-uptake groups out of contact with the service, but may be related both to the style of service provision and to the socially cohesive nature of the area under study. Local variation should be given due importance when community services are being developed.