Crime and victimisation in people with intellectual disability: a case linkage study

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.

Intellectual Ability and Sexual Recidivism Risk Assessment: Comparing Predictive Accuracy in an Incarcerated U.S. Sample

While studies indicate that individuals with intellectual disabilities (ID) and borderline intellectual functioning (BIF) are overrepresented among those incarcerated for sexual offenses, there is a paucity of research with respect to risk assessment for this population, particularly among incarcerated U.S. samples. This gap is concerning given that individuals perceived as high risk may be denied bail, given harsher sentences, or subject to civil confinement. The present study examined the predictive validity of the Static-99 and Static-99R, which rely on historical predictors, and the MnSOST-R, which includes a dynamic subscale. Archival records were used to compare individuals with (n = 459) and without (n = 459) ID/BIF released from New Jersey state prisons between 1996 and 2007, with an average follow-up period of 5.7 years. All three instruments demonstrated good predictive validity for those without ID/BIF, while only the MnSOST-R produced a significant AUC value for those with ID/BIF. Reincarceration rates for those with ID/BIF within high-risk groups ranged from 0% to 8%, similar to the overall recidivism base rate of 4%. Results highlight the need for additional research to determine which risk factors should be considered for those with ID/BIF.

The role of relational work in promoting safe community participation by people with mild intellectual disabilities and severe challenging behaviour living in residential facilities

BACKGROUND

Promoting the level of community participation by people with mild intellectual disabilities who exhibit severe challenging behaviour is complex due to a variety of safety issues.

METHOD

This qualitative study explored what residential facilities for people with intellectual disabilities as well as their external stakeholders do to promote safe community participation, taking feelings of safety of service users and their environment into account. Interview and focus group data from professionals of residential facilities and stakeholders from the police and municipality were thematically analysed, resulting in the identification of two main themes.

RESULTS

The first theme concerns taking risks responsibly together, by identifying, weighing up, and managing risks, whilst the second pertains to residential facilities and stakeholders' ongoing efforts to change the perceptions and attitudes of the public and each other. Overall, the significance of relational work in promoting safe community participation was found.

CONCLUSIONS

Residential facilities and external stakeholders should invest in strengthening their relationship.

Victimization status among persons with disabilities and its predictors: Evidence from Bangladesh National Survey on Persons with Disabilities

BACKGROUND

Persons with disabilities often face various forms of victimization, yet there is limited research exploring this phenomenon in Bangladesh. This study aims to investigate the victimization status among persons with disabilities and identify its predictors.

METHODS

Data of 4293 persons with disabilities analyzed in this study were extracted from the 2021 National Survey on Persons with Disabilities. Victimization status (yes, no) was considered as the outcome variables. Explanatory variables considered were factors at the individual, household, and community levels. A multilevel mixed-effect logistic regression model was used to explore the association of the outcome variable with explanatory variables by dividing the total sample into age groups of 0-17 years, 18-59 years, and ≥ 60 years.

RESULTS

The study found that 44% of persons with disabilities in Bangladesh experienced victimization, primarily involving neighbours (90.64%), relatives (43.41%), friends (28.41%), and family members (27.07%). Among persons aged 0-17 years, increasing age was associated with a higher likelihood of being victimized, while residing in the wealthiest households or in certain divisions like Khulna and Rangpur was associated with lower likelihoods. Conversely, among respondents aged 18-59 and ≥ 60 years, increasing age was associated with a lower likelihood of being victimized. Unmarried respondents aged 18-59 years had an increased likelihood of victimization compared to married individuals. For persons with disabilities aged ≥ 60 years, a higher level of schooling was associated with a reduced likelihood of being victimized. We also found divisional differences in the likelihood of victimization, with respondents residing in Chattogram, Khulna, Mymensingh, Rangpur, and Sylhet reporting lower likelihoods compared to those residing in the Barishal division, among persons with disabilities aged 18-59 and ≥ 60 years.

CONCLUSION

This study's findings underscore that around 4 in 10 persons with disabilities are being victimized. Tailored programs and awareness-building initiatives covering neighbours, relatives, friends, and family members of persons with disabilities are important to ensure dignified lives for this population.

Differences and similarities between children and adolescent exposed to interpersonal traumas with and without Intellectual Disability: An explorative study

BACKGROUND

Individuals with intellectual disability (ID) are more vulnerable to traumatic and stressful events, increasing their risk of developing post-traumatic stress disorder (PTSD).

AIMS

This study aimed to investigate differences in psychopathology, post-traumatic symptoms, and adaptive functioning in a sample of Italian children and adolescents with and without ID. It also sought to determine whether the type of interpersonal trauma was associated with distinct psychopathological outcomes.

METHODS AND PROCEDURES

Sixty-six children and adolescents exposed to interpersonal trauma (physical/sexual abuse, domestic violence, and neglect), were selected and divided into two groups based on the presence or absence of ID. Assessment consisted of structured parent interviews and parent-reported questionnaires. For each scale, comparisons between subtests were performed.

OUTCOMES AND RESULTS

Children and adolescents with ID were more likely to exhibit more severe post-traumatic symptoms, anxiety issues, social problems, and poorer adaptive functioning, with the exception of the practical domain, which appeared to be equally impaired in both groups. In terms of interpersonal trauma typology, exposure to physical/sexual abuse and domestic violence led to greater post-traumatic symptoms compared to neglect.

CONCLUSION AND IMPLICATIONS

Interpersonal trauma significantly affects children and adolescents, with or without ID, highlighting the need for tailored treatments for both groups.

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.

Post-traumatic stress disorder and experiences involving violence or sexual abuse in a clinical sample of autistic adults with intellectual disabilities: Prevalence and clinical correlates

LAY ABSTRACT

Post-traumatic stress disorder is a mental health disorder that may be triggered by the experience of events perceived as terrifying or overwhelming. Examples of such events include being the victim of violence or sexual abuse. Compared with other people, autistic people have increased risk of being exposed to violence or sexual abuse. In addition, autistic people may be more vulnerable to developing post-traumatic stress disorder following such exposure. However, knowledge is limited concerning the prevalence of experiences involving violence and sexual abuse, and post-traumatic stress disorder, in autistic people with co-occurring intellectual disabilities. Detection of these experiences, and identification of post-traumatic stress disorder, may be challenging in these individuals, and previous research indicates that post-traumatic stress disorder symptoms may be overlooked or misinterpreted. In this study, we examined prevalence of post-traumatic stress disorder, violence and sexual abuse in a clinical sample of 88 autistic adults with intellectual disabilities referred for mental health assessment. Only 3.4% were diagnosed with post-traumatic stress disorder, even if experiences involving violence (34.1%) or sexual abuse (17.0%) were common. Anxiety and affective disorders were common diagnoses among participants with these experiences. Controlling for autism characteristics, level of intellectual disability and communication skills, experiences of violence/sexual abuse were found to be associated with a measure of 'challenging' behaviours. These results indicate that potentially traumatic experiences are common in autistic adults with intellectual disabilities referred for mental health assessment, and that post-traumatic stress disorder may be under-recognised. The findings highlight the importance of trauma screening and post-traumatic stress disorder assessment, as well as the importance of trauma-informed care, in this population.

Identifying victimization clusters across people with intellectual disabilities: A latent class analysis

BACKGROUND

Research has shown high rates of victimization among people with intellectual disabilities (ID), but victimization clusters have been barely explored.

OBJECTIVE

We address the gap by examining how reported victimization experiences are grouped into different classes and identifying differences in the characteristics of the individuals in each class.

METHODS

We conducted a cross-sectional self-report study with a sample of adults with an ID diagnosis (n = 260). We gathered data about the participants' victimization experiences and socio-demographics, and then subjected the data to latent class analysis (LCA).

RESULTS

Three different classes were detected: High victimization (n = 27, 10.4 %); medium victimization, low sexual (n = 97, 37.3 %); and low victimization (n = 136, 52.3 %). The results highlight the experiences of sexual and physical victimization among the high-victimization class, in which women are overrepresented, and physical victimization among the medium-victimization class. The study also found that experiences of assault and bias attacks occur to a varying extent across all three classes. The LCA and poly-victimization methods showed substantial agreement but also differences when identifying the most victimized participants. In addition, we detected significant differences between classes in gender, type of school attended, place of residence, legal incapacity, type of support needed, secondary disability and poly-victimization status.

CONCLUSION

We identified distinct underlying ingroup patterns of victimization and sociodemographic inter-class differences that contribute to a better understanding of victimization within the population in question. The results have prevention and intervention implications for caregivers and providers of services for people with ID.

[Disability status and robbery victimization in Peruvian villagers]

OBJECTIVE

About 15% of the world's population has some degree of disability. Violence and crime primarily affect the Latin American region, especially Peru. This study aimed to determine the association between disability status and robbery victimization in Peruvian villagers in 2017.

METHODS

A cross-sectional study of secondary data analysis from the National Specialized Victimization Survey (ENEVIC) 2017 was conducted. The independent variable was disability status, and the dependent variable was robbery victimization; in addition, confounding variables were included. Poisson regression was performed to demonstrate the association, and prevalence ratios (PR) with their 95% confidence intervals (95%CI) were calculated.

RESULTS

Records of 32,199 Peruvians aged 18 years or older were included. People with disabilities were 24% less likely to be robbery victims than people without disabilities (PR=0.76; 95%CI: 0.61-0.95), adjusted for confounding variables. However, this association was only statistically significant in women, older adults, and the high socioeconomic stratum.

CONCLUSIONS

In Peru, people with disabilities are less likely to be robbery victims than people without disabilities. However, only if they are women, older adults, and come from a high socioeconomic level. In the other population groups, the probabilities of suffering this victimization would be similar between people with and without disabilities.

Israeli social workers' recommendations on residential settings for individuals with intellectual disabilities

BACKGROUND

People with intellectual disabilities have the right to live in the community. As social workers have an important role in decisions regarding residential settings, this study examined their recommendations regarding residential living arrangements of individuals with intellectual disabilities.

METHOD

Using a factorial survey approach 174 social workers were presented with true-to-life vignettes and asked to provide their recommendations regarding housing in community apartments, hostels (large group homes) and meonot (large institutions).

RESULTS

Higher likelihood of recommending housing in a community apartment was associated with mild intellectual disability, lack of daily support needs, no sexual abuse history, and stated preference for a community apartment. Social workers' experience in working in a specific residential setting was associated with recommending it.

CONCLUSIONS

Ongoing training on rights-based ethics and the importance of community inclusion should be provided to social workers. Further, community alternatives should be made available to all individuals with disabilities.

Crisis Response Model Preferences of Mental Health Care Clients With Prior Misdemeanor Arrests and of Their Family and Friends

The overrepresentation of people with serious mental illnesses in the criminal legal system has spurred the development of crisis response models to improve or reduce police response to a mental health crisis. However, limited research has explored preferences for crisis response, and no research in the United States has examined the responses desired by mental health care clients or their family members. This study aimed to understand the experiences of people with serious mental illnesses interacting with police and to learn about their preferences for crisis response models. The authors interviewed 50 clients with serious mental illnesses and a history of arrest who were enrolled in a randomized controlled trial of a police-mental health linkage system, as well as 18 of their family members and friends. Data were coded with deductive and inductive approaches and were grouped into larger themes. Clients and family or friends described needing a calm environment and empathy during a crisis. They selected a nonpolice response as their first choice and response from a crisis intervention team as their last choice among four options, highlighting the importance of trained responders and past negative interactions with police. However, they also noted concerns about safety and the shortcomings of a nonpolice response. These findings build understanding about clients' and family members' preferences for crisis response and highlight concerns that are relevant for policy makers.

The Extent and Nature of Autistic People's Violence Experiences During Adulthood: A Cross-sectional Study of Victimisation

This study investigated the extent and nature of violence experiences reported by autistic adults. Autistic (n = 118) and non-autistic (n = 110) adults completed a questionnaire about their experiences of sexual harassment, stalking and harassment, sexual violence and physical violence since the age of 15. Autistic adults reported higher rates of all violence types, multiple forms of violence and repeated instances of the same type of violence. Typical gender differences in the patterns of violence (more physical violence reported by men and more sexual violence reported by women) were apparent in the non-autistic but not the autistic group. Findings add to the limited research in this area and highlight the need to identify risk and protective factors. Policy and practice implications are also discussed.

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.

Neurodevelopmental disorders and subsequent risk of violent victimization: exploring sex differences and mechanisms

BACKGROUND

Neurodevelopmental disorders (NDs) are associated with experiences of victimization, but mechanisms remain unclear. We explored sex differences and the role of familial factors and externalizing problems in the association between several NDs and violent victimization in adolescence and young adulthood.

METHODS

Individuals born in Sweden 1985-1997, residing in Sweden at their 15th birthday, were followed until date of violent victimization causing a hospital visit or death, death due to other causes, emigration, or December 31, 2013, whichever came first. The exposures were diagnoses of attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), intellectual disability (ID) and other NDs. We used three different Cox regression models: a crude model, a model adjusted for familial confounding using sibling-comparisons, and a model additionally adjusted for externalizing problems.

RESULTS

Among 1 344 944 individuals followed, on average, for 5 years, 74 487 were diagnosed with NDs and 37 765 had a hospital visit or died due to violence. ADHD was associated with an increased risk of violent victimization in males [hazard ratio (HR) 2.56; 95% confidence interval (CI) 2.43-2.70) and females (HR 5.39; 95% CI 4.97-5.85). ASD and ID were associated with an increased risk of violent victimization in females only. After adjusting for familial factors and externalizing problems, only ADHD was associated with violent victimization among males (HR 1.27; 95% CI 1.06-1.51) and females (HR 1.69; 95% CI 1.21-2.36).

CONCLUSIONS

Females with NDs and males with ADHD are at greater risk of being victim of severe violence during adolescence and young adulthood. Relevant mechanisms include shared familial liability and externalizing problems. ADHD may be independently associated with violent victimization.

Sexual Violence Against Persons With Disabilities: A Meta-Analysis

A growing number of large-scale studies suggest that people with disabilities are at greater risk of sexual victimization than nondisabled individuals. However, certain results are inconsistent and whether potential moderators explain this variability in previous findings remain to be considered. This meta-analysis aimed to determine the magnitude of the difference in risk of being sexually victimized based on the presence of a disability. An additional objective was to evaluate the relative influence of gender, age, type of disability, type of sexual violence, and relationship with the perpetrator on the association between the presence of a disability and sexual victimization. Studies were searched using pertinent databases and retained if they included a group with a disability, provided data that quantify the occurrence of abuse, indicated the type of sexual violence, and was published between 1970 and 2018 in French or English. A total of 68 studies, allowing 84 independent samples and 12,427 participants, were included. Individuals with disabilities were at significantly higher risk of sexual victimization than persons without disabilities (odds ratio = 2.27). The risk of sexual victimization among individuals with a disability was significantly higher in adult participants compared with the risk in minor participants. Sensory impairment was the type of disability associated with the highest risk of sexual victimization. Odds of sexual victimization among individuals with a disability were significantly higher in African countries compared with all others, and odds in Western Europe were significantly lower than in the United States. No significant differences emerged across eras.

Prevalence of Secondary Traumatic Stress Among Direct Support Professionals in Intellectual and Developmental Disabilities Field

Direct support professionals (DSPs) are deemed by existing literature as vital support to persons with intellectual or developmental disabilities (IDD). They may be exposed to the traumatic experiences of people with IDD with potential psychological implications. Secondary traumatic stress (STS) has been studied among related professionals across human services, but little is known among DSPs. The current study examines the prevalence of STS in a sample of DSPs. The results suggested that DSPs are exposed to traumatic experiences, and exposure to a greater number of traumatized clients is significantly correlated with symptoms of STS. At least 12.4% of DSPs in this sample met the diagnostic criteria for experiencing post-traumatic stress disorder (PTSD) symptoms. Also, results suggest STS differences in DSPs based on demographics.

Dutch forensic patients with and without intellectual disabilities: A comparison of demographic, offence, and diagnostic characteristics

BACKGROUND

Patients with an intellectual disability (ID) and offending histories constitute a challenging clinical group. The present study examined commonalities and differences in demographic, diagnostic and offence characteristics in patients with and without intellectual disabilities who were either convicted for violent or sexual offences and who resided in mandated care in the Netherlands.

METHOD

We compared 165 offenders with an ID to 249 offenders without an ID. We compared both groups by type of offence (i.e., sexual versus violent offence) using Mann-Whitney U-test or independent samples t-tests for continuous variables and Chi-square tests for categorical variables.

RESULTS

In general, forensic patients with an ID were younger at admission (U=357, z = -12.668, p < .001), had more prior convictions for violent offences (χ²(1)= 6.175, p = .013) and more prevalent diagnoses of substance abuse disorders (χ²(1)= 9.266, p = .002) than those without an ID. Similar results were found for patients with IDs with sexual offence histories.

CONCLUSION

A clear understanding of distinct characteristics of forensic patients with intellectual disabilities is crucial in understanding (sexual) violent behavior in this population as it mayassistclinicians in prioritizing interventionstrategies.

Acceptance and potential clinical added value of biocueing in forensic psychiatric patients with autism spectrum disorder and/or intellectual disability

Autism spectrum disorder (ASD) and intellectual disability (ID) are prevalent in forensic psychiatric samples. People with ASD and/or ID often experience difficulties in emotion processing which can lead to aggressive or self-harming behavior. The use of biocueing (using wearable technology to constantly monitor and provide feedback on bodily changes) shows promise for improving emotion processing and, thus, potentially reducing aggressive behavior in this population. Both qualitative and quantitative methods were used to examine the feasibility and acceptance of Sense-IT, a biocueing application, in a sample of forensic psychiatric patients with ASD and/or ID and their forensic psychiatric nurses. To our knowledge, the current study is the first to examine first-person experiences with biocueing in forensic psychiatric patients with ASD and/or ID. Results show that, in general, participants experienced the biocueing application as positive and are willing to use biocueing. This is an important finding since forensic patients are often unmotivated to engage with therapeutic techniques. An exploration of trends in aggression and self-harm prior to and during the use of biocueing showed no significant changes. Future research should focus on the way biocueing can be implemented in clinical practice.

Post-traumatic stress disorder symptom manifestations in an autistic man with severe intellectual disability following coercion and scalding

BACKGROUND

Autistic adults with intellectual disabilities (ID) seem to be particularly vulnerable to potentially traumatic experiences and post-traumatic stress disorder (PTSD). Furthermore, this population may be at risk for a different set of traumatic experiences than the general population. However, knowledge is sparse concerning PTSD symptom manifestations in individuals with severe ID.

METHOD

Exploration of PTSD symptom trajectories and manifestations in an adult, autistic man with severe ID.

RESULTS

Altered arousal/reactivity and problematic avoidance were the most easily observable symptoms. Avoidance seemed to become more generalised over time, and the impact of PTSD on behaviour, level of functioning, and quality of life was severe.

CONCLUSIONS

Negligence and coercion in services for autistic adults with ID may involve a traumatic potential for these individuals. Increased awareness of this risk is needed in service providers and mental health professionals.

Exploring the victim offender overlap among people with an intellectual disability

BACKGROUND

While there is growing international evidence pointing to the increased risks of crime perpetration and victimisation for some people with an intellectual disability, the overlap between offending and victimisation (the victim-offender overlap) remains unclear.

METHOD

This study utilised a data linkage methodology of 2600 people with an intellectual disability, exploring their contacts with public mental health services and the police in Victoria, Australia.

RESULTS

Victim-offenders accounted for a small proportion of the sample (n = 148, 5.7%). The victim-offender overlap was evident for both violent and nonviolent nonsexual crimes, particularly for theft, burglary, and threat-related crimes. Key differences were also noted between males and females.

CONCLUSIONS

People with an intellectual disability who are both victim and offenders comprise a small but particularly complex justice-involved population. Future research should explore the victim offender overlap for males and females separately, as well as any additional risks and vulnerabilities associated with specific mental health diagnoses.

Crimes and sentences in individuals with intellectual disability in a forensic psychiatric context: a register-based study

Aims

To study associations between intellectual disability (ID) and sexual and violent offending among individuals subject to pre-trial forensic psychiatric assessment. To investigate sentences following pre-trial forensic psychiatric assessment in offenders with and without ID.

Methods

A population-based observational study using data from pre-trial forensic psychiatric assessments in Sweden (1997–2013), the Swedish National Crime Register and several other Swedish national registers. The study population consisted of 7450 offenders (87% men, 13% women) who were subject to forensic psychiatric assessment in 1997–2013, of whom 481 (6.5%) were clinically assessed as having ID.

Results

ID offenders were more likely than non-ID offenders to have a sexual crime as an index crime [26.2 v. 11.5%, adjusted odds ratio (OR) 2.7, 95% confidence interval (CI) 2.02–3.58] as well as previous convictions regarding sexual offending (10.4 v. 5.6%, adj OR 2.3, 95% CI 1.70–3.12). These associations were restricted to male offenders; sexual offending was uncommon among women. Comorbid attention-deficit hyperactivity disorder reduced the association between ID and sexual offending (adj OR 2.7 v. 3.1, p = 0.017), while comorbid autism spectrum disorder had no significant influence on the association (adj OR 2.7 v. 3.0, p = 0.059). Violent crime was equally common among ID and non-ID offenders. Offenders with ID were more likely than non-ID offenders to be sentenced to forensic psychiatric care or community sanctions and measures (such as probation, conditional sentences or fines) than to prison; however, 15% of individuals who received an ID diagnosis during the forensic psychiatric assessment were sentenced to prison. Previous criminal convictions, concurrent antisocial personality disorders and substance use disorders were associated with a higher probability of a prison sentence among offenders with ID.

Conclusions

Sexual crime is overrepresented among offenders with ID compared to offenders with other mental disorders than ID in forensic psychiatric contexts. ID offenders become subject to forensic psychiatric care and forensic psychiatric services need evidence-based treatment programmes for offenders with ID. In addition, there is a need for early intervention strategies suitable for disability services and special education schools, in order to address the complex needs of individuals with ID and prevent sexual and violent offending.

Criminal recidivism in offenders with and without intellectual disability sentenced to forensic psychiatric care in Sweden-A 17-year follow-up study

BACKGROUND

Offenders with intellectual disability (ID) constitute a distinct subgroup of offenders with mental disorders. Regarding criminal recidivism, it is unclear whether or not offenders with ID in forensic psychiatric settings differ from offenders without ID. Factors associated with criminal recidivism among offenders with ID have been scarcely investigated.

AIM

To investigate the association between ID and criminal recidivism among offenders sentenced to forensic psychiatric care and to explore the impact of clinical, sociodemographic and offense variables.

MATERIALS AND METHODS

We conducted a retrospective cohort study based on Swedish nationwide registers. A total of 3,365 individuals being sentenced to forensic psychiatric care in Sweden in 1997-2013 were followed from the forensic psychiatric assessment until first reconviction, death, emigration, or 31 December 2013, whichever occurred first. Cox regression models compared rates of recidivism in individuals with and without ID. Impact of clinical, sociodemographic, and offense variables on risk of criminal recidivism was presented as hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

Out of 3,365 offenders sentenced to forensic psychiatric care, 259 (7.7%) were diagnosed with ID. During follow-up (0-17 years, median 6 years), one third (n = 1,099) of the study population relapsed into criminality, giving a recidivism rate of 50.5 per 1,000 person-years. We observed an association between ID and a decreased risk of recidivism (HR 0.8, 95% CI 0.6-1.0, p = 0.063), although this reached statistical significance only for the subgroup of male offenders (HR 0.8, 95% CI 0.6-1.0, p = 0.040) and not females (HR 1.0, 95% CI 0.6-1.8). ID offenders with concurrent ADHD tended to have a higher rate of recidivism (73.9 per 1,000 person-years, HR 1.2, 95% CI 0.6-2.4) than ID offenders without ADHD (42.5 per 1,000 person-years, HR 0.8, 95% CI 0.6-1.1). Amongst ID offenders, concurrent autism spectrum disorder, young age or male sex were not associated with recidivism, while previous criminal convictions were strongly associated with recidivism.

CONCLUSION

A diagnosis of ID was associated with a lower risk of criminal recidivism among male offenders sentenced to forensic psychiatric care. The association between ADHD and recidivism among ID offenders highlights eligible focus areas in the management of offenders with ID.

Sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the Dutch Health and Youth Care Inspectorate

OBJECTIVES

To explore characteristics of sexual abuse within residential settings for people with an intellectual disability and to map out measures undertaken and improvement plans made by healthcare organisations after sexual abuse.

DESIGN

Descriptive analysis of reports about sexual violence against persons with an intellectual disability submitted to the Dutch Health and Youth Care Inspectorate by healthcare organisations.

SETTING

Residential settings for people with an intellectual disability in The Netherlands.

SELECTION

186 incident reports submitted to the Inspectorate between January 2017 and December 2019 were included.

RESULTS

125 incident reports concerned sexual abuse by fellow clients and 61 reports concerned sexual abuse by professionals. Client perpetrators were predominantly male whereas almost 30% of the abusing professionals were female. The majority of the perpetrating professionals were unlicensed professionals. Clients who committed sexual abuse were mostly relocated to another residential setting. Most healthcare organisations invested in education and training for employees instead of improving the sexual education programme for clients after an incident of sexual abuse. If there was a strong suspicion of sexual abuse by a professional, resignation followed in most cases. In just two cases, the perpetrating professional was reported to a warning registry.

CONCLUSIONS

A small amount of the perpetrating professionals held a licensed profession, which makes it challenging to address this form of sexual abuse through healthcare regulation. It raises the question why warning registries are not engaged more often after alleged sexual abuse. Constantly relocating abusing clients might endanger the (sexual) safety of clients in these new environments. Previous literature suggests that adequate sexual education regarding social skills and sexual behaviour is very effective for the majority of clients who commit sexual abuse. Healthcare organisations could take up a more prominent role in this to ensure safety for their own clients and for clients residing elsewhere.

Trauma-informed care in the context of intellectual and developmental disability services: Perceptions of service providers

Traumatic life events have pervasive impacts on health and well-being. A growing body of literature shows that people with intellectual and developmental disabilities are disproportionately impacted by trauma. Trauma-informed care (TIC) is a philosophy of service provision that is committed to preventing traumatization and re-traumatization and promoting healing. This study explores the perceptions of 130 leaders in the field of intellectual and developmental disabilities services on the adoption and practice of TIC through the analysis of quantitative data. Results indicated a disconnect between the level of TIC integration and perceptions detailing how well organizations are currently performing in aspects of TIC. Barriers to TIC included high staff turnover, lack of accessible mental health providers, lack of affordable training, stigma, and restrictive funding structures. Implications and recommendations for service organizations and educators are provided.

Mothers With Mild Levels of Intellectual Disability: Emotion-Interpretation, Traumatization, and Child Attachment Representations

Prior research indicates links between parents' experiences of interpersonal trauma and emotion-interpretation difficulties, and between such difficulties and child attachment insecurity and disorganization. Although mothers with mild levels of intellectual disability (ID) are at heightened risk for trauma and emotion-interpretation difficulties, and their children for attachment insecurity, corresponding links in this population have not been examined. We therefore investigated emotional interpretations among mothers with mild levels of ID (n = 23) and matched comparison mothers without ID (n = 25), in relation to mothers' experiences of trauma and their children's attachment representations. Mothers with mild levels of ID were not less accurate than comparison mothers with regard to general positive and negative emotion-interpretation accuracy, but they were significantly more likely to misinterpret shame and anger. Among mothers with mild levels of ID, misinterpretations of shame were positively related to maternal experiences of trauma, and to child attachment insecurity and disorganization.

Effects of Integrated Violence Intervention on Alexithymia, Cognitive, and Neurocognitive Features of Violence in Schizophrenia: A Randomized Controlled Trial

Patients with schizophrenia and repetitive violence express core impairments that encompass multiple domains. To date, there have been few interventions integrating neurocognition, social cognition, alexithymia, and emotion regulation together as an approach to manage repetitive violence. The aim of this open-label randomized controlled trial was to examine more comprehensively the effectiveness of a novel Integrated Cognitive Based Violence Intervention Program on management of repetitive violence in patients with schizophrenia (vSZ). Sixty recruited patients were aged ≥20 years, diagnosed with schizophrenia for >2 years, had repetitive violent behavior within one year, and were psychiatrically hospitalized. The vSZ patients were randomly allocated to two groups and received either the intervention or treatment as usual. The intervention module, consisting of all defined 11 cognitive and social cognitive domains as well as emotion regulation, which were grouped into four modules. The intervention placed emphasis on the patients’ behavioral problems or intrinsic conflicts in relation to repetitive violence. The results indicate a statistically significant trend toward reducing impulsivity, anger with resentment, physical aggression, suspicion, and hostility (p < 0.05). The intervention significantly alleviated the intensity of cognitive failure, improved the management of alexithymic features and attribution styles and errors, and fostered adequate decision-making styles and emotion regulation capacity (p < 0.05). The intervention, when applied in conjunction with psychiatric standard care, could exert synergistic effects on alexithymia and cognitive, clinical, and neurocognitive features of repetitive violence in schizophrenia. This intervention provided patients a more active role to manage their violent behavior with the involvement of alexithymia.

Prevalence of Sexual Abuse in Adults with Intellectual Disability: Systematic Review and Meta-Analysis

This study presents the results of a systematic review on the prevalence of sexual abuse experienced in adulthood by individuals with intellectual disability. An electronic and manual search of academic journals was performed on four databases via EBSCO Host: Academic Search Complete, PsycINFO, Medline, CINAHL Full-Text. In addition, PubMed, ProQuest, and Web of Science (core collection) were searched. After an initial selection of 1037 documents, 25 articles remained for quantitative synthesis. The combined prevalence of sexual abuse in adults with intellectual disability was 32.9% (95% CI: 22.7–43.0) and sensitivity analysis revealed that the prevalence was not outweighed by a single study. Overall, the United Kingdom had the highest prevalence (r = 34.1%), and the USA had the lowest (r = 15.2%). The overall prevalence in females was lower (r = 31.8%) than that in males (r = 39.9%). Subgroup analyses revealed that prevalence of sexual abuse was higher in institutionalized individuals. The most prevalent profile of abuser is of a peer with intellectual disability. Prevalence increases from mild to severe levels of intellectual disability and decreases in profound levels. It is also more prevalent when the informant is the individual with intellectual disability than when someone else reports abuse. In sum, one in three adults with intellectual disability suffers sexual abuse in adulthood. Special attention should be paid for early detection and intervention in high risk situations.

Perceived neighborhood safety and exercise behavior among community dwellers in Gauteng, South Africa

ABSTRACT

Maintaining a physically active life is an important determinant of overall health and psychosocial wellbeing among adults. Physical exercise behavior can be influenced by various social and environmental circumstances including neighborhood safety. Using data from South Africa Quality of life Survey 2015/16, this study aimed to assess the hypothesis that lack of perceived neighborhood safety (PNS) can reduce the likelihood of engaging in physical exercise (PE). The participants were 30,002 men and women aged 18 years and above. The association between self-reported PE behavior and neighborhood safety were assessed by multivariable regression method while adjusting for potentially confounding factors. Less than a quarter (23.41%) of the participants reported taking exercise on daily basis whereas 27.90% reported never taking any. Respectively 6.0% and 38.1% of the participants reported feeling very unsafe walking in the neighborhood during day and night. In regression analysis, both the pooled and stratified models indicated that lack of PNS was inversely associated with regular PE. Lack of PNS (bit unsafe) during day was associated with lower odds of PE both among men (OR = 0.776, P < .001) and women (OR = 0.874, P < .001). The negative association between lack of PNS and PE during day was significant among those living with disability (OR = 0.758, P < .001). Further analysis showed that the negative association between lack of PNS with regular PE during day was significant in Johannesburg (OR = 0.800, P < .001), Tshwane (OR = 0.735, P < .001) and Emfuleni (OR = 0.619, P < .001) only, while that during night was significant in Johannesburg (OR = 0.737, P < .001), Ekurhuleni (OR = 0.673, P < .001), Emfuleni (OR = 0.418, P < .001), Lesedi (OR = 0.385, P < .001), Mogale City (OR = 0.693, P < .001), and Randfontein (OR = 0.565, P < .001). Overall, the findings highlight a significantly inverse association between lack of PNS and PE behavior. In light of the current findings, it is recommended that PE promotion programs pay special attention on population living in the neighborhoods fraught with crime concerns.

A randomised controlled feasibility study of interpersonal art psychotherapy for the treatment of aggression in people with intellectual disabilities in secure care

BACKGROUND

Rates of aggression in inpatient secure care are higher than in other psychiatric inpatient settings. People with intellectual disabilities in secure care require adapted psychological treatments. Interpersonal art psychotherapy incorporates the use of creative art making approaches by participants, thus reducing sole reliance upon verbal interactions during psychotherapy for people who may have communication difficulties. During interpersonal art psychotherapy, participants are individually supported by their therapist to consider how they conduct relationships. This includes the influence and impact of interpersonal issues resulting in repeated patterns of conflict. The key feasibility objectives were to assess recruitment and retention rates, follow-up rates and trial procedures such as randomisation, allocation and identifying any practical or ethical problems. In addition, a preliminary 'signal' for the intervention was considered and an indicative sample size calculation completed. The acceptability of a potential third trial arm attentional control condition, mindful colouring-in, was assessed using four single-case design studies and a UK trial capacity survey was conducted.

METHODS

Adult patients with intellectual disabilities in secure care were recruited and randomised to either interpersonal art psychotherapy or delayed treatment in this multi-site study. Outcomes were assessed using weekly observations via the Modified Overt Aggression Scale and a range of self-report measures. Within study reporting processes, qualitative interviews and a survey were completed to inform trial feasibility.

RESULTS

Recruitment procedures were successful. The target of recruiting 20 participants to the trial from multiple sites was achieved within 8 months of the study opening. All participants recruited to the treatment arm completed interpersonal art psychotherapy. Between-group differences of interpersonal art psychotherapy versus the delayed treatment control showed a 'signal' effect-size of .65 for total scores and .93 in the verbal aggression sub-scale. There were no amendments to the published protocol. The assessment of key feasibility objectives were met and the trial procedures were acceptable to all involved in the research.

CONCLUSION

This study suggested that a randomised controlled trial of interpersonal art psychotherapy is acceptable and feasible.

TRIAL REGISTRATION

ISRCTN14326119 (Retrospectively Registered).

Social reactions to disclosure of sexual violence in female adults with mild to moderate intellectual disabilities: a qualitative analysis of four cases

Socio-interpersonal factors have a strong potential to protect individuals against pathological processing of traumatic events. While perceived social support has emerged as an important protective factor, this effect has not been replicated in people with intellectual disabilities (ID). One reason for this might be that the relevance of socio-interpersonal factors differs in people with ID: Social support may be associated with more stress due to a generally high dependency on sometimes unwanted support. An exploration of the role of posttraumatic, socio-interpersonal factors for people with ID is therefore necessary in order to provide adequate support. The current study aims to explore the subjective perception of social reactions to disclosure of sexual violence in four women with mild to moderate ID. The study was conducted in Austria. The women were interviewed about their perception of received social reactions as benevolent or harmful, their emotional response, and whether they perceived being treated differently due to their ID diagnosis. The interviews were analysed using qualitative content analysis. First, the interviews were coded inductively, and social reactions were then deductively assigned to three categories that were derived from general research: positive reactions, unsupportive acknowledgement, turning against. Findings on the perception of social reactions were in line with findings from the general population. Overall, participants reported that they did not feel that they were treated any differently from persons without disabilities. However, the social reactions they received included unjustified social reactions, such as perpetrators not being held accountable. A possible explanation may be a habituation and internalisation of negative societal attitudes towards women with ID. Empowerment programmes and barrier-free structural support for women with ID following trauma exposure should be improved.

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.

Sexual abuse and violence against people with intellectual disability and physical impairments: Characteristics of police-investigated cases in a Norwegian national sample

BACKGROUND

Although people with disabilities are more exposed to violence and sexual abuse, research on the judicial process in such cases is still lacking. This study uses crime statistics to describe this phenomenon.

METHOD

A national sample from the National Criminal Investigation Service in Norway was analysed for the period October 2015 to December 2017.

RESULTS

The total number of alleged victims was 175, across 74 cases. The majority of the victims (71.2%) were females, subjected to a sexual offence. Overall, 30% of all cases led to a penal sanction.

CONCLUSION

The study shows a preponderance of sexual offences against females with disabilities and few cases comprise violence. Relatively, few cases involve violations against children with disabilities. This might suggest an underreporting of such criminal acts. The knowledge of potential reasons why violent crime and offences against children with disabilities are absent from the data registry needs to be strengthened.

'Taking the wheels off': young people with cognitive impairment in out-of-home care

Children with cognitive impairment in out-of-home care (OOHC) are significantly over-represented in the criminal justice system. Little attention has been given to the connection between those with cognitive impairment who also have a care background and how these combined factors are linked to their criminal behaviour. A qualitative study utilising semi-structured interviews with 11 senior strategic officers and service providers to this cohort was conducted with the aim of investigating the views of these professionals and gaining insight into factors contributing to the criminalisation of children with cognitive impairment in OOHC. Five themes were identified using thematic analysis, suggesting that the primary areas of concern are: (a) increased vulnerability, (b) lack of belonging and security, (c) challenges with identification, (d) steering to the criminal justice system and (e) lack of support. These findings have important implications for both policy and practice, which are discussed in full.

Strategies to Promote the Inclusion of Young Adults With Developmental Disabilities in Community-Based Health Studies

We discuss strategies to promote the inclusion of people with developmental disabilities (DDs) in qualitative community-based research studies. Strategies were applied in three projects conducted between 2012 and 2017 that addressed issues of socioeconomic challenges, discrimination, and exclusion of children and young adults with developmental disabilities (YADD). Strategies included partnership with community organizations; inclusion of YADD, family caregivers (FCs), and service providers in advisory committees (ACs); and strategies to accommodate YADD. As part of our contribution, we discuss issues of invisibility and exclusion of individuals with DDs who have "low" functioning capacities. There is a need to review studies sampling inclusion criteria as they may constitute a barrier for participation. Preference for sampling "high" functioning individuals may reinforce exclusion in research, and replicate broader patterns of socioeconomic exclusion of individuals with disabilities. Our discussion of inclusive research is informed by critical disability studies and the underlying principle "nothing about us without us."

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.

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.

Gender differences in characteristics of physical and sexual victimization in patients with dual diagnosis: a cross-sectional study

BACKGROUND

Patients with substance use disorders and co-occurring mental health disorders are vulnerable to violent victimization. However, no evidence-based interventions are available to reduce patients' vulnerability. An exploration of the characteristics of physical and sexual violence can provide valuable information to support the development of interventions for these patients. This study aimed to examine gender differences in characteristics of violent victimization in patients with dual diagnosis.

METHODS

In this cross-sectional survey study recent incidents of physical and sexual assault were examined with the Safety Monitor in 243 patients with dual diagnosis. Chi-square tests were used to examine gender differences in the prevalence of physical and sexual victimization. Fisher's exact tests and Fisher-Freeman-Halton exact tests were used to determine whether there were significant differences between victimized men and women with regard to perpetrators, locations, reporting to the police and speaking about the assault with others.

RESULTS

There was no significant difference in the prevalence of physical violence in men (35%) and women (47%) with dual diagnosis. There was a significant association between gender of the victim and type of perpetrator (P < .001). Men were most often physically abused by a stranger or an acquaintance, whereas women were most frequently abused by an (ex)partner. Sexual violence was more prevalent in women (29%) compared to men (4%) (P < .001). Patients with dual diagnosis were unlikely to report incidents of physical abuse and sexual assault to the police and to speak about it with caregivers.

CONCLUSIONS

Characteristics of physical violence are different for men and women with dual diagnosis. Women with dual diagnosis are more often victims of sexual violence compared to men. Interventions aimed at reducing patients' vulnerability for victimization should take gender differences into account.

Disconnected lives: Women with intellectual disabilities in conflict with the law

BACKGROUND

Women with intellectual/developmental disabilities in conflict with the law experience childhood trauma, substance abuse and intimate partner violence but continue to have difficulty accessing appropriate therapeutic services, both within correctional settings and upon discharge. The aim of this study is to explore women's service needs and to critically assess whether the available services are meeting their identified needs.

METHOD

Semi-structured interviews were conducted with 16 women with intellectual/developmental disabilities who were in the Special Needs Unit of a women's correctional centre from December 2014 to March 2015.

RESULTS

Women with intellectual/developmental disabilities struggle to manage the impact of intergenerational trauma, exacerbated by issues of substance abuse and addiction, poor coping skills and minimal education, all of which impact their sense of well-being.

CONCLUSIONS

This study highlights the need for increasing trauma treatment for women with intellectual/developmental disabilities, and emphasizes the need for accessible intervention to facilitate coping, trauma processing and community integration.

Estimating the risk of crime and victimisation in people with intellectual disability: a data-linkage study

PURPOSE

People with intellectual disability (PWID) appear more likely to be victims and perpetrators of crime. However, extant evidence pertaining to these risks is limited by methodological weaknesses and the absence of consistent operational definitions. This research aimed to estimate the prevalence of criminal histories and victimisation using a large, well-defined sample of PWID.

METHODS

A case-linkage study was conducted comprising 2220 PWID registered with disability services in Victoria, Australia, whose personal details were linked with a state-wide police database. Criminal charges and reports of victimisation were compared to a non-disabled community comparison sample (n = 2085).

RESULTS

PWID were at increased risk of having a history of criminal charges, particularly for violent and sexual offences. Although the non-disabled comparison group had a greater risk of criminal victimisation overall, PWID had a greatly increased risk of sexual and violent crime victimisation.

CONCLUSIONS

PWID are at increased risk of victimisation and perpetration of violent and sexual crimes. Risk of sex offending and victimisation is particularly elevated, and signalling the need for specialised interventions to prevent offending and to ensure victims is assisted with access to justice, support, and treatment.