Intellectual Disabilities Among Prisoners: Prevalence and Mental and Physical Health Comorbidities

Criminal Justice and People With Intellectual and Developmental Disabilities

People with intellectual and developmental disabilities (IDD) are overrepresented in the criminal justice system both as victims/survivors and as offenders. The needs and circumstances of individuals from underserved communities have received scant attention in the literature. Stakeholders met online at the 2022 State of the Science Conference on Community Living to discuss criminal justice and to identify goals for research involving people with IDD. The group focused more on victimization and less on offenders. Victimization issues examined included prevalence, people from underserved communities, sexual victimization, consequences of victimization, victim compensation, prevention, and risk reduction. Issues regarding offenders included prevalence, people from underserved communities, and competency to stand trial. Future directions are proposed for research on victimization and on offenders.

Neuropsychological assessment of aggressive offenders: a Delphi consensus study

Objective

This study explores the intricate relationship between cognitive functioning and aggression, with a specific focus on individuals prone to reactive or proactive aggression. The purpose of the study was to identify important neuropsychological constructs and suitable tests for comprehending and addressing aggression.

Methods

An international panel of 32 forensic neuropsychology experts participated in this three-round Delphi study consisting of iterative online questionnaires. The experts rated the importance of constructs based on the Research Domain Criteria (RDoC) framework. Subsequently, they suggested tests that can be used to assess these constructs and rated their suitability.

Results

The panel identified the RDoC domains Negative Valence Systems, Social Processes, Cognitive Systems and Positive Valence Systems as most important in understanding aggression. Notably, the results underscore the significance of Positive Valence Systems in proactive aggression and Negative Valence Systems in reactive aggression. The panel suggested a diverse array of 223 different tests, although they noted that not every RDoC construct can be effectively measured through a neuropsychological test. The added value of a multimodal assessment strategy is discussed.

Conclusions

This research advances our understanding of the RDoC constructs related to aggression and provides valuable insights for assessment strategies. Rather than suggesting a fixed set of tests, our study takes a flexible approach by presenting a top-3 list for each construct. This approach allows for tailored assessment to meet specific clinical or research needs. An important limitation is the predominantly Dutch composition of the expert panel, despite extensive efforts to diversify.

Measurement invariance of the group climate inventory across adults with and without mild intellectual disability in secure residential facilities

BACKGROUND

The Group Climate Inventory (GCI) was tested for measurement invariance across 332 adults with and 225 adults without mild intellectual disabilities in Dutch forensic treatment, and for latent mean differences on its Support, Growth, Repression, and Atmosphere subscales.

METHOD

Multigroup confirmatory factor analysis was used to evaluate the configural, threshold, and loading and threshold invariance of the GCI across both groups, and to compare group latent means on each subscale.

RESULTS

Measurement invariance was found across groups. Latent mean group comparisons showed small but significant differences reflected in lower scores on Support and Atmosphere in the group with mild intellectual disabilities.

CONCLUSION

The GCI allows meaningful comparisons between clients with and without mild intellectual disabilities in secure facilities. Results from the between-group comparisons suggest that consideration should be given as to whether, and why, the support and atmosphere perceptions of clients with mild intellectual disabilities might be less good.

The evaluation of a training course to enhance intellectual disability awareness amongst law enforcement officers: a pilot study

OBJECTIVES

Disability awareness training is mandated by the United Nations Convention on People with Disabilities (UNCRPD), but there is a paucity of evidence regarding the systematic evaluation of the effectiveness of such training. This study describes the evaluation of a pilot intellectual disability awareness programme for law enforcement officers (LEOs) in Ireland.

METHODS

Pre-and post-training Likert scales and a semi-structured survey were used to evaluate the effectiveness of an intellectual disabilities awareness programme delivered to LEOs. Quantitative differences in Likert scores and thematic analyses of practice-based responses were used in evaluation.

RESULTS

Twenty-two LEOs participated in the training and 11 completed the evaluation cycle. Statistically significant improvements were found in participants' self-rated knowledge of intellectual disability, their understanding of the challenges faced by people with intellectual disabilities in law enforcement interactions, their communication skills and their knowledge of how to approach a person with a disability in crisis. Thematic analysis excavated potential practical application of learning around pre-arrest considerations, recognition of disability, communication skills and need for procedural safeguards.

CONCLUSIONS

An approach grounded in the views of people with intellectual disabilities and with emphasis on recognition of disability, communication, accessibility of information and providing appropriate support in custody, appears to promote improvement in self-reported knowledge and prospective application in LEOs. The findings of this study are potentially applicable to countries that have ratified the UNCRPD.

Falling through the cracks: Failing to identify compromised Miranda abilities for defendants with limited cognitive capacities

Custodial suspects must be informed of their Miranda rights (Miranda v. Arizona, 1966) prior to police questioning. Since this landmark decision, scholars have rigorously studied Miranda comprehension and reasoning among vulnerable groups including those with intellectual disabilities (ID). However, the focus on ID has left arrestees with limited cognitive capacities (i.e., LCCs with IQs between 70 and 85) entirely overlooked. The current dataset addressed this oversight using a large (N = 820) sample of pretrial defendants who had completed the Standardized Assessment of Miranda Abilities (SAMA). Traditional (i.e., ID and no-ID) criterion groups were first analyzed with the standard error of measurement (SEM) removed. Second, a nuanced three-group framework included defendants with LCCs. Results indicate that LCC defendants are vulnerable to impaired Miranda comprehension (i.e., limited recall of the Miranda warning and deficits in Miranda-related vocabulary knowledge). Not surprisingly, their waiver decisions were often impaired by crucial misconceptions (e.g., seeing the investigating officers as beneficently on their side). The practical implications of these findings were underscored with respect to Constitutional safeguards for this critically important group, who have appeared to fall through the cracks in the criminal justice system.

Association of intellectual disability with violent and sexual crime and victimization: a population-based cohort study

BACKGROUND

Intellectual disability (ID) is associated with violent and sexual offending and victimization, but the importance of neuropsychiatric comorbidity and severity of disability remains unclear.

METHODS

In a register-based cohort study of people born in Sweden 1980-1991 (n = 1 232 564), we investigated associations of mild and moderate/severe ID with any, violent and sexual crimes, and with assault victimization, stratified by comorbid autism and attention deficit hyperactivity disorder (ADHD). We defined ID by attendance at a special school or registered diagnosis and obtained data on criminal convictions and injuries or deaths due to assaults from nationwide registers until end of 2013.

RESULTS

Compared to people without ID, autism or ADHD, men and women with mild or moderate/severe ID and comorbid ADHD had elevated risks of violent crimes [range of hazard ratios (HRs) 4.4-10.4] and assault victimization (HRs 2.0-7.7). Women with mild ID without comorbidities or with comorbid autism also had elevated risks of violent crimes and victimization (HRs 1.8-4.6) compared to women without ID, autism or ADHD. The relative risks of sexual offending and victimization were elevated in men and women with ID without comorbidities (HRs 2.6-12.7). The highest risks for sexual offending in men (HRs 9.4-11.0) and for sexual assault victimization in women (HRs 11.0-17.1) related to ID and comorbid ADHD.

CONCLUSIONS

The elevated risk of violent offending and assault victimization in people with ID is largely explained by comorbid ADHD, whereas ID is independently associated with sexual crimes and victimization, even though absolute risks are low.

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.

Police suspect interviews with autistic adults: The impact of truth telling versus deception on testimony

Investigative interviews by police are socially and cognitively demanding encounters, likely presenting significant challenges to those on the autism spectrum. Behavioral and communication differences mean that autistic people may also be more likely to be perceived as deceptive in the context of an investigative interview. In the present study, 32 autistic and 33 (age and IQ-matched) non-autistic adults took part in a novel virtual burglary scenario in either an 'innocent' or 'guilty' condition. In a subsequent mock-police interview, innocent suspects were instructed to tell the truth about what they did, while guilty suspects were instructed to lie in order to convince the interviewer of their innocence. In the mock-interviews, innocent autistic mock-suspects reported fewer details that would support their innocence than non-autistic mock-suspects, although both innocent and guilty autistic and non-autistic mock-suspects reported similar levels of investigation-relevant information and had similar levels of statement-evidence consistency. In post-interview questionnaires, innocent and guilty autistic mock-suspects self-reported greater difficulty in understanding interview questions, higher anxiety and perceived the interview as less supportive than non-autistic participants. Implications for investigative interviewing with autistic suspects and cues to deception are discussed.

The collaborative development through multidisciplinary and advocate consensus of an accessible notice of rights for people with intellectual disabilities in police custody

Background People with intellectual disabilities are over-represented in the criminal justice system. The United Nations' Convention on the Rights of Persons with Disabilities (UNCRPD) enshrines a right to equal access to justice for persons with disabilities (Article 13, UNCRPD). Accessible information is a key aspect of exercising this right. Yet, many jurisdictions, including Ireland, are yet to develop accessible information for disabled people who may be arrested. Aims This paper describes the collaborative development through multidisciplinary and advocate consensus of an accessible (Easy -to- Read) Notice of Rights (ERNR) for people with intellectual disabilities in police custody in Ireland. Methods Guidelines developed by Ireland's representative organisation for people with intellectual disabilities and examples of international practice were used to develop a draft ERNR by the primary researcher in partnership with an expert from a representative organisation for people with intellectual disabilities. The ERNR was developed thereafter through two focus groups with a view to achieving consensus with a focus on accessibility, accuracy and layout. This included a multidisciplinary focus group with participants from a representative organisation for people with intellectual disabilities, psychology, speech and language therapy, the police force, public health, forensic psychiatry, mental health, law and, subsequently, a focus group of people with lived experience of intellectual disability. Results Progressive development of the ERNR resulted in incremental improvements in textual accuracy as well as the inclusion of more accessible language and imagery. Originality/value This is the first attempt at developing an easy-to-read document relating to the legal rights of suspects in police custody in Ireland and, accordingly, this procedural innovation promises to assist, not just persons with intellectual disabilities, but also those with limited literacy at the point of arrest. The methodology used in the preparation of the document, employing a focus group to achieve consensus with participation from both multiple disciplines and persons with an intellectual disability, is in harmony with the ethos of the UNCPRD. This methodology may usefully be employed by other member states that have ratified the Convention but have yet to develop accessible version of the legal rights and entitlements that extend to arrested persons under their domestic law.

Reflecting on the Value of Community Researchers in Criminal Justice Research Projects

While the importance of community researchers has long been acknowledged in disability studies, inclusive research practices such as these are less common in research about another marginalised group: people who are in prison or have spent time in prison. Over the past decade in Australia, the number and rate of people imprisoned has risen rapidly, and recidivism rates remain high, indicating a need for improved services. In this article, we draw on methodological reflections from two case studies on research with marginalised communities, one in disability studies and one in post-prison research. We apply insights from disability research to argue the importance of incorporating community researchers in qualitative research projects seeking to explore the experiences of people involved with the criminal justice system, such as people who have been released from prison.

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.

Evaluation of a liaison and diversion Court Mental Health Service for defendants with neurodevelopmental disorders

AIM

Neurodevelopmental disorders (NDD) may present as neuropsychiatric problems as well as impairments of motor, cognitive, social and communication functioning. This study describes the introduction of a specialist service with expertise in NDD into an existing court mental health liaison and diversion service to determine if the service would impact on the health needs or disposal outcomes of defendants.

METHODS

We examined referrals of defendants with NDD disorders over 30-months at a London Magistrates' Court. The pre-existing Court Mental Health (CMH) service was enhanced to provide additional expertise and hereafter referred to as the CMH + NDD Service. Baseline data including gender, ethnicity, remands and the rates of mental disorders was collected from the CMH Service using the existing minimum mental health service dataset. This was compared with data collected from the CMH + NDD Service.

RESULTS

We found the following rates of NDD 9.5 % (n = 43) for the CMH service, and 9.5 % (n = 79) for the CMH + NDD service. Although overall the rates were the same the number of defendants with a single NDD diagnosis was increased in the CMH + NDD service with ADHD 10 %, ASD and ID 4% higher, the rates of comorbid NDD decreased in the CMH + NDD service compared to baseline. Specific disorders such as depression were recorded at higher rates for NDD defendants in both phases, however, this did not reach significance. In contrast, schizophrenia and delusional disorders, alcohol and substance use were observed at much higher in the non-NDD defendants during both phases of the study. The rates of diagnosis of schizophrenia and delusional disorders increased for the NDD group within the CMH + NDD service. Following the first court appearance, there was a 10 % reduction in custodial remands for defendants with NDD who were seen by the CMH + NDD service (34.2 %, n = 25 in the CMH + NDD service vs 43.8 %, n = 14 in the CMH service).

CONCLUSION

The study found it is possible to successfully integrate practitioners with expertise of NDD into existing liaison and diversion services. This service enhancement demonstrated modest evidence of service effectiveness, including an increase in the detection of comorbid mental illness and a reduction in custodial remands for defendants with NDD. Further work needs to be completed to examine how this model can be rolled out across multiple courts and in particular, a cost-benefit analysis is required to understand whether an approach involving a cluster of Courts, as opposed to a single site is the most effective approach for this group of defendants.

The ADaptive Ability Performance Test (ADAPT): A new instrument for measuring adaptive skills in people with intellectual disabilities and borderline intellectual functioning

BACKGROUND

Since the DSM-5, adaptive functioning has taken a prominent place in the classification of intellectual disability (ID). The ADAPT was developed to assess adaptive skills in individuals with ID.

METHOD

A total of 2,081 ADAPTs from clients with suspected ID or borderline intellectual functioning and 129 ADAPTs from people from the general population (non-ID) were collected, along with background characteristics.

RESULTS

Internal consistency of the ADAPT was high (α = 0.98). ADAPT scores were positively associated with IQ, educational level and level of independent living. Furthermore, individuals without ID scored significantly higher than the clients on all of the 65 ADAPT items. Reference values were established for different IQ groups and living situations.

CONCLUSION

Results suggest that the ADAPT is a valid instrument for measuring adaptive skills in individuals with ID. The reference values may be used for the purpose of estimating the level of ID and the needed intensity of support.

Using linked administrative data to determine the prevalence of intellectual disability in adult prison in New South Wales, Australia

BACKGROUND

Studies of the representation of people with intellectual disability (ID) in custody report widely inconsistent findings that reflect variation in how ID is defined and the methods employed for identification. Using linked administrative data may be of utility in studies of the representation of people with ID in custody. However, this approach requires an understanding of the purpose of and factors influencing identification in disparate administrative datasets.

METHODS

This study uses linked administrative data encompassing disability, health and corrections data for the year 2014 to estimate the prevalence of ID in adult custody and explore how ID representation within administrative data impacts prevalence estimates and what patterns of identification reveal about support service access for this group.

RESULTS

This study finds that 4.3% of the New South Wales adult custody population had an identified ID. Prisoners with ID were younger, more likely to have had a previous custodial episode and more likely to be Indigenous than the general prison population. Identification of ID across linked administrative datasets is uneven, which, if used in isolation, would result in variation in prevalence estimates according to source data.

CONCLUSIONS

The utilisation of linkage data from a broad range of health and support services including custody offers a comprehensive identification methodology. Inconsistency in the identification of ID across datasets indicates a potential disjuncture between prisoners with ID and support services, which may have relevance for efforts to reduce reincarceration of those in this population.

Challenges for people with intellectual disabilities in law enforcement interactions in Ireland; thematic analysis informed by 1537 person-years' experience

BACKGROUND

People with intellectual disabilities (PWID) are over-represented in criminal justice systems globally. This over-representation reveals itself at once in the demographic make-up of prison populations, as well as those detained in police settings as suspects of crime. While it is well-established in international literature that individuals who find themselves in the latter scenario face particular challenges in negotiating the forensic formalities routinely followed by the police at the pre-trial stage of criminal proceedings on account of their impairments, the specific difficulties experienced by PWID as suspects within Ireland's criminal justice system has yet to be explained, or indeed, understood. In seeking to address this research lacuna, this paper yields an account of a qualitative study which was aimed at identifying the unique challenges which PWID face in their interactions with Law Enforcement Officials (LEOs) in Ireland.

AIMS

This study aimed to elicit perspectives across a range of disciplines with regard to barriers for PWID interacting with LEOs in Ireland, and sought viewpoints on the content of a proposed awareness programme.

METHODS

A survey using purposive sampling was used to elicit viewpoints from people from representative organisations for PWID, people working with voluntary organisations for PWID, healthcare professionals working with PWID and professionals from the criminal justice system (including members of An Garda Siochana, lawyers, members of the Irish judiciary and officials within the Airport Police). Data were anonymised at the point of collection. Qualitative thematic analysis was conducted to extract themes based on the data retrieved through the survey.

RESULTS

Ninety-five (n = 95) responses were received from individuals reporting a cumulative experience of 1537 person-years. Respondents identified themselves as members of one of three groups; people working in a voluntary or representative organisation for PWID (n = 42, 44.2%); people working in healthcare (n = 31, 32.6%); and people working in law enforcement (n = 22, 23.1%). Three themes were identified from the qualitative thematic analysis. The first theme, "Barriers to Communication", identified challenges which PWID and LEO experience in their mutual interactions and communications with one another. The second theme, "Building Awareness and Skills", identified elements of an ID awareness programme for LEOs. The third theme, "Institutional and System Change", identified possible lines of innovation with respect to contemporary police practice and the availability of supports for both PWID and the LEOs who work with them.

ORIGINALITY/VALUE

This study represents the first dedicated qualitative inquiry conducted on a multidisciplinary level into the barriers which healthcare professionals, legal professionals and disability advocacy groups perceive to be faced by PWID in their interactions with LEOs in Ireland. Consequently, the findings from this study will act as a valuable template in the direction of informing the development of an ID awareness programme for LEOs in Ireland. In addition, these research findings are expected to usefully inform the development of national policy and protocols in areas related to health, disability and justice. In offering a rich evidence-base for future policy initiatives, the timing of this study is particularly significant. The recent ratification by Ireland of the UN Convention for the Rights of People with Disabilities (UNCRPD), together with the synchronous emergence of an evolving emphasis on human rights-based policing at a national level in Ireland, has meant that Irish policymakers have a unique opportunity to re-imagine the pre-trial formalities of Ireland's criminal process in order to demonstrate an increased sensitivity to the needs of PWID. Securing equal access to justice for such individuals, it is important to emphasise, is a legal requirement pursuant to Article 13 of the UNCRPD. To the extent therefore that this study yields unique insights into the barriers faced by PWID in their interactions with LEOs, the results of this study are potentially generalisable to other jurisdictions that have ratified the UNCRPD and are developing policy to accord with Article 13.

Performance Validity Testing in Justice-Involved Adults with Fetal Alcohol Spectrum Disorder

OBJECTIVES

A number of commonly used performance validity tests (PVTs) may be prone to high failure rates when used for individuals with severe neurocognitive deficits. This study investigated the validity of 10 PVT scores in justice-involved adults with fetal alcohol spectrum disorder (FASD), a neurodevelopmental disability stemming from prenatal alcohol exposure and linked with severe neurocognitive deficits.

METHOD

The sample comprised 80 justice-involved adults (ages 19-40) including 25 with confirmed or possible FASD and 55 where FASD was ruled out. Ten PVT scores were calculated, derived from Word Memory Test, Genuine Memory Impairment Profile, Advanced Clinical Solutions (Word Choice), the Wechsler Adult Intelligence Scale - Fourth Edition (Reliable Digit Span and age-corrected scaled scores (ACSS) from Digit Span, Coding, Symbol Search, Coding - Symbol Search, Vocabulary - Digit Span), and the Wechsler Memory Scale - Fourth Edition (Logical Memory II Recognition).

RESULTS

Participants with diagnosed/possible FASD were more likely to fail any single PVT, and failed a greater number of PVTs overall, compared to those without FASD. They were also more likely to fail based on Word Memory Test, Digit Span ACSS, Coding ACSS, Symbol Search ACSS, and Logical Memory II Recognition, compared to controls (35-76%). Across both groups, substantially more participants with IQ <70 failed two or more PVTs (90%), compared to those with an IQ ≥70 (44%).

CONCLUSIONS

Results highlight the need for additional research examining the use of PVTs in justice-involved populations with FASD.

Difficulties in Daily Living Experienced by Adolescents, Transition-Aged Youth, and Adults With Fetal Alcohol Spectrum Disorder

BACKGROUND

Individuals with fetal alcohol spectrum disorder (FASD) experience a range of problems in their cognitive, affective, and physical functioning following prenatal alcohol exposure (PAE), in addition to multiple complex difficulties in daily living that impact well-being. Using the Canadian National FASD Database, we sought to profile a range of difficulties in daily living, along with risk factors, in a large cross-sectional cohort of adolescents, transition-aged youth, and adults with PAE, of which a subset was ultimately diagnosed with FASD.

METHODS

We summarized data for 9 current difficulties in daily living reported at the time of diagnostic assessment for 726 individuals with PAE assessed at 26 FASD diagnostic clinics across Canada, including 443 adolescents (12 to 17 years), 135 transition-aged youth (18 to 24 years), and 148 adults (25 to 60 years). Difficulties included problems related to school disruption, employment, independent living needs, supportive or sheltered housing, legal problems with victimization, legal problems with offending, incarceration, alcohol misuse, and other substance misuse. Risk factors included age, gender, living placement, postnatal trauma, and neurodevelopmental impairment.

RESULTS

Across the full PAE sample, adolescents, transition-aged youth, and adults presented with high rates of difficulties in daily living, including independent living support needs (63%), alcohol misuse (38%), other substance misuse (46%), employment problems (37%), legal problems with offending (30%), assisted or sheltered housing (21%), school disruption (18%), legal problems with victimization (4%), and incarceration (3%). Difficulty rates were similar for those with FASD irrespective of diagnosis (e.g., with or without sentinel facial features), but rates greater for adults, and those with low overall intellectual functioning (IQ < 70). Controlling for age and IQ, cumulative difficulty was independently associated with gender, living placement, and neurodevelopmental impairment.

CONCLUSIONS

Adolescents, transition-aged youth, and adults with FASD experienced a range of substantial and complex difficulties at the time of their diagnostic assessment, signaling a high level of service needs. These findings underscore the importance of developmentally informed assessment continued through childhood, as well as ongoing functional and needs-based service provision as youth with FASD transition to adulthood and beyond.

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.

Intellectual disability rates among male prison inmates

While only a small percentage of people with intellectual disabilities are responsible for criminal behaviors, the literature points to their overrepresentation in prisons, although not enough attention has been paid to intellectual disability data for inmates. We retrieved studies - in English, Spanish, Italian or French and indexed in Medline between 2000 and 2018 - that provided intellectual disability data for prisons collected by the administration of validated tests to male inmates. Identified were 13 studies involving more than 15,000 inmates referring to intellectual disability and borderline intellectual disability. The general findings of our review corroborate the overrepresentation of people with ID in prisons, although prevalence rates range widely, from as low as 1% to as high as 69.9% (p<0.000001), reflecting to differences in methodology, in local, social and cultural factors and in judicial procedures. Published studies clearly underline the overrepresentation of people with intellectual disabilities in prisons, differences between countries, the vulnerabilities of persons with intellectual disabilities and the need for proper assessment and management policies in prisons worldwide.

Intellectual disabilities in Irish prisons: Could Article 13 of the UNCRPD hold the key?

The prevalence of intellectual disabilities amongst adult prisoners in Ireland is higher than international estimates. There is little evidence that the development of diversion services has impacted such prevalence. The authors argue that Ireland's ratification of the UNCRPD presents a timely opportunity to address this problem through an awareness programme aimed at frontline law enforcement officials.

Clinical Characteristics and Pharmacological Treatment of Individuals With and Without Intellectual Disability in Pre-trial Assessment-A Population-Based Study

Background: The current lack of knowledge about intellectual disability (ID) in forensic psychiatric contexts can compromise the legal certainty of these individuals during the medico-legal process. To address ambiguous results in previous literature, the aim of the current study was to estimate the prevalence of ID in a pre-trial forensic psychiatric settings. Moreover, as little is known about the characteristics of offenders with ID, we conducted a clinical characterization of individuals with and without ID being subject to forensic psychiatric assessment. Methods: Using data from several Swedish national registers, we conducted a population-based retrospective observational study on 8,442 individuals being subject to pre-trial forensic psychiatric assessments in Sweden in 1997-2013. We performed univariate analyses to compare the characteristics of individuals with (n = 537) and without ID (n = 7,905). Results: The prevalence of ID was 6.4% in the Swedish pre-trial forensic psychiatric context during the observational period. Compared with individuals without ID, individuals with ID were younger at the time of assessment, had a lower educational level, and had less frequently started families. ID was associated with lower frequency of diagnosed psychotic and bipolar disorders. However, a similar prescription rate of antipsychotics, and a comparable rate of previous inpatient care was observed among individuals with and without ID. Individuals with ID had more often been prescribed anti-libidinal treatments often used for treating sexual disorders, although did not present a higher prevalence of sexual disorder. Conclusions: The prevalence of ID among pre-trial individuals being subject to forensic psychiatric assessment was more than twice as high as assumed in the general population. Our results suggest that individuals with ID received pharmacotherapy without clear indication. Remaining challenges in the clinical management of individuals with ID were indicated by the discrepancy between the occurrence of psychiatric diagnoses, pharmacological treatment patterns, and rates of inpatient care.

A Preliminary Investigation of the Intersection of Race and Disabilities among Inmates in the U.S. State Prison System

The American prison system is overcrowded with minorities in general, and African Americans, in particular. The Department of Justice notes that more than 50% of the prison population have some type of mental disability. In this study, we examine the intersection between race and disabilities in the U.S. State prison system. Using the Rehabilitation Services Administration data set, the study highlights the prevalence and type of disabilities in the prison inmate population. Results demonstrate that African American inmates are overrepresented among inmates with disabilities, are more likely to have mental disabilities relative to physical disabilities, and these results hold for various types of mental disabilities including cognitive, psychosocial, and other mental disabilities. Study limitations and directions for future research are also discussed.

Prisoner exposure to nature: Benefits for wellbeing and citizenship

The direct or indirect experience of crime can cause individuals to feel vengeful against the perpetrator(s). The prison system reflects this sentiment by creating austere environments that are dehumanizing, punitive, and hopeless. Prisons are, therefore, environments in which retribution and punishment take priority over rehabilitation. Frequently, prisoners are believed to be untreatable because of their antisocial orientation. However, several factors influence an antisocial orientation such as socioeconomic status, family of origin, and mental health. The ubiquitous nothing works misbelief has resulted in prisoner marginalization and increased recidivism because of insufficient treatment. In 2015, 10 million individuals were incarcerated worldwide with around 30 million circulating through prisons each year. The prison environment decreases prisoner life expectancy and overall health. Sadly, prisoner benefits from treatment post-incarceration dissipate after 3-6 months and many prisoners die by suicide or drug overdose. Prison overpopulation, as well as poor outcome post-incarceration, requires more effective treatment. We hypothesize that Prisoner Exposure to Nature (PEN) can transform prisons into environments that are conducive to maintaining and improving physical and mental health. In prior work we proposed the continuum Nature Exposure Sufficiency (NES) versus Nature Exposure Insufficiency (NEI). Prisons are impoverished environments that limit Nature Exposure (NE) which results in NEI. Individuals experience fluctuations in mental and physical health as a result of NEI. Numerous studies have shown that direct and indirect NE can improve mood, physical health, and facilitate connectivity with self and society. It is necessary to consider ways in which we can incorporate NE for prisoner wellbeing. Additionally, it is crucial that prison personnel and prisoners develop a therapeutic/helping relationship (i.e., alliance) that is facilitated by friendliness and warmth to foster social change and citizenship. Many prisoners experience isolation and disconnection with society upon reentry. Given that most prisoners are eventually released into the community, we are obligated not to make them worse. Hence, it is important that prisons create programs that develop citizenship to engender prisoner volition to become positive and active citizens. We focus on the prison and prisoners, however our work is relevant to all total institutions (e.g., mental hospitals, nursing homes, schools, etc.). The prison system favors punishment and mass incarceration over treatment and decarceration. The deleterious effects of incarceration are clear and it is time to implement treatments based on the principles of PEN to improve prisoner wellbeing and citizenship.

A novel care pathway for prisoners with intellectual disability designed through a Delphi process

Purpose

Individuals with an intellectual disability (ID) form a significant minority in the Irish prison population and worldwide prison populations. There is growing recognition that specialist services for such individuals are in need of development. The purpose of this paper is to propose a care pathway for the management of individuals with an ID who present in prison, based on expert elicitation and consensus.

Design/methodology/approach

A convenience sample of professionals with a special interest in forensic intellectual disabilities was invited to participate in a Delphi exercise. In total, 12 agreed to participation and 10 subsequently completed the study (83.3 per cent). Expert views were elicited using a semi-structured questionnaire. Content analysis was completed using NVivo 11 software. A care pathway was subsequently proposed, based on the outcomes of the analysis, and circulated to participants for debate and consensus. A consensus was reached on management considerations.

Findings

Ten experts across a range of disciplines with a combined experience of 187 years participated in the study. Current provision of care was seen as limited and geographically variable. The vulnerability of prisoners with ID was highlighted. The need for equivalence of care with the community through multidisciplinary input and development of specialist secure and residential placements to facilitate diversion was identified. Consensus was achieved on a proposed care pathway.

Originality/value

This study proposes a care pathway for the assessment and management of prisoners with an ID and is, therefore, potentially relevant to those interested in this topic internationally who may similarly struggle with the current lack of decision-making tools for this setting. Although written from an Irish perspective, it outlines key considerations for psychiatrists in keeping with international guidance and, therefore, may be generalisable to other jurisdictions.

Intellectual disability in Irish prisoners: systematic review of prevalence

Purpose While individuals with an intellectual disability form a significant minority in the worldwide prison population, their healthcare needs require specialist attention. In Ireland, services for prisoners with intellectual disabilities need development. However, there is little substantive data estimating the prevalence of intellectual disabilities within the Irish prison system. The paper aims to discuss these issues. Design/methodology/approach The authors systematically review published data relating to the prevalence of intellectual disabilities in prisons in the Republic of Ireland. The authors searched four databases, governmental websites and corresponded with experts. Findings Little published data were elicited from searches except for one nationwide cross-sectional survey which reflected a higher prevalence than reported in international studies. Studies from forensic mental health populations are narrated to contextualise findings. Originality/value This study found that there is little data to accurately estimate the prevalence of intellectual disabilities in the Irish prison system and the limited data available suggests that this is likely to be higher than international estimates. The authors highlight the need for further research to accurately estimate prevalence in this jurisdiction, alongside the need to develop screening and care pathways for prisoners with an intellectual disability.

Intellectual disability and patient activation after release from prison: a prospective cohort study

BACKGROUND

Intellectual disability and patient activation may be important drivers of inequities in health service access and health outcomes for people with intellectual disability transitioning from prison to the community. We assessed the association between intellectual disability and patient activation after prison release and examined whether this association varied, depending on whether intellectual disability was identified prior to prison release.

METHODS

Overall, 936 prisoners were screened for intellectual disability by using the Hayes Ability Screening Index and completed the Patient Activation Measure (PAM) within 6 weeks of prison release and again at 1, 3 and 6 months post-release. We estimated the association between intellectual disability status and PAM scores by using a multilevel linear model, adjusting for sociodemographic, behavioural, health and criminogenic factors. We used propensity score matching to estimate the impact of being identified with intellectual disability prior to release from prison on the change in mean PAM score after prison release.

RESULTS

Compared with those who screened negative for intellectual disability, ex-prisoners who screened positive, both with and without prior identification of intellectual disability, had significantly decreased mean PAM scores [(B = -4.3; 95% CI: -6.3, -2.4) and (B = -4.5; 95% CI: -6.8, -2.3), respectively] over 6 months of follow-up. Among those who reported being identified with intellectual disability prior to release from prison, a significant increase in PAM score at the 6-month follow-up interview (B = 5.89; 95% CI: 2.35, 9.42; P = 0.001) was attributable to being identified with intellectual disability prior to release.

CONCLUSIONS

Ex-prisoners screening positive for possible intellectual disability have decreased patient activation for at least 6 months after release from prison. However, individuals whose possible intellectual disability is unidentified appear to be particularly vulnerable. Incarceration is a pivotal opportunity for the identification of intellectual disability and for initiating transitional linkages to health and intellectual disability-specific community services for this marginalised population.