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Motivating Offenders with a Learning Disability to Change Kirsty Lowe Northgate & Prudhoe NHS Trust Introduction

Working with offenders with a learning disability can evoke many emotions. There is the pleasure of seeing people that we work with progress and gain a better quality of life. However, there are also many occasions when the predominant feelings are frustration and a sense of lack of direction. Whilst some offenders with a learning disability are ready, willing and able to utilise the treatment offered to them, some present with active opposition or „working the system‟. As noted by various contributors in Motivating Offenders to Change (McMurran, 2002), such individuals may comply when they enjoy aspects of the intervention, and then withdraw when it becomes difficult. They may talk in a motivated way whilst continuing to behave in an unmotivated way or repeat patterns of engagement and disengagement over time. Often we see such individuals as going through the motions and it is easy to interpret the lack of compliance not as therapist failure but as an unmotivated client. However, as long as we do so we will remain as „stuck‟ as the individual we are working with. Instead, we need to work under the assertion that motivation is modifiable and that there is a way forward. Over the last decade, research about how to motivate people has gained increasing importance. Initially the development of motivational interventions was undertaken mainly within the field of addictions, though more recently motivational programmes have been developed across a range of health risk and health protective behaviours. The aim of this paper is to provide an overview of a motivational programme developed for offenders with a learning disability residing in secure care. This programme has been developed within a number of different settings, initially within an inpatient and day service setting in a secure unit for offenders with a learning disability, then within a special security hospital and more latterly within a medium secure unit. Motivational interviewing techniques (Miller and Rollnick, 2002) underpin the motivational programme. They define motivational interviewing as “a client-centered, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence”. Miller and Rollnick (2002) further note that “it is a method of communication rather than a set of techniques”. They outline four principles: express empathy, develop discrepancy, roll with resistance and support selfefficacy and provide others methods for eliciting intrinsic motivation. Of note, motivational interventions/programmes are not seen as a substitute for action orientated programmes but as targeting a specific client group i.e. those that are in the early stages of change. This motivational programme is not intended to be a stand-alone treatment but is to act as a precursor to the offence specific interventions, with evidence indicating that people who undertake motivational work achieve better outcomes in subsequent interventions (see Miller & Rollnick, 2002) and such interventions are brief and cost effective increase morale (Prochasqua and Levesque, 2002). In addition, they have become increasingly required for purposes of accreditation (McGuire, 2000). As stated by Mann et al (2002) cognitive behavioural programme teach the “how to” of change whilst motivational interventions address the “why to” of change. Frequently the offenders with a learning disability within secure settings present with complex and multiple difficulties. They may have anger or sexual problems but are also subject to anxiety, depression or loneliness, perhaps compensating by use of drugs or alcohol. Abuse may have occurred in the past with unaddressed victim issues. The individuals may see themselves as misunderstood, neglected and „unheard‟. Motivation to change is low, with

little self-efficacy in their ability to change. Frequently their behaviour has led to multiple care settings, moving from service to service and the individual becomes „infamous‟, a big fish in a little pond with local services wondering what to do next. For such an individual, we have to begin by understanding their experiences and allow them to be heard. The phrase: “Seek first to understand, then to be understood” (Covey 1989) is key principle of the motivational work I undertake. As Covey states “Most people do not listen with the intent to understand, but the intent to reply”. Simply continuing to expect the person to come around to our point of view inevitably leads to battle of wills. Instead, empathic listening is required i.e. listening with intent to understand the other individual's frame of reference and feelings, enabling the individual to be understood, to be affirmed and to be validated. The aim is to work collaboratively with the individual and to elicit, not impose, change. This often requires a change in our approach and reflects the interpersonal nature of motivational interventions. The aim is for the patient to decide if they want to make changes and for any change to be internally not externally driven. The clinician needs to „roll with resistance‟ and avoid argumentation. The clinician and patient explore change together, this includes exploring the person‟s past, and what are their current concerns and goals.
Often I find that the first step in assessing the unmotivated offender with a learning disability is to look at whether there is a discrepancy between where they are and where they want to be. Frequently we impose our values rather than ask the person what their values are. If these differ, we need to accept this whilst exploring the concerns regarding change. For example, the following are some of the worries expressed by a group of individuals in the early stage of a motivational programme, who were considering moving from a medium to a low secure unit: “I live in a nice place now. I don’t want to leave”. “I am having a settled time at the moment”. “I might not get as much help as I need if I move on” “I might get in trouble again if I leave”. “I might go back to being bad”. “No one would like me outside”. “I worry that when I get out I will mix with the wrong people and friends will get me into trouble”. “Things might go wrong again”. “I tried it before it never worked for me”. “I might let my family down”. “People might not listen to me”. “I worry about what people would do to me, the victims and their families”`. “I might find it difficult to cope, no job, lack of money. I’m easily led”. “I am scared”.

Therefore rather than being motivated to move out of a medium secure setting the group members were telling us that they felt secure in their current residence. They also appeared relieved to be able to share this with us and to realise that change would not be enforced.

Once we establish shared goals we can work on other areas such if the person we are working with feels able to change, knows where to begin, knows what they will get from making changes and has talked to us about what has happened previously when they tried to change. Without this shared understanding, it is likely that any changes made will be transient and superficial. We then need to assist the patient in identifying what things are getting in the way of what they want. We then assist the patient in working out their goal plans, for example what are the small steps, how will they know then a step has been achieved and what will be the rewards and those working with the patients need to instil self-efficacy in ability to make changes and show interest in the change process.

The Motivational Programme in Practice Currently the motivational programme is being delivered within the Kenneth Day Unit. The 30-bedded Unit is part of the Northgate and Prudhoe NHS Trust: Forensic Division. This Trust is a specialist service provider of health and social care services to people with learning disability This unit consists of four separate houses and provides an environment that meets basic needs such as safety, valorisation, and belonging. The Unit has dedicated therapeutic space and smart cards, discreetly concealed in staff clothing allow them to pass through locked doors without the need for keys. As noted by Hodge and Renwick (2002), provision of suitable therapeutic space and “creative and dynamic security systems and procedures” one can permit “the development and application of powerful therapeutic opportunities”. The therapeutic milieu provided by the multi-disciplinary team, particularly nursing, engenders the patients with the basis to make changes. With this foundation, patients who have led chaotic and disorganised lives are in a position to explore potential changes to their lives. For such patients the Motivational Programme offers a stepping stone to the offence specific Programmes, such as the Sex Offender, Anger, or Fire-Setters Treatment Programmes. Throughout the eighteen sessions Motivational Programme, participants identify what is important to them. We begin to look at negative aspects of the status quo and to create a discrepancy between what is personally valued and what the current situation is. We also accept ambivalence concerning change. During the main module, we assist participants in identifying whether certain behaviours are preventing them from obtaining what they value. We then enable the participants to identify the priority for change. Following this, participants identify barriers to progress and we again explore their feelings about change. We further explore their fears around change and whether they feel ready, willing and able to make changes. We explore relapses, delayed moves and ways to cope with setbacks. The process finishes with the participants compiling a goal plan relating to short term and long term goals. At the end of the Programme, there is a Team Invite session where members of the clinical team, Responsible Medical Officers etc., attend and the participants present what we have covered. The participants then meet once a month, as a group, to explore their goal plans, problems that have arisen and possible ways forward. There are 7-8 participants in each group and participants within the programme usually have a full scale IQ within the range of 60-80. The programme is psychology led but multidisciplinary in delivery and is held weekly (twice weekly during the main module). Each session lasts two and a half hours, with a mixture of group and individual work and is delivered via a structured treatment manual. The programme is delivered in a large therapeutic space with participants undertaking more general group discussion and working on a 1:1 basis with a facilitator when discussing their own situations. This is essential, as the group members have mixed offences and aetiologies. An essential component is the multi-disciplinary facilitation, with facilitators coming from psychology, nursing, psychiatry, speech and language therapy and social work. A nurse from each of the houses within the Kenneth Day Unit is at each session. These nurses will have undertaken an awareness session, but may be qualified or unqualified. Whilst there is a cohort of nurses that facilitate the group, there will be a different cohort of facilitators at each session. Rather than impede continuity, it has become evident that this allows many people to be involved in the participants‟ change process, as there is a wide understanding of what it is that they are undertaking in the sessions. This is further aided by the use of the course

workbook. Within each session, the participants are given course work assignments to undertake between the sessions. They do this with the assistance of nursing staff again involving others in the change process. The theme of a pyramid is used throughout the Programme to emphasise participants building a base, from learning from the past, and then working upwards, through modules towards a goal. The participants know the group as „The Pyramid Programme‟. Evaluation There is extensive pre and post assessment. This includes questions concerning stage of change, insight, relapse prevention concepts etc. However, there is an absence of a structured and validated assessment of motivation for offenders with a learning disability. The Programme is to be subject to a controlled clinical trial, with the author currently undertaking a research project to develop validated assessments of motivation for use with offenders with a learning disability. This includes adaptation of a validated assessment of stages of change, an interview schedule and an observer based rating of motivation. The motivational programme will then be evaluated using these validated measures. Observation of participation and subsequent engagement in the offence specific treatments also provides qualitative information. Qualitatively the programme appears to increase insight, trust and engagement. In addition, the group provides a shared formulation between the clinician and the participant and a sense on the part of the participant that they have been „heard‟ and „understood‟. Given that we gain much information concerning the difficulties that have led to offending, the programme also adds risk assessment information. Most importantly, the participants appear more ready, willing and able to change and there is an increased morale amongst those working within the unit.

Offenders with a learning disability who are not motivated to change will be found in any service caring for them. Expecting such individuals to accept our point of view will lead to frustration or externally driven change that is not maintained. Rather it is our task to see their point of view and to work collaboratively to explore change together. This paper describes a motivational programme that has been developed for offenders with a learning disability, which encompasses the principles of motivational interviewing as described by Miller and Rollnick (2002). A research project is in progress, first developing assessment of motivation that are applicable to offenders with a learning disability, then subjecting the motivational programme to a controlled clinical trial using the new measures.
References Covey, S. R., (1989) The 7 Habits of Highly Effective People. Simon & Schuster. DiClemente C. C., & Hughes S. O., (1990). Stages of change profiles in outpatient alcoholism treatment. Journal of Substance Abuse, 2, 217-235. Hodge, J., & Renwick, S. J., (2002). Motivating Mentally Disordered Offenders. In McMurran, M., (Ed.), Motivating Offenders to Change. A Guide to Enhancing Engagement in Therapy. Wiley Mann, R. E., Ginsberg, J. I. D., Weekes J. R., (2002). Motivational Interviewing with Offenders. In McMurran, M., (Ed.), Motivating Offenders to Change. A Guide to Enhancing Engagement in Therapy. Wiley McGuire, J. (2000). Think First. Manual and programme materials. London. Home Office McMurran, M., (Ed.). (2002). Motivating Offenders to Change. A Guide to Enhancing Engagement in Therapy. Wiley McGuire, J., (2002) Motivation for What? In McMurran, M., (Ed.), Motivating Offenders to Change. A Guide to Enhancing Engagement in Therapy. Wiley

Miller W. R. and Rollnick, S. (2002). Motivational Interviewing. Preparing people for Change. Guilford Press. Prochaska, J. O., & Levesque, D. A., (2002). Enhancing Motivation of Offenders at Each Stage of Changes and Phase of Therapy. In McMurran, M., (Ed.), Motivating Offenders to Change. A Guide to Enhancing Engagement in Therapy. Wiley

Nurses Experiences of Working with People who Self-Harm Within a Male Forensic Learning Disability Service Helen Reid Northgate & Prudhoe NHS Trust Deliberate self-harm is frequently encontered in health care settings and is a behaviour that remains poorly understood and difficult to treat. According to Smith [1998] self – harm is one of the most misunderstood and heartlessly represented areas of British health care. Nurses and medics speak of symptoms, borderline personality disorder and attention seeking. Traditionally psychiatric responses to self – harm are to see it as deviancy, behaviour, attention seeking, hysteria, weak mindedness or suicidal intent. Smith argues that self – harm is rooted firmly in the person. It is a form of communication, an expression of frustration, a metaphor, and many things to many people, the common feature being that it is a real response to real feelings. Clinical management is often complicated by the well-documented capacity for selfharming patients to evoke powerful emotions in those involved in their care. Government policy such as Saving Lives: Our Healthier Nation [1998], the National Service Framework for Mental Health, [DoH 1999] and the National Suicide Prevention Strategy for England [2002] have outlined targets for suicide reduction rates. Although it must be said that most incidents of self-harm do not involve suicidal intent of all known risk factors for completed suicide, self-harm has the strongest association. Personal clinical experience of working with a man who intentionally harmed himself almost daily revealed the issue to be an area of practice that we as nurses appeared to struggle with beyond the reactive intervention of keeping the person safe. Northgate and Prudhoe NHS Trust provide a comprehensive range of therapeutic interventions aimed at assisting the person to lead a lifestyle incompatible with offending. However, at the time that this research project was carried out in 2001 there appeared to be an area of development within the mens‟ service specifically involving interventions with people who self-harm in the longer term. As part of my own professional development the research study that I will describe in this paper was undertaken as part of an academic course of study whereby I took the opportunity to develop this area of practice in line with the divisions service development agenda. Aims of the study The aims of the study were as follows:  To provide an overview of self-harm within Northgate and Prudhoe NHS Trust – it wasn‟t intended that this would be a comprehensive study of a

particular aspect of self harm but rather a broad overview of the issues involved for nurses in clinical practice  To explore nurses experiences of working with people who self-harm  To inform policy and practice development  To address a gap in existing research – i.e. a study that focused on forensic learning disability nursing practice that utilised primarily qualitative methods. When reviewing the literature it was apparent that most studies had used questionnaires and case vignettes as research methods, whereas this study used semi-structured interviews as a method of data collection Research group The ward managers from each of the male forensic wards were asked to look back over their incident recording forms for the last incident occurring on their ward concerning a patient either actually self harming or threatening to do so. The managers were then asked for a list of names of registered nurses that were on duty at the time of the incident. The qualified nurse in charge of the ward at the time of these incidents was approached by myself and asked if they would be interested in taking part in the study The resultant sample consisted of eight registered nurses from within the male forensic division of the Trust. Every one approached consented to take part in the study 2 charge nurses at F grade level 5 senior staff nurses at E grade level 1 enrolled nurse at C grade level The sample was representative of all security levels of the male service – that is medium security, low security and rehabilitation services based on the Northgate Hospital site Ethical approval from Northumberland Local Research Ethics Committee was granted at this stage of the study Data collection Interviews were conducted using a pre designed interview guide although this was not prescriptive and not used as a definitive topic guide, rather it was used to steer the direction of the conversation Interviews were tape recorded and transcribed and copies of the transcripts were sent out to the nurses to check for accuracy An interview as a method involves the researcher directly and therefore it is argued that there is greater potential for the researcher to influence the data that is collected.

It was therefore at this stage important to reflect upon and acknowledge in the report the effect of my own presence and my own views may have had on the data. Data analysis Transcripts were read and re read in order that the researcher (in this case myself) became immersed in the data. Content analysis was performed and the text within the transcripts divided into units of meaning. Recurrent themes were identified and construction of several categories resulted from the main themes identified. Following this process all of the data were coded into the categories The findings Specific categories that emerged from the data are highlighted in bold: The types of self-harming behaviour described by the nurses included many behaviours that are frequently referred to in the literature pertaining to self-harm and included: Cutting, slapping and punching, scratching, inserting objects, slamming fists and arms against walls, drinking or swallowing harmful substances, biting Other behaviours were described that would not be commonly viewed as self harm and not so well documented in the literature and these included: Refusing insulin, refusing anti-convulsant medication and not eating The nurses were then asked for their views on what they perceived to be behind the behaviour, what did they feel was the motivation of the person to harm themselves. Several factors were identified and these included:          Communication difficulties A cry for help Low self-image or self esteem Agitation A means of punishing themselves Anger History of abuse Mental health problems Regaining control over their lives this was felt to be an important issue that emerged because of the restrictive environment the person was living in

The nurses were then asked to talk about treatment options in relation to self-harm. All of the nurses interviewed in this study described the importance of having an agreed action plan in place detailing what would need to happen in the event of an incident of self-harm occurring on the ward.

The plan would involve primarily increasing the observation levels of the person and restricting access to items that may be used to cause further damage. At this stage intervention is reactive and very much aimed at keeping the person safe Rewarding good behaviour was felt to be a way of reducing incidents of self-harm as was the importance of exploring longer-term issues in order to effectively help the person manage their behaviour. It was apparent from the data that the nurses felt they were handling initial interventions effectively in terms of assessing and managing further risk to the persons safety, however they felt that they were 'not dealing with the longer term issues involved in an effective manner. One of the nurses interviewed described his practice in treating self-harm as consisting of: “ Putting the fire out only for it to flare up again soon afterwards.” It was evident from the data that the issue of self –harm evoked very powerful emotions in the nurses. This is in line with other studies and literature pertaining to staff attitudes to self-harm. Arnold (1995) reported in her survey of 76 women in Bristol the professional attitudes varied according to theoretical stance and Frances in 1987 reported, “Of all disturbing patient behaviours, self-mutilation is the most difficult for clinicians to understand and treat. …and goes on to say that the typical clinician treating a patient who selfmutilates is often left feeling a combination of helplessness, horror, guilt, anger, betrayal, disgust, dismay and sadness.” Tantam and Whitaker (1992) also commented on the fear, anger and anxiety that a person who deliberately harming themselves produces in carers and fellow patients, who may stigmatise the person as “bad, attention seeking or manipulative.” The nurses interviewed on the one hand described feelings of great concern, empathy and understanding towards the person but on the other hand they also described more negative feelings including frustration, vulnerability, distress, fear and anxiety. Staff support was felt to be an important issue for practice when working with people who self-harm. Reflection, critical incident debriefing and post incident counseling were all felt to be useful support systems that could be applied following incidents relating to self harm, whereby feelings could be shared and discussed in an open manner. Good communication systems therefore were felt to be vital. Other, practical solutions were given and included the practice of staff rotation systems for nurses working in particularly stressful situations. Self harm was felt to be an important issue for the whole multi-disciplinary team that whilst nurses were in the front line so to speak it is important to include all team members when considering risk assessment and treatment options.

Implications for practice Having said all of that what did it mean in practice? It was clear from the data that the nurses felt that working with people who self-harm constituted a significant part of their practice, but that this was an aspect of their role that perhaps needed some development. They reported a wide range of issues and described this to be a most challenging aspect of their practice It was clear that self -harm should be recognized as an important issue for all members of the multi – disciplinary team involved in the persons care and treatment in order that assessment and treatment plan assists the person to deal with the complex issues involved in the behaviour. The nurses valued support and guidance from other members of the team and felt that they were perhaps in the best position to be at the forefront of developing treatment programmes The feelings and emotions involved in working with people who self harm should be acknowledged as powerful and existing support mechanisms available to staff should be utilized and accessed following incidents Training was identified as a major area for development, which is the focus of current work that is ongoing within the Trust. Current work In order to develop this work further we applied and were awarded a HAZ fellowship in November 2002. The focus of the fellowship is staff training in this area and we are currently in the process of developing an evidence based educational resource for delivery to staff across the Trust but also into local Accident and Emergency departments. References Arnold, L. (1995). Women and self-injury: a survey of 76 women. Bristol Crisis Service for Women. Department of Health (1998) Saving Lives: our healthier nation. London. Department of Health (1999). National Service Framework for Mental Health: Modern standards and service models for mental health. London. Department of Health (2002) National Suicide Prevention Strategy for England. London.

Smith, M. (1998). Working with People who Self-harm: Victim to Victor. Handsell Publishing. Tantam, D. Whittaker,J. (1992). Personality disorder and self-wounding. British journal of Psychiatry. 161, 451-464.

Developmental Disorders in Prisoners Volunteering for DSPD Assessment Dr Val Hawes HMP Whitemoor The aim of this paper is to briefly describe the DSPD Unit at HMP Whitemoor and the variety of developmental disorders evident in those prisoners so far assessed. Progress so far in the DSPD Unit at HMP Whitemoor The DSPD Programme is being developed to provide services for those offenders who are dangerous (i.e. they pose a risk of violent or sexual re-offending) by reason of severe personality disorder, the outline of these services having been first described in joint Department of Health/Home Office publications in July 1996 and December 2000. The Programme is jointly owned by the Department of Health, Home Office and the Prison Service and it is managed from the Home Office, alongside the Mental Health Unit. So far the main focus has been on the development of services in high secure settings but plans are being developed for medium secure and community services. DSPD High Secure Services are being developed at four sites, two in prisons (HMP Whitemoor and HMP Frankland) and two in hospitals (Broadmoor and Rampton). The DSPD Unit at HMP Whitemoor has been developed on an existing prison wing with conversion of some cells to provide additional space for interview rooms, group rooms and offices. It was first opened to take prisoners in September 2000 and has capacity for 90 prisoners. At HMP Frankland there will be 80 places with first prisoners expected in early 2004. At Broadmoor Hospital a 10-bed unit was opened in April 2003 on an existing ward and a 70 bed unit is due to open in late 2004. The unit at Rampton Hospital will take 70 patients beginning early 2004. The three units yet to be opened are all new purpose-designed buildings. The process and duration of DSPD assessment at the Whitemoor Unit has varied somewhat over time but the main elements have remained consistent throughout. The most important of these is the provision of a high-staffed residential setting dedicated to DSPD assessment. This provides the context for interaction between staff and prisoners and for detailed behavioural observations, also for the more structured psychological and psychiatric assessments. The prisoners are involved in a daily programme of activities that are led by prison officers. These include group discussions, problem-solving and creative activities, wing cleaning etc. Officers are also involved in structured association activities - playing pool, table tennis and board games with prisoners. The structured assessments include the application of a range of actuarial risk measures, full psychiatric assessment, structured interviews for International Personality Disorder Examination (IPDE) and the Hare Psychopathy Checklist Revised (PCL-R). Assessment also includes detailed analysis of past offending with all findings being brought together in a formulation with identification of treatment needs. For each prisoner, findings are reviewed by the multi-disciplinary team at three case conferences during the course of assessment. Although assessment has been ongoing since late 2000, for a number of reasons there have been delays in starting a formal programme of DSPD Intervention but this has

now got under way. The main approach will be cognitive-behavioural using schemafocused therapy. Each prisoner will have an individual treatment plan to include both individual and group work and expected to take 3-5 years. Other important aspects are ongoing informal interaction with staff, high staffing levels (both discipline and clinical staff) and the provision of educational/vocational activities in a dedicated workshop. The Unit is for adult male sentenced prisoners with at least two years to serve. Those with measured IQ of less than 70 and those with current active or lengthy past psychotic illness will be excluded. So far all prisoners have come to the Unit as volunteers and many are serving life-sentences but we expect to move to more active recruitment of fixed term prisoners. Over the time since opening, there have been a number of achievements at the Whitemoor unit. A therapeutic environment has been created and maintained in a high secure prison without compromising security. Much of this is due to the commitment of the staff group, including a number of mature and experienced prison officers, some of whom have been involved in the development and adaptation of the programme of officer-led group work. A multi-disciplinary team including both discipline and clinical staff has been developed and is responsible for most operational and clinical decisions. A dedicated workshop providing a range of educational, vocational and creative activities for prisoners undertaking DSPD intervention is now well established. The therapeutic environment, the quality of staff-prisoner relationships and the workshop have all contributed to engagement and motivation for treatment in a number of previously problematic prisoners. Unsurprisingly, there have also been a number of difficulties. During the first two years of the unit, there was considerable difficulty in recruiting experienced clinicians but in recent months this has begun to change such that by mid-2003, there are real prospects of a strong and experienced clinical team. The recruitment difficulties have led to unwanted breaks in assessment and to delays and changes of plan for the intervention programme. A downside of the growth of the clinical team and anticipated increase in prisoners is increasing awareness of the limitations of the existing building but with limited scope for major change. From the beginning there have been some tensions between the unit and the rest of the prison. Such tensions and that of constantly needing to keep the right balance between custody and therapy are ongoing and only to be expected with such a unit. One area of concern that was perhaps less expected is an increased level of self-harm among prisoners but this almost certainly reflects a move away from outward-directed aggression. An as-yet unresolved issue is how to validate the progress of prisoners without the use of accredited offending behaviour programmes that have become the main evidence of risk reduction in the Prison Service. Developmental disorders evident among prisoners assessed While the main focus is on the diagnosis and treatment of personality disorder, it has been clear since the start of the unit, that quite a number of prisoners show definite or likely evidence of a range of developmental disorders. Of the 72 men for whom data is available, 31 show such evidence. The developmental disorders can be divided into four main groups – proven organic factors, learning disabilities, autistic-spectrum disorders and neuro-psychiatric conditions.

Probably the most important of the proven organic factors is the group of four men with history of brain damage during the developmental period confirmed by neuropsychological assessment. The cause of brain damage was different in each case – one had suffered carbon monoxide poisoning at age 3, the second had meningitis at age 7, the third a frontal head injury at age 8 and the fourth almost certainly had early brain damage of unknown cause exacerbated by a head injury at age 20. None of the prisoners so far assessed has had a clear diagnosis of epilepsy but four have had a history of seizures or abnormal EEG. A surprising finding is that four men were known to have XYY chromosomes – three had been tested during earlier hospital admissions, one while on remand because of his height (6ft 7in). Only two of the other 68 men are known to have been karyotyped. The finding that a number of men have learning disabilities is unsurprising. Thirteen had measured IQ in the borderline learning disabilities range (70-79) and one had mild learning disabilities (IQ below 70). There were a number of men with a history of literacy difficulties. Of these one gave a very clear history of dyslexia and another had ongoing reading difficulties despite measured IQ of 100. The author has a particular interest in autistic-spectrum disorder and this interest has contributed to the recognition of a number of cases among those assessed. In two cases (both in their twenties) it was possible to make a definite diagnosis of Asperger syndrome on the basis of parental account of early social communication difficulties. In four other men, without parental information, a provisional diagnosis of Asperger syndrome was made from clinical assessment and the use of questionnaires designed by the Cambridge Autism Research Centre. A further four men were considered to show evidence of autistic traits. The specific neuro-psychiatric disorders so far encountered are ADHD and Tourette syndrome. Histories strongly suggestive of childhood ADHD were noted in seven men. More surprising was evidence of adult ADHD in four men. In the first two cases, the diagnosis was confirmed by a specialist psychologist but in the other two cases, the diagnosis was made on clinical grounds, including evidence of improvement on prescribed stimulant medication. One of those with probable ADHD, had a primary diagnosis of Tourette syndrome, the diagnosis having been made in his twenties. Tic symptoms had improved over time but he had many other symptoms commonly associated with Tourette syndrome i.e. in addition to ADHD, he had marked obsessive-compulsive behaviours, anxiety, depression as well as meeting criteria for several personality disorders. Another man in his forties had very marked symptoms of Tourette syndrome but this had not previously been diagnosed. In conclusion, a number of issues can be raised in relation to the findings of developmental disorders. One striking factor is that these disorders had often previously been unrecognised as a contributory factor to the man‟s difficulties – many only had a previous non-specific diagnosis of personality disorder. Given the prevalence of such disorders, it would be very helpful to have access to further investigations including neuro-imaging in at least some cases. Reference has been made to those with borderline learning disabilities and earlier to the guideline that men with IQ below 70 are unlikely to be suitable for intervention. Part of the difficulty related to those with learning disabilities is that the instruments used for DSPD assessment have not been validated for the learning disabled population. The

other aspect is the lack of suitable programmes and facilities for the treatment of those with personality disorder and learning disabilities. Overall it is clear from the experience of the Whitemoor DSPD Unit, that there is a significant overlap between developmental disorders and personality disorder. It is hoped that one further development of the DSPD programme will be renewed interest in research into developmental aspects of personality disorder, including specific developmental disorders.

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