Intellectual disability and mental illness in the NSW criminal justice system

Development of an Evidence-based Violence Rehabilitation Program for Offenders With Intellectual Disability

A review of the current literature on evidence-based violence prevention programs developed for individuals with an intellectual disability (ID) reveals a paucity of direct evidence for this population. In addition, the existing offence-specific programs are primarily grounded in adapted cognitive behaviour therapy (CBT) programs designed for the mainstream offender population, which may not be suitable for offenders with co-morbid mental health and personality disorders. The current paper discusses the development of a violence rehabilitation program for offenders with an ID. The focus of the article is on the exploration of the empirically supported risk factors associated with violent offending and the incorporation of these dynamic risk factors into the program modules. A case study example was utilized to examine the process of VRP-ID and how the modules targeted the offenders' treatment needs. Responsivity issues are addressed by identifying cognitive difficulties experienced by this cohort and the implications for treatment. The Risk/Need/Responsivity (RNR) model and the good lives Model (GLM) are widely used offender rehabilitation models that can be considered the guiding principles in developing this program. Furthermore, it utilizes contemporary therapeutic frameworks such as motivational interviewing (MI), cognitive behavior therapy (CBT), dialectical behavior therapy (DBT), and GLM reconceptualization and skills. The program is grounded in trauma-informed principles, which acknowledge this client group's high prevalence of victimization.

Impact of post-release community mental health and disability support on reincarceration for prisoners with intellectual disability and serious mental illness in NSW, Australia

BACKGROUND

Prisoners with an intellectual disability are overrepresented in custody and more likely to reoffend and be reincarcerated compared with the general prison population. Although prisoners with intellectual disability have many of the same risk factors for recidivism as the general prison population, the high rates of mental illness experienced by this group are key drivers of recidivism.

AIMS

We aimed to assess the impact of provision of post-release disability and community mental health support on rates of reincarceration in a cohort with identified intellectual disability and serious mental illness diagnosis.

METHOD

We conducted a historical cohort study using linked administrative data-sets, including data on hospital admissions, community mental health, disability support and corrections custody in New South Wales, Australia (n = 484). To assess the time to return to adult custody, we used survival analysis on multiple failure-time data.

RESULTS

Over the median follow-up period of 7.4 years, 73.7% (357) received community mental health support, 19.8% (96) received disability support and 18.6% (85) received a combination of supports during a post-release period from prison. Lower hazards of reincarceration in a post-release period were associated with receipt of community mental health support (hazard ratio [HR] = 0.58, CI 0.49-0.69, P < 0.001), or a combination of community mental health and disability support (HR = 0.46, CI 0.34-0.61, P < 0.001).

CONCLUSIONS

High rates of reincarceration for prisoners with intellectual disability and history of serious mental illness may be modifiable by provision of appropriate mental health and disability supports.

The prevalence and health status of people with developmental disabilities in provincial prisons in Ontario, Canada: A retrospective cohort study

BACKGROUND

Data on the prevalence of developmental disabilities in people who experience imprisonment and on their characteristics are lacking.

METHODS

The present authors identified adults with developmental disabilities who were released from Ontario provincial prisons in 2010 and a general population comparator group using administrative data. The present authors examined demographic characteristics, morbidity and healthcare use.

RESULTS

The prevalence of developmental disabilities was 2.2% in the prison group (N = 52,302) and 0.7% in the general population (N = 10,466,847). The prevalence of psychotic illness, substance-related disorder and self-harm was higher among people in the prison group with developmental disabilities. People with developmental disabilities were more likely to have emergency department visits and hospitalizations in prison and in the year after release.

CONCLUSIONS

People with developmental disabilities are overrepresented in provincial prisons and have a high burden of disease. Strategies are indicated to prevent incarceration and to improve health.

Demographic, clinical and forensic characteristics of alleged offenders referred to West End Specialised Hospital, Kimberley, South Africa

The study investigated demographic, clinical and forensic characteristics of alleged offenders referred for forensic assessment. A data collection form was used to gather information from 155 offenders' clinical records. The subjects were mainly young males, aged between 18 and 35 years, with low educational levels and high unemployment rate. The most common diagnoses were substance-related and addictive disorders, and schizophrenia spectrum and other psychotic disorders. A sizeable number of offenders were diagnosed with an intellectual disability. The comorbidity of other medical conditions such as epilepsy and HIV/AIDS was also noteworthy. In total, 55.5% of the offenders were found competent to stand trial, and 46.5% were declared criminally responsible. Offenders presenting with schizophrenia and intellectual disabilities were often declared incompetent to stand trial and were generally not responsible for alleged crimes. There was association between adjudicative competence and criminal responsibility. The results highlight effect of substances on mental illness and crime.

A qualitative analysis of the experience of staff employed within the forensic disability sector in Victoria, Australia

BACKGROUND

This paper explores the experience of staff employed within forensic disability across Victoria in an attempt to better understand service needs in this field. The complex needs of individuals with disabilities involved in the criminal justice system or presenting with offence-related behaviours suggest that there is a requirement to improve services directed towards forensic disability.

METHODS

Four semi-structured group interviews, determined by geographical location, were completed with employees (n = 14) within the Australian Community Support Organisation, with an average of 5 years of forensic disability experience. Data were analysed based on thematic analysis.

RESULTS

Five themes were revealed. Three pre-existing themes were emphasized that included client complexity; poor responses from external services; and funding, and two novel themes labelled as staff well-being and responses to risk.

CONCLUSIONS

Recommendations include multiagency collaboration, funding forensic disability services, development of best practice initiatives and advocacy.

Crime and victimization among people with intellectual disability with and without comorbid mental illness

BACKGROUND

Accumulating evidence internationally points to an increased risk of crime perpetration and victimization among people with an intellectual disability (ID). This study aimed to examine the impact that comorbid mental illness had on the association between intellectual disability, crime perpetration and criminal victimization.

METHOD

A case linkage methodology involving 2,220 individuals with an intellectual disability from an Australian State.

RESULTS

One in four (27%) had contacts with public mental health services; 8.2% had a comorbid mental illness. This "dual disability" group was between 2.97 and 3.22 times more likely than those with intellectual disability alone to have a history of criminal charges, and between 2.76 and 2.97 times more likely to have been a victim of crime.

CONCLUSIONS

The extent of criminality and victimization found among people with dual disability indicates a potentially multiply stigmatized group for whom the need for a coordinated cross-agency service response remains paramount.

Intelligence Assessment Instruments in Adult Prison Populations: A Systematic Review

Detection of intellectual disability (ID) in the penitentiary system is important for the following reasons: (a) to provide assistance to people with ID in understanding their legal rights and court proceedings; (b) to facilitate rehabilitation programs tailored to ID patients, which improves the enhancement of their quality of life and reduces their risk of reoffending; and (c) to provide a reliable estimate of the risk of offence recidivism. It requires a short assessment instrument that provides a reliable estimation of a person's intellectual functioning at the earliest possible stage of this process. The aim of this systematic review is (a) to provide an overview of recent short assessment instruments that provide a full-scale IQ score in adult prison populations and (b) to achieve a quality measurement of the validation studies regarding these instruments to determine which tests are most feasible in this target population. The Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement is used to ensure reliability. The Satz-Mögel, an item-reduction short form of the Wechsler Adult Intelligence Scale, shows the highest correlation with the golden standard and is described to be most reliable. Nevertheless, when it comes to applicability in prison populations, the shorter and less verbal Quick Test can be preferred over others. Without affecting these conclusions, major limitations emerge from the present systematic review, which give rise to several important recommendations for further research.

Aboriginal prisoners and cognitive impairment: the impact of dual disadvantage on Social and Emotional Wellbeing

BACKGROUND

Negligible information is available regarding the Social and Emotional Wellbeing (SEWB) needs of Aboriginal Australian individuals in custody with cognitive impairment. This is problematic given that Aboriginal people with cognitive impairment often experience dual disadvantage in the context of the justice system. This study sought to ascertain the relationship between cognitive impairment and mental health/cultural needs (SEWB) Aboriginal and Torres Strait Islander people in custody.

METHOD

A sample of 122 Aboriginal and Torres Strait Islander people were administered a culturally themed semi-structured questionnaire in custodial settings in Victoria, Australia. The questionnaire included measures of cognitive impairment, SEWB and forensic needs. Analyses were performed to determine differences in the presence of SEWB and unmet custodial needs by level of cognitive impairment.

RESULTS

Findings revealed a diminished level of wellbeing for cognitively impaired participants across several factors. Cognitive impairment was associated with poorer coping mechanisms, additional experiences of racism, difficulties handling emotions, discomfort around non-Aboriginal people and reduced access to meaningful activities in custody. All participants regardless of their level of impairment recognised the importance of cultural engagement; however, cognitively impaired participants had greater difficulty accessing/practicing cultural activities.

CONCLUSIONS

Culturally responsive disability assistance should be available at all phases of the justice system for Indigenous people with cognitive impairment to ensure that equitable care is accessible and needs are addressed.

Intellectual disability screening in women prisoners: preliminary evaluation

PURPOSE

- The purpose of this paper is to evaluate a new Intellectual Disability (ID) screening service within a women's prison in England.

DESIGN/METHODOLOGY/APPROACH

- Analysis of prisoner records was carried out to establish characteristics of women entering the prison, rates of screening completion and time intervals for all stages of the assessment pathway.

FINDINGS

- In total 198 women were received into prison and underwent 202 ID screens. Nine out of ten women completed a screen, almost all on arrival or very soon afterwards. There were 23 referrals for secondary assessment but only four were completed. Most of the women identified for additional screening left the prison before this could be achieved.

ORIGINALITY/VALUE

- This evaluation is the first to show that preliminary screening for ID is feasible in prison. This screening alone is useful for prisons to make the kind of reasonable adjustment required of public bodies by the Equality Act. However, its value is constrained unless resources are also dedicated to the kind of additional screening which might lead to definitive diagnosis and care planning for intellectual disability. This model of assessment would be of considerable value in establishing prisoners at risk by virtue of different levels of intellectual disability and could be used to provide more reliable and routine estimates of prevalence contributing to overall better service planning.

Intellectual disability in young people in custody in New South Wales, Australia - prevalence and markers

BACKGROUND

Intellectual disability (ID) is known to be more common in incarcerated groups, especially incarcerated youth. Aboriginal young people have higher rates of ID, and make up half of all youth in juvenile custody in New South Wales (NSW), Australia. We aimed to describe the prevalence of possible ID and borderline intellectual functioning (BIF) in young people in NSW custody, and to describe the association between possible ID and Aboriginality after adjusting for the inequalities in social disadvantage.

METHODS

Baseline study of all youth in NSW Custodial Centres between August and October 2009, with 18-month follow-up. Using Wechsler Intelligence Scale for Children - Fourth Edition (WISC-IV) and Wechsler Adult Intelligence Scale - Fourth Edition (WAIS-IV) cognitive assessments, possible ID was defined as Extremely Low Intellectual Quotient range (Full Scale Intellectual Quotient, FSIQ < 70), and possible BIF was defined as Borderline IQ range (FSIQ < 80). Risk factors for possible ID and BIF included age, gender, Aboriginality, socio-economic disadvantage, offending history and psychological disorders.

RESULTS

N = 295 (65%) of all young people in NSW custody completed cognitive and psychological assessments (87% male, 50% Aboriginal, average age 17 years). Almost one half (45.8%) of young people had borderline or lower intellectual functioning (by IQ assessment), and 14% had an IQ in the extremely low range (FSIQ < 70), indicating a possible ID. Aboriginal participants were three times more likely than non-Aboriginal participants to have a possible ID, but after accounting for the excess disadvantage in the Aboriginal group, Aboriginality was no longer a marker of ID. Incarceration from a young age and psychosis were significantly associated with possible ID in Aboriginal participants, compared with Aboriginal participants first incarcerated at a later age, and Aboriginal participants without psychosis.

CONCLUSION

The inequalities in criminal justice between Aboriginal and non-Aboriginal youth may exacerbate or contribute to the intellectual impairment of those incarcerated from a young age. Aboriginal young people with psychosis are also at high risk of cognitive impairments that might indicate a possible co-morbid ID, and these patients should be diverted at court into community assessment services, rather than incarcerated. These results highlight a need for better and earlier identification of young people (particularly Aboriginal youth) at risk of ID and other co-morbidities in the juvenile justice system.

Forensic psychiatric perspective on criminality associated with intellectual disability: a nationwide register-based study

BACKGROUND

Contrasting views exist over the association of intellectual disability (ID) and criminal offending. This nationwide study attempts to shed further light to expand understanding to substantiate the relation between socio-demographic characteristics, psychiatric co-morbidity and criminal behaviour among the Finnish forensic population with ID.

METHOD

We reviewed all forensic psychiatric examination reports of individuals with ID who underwent a pre-trial forensic psychiatric evaluation in Finland during an 11-year period (1996-2006).

RESULTS

One-third of the offenders had been regularly and sufficiently treated as outpatients. Half of the offenders had previous criminality, and the single most common crime was arson. Almost half of the offenders were diagnosed with alcohol abuse/dependence and two-thirds with any substance abuse/dependence. Furthermore, almost half were intoxicated during the index crime. Antisocial personality disorder was diagnosed in 25% of the offenders. Almost half of the offenders were placed in involuntary special care for the ID, which lasted ca 2 years. Among the last-mentioned, two-thirds of the nursing care plans lacked recommended structure.

CONCLUSIONS

The offenders with so-called triple diagnosis - substance abuse, mental illness and ID - form a small subgroup of criminal offenders with complex needs. The results of the present study underline the importance of close, long-term cooperation among specialists in the field of ID, addiction service, mental health services and forensic psychiatry.

The prevalence and nature of intellectual disability in Norwegian prisons

BACKGROUND

The objective of the study was to calculate the prevalence of inmates with intellectual disabilities (ID), and identify historical, medical and criminological characteristics of a certain impact.

METHODS

A random sample of 143 inmates from a Norwegian prison cross sectional sample was studied. The Hayes Ability Screening Index (HASI) was validated with the Wechsler Abbreviated Scale of Intelligence (WASI).

RESULTS

The prevalence of inmates with ID, IQ < 70, was 10.8%. Some essential characteristics of inmates with ID were more frequent medication for mental disorders, a higher number of imprisonments, less drug abuse and less education than the other inmates. The results indicated that the HASI is a valid tool for screening of ID for the Norwegian inmates.

CONCLUSIONS

The prevalence of ID in Norwegian inmates is significant, measured by WASI and HASI. Identification, rehabilitation and care, concerning an intellectual handicap, are mostly absent in the Norwegian criminal justice system.

Forensic issues in intellectual disability

PURPOSE OF REVIEW

The present paper reviews some of the most significant findings in the field of forensic issues related to intellectual disability over the last 2 years.

RECENT FINDINGS

Recent publications have explored the prevalence and assessment of intellectual disabilities in the criminal justice system, as well as individual characteristics of intellectual disabled offenders. Service by the criminal justice system and treatment of intellectual disabled offenders have also been explored. New insights into violence and sexual offences have been achieved, however identification and evidence-based treatment of intellectual disabled offenders are not widely explored issues.

SUMMARY

Progress in treatment studies, studies of the function of the criminal justice system and risk assessments have resulted in improvements in these aspects during recent years. The wide range of services involved in successful initiatives has been addressed, but some crucial aspects still receive too little attention. Differences between countries and cultures have not been emphasized, and the progress that has been achieved seems to be confined to countries with a clear policy and organized services for offenders with intellectual disabilities.

Research issues in forensic psychiatry

PURPOSE OF REVIEW

Forensic psychiatry is a multidisciplinary specialty within the context of criminal and civil law. This paper reviews a broad spectrum of research areas within the forensic psychiatric field, covering publications in 2006.

RECENT FINDINGS

New developments can be divided into four subject areas. The first relates to risk assessment, the second to the epidemiology of violence, the third refers to treatment outcome studies, and the fourth relates to topics of interest within different offender groups.

SUMMARY

There seems to be a growing interest in specifying the needs of different offender groups, such as intellectually-disabled patients, adolescents and women. When it comes to effective treatment models for these subgroups, however, it is not always clear if sufficient attention is paid to the presence of comorbid disorders and their consequences, even in research publications.

Deinstitutionalization in intellectual disabilities

PURPOSE OF REVIEW

The process of deinstitutionalization for intellectual disability services is at different stages across the world, varying from complete closure in Sweden to a vague hope in Taiwan. This review explores recent literature on deinstitutionalization and intellectual disabilities and focuses on papers published in academic journals mainly during 2006.

RECENT FINDINGS

Work on deinstitutionalization continues to show that outcomes are better in the community than in institutional care but recent papers highlight that there is more to deinstitutionalization than just hospital closure. Just moving people out of institutions into community settings does not bring about automatic improvement in quality of life in terms of choice and inclusion as well as self-identity and access to effective healthcare and treatment. This is especially true for people with more severe intellectual disabilities as well as complex needs such as challenging behaviour. Some of the current research illustrates that even offenders with intellectual disability can be successfully supported in the community.

SUMMARY

Recent research provides further examples and lessons on how community care can and should work, which it would be hoped will help those countries just starting the process of institutional closure to move more quickly to full deinstitutionalization.