Extending section 12 approval under the Mental Health Act to professions other than medicine

Applications for detention under civil sections of the England and Wales Mental Health Act 1983 require at least one recommendation from a registered medical practitioner who is approved under section 12 of the Act. The Mental Health Act 2007 introduced multi-professional approved clinicians who may act as a patient's responsible clinician with responsibilities that include renewal of detention for treatment. Approved clinicians who are medical practitioners are automatically approved for section 12 purposes, whereas other approved clinicians are not. It is argued in this paper that this inconsistency is illogical, has implications for patient care and needs to be remedied.

Cognitive behavioural anger treatment for adults with intellectual disabilities: effects of therapist experience on outcome

BACKGROUND

Anger has been shown to be associated with aggression and violence in adults with intellectual disabilities in both community and secure settings. Emerging evidence has indicated that cognitive behavioural anger treatment can be effective in reducing assessed levels of anger and violent behaviour in these patient populations. However, it has been suggested that the effectiveness of these types of interventions is influenced by the experience and training of the therapists.

METHOD

In this service evaluation study, the pre- and post-treatment and 12-month follow-up assessment scores of 88 detained in-patient adults with intellectual disabilities and forensic histories who received cognitive behavioural anger treatment were examined in order to investigate whether participants' responsiveness to treatment was associated with treatment being delivered by qualified versus unqualified therapists.

RESULTS

Overall significant reductions in self-reported measures of anger disposition and anger reactivity were found with no significant time × therapist experience interaction effects. However, the patients treated by qualified therapists improved significantly on measures of anger control compared with those allocated to unqualified therapists.

CONCLUSIONS

Male and female detained patients with intellectual disabilities and forensic histories can benefit from an individual cognitive behavioural anger treatment intervention delivered by qualified and unqualified therapists, but therapist experience may be important in supporting patients to develop more complex anger control coping skills.

England and Wales draft Mental Health Bill: Implications for people with intellectual disabilities

The draft Mental Health Bill published by the UK Government in July 2022 aims to reform mental health legislation in England and Wales. One significant proposal is to remove intellectual disability and autism from the scope of the legislation in all but a limited number of circumstances. The basis for this proposed change is not clear and there are no plans to introduce alternatives to the current legislation for people with intellectual disabilities and autism whose behaviour is challenging and present significant risks to themselves or others. This paper examines the implications of these proposals for people with intellectual disabilities. It considers the New Zealand experience as the only other common-law jurisdiction to implement a similar legislative change. Links to the government's Transforming Care de-institutionalisation programme and associated policies are explored and calls for a review of this approach are set out.

Experiences of Parents of Specialist Peer Mentored Autistic University Students

ABSTRCTBackground: Parents continue to support to autistic university students, and consequently, experience considerable stress.Aim: To explore the experiences of parents of specialist peer mentored university students and to examine these using the ICF as a theoretical framework.Method: Thirteen semi-structured interviews were completed and analyzed using thematic analysis. Directive content analysis linked the data to the ICF core set for autism spectrum disorders (ASD).Results: Five interrelated themes emerged: The mentoring relationship is a facilitator, Developing skills for university, Mentoring changes lives, Mentoring is not a substitute for other supports, and University is an emotional rollercoaster. Specialist peer mentoring was linked to Activity and Participation (44%) and Environmental factors (32%) of the ICF core set for ASD.Conclusion: These results add to the specialist peer mentoring evidence-base, and indicate perceived benefits for autistic university students and their parents. An unintended consequence was that parents broadened their participation in activities.

Contralateral Effects of Unilateral Strength and Skill Training: Modified Delphi Consensus to Establish Key Aspects of Cross-Education

Background

Cross-education refers to increased motor output (i.e., force generation, skill) of the opposite, untrained limb following a period of unilateral exercise training. Despite extensive research, several aspects of the transfer phenomenon remain controversial.

Methods

A modified two-round Delphi online survey was conducted among international experts to reach consensus on terminology, methodology, mechanisms of action, and translational potential of cross-education, and to provide a framework for future research.

Results

Through purposive sampling of the literature, we identified 56 noted experts in the field, of whom 32 completed the survey, and reached consensus (75% threshold) on 17 out of 27 items.

Conclusion

Our consensus-based recommendations for future studies are that (1) the term ‘cross-education’ should be adopted to refer to the transfer phenomenon, also specifying if transfer of strength or skill is meant; (2) functional magnetic resonance imaging, short-interval intracortical inhibition and interhemispheric inhibition appear to be promising tools to study the mechanisms of transfer; (3) strategies which maximize cross-education, such as high-intensity training, eccentric contractions, and mirror illusion, seem worth being included in the intervention plan; (4) study protocols should be designed to include at least 13–18 sessions or 4–6 weeks to produce functionally meaningful transfer of strength, and (5) cross-education could be considered as an adjuvant treatment particularly for unilateral orthopedic conditions and sports injuries. Additionally, a clear gap in views emerged between the research field and the purely clinical field.

The present consensus statement clarifies relevant aspects of cross-education including neurophysiological, neuroanatomical, and methodological characteristics of the transfer phenomenon, and provides guidance on how to improve the quality and usability of future cross-education studies.

Electronic supplementary material

The online version of this article (10.1007/s40279-020-01377-7) contains supplementary material, which is available to authorized users.

Short report and initial evaluation of the factor structure of the Lancaster and Northgate Trauma Scales (LANTS)

BACKGROUND

Research suggests exposure to adverse life events is elevated in people with intellectual disabilities. We developed the Lancaster and Northgate Trauma Scales (LANTS) to address the limited availability of screening questionnaires for people with intellectual disabilities affected by adverse traumatic experiences.

AIMS

The aims of this study were to (i) evaluate the factor structure of the self-report LANTS and (ii) assess compatibility with the International Classification of Diseases Eleventh Revision (ICD-11) criteria for complex PTSD.

METHODS AND PROCEDURE

Ninety-eight people with mild to moderate intellectual disability (86 % men; mean age 41 years) completed the self-report LANTS. Exploratory factor analysis was undertaken using a polychoric correlation matrix, appropriate for the LANTS ordinal response options.

OUTCOMES AND RESULTS

Seven items including self-harm and anger were non-normal in distribution and excluded from the analysis; a four-factor structure was identified for the 22 remaining items. We make suggestions for correspondence of LANTS items to ICD-11 criteria for complex PTSD.

CONCLUSIONS AND IMPLICATIONS

This is the first exploratory factor analysis of the LANTS. Items pertaining to anger and self-harm may be prone to response bias and development of these items using qualitative methods would be useful. The findings require replication with a larger group of people with intellectual disabilities, including more women.

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).

Prevalence of motor impairment in residents of New South Wales, Australia aged 55 years and over: cross-sectional survey of the 45 and Up cohort

BACKGROUND

The population prevalence of many diseases is known. However, little is known of the population prevalence of motor impairments.

METHODS

The aim of this study was to determine the point prevalence of specific motor impairments (weakness, fatigue, contracture, impaired balance and impaired coordination) in the population aged 55 years and older resident in New South Wales, Australia in 2018. 55,210 members of the 45 and Up cohort were invited to participate in a follow-up survey that included questions on motor impairment. Responses were received from 20,141 people (36%). Calibrated estimates of prevalence of specific motor impairments, and of having at least one motor impairment, were obtained using survey weights based on the known multivariate distributions of age, gender and geographical location (28 regions) in the population.

RESULTS

More than one-third of adults aged over 55 residing in New South Wales have difficulty using their hands, arms or legs. The prevalence of each motor impairment (muscle weakness, fatigue, contracture, impaired balance or impaired coordination) in this population is between 4 and 12%. The prevalence of at least one of these impairments is 21%. The prevalence of at least one impairment in people aged 85 and over is 42%. Women consistently had more difficulty using hands, arms and legs, and more motor impairment, than men. Difficulty using hands, arms and legs and the prevalence of all motor impairments, especially poor balance, greatly increased with age.

CONCLUSION

The prevalence of specific motor impairments in older Australian adults is high - comparable to that of the most prevalent diseases. There may be merit in considering motor impairment as a significant public health problem in its own right.

1137 Sleep Duration, Physical Activity And Cognitive Decline In Chinese Older Adults: Findings From The CHARLS

Introduction

Lack of physical activity and disturbed sleep have been linked to older adult’s poor cognitive outcomes; however, little is unknown how they interact to affect cognition long-term. The purpose of this study was to examine the association of baseline sleep duration and physical activity (PA) with change in cognition independently and interactively over four years.

Methods

The sample included 1126 community-dwelling older adults aged 60+ (mean age 67.1±5.9 years, 51% female) from the 2011 baseline and 2015 follow-up data of the China Health and Retirement Longitudinal Study (CHARLS). All variables were assessed through interviews. Sleep duration was measured with hours per 30-minute interval and categorized as very-short (<5h), short (5-6.5h), normal (7-8.5h), and long (≥9h). PA was calculated based on PA intensity, duration, and number of days. Cognition was a composite score of mental capacity, episodic memory, and visuospatial abilities. Data were analyzed using multiple regression (primary outcome: change in cognition; main independent variables: baseline sleep, PA, and sleep PA interaction).

Results

At baseline, 19% of participants had very-short sleep duration, 34.4% had short sleep, 39.2% had normal sleep, and 7.2% had long sleep. At follow-up, 57.5% of participants experienced cognitive decline (-3.5±2.5). After controlling for age, gender, education, region, body mass index, smoking, drinking, number of chronic conditions, pain, depression, and cognition at baseline, compared to participants reporting 7-8.5h sleep, those with ≥9h sleep had significantly greater decline in cognition [β=-1.4, 95% CI=2.4, -0.4], while those with <5h sleep [β=-0.5, 95% CI=-1.2, 0.2] and 5-6.5h sleep did not [β=-0.1, 95% CI=-0.7, 0.5]. PA was neither associated with cognitive decline, nor moderated the relationship between sleep duration and cognitive decline.

Conclusion

Long sleep might be a marker of cognitive decline in older adults. Prospective analysis, using objectively measured PA and sleep should be conducted to further examine these associations.

Support

National Institute of Nursing Research R00NR016484

Unlike voluntary contractions, stimulated contractions of a hand muscle do not reduce voluntary activation or motoneuronal excitability

Voluntary force declines during sustained, maximal voluntary contractions (MVC) due to changes in muscle and central nervous system properties. Central fatigue, an exercise-induced reduction in voluntary activation, is influenced by multiple processes. Some may occur independently of descending voluntary drive. To differentiate the effects associated with voluntary drive from other central and peripheral influences, we measured voluntary activation and motoneuron excitability following fatiguing contractions produced voluntarily or by electrical stimulation. On two separate days, participants performed either a 2-min MVC of adductor pollicis muscle or received 2-min continuous supramaximal electrical stimulation of the ulnar nerve. In study 1 (n = 14), the superimposed twitch elicited by ulnar nerve stimulation during brief MVCs was increased, and, hence, voluntary activation was reduced, up to 240 s after the 2-min MVC [-20 ± 12% (SD), P = 0.002] but not the 2-min stimulated contraction (-4 ± 7%), despite large reductions in MVC force (voluntary, -54 ± 18%; stimulated, -46 ± 16%). In study 2 (n = 12), F-waves recorded from the adductor pollicis were reduced in area for 150 s following the 2-min MVC (-21 ± 16%, P = 0.007) but not after the stimulated contraction (5 ± 27%). Therefore, voluntary activation and motoneuron excitability decreased only when descending voluntary drive was present during the fatiguing task. The findings do not exclude a cortical or brain stem contribution to the reduced voluntary activation but suggest that neither sensory feedback from the fatigued muscle nor repetitive activation of motoneurons underlie the changes, whereas they are consistent with motoneuronal inhibition by released factors linked to voluntary drive.NEW & NOTEWORTHY We demonstrate that reductions in voluntary activation and motoneuron excitability following 2-min isometric maximal contractions in humans occur only when fatigue is produced through voluntary contractions and not through electrically stimulated contractions. This is contrary to studies that suggest that changes in the superimposed twitch and therefore voluntary activation are explained by changes in peripheral factors alone. Thus, the interpolated twitch technique remains a viable tool to assess voluntary activation and central fatigue.

Delivering the Transforming Care programme: a case of smoke and mirrors?

SummaryThe Transforming Care national plan for England to develop community services and close hospital beds for people with intellectual disabilities and/or autism was published in October 2015 and is due to finish in March 2019. In this editorial the key plan objectives are evaluated, with particular reference to people with intellectual disabilities and/or autism who offend or are at risk of offending. The conclusion is that, to date, the plan has failed to meet its targets to reduce the number of in-patients with intellectual disabilities and/or autism and to invest in community services, and the number of patients in independent sector beds is increasing.Declaration of interestThe author is employed by Northumberland, Tyne and Wear National Health Service Foundation Trust, however the opinions expressed in this article are the author's own and do not reflect the views of the Trust.

Effects of acute isometric resistance exercise on cervicomedullary motor evoked potentials

Cervicomedullary motor evoked potentials (CMEPs) in relaxed biceps brachii have been reported to facilitate after acute isometric exercise of the elbow flexors. This facilitation, which reflects either enhanced corticospinal transmission or increased motoneurone excitability, has only been documented in the limb posture used during exercise. In Experiment 1, we tested if these spinal changes "transfer" to a second posture. Fourteen individuals completed 12 sets of high-force isometric contractions of the elbow flexors with the forearm pronated. Before and after exercise, biceps CMEPs were acquired with the forearm either pronated or supinated. CMEPs in pronation and supination were facilitated after exercise, indicating transfer (57.5 ± 55.5% and 53.9 ± 54.9%, respectively; mean ± SD). In Experiment 2, we examined if exercise posture influences the effect that exercise has on CMEPs. A different sample of 14 individuals performed isometric exercise in 2 sessions. In one, exercise was performed in supination. In the other, exercise was performed in pronation. Exercise intensity and volume were the same as in Experiment 1, as were participant characteristics. CMEPs were unchanged after exercise in supination (13.6 ± 31.2%) and pronation (7.7 ± 41.5%). The absence of an effect differs from the finding of Experiment 1. Thus, effects of acute isometric resistance exercise on corticospinal transmission and/or motoneurone excitability are not as consistent as previously thought. When exercise induces this spinal change, the effect is not specific to the posture used for exercise. However, the change does not always occur, and the reasons for this remain unknown.

Interpersonal art psychotherapy for the treatment of aggression in people with learning disabilities in secure care: a protocol for a randomised controlled feasibility study

Background

Art psychotherapy has greater potential for use with adults with mild to moderate learning disabilities as it places less of a burden on verbal interaction to achieve positive therapeutic, psychological, and behavioural goals. The feasibility study objectives include testing procedures, outcomes, validated tools, recruitment and attrition rates, acceptability, and treatment fidelity for manualised interpersonal art psychotherapy.

Methods

Adult males and females with mild to moderate learning disabilities will be recruited from four NHS secure hospitals. Twenty patients will be recruited and randomly assigned to one of two treatment groups: fifteen 1-h individual sessions of manualised interpersonal art psychotherapy, or a treatment as usual waiting list control group. The Modified Overt Aggression Scale will be administered to both treatment arms. Four patients will be recruited to a single-case design component of the study exploring the acceptability of an attentional condition.

Discussion

This multi-site study will assist in future trial planning and inform feasibility including, procedures, treatment acceptability, therapist adherence, and estimation of samples size for a definitive RCT.

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0186-z) contains supplementary material, which is available to authorized users.

The impact of transforming care on the care and safety of patients with intellectual disabilities and forensic needs

NHS England recently published a national plan to develop community services for people with intellectual disabilities and autism who display challenging behaviour by using resources from the closure of a large number of hospital beds. An ambitious timescale has been set to implement this plan. The bed closure programme is moving ahead rapidly, but there has been little progress in developing community services to support it. This paper discusses the impact of the gap between policy and practice on the care and safety of patients with intellectual disabilities and forensic needs who form a distinct subgroup of the target population and are being disproportionately affected by this government policy.

[The application of yeast hybrid systems in protein interaction analysis]

Yeast hybrid systems have been widely used due to their convenience and low cost. Based on these systems, many methods have been developed to analyze protein-protein, protein-DNA and protein-RNA interactions. In this paper, we are reviewing these different yeast hybrid systems. According to the number of hybrid proteins, yeast hybrid systems can be divided into three categories, yeast one-hybrid, yeast two-hybrid and yeast three-hybrid systems. Alternatively, yeast hybrid systems can be categorized according to the subcellular localization of the protein interaction process in the cell into nuclear protein-protein interactions, cytosol protein-protein interactions and membrane protein-protein interactions. Throughout the review, we focus on the progress and limitations of each yeast hybrid system over the recent years.

Reductions in aggression and violence following cognitive behavioural anger treatment for detained patients with intellectual disabilities

BACKGROUND

Aggression is a significant problem amongst people with intellectual disabilities (ID), particularly those residing in hospital settings. Anger is related to aggression in secure services working people with ID, and the effectiveness of psychological interventions in reducing anger has been demonstrated in this population. However, no studies have systematically examined whether levels of aggression reduce following anger treatment with people with ID detained in secure settings.

METHOD

This programme evaluation study concerns individually delivered cognitive anger treatment delivered to 50 patients (44 men and 6 women) with mild to borderline ID, delivered twice weekly for 18 sessions in a specialist forensic hospital service. Aggressive incidents and physical assault data were obtained from records 12 months pre-treatment and 12 months post-treatment.

RESULTS

Following completion of treatment, the total number of aggressive incidents recorded in patients' files fell by 34.5%, and the post-treatment reduction in the number of physical assaults was 55.9%. Analysis of the data partitioned into 6-month blocks over the 24-month study period showed that significant reductions in aggressive and violent incidents occurred in the assessment intervals following anger treatment.

CONCLUSIONS

These findings reinforce the efficacy of cognitive behavioural anger treatment for detained patients with ID and histories of aggression; and despite its methodical limitations the study indicates the ecological validity of this treatment approach.

A preliminary controlled trial of a trans-diagnostic programme for cognitive behaviour therapy with adults with intellectual disability

BACKGROUND

Several studies have found a heightened prevalence of mental health disorders in people with intellectual disabilities (ID). There have been a number of successful case series and two promising controlled treatment trials of cognitive behaviour therapy (CBT) for emotional disorders (excluding anger) for people with ID. Several authors have promoted the development of trans-diagnostic approaches to cognitive treatment. The present study extends this work with the development and evaluation of a trans-diagnostic treatment manual for CBT in people with ID.

METHOD

A controlled treatment trial was conducted with 12 participants in treatment and waiting list control data. Each treatment participant was matched to a control on age, IQ, presenting problem, and Brief Symptom Inventory (BSI) global severity index (GSI) score. The treatment group was also evaluated on the Glasgow anxiety and depression scales and was followed up for 3 to 6 months after treatment.

RESULTS

There were no significant differences between groups at baseline. Following treatment, the CBT group was significantly improved when compared with the control group on the GSI scale of the BSI. The ancovas for all other measures were not significant but there were significant improvements for the treatment group on all scaled except BSI depression from pre to post-CBT. Gains were maintained to follow up, and changes were associated with large effect sizes.

CONCLUSIONS

It was possible to treat a range of symptoms and psychiatric diagnoses with a general trans-diagnostic CBT manual. The effects of therapy were promising, suggesting that the participants could respond to treatment in a meaningful and helpful manner and supporting the case for further evaluation of the trans-diagnostic approach in ID.

A prospective study of the relationship between adverse life events and trauma in adults with mild to moderate intellectual disabilities

BACKGROUND

Research has demonstrated a relationship between the experience of life events and psychopathology in people with intellectual disabilities (ID), however few studies have established causal links and to date no prospective studies have utilised a measure of trauma that has been developed specifically for this population group.

METHOD

This 6-month prospective study examined longitudinal relationships between adverse life events and trauma in 99 adults with mild to moderate ID.

RESULTS

Life events during the previous 6 months were significantly predictive of levels of trauma as measured by the self-report Lancaster and Northgate trauma scales (LANTS), and the informant LANTS behavioural changes, frequency and severity sub-scales. This prospective causal relationship was demonstrated while controlling for any prior life events or pre-existing trauma, though the relationship was not moderated by social support.

CONCLUSIONS

Evidence of a causal relationship between adverse life events and trauma symptoms is important for treatment planning and funding allocation.

How do static and dynamic risk factors work together to predict violent behaviour among offenders with an intellectual disability?

BACKGROUND

Research on risk assessment with offenders with an intellectual disability (ID) has largely focused on estimating the predictive accuracy of static or dynamic risk assessments, or a comparison of the two approaches. The aim of this study was to explore how static and dynamic risk variables may 'work together' to predict violent behaviour.

METHODS

Data from 212 offenders with an ID were analysed. Risk assessment tools included one static measure (Violence Risk Appraisal Guide), and two dynamic measures (Emotional Problems Scale and the Short Dynamic Risk Scale). Six-month concurrent prediction data on violent behaviour were collected. A structured methodology was employed to explore putative relationships between static and dynamic factors.

RESULTS

Static risk factors temporally preceded dynamic ones, and were shown to dominate both dynamic measures, while there was a non-zero relationship between the static and the two dynamic measures. According to Kraemer et al., these findings suggest that dynamic risk factors function as proxy risk factors for static risk.

CONCLUSIONS

Dynamic and static risk factors appear to capture elements of the same underlying risk associated with violent behaviour in individuals with an ID. This is the first study to empirically explore risk interrelationships in the forensic ID field. We discuss the importance of the contribution of dynamic variables in the prediction and management of risk.

Alcohol and its relationship to offence variables in a cohort of offenders with intellectual disability

BACKGROUND

Alcohol use and misuse may be lower in people with intellectual disability (ID) than in the general population but may be related to offending.

METHOD

Alcohol-related crime and history of alcohol use was recorded in 477 participants with ID referred to forensic ID services and related to offending.

RESULTS

Level of alcohol-related crime and history of alcohol misuse was lower than in some previous studies at 5.9% and 20.8%, respectively. History of alcohol abuse was associated with alcohol-related offences and theft. Higher rates of alcohol problem history were associated with histories of a number of offences, psychiatric disturbance in adulthood, psychiatric disturbance in childhood, and experiences of childhood adversity. Most effect sizes were weak or moderate.

CONCLUSIONS

The convergence of childhood adversity, psychiatric problems in childhood and adulthood, and alcohol abuse is consistent with studies that have found these as risk markers for offending.

The impact of known criminogenic factors on offenders with intellectual disability: previous findings and new results on ADHD

BACKGROUND

Developmental and index offence variables have been implicated strongly in later criminal behaviour and service pathways and this paper investigated attention deficit hyperactivity disorder (ADHD) which, with conduct disorder, has emerged from previous studies on offenders. ADHD and conduct disorder are over-represented among criminal populations when compared to the general population. The present authors reviewed the extent to which ADHD affected the presentation of offenders with intellectual disability.

METHOD

Information related to index behaviour, history of problem behaviours, childhood adversity and psychiatric diagnoses was recorded in 477 referrals to forensic intellectual disability services. Comparisons were made between those with a previous diagnosis of ADHD and those without.

RESULTS

The ADHD group showed higher proportions of physical aggression, substance use, previous problems including aggression, sexual offences and property offences, birth problems and abuse in childhood. Effect sizes were small.

CONCLUSION

Attention deficit hyperactivity disorder with conduct disorder is associated with a greater degree and history of problematic behaviour in offenders with intellectual disability.

A multicentre study comparing two methods for serum free light chain analysis

Background

Serum free light chain analysis is now well established in the investigation of monoclonal gammopathies. In the UK there has, until recently, been a single supplier of kits for such analysis. Recently, a second method using monoclonal antisera was introduced. We have compared the performance of these two kits in four routine laboratories.

Method

Samples submitted for routine analysis (327 samples, 258 [79%] from patients with B-cell lymphoproliferative disease) for serum free light chains were tested by both technologies (Freelite, Binding Site and N Latex FLC, Siemens), according to the manufacturers’ instructions.

Results

Qualitative data were available by both methods on 313 samples for serum free kappa chains and 324 samples for lambda free light chains. We found poor correspondence of 81% for kappa and 74% for lambda. Five percent of samples were significantly discordant in these assays.

Conclusions

These assays perform very differently in clinical practice. They cannot be used interchangeably, especially if monitoring patient responses to therapy.

Twitch interpolation: superimposed twitches decline progressively during a tetanic contraction of human adductor pollicis

The assessment of voluntary activation of human muscles usually depends on measurement of the size of the twitch produced by an interpolated nerve or cortical stimulus. In many forms of fatiguing exercise the superimposed twitch increases and thus voluntary activation appears to decline. This is termed 'central' fatigue. Recent studies on isolated mouse muscle suggest that a peripheral mechanism related to intracellular calcium sensitivity increases interpolated twitches. To test whether this problem developed with human voluntary contractions we delivered maximal tetanic stimulation to the ulnar nerve (≥60 s at physiological motoneuronal frequencies, 30 and 15 Hz). During the tetani (at 30 Hz) in which the force declined by 42%, the absolute size of the twitches evoked by interpolated stimuli (delivered regularly or only in the last second of the tetanus) diminished progressively to less than 1%. With stimulation at 30 Hz, there was also a marked reduction in size and area of the interpolated compound muscle action potential (M wave). With a 15 Hz tetanus, a progressive decline in the interpolated twitch force also occurred (to ∼10%) but did so before the area of the interpolated M wave diminished. These results indicate that the increase in interpolated twitch size predicted from the mouse studies does not occur. Diminution in superimposed twitches occurred whether or not the M wave indicated marked impairment at sarcolemmal/t-tubular levels. Consequently, the increase in superimposed twitch, which is used to denote central fatigue in human fatiguing exercise, is likely to reflect low volitional drive to high-threshold motor units, which stop firing or are discharging at low frequencies.

Responsivity to criminogenic need in forensic intellectual disability services

BACKGROUND

Research has shown for some time that addressing criminogenic need is one of the crucial aspects of reducing reoffending in all types of offenders. Criminogenic need such as anger or inappropriate sexual interest is considered to be crucial in the commission of the offence. The aim of the present study is to investigate the extent to which forensic services address the needs of those accepted into services.

METHOD

This study reviews the treatment for 197 offenders with intellectual disability accepted into a range of services. Participants' case files were examined to ascertain the extent to which need was addressed through recognised therapies. A standard pro forma was used on which we had established good reliability across four research assistants.

RESULTS

The most frequently referred problems were violence and sexual offending. Specialist forensic intellectual disability community services were significantly more likely to provide treatment specifically designed to address index behaviours when compared to generic community services and secure services.

CONCLUSIONS

Various possible explanations of these findings are explored including staffing levels, diagnosed mental illness, expertise of staff and clarity of purpose in services.

A brief screening instrument for emotionally unstable and dissocial personality disorder in male offenders with intellectual disabilities

Personality disorder is prevalent among offenders with intellectual disabilities (ID), and it is associated with their risk for violence and recurrent offending behaviour. A new staff-rated instrument, the Personality Disorder Characteristics Checklist (PDCC), designed to screen for ICD-10 dissocial and emotionally unstable personality characteristics was evaluated for its reliability and validity, as applied to 129 male forensic patients with ID. Internal consistency and test-retest reliability were very good. Supportive evidence for concurrent and discriminant validity was obtained in conjunction with an established staff-rated instrument, but not for patient self-report measures. Construct validity support was found for the PDCC in association with violent offence and hospital assault history and in significantly accounting for the number of physical assaults in hospital, controlling for multiple covariates. Results for the new measure were favourable in comparison to established instruments. It clinical utility for treatment planning and for the management of risk is discussed.

The Lancaster and Northgate Trauma Scales (LANTS): the development and psychometric properties of a measure of trauma for people with mild to moderate intellectual disabilities

People with intellectual disabilities are exposed to a high number of adverse life events, and evidence supports a link between the experience of adverse life events and trauma. Interventions for trauma have been found to be efficacious if case recognition can be facilitated. However to date there are no psychometrically validated measures of trauma for people with intellectual disabilities. This study describes the development of the Lancaster and Northgate Trauma Scales (LANTS), which comprise a self-report and an informant measure of the effects of traumatic life events on people with intellectual disabilities. The pool of items for the measures was created via a systematic review, and consultation with key stakeholders. 99 service users and 88 staff completed the LANTS measures during a pilot. The 29-item self-report LANTS and the 43-item informant LANTS were found to have good psychometric properties, including internal and test retest reliability, plus convergent and construct validity. The findings suggest the LANTS are promising trauma screening tools for use in clinical and research settings.

Dynamic changes in the perceived posture of the hand during ischaemic anaesthesia of the arm

Contorted 'phantom' limbs often form when sensory inputs are removed, but the neural mechanisms underlying their formation are poorly understood. We tracked the evolution of an experimental phantom hand during ischaemic anaesthesia of the arm. In the first study subjects showed the perceived posture of their hand and fingers using a model hand. Surprisingly, if the wrist and fingers were held straight before and during anaesthesia, the final phantom hand was bent at the wrist and fingers, but if the wrist and fingers were flexed before and during anaesthesia, the final phantom was extended at wrist and fingers. Hence, no 'default' posture existed for the phantom hand. The final perceived posture may depend on the initial and evolving sensory input during the block rather than the final sensory input (which should not differ for the two postures). In the second study subjects selected templates to indicate the perceived size of their hand. Perceived hand size increased by 34 ± 4% (mean ± 95% CI) during the block. Sensory changes were monitored. In all subjects, impairment of large-fibre cutaneous sensation began distally with von Frey thresholds increasing before cold detection thresholds (Aδ fibres) increased. Some C fibres subserving heat pain still conducted at the end of cuff inflation. These data suggest that changes in both perceived hand size and perceived position of the finger joints develop early when large-fibre cutaneous sensation is beginning to degrade. Hence it is unlikely that block of small-fibre afferents is critical for phantom formation in an ischaemic block.

Therapeutic effectiveness of intratumorally delivered dendritic cells engineered to express the pro-inflammatory cytokine, interleukin (IL)-32

Interleukin-32 (IL-32) is a pro-inflammatory cytokine conditionally produced by T cells, natural killer (NK) cells, monocytes, epithelial cells and keratinocytes, which has an important role in host resistance against infectious disease. Interestingly, elevated levels of IL-32 transcripts in fine needle aspirates of tumor tissue have also been correlated with objective clinical responses in cancer patients receiving immunotherapy. To evaluate the antitumor impact of IL-32 gene therapy, we treated BALB/c mice bearing established subcutaneous CMS4 sarcomas with intratumoral (i.t.) injections of syngenic dendritic cells (DCs) engineered to express human IL-32β complementary DNA (that is, DC.IL32). Although ectopic expression of IL-32β by DC resulted in only modest phenotypic changes in these antigen-presenting cells, DC.IL32 produced higher levels of IL-12p70 than control DC. DC.IL32 were more potent activators of type-1 T-cell responses in vitro and in vivo, with i.t. administration of DC.IL32 leading to the CD8(+) T-cell-dependent (but CD4(+) T-cell- and NK cell-independent) suppression of tumor growth. Effective DC.IL32-based therapy promoted infiltration of tumors by type-1 (that is, CXCR3(+)VLA-4(+)GrB(+)) CD8(+) T cells and CD11b(+)CD11c(+) host myeloid DC, but led to reductions in the prevalence of CD11b(+)Gr1(+) myeloid-derived suppressor cells and CD31(+) blood vessels.

Individual cognitive-behavioural anger treatment for people with mild-borderline intellectual disabilities and histories of aggression: A controlled trial

OBJECTIVES

Anger is a significant predictor and activator of violent behaviour in patients living in institutional settings. There is some evidence for the value of cognitive-behavioural treatments for anger problems with people with intellectual disabilities. In this study, a newly designed treatment targeted at anger disposition, reactivity, and control was provided to intellectually disabled offenders with aggression histories living in secure settings.

DESIGN

About forty detained patients with mild-borderline intellectual disabilities and histories of serious aggression were allocated to specially modified cognitive-behavioural anger treatment (AT group) or to routine care waiting-list control (RC group) conditions.

METHODS

AT group participants received 18 sessions of individual treatment. The AT and RC groups were assessed simultaneously at 4 time points: screen, pre- and post-treatment, and at 4-month follow-up using a range of self- and staff-rated anger measures. The effectiveness of the treatment was evaluated using ANCOVA linear trend analyses of group differences on the main outcome measures.

RESULTS

The AT group's self-reported anger scores on a number of measures were significantly lower following treatment, compared with the RC wait-list condition, and these improvements were maintained at follow-up. Limited evidence for the effectiveness of treatment was provided by staffs' ratings of patient behaviour post-treatment.

CONCLUSIONS

Detained men with mild-moderate intellectual disabilities and histories of severe aggression can successfully engage in, and benefit from, an intensive individual cognitive-behavioural anger treatment that also appears to have beneficial systemic effects.

Pathways through services for offenders with intellectual disability: a one- and two-year follow-up study

The pathways through services for offenders with intellectual disability were reviewed. Participants were 197 offenders with intellectual disability accepted into three types of community and three types of secure forensic intellectual disability services. They were first compared with 280 participants referred but not accepted into services and were then followed-up for 2 years to review pathways through services. Those accepted into services had a higher charge rate than did those who were referred (46% and 25%, respectively). The greatest diversity in pathway was seen in participants in community forensic intellectual disability and inpatient services. Individuals in secure settings showed the least diversity over time, and, similarly, a relatively high percentage of those accepted into generic community services remained in these services.

Probing the corticospinal link between the motor cortex and motoneurones: some neglected aspects of human motor cortical function

This review considers the operation of the corticospinal system in primates. There is a relatively widespread cortical area containing corticospinal outputs to a single muscle and thus a motoneurone pool receives corticospinal input from a wide region of the cortex. In addition, corticospinal cells themselves have divergent intraspinal branches which innervate more than one motoneuronal pool but the synergistic couplings involving the many hand muscles are likely to be more diverse than can be accommodated simply by fixed patterns of corticospinal divergence. Many studies using transcranial magnetic stimulation of the human motor cortex have highlighted the capacity of the cortex to modify its apparent excitability in response to altered afferent inputs, training and various pathologies. Studies using cortical stimulation at 'very low' intensities which elicit only short-latency suppression of the discharge of motor units have revealed that the rapidly conducting corticospinal axons (stimulated at higher intensities) drive motoneurones in normal voluntary contractions. There are also major non-linearities generated at a spinal level in the relation between corticospinal output and the output from the motoneurone pool. For example, recent studies have revealed that the efficacy of the human corticospinal connection with motoneurones undergoes activity-dependent changes which influence the size of voluntary contractions. Hence, corticospinal drives must be sculpted continuously to compensate for the changing functional efficacy of the descending systems which activate the motoneurones. This highlights the need for proprioceptive monitoring of movements to ensure their accurate execution.

Referrals into services for offenders with intellectual disabilities: variables predicting community or secure provision

BACKGROUND

There is a need for research to promote an understanding among service developers on why people with intellectual disabilities (ID) are referred to offender services in order for them to receive appropriate assessment and treatment. Previous studies investigating referrals into forensic ID services have concentrated on referral sources and administrative variables such as legal status.

AIMS

To construct a predictive model for choice of service referral based on a comprehensive range of information about the clientele.

METHOD

We conducted a case record study of 336 people referred to community services and 141 to secure provision. We gathered information on referral source, demographics, diagnosis, index behaviour, prior problem behaviours and history of abuse.

RESULTS

Comparisons revealed 19 candidate variables which were then entered into multivariate logistic regression. The resulting model retained six variables: community living at time of referral, physical aggression, being charged, referral from tertiary health care, diverse problem behaviour and IQ < 50, which correctly predicted the referral pathway for 85.7% of cases.

CONCLUSIONS

An index act of physical aggression and a history of diversity of problem behaviours as predictors against the likelihood of community service referral suggest that professionals have similar concerns about people with ID as they do about their more average offending peers; however, the more severe levels of ID mitigated in favour of community referral, regardless. Offenders with ID tend to be referred within levels of service rather than between them, for example, form tertiary services into generic community services.

Structural, Item, and Test Generalizability of the Psychopathy Checklist—Revised to Offenders With Intellectual Disabilities

The Psychopathy Checklist—Revised (PCL-R) is the most widely used measure of psychopathy in forensic clinical practice, but the generalizability of the measure to offenders with intellectual disabilities (ID) has not been clearly established. This study examined the structural equivalence and scalar equivalence of the PCL-R in a sample of 185 male offenders with ID in forensic mental health settings, as compared with a sample of 1,212 male prisoners without ID. Three models of the PCL-R’s factor structure were evaluated with confirmatory factor analysis. The 3-factor hierarchical model of psychopathy was found to be a good fit to the ID PCL-R data, whereas neither the 4-factor model nor the traditional 2-factor model fitted. There were no cross-group differences in the factor structure, providing evidence of structural equivalence. However, item response theory analyses indicated metric differences in the ratings of psychopathy symptoms between the ID group and the comparison prisoner group. This finding has potential implications for the interpretation of PCL-R scores obtained with people with ID in forensic psychiatric settings.

Structure, fit and coherence of two circumplex assessments of personality in a population with intellectual disabilities

BACKGROUND

Little research has been conducted investigating the way in which personality constructs relate to people with intellectual disabilities. The small amount of research that does exist suggests that underlying personality structure may be considerably different to that found in mainstream research. This hypothesis is, however, untested because so little work has been conducted with this population.

METHOD

Two circumplex models, the Interpersonal Adjective Scales and the CIRCLE, were employed to explore the factor structure, coherence and fit of these models with this population. One hundred and twenty-three participants from forensic intellectual disability services were rated by staff on the assessments, although not all assessments were completed for all participants.

RESULTS

The factor structures for both assessments conform broadly with a theoretical structure. Hypotheses concerning the magnitude and direction of Spearman's correlations both within and between assessments were generally confirmed.

CONCLUSION

While results would support the applicability of mainstream personality assessments to this client group, cautions were expressed in relation to the source of the sample and to the method of data collection.

Factor structure of the PAS-ADD Checklist with adults with intellectual disabilities

BACKGROUND

The PAS-ADD Checklist is designed to screen for likely mental health problems in people with intellectual disabilities (ID). The specificity of recommended subscales derived from diagnostic criteria is unclear. This paper therefore investigates the factor structure of the PAS-ADD Checklist to determine the adequacy of empirically derived subscales.

METHOD

A total of 1,115 informants who had known service users for a median of 24 months completed the PAS-ADD Checklist on 1,155 adults with ID living either in the community, in residential care, or in hospital settings in a county in North-East England.

RESULTS

The sample was randomly divided into two, with all item scores dichotomised. An exploratory principal components factor analysis with varimax rotation was conducted on Subsample A, producing an optimal 7-factor solution. However, a confirmatory factor analysis using this factor structure for Subsample B revealed a mediocre to poor fit. Further exploratory and confirmatory factor analyses also indicated that empirically derived PAS-ADD Checklist subscales were inconsistent.

CONCLUSION

Given the inconsistency of empirically derived subscales, we do not recommend using the PAS-ADD Checklist to identify specific types of psychopathology. The Checklist may have more utility as a screening tool for general psychopathology and subsequent referral for more detailed assessment.

Anger and assaultiveness of male forensic patients with developmental disabilities: links to volatile parents

This study with 107 male forensic patients with developmental disabilities investigated whether exposure to parental anger and aggression was related to anger and assaultiveness in a hospital, controlling for background variables. Patient anger and aggression were assessed by self-report, staff-ratings, and archival records. Exposure to parental anger/aggression, assessed by a clinical interview, was significantly related to patient self-reported anger, staff-rated anger and aggression, and physical assaults in hospital, controlling for age, intelligence quotient, length of hospital stay, violent offense history, and childhood physical abuse. Results are consonant with previous findings concerning detrimental effects of witnessing parental violence and with the theory on acquisition of cognitive scripts for aggression. Implications for clinical assessment and cognitive restructuring in anger treatment are discussed.

Local subcutaneous and muscle pain impairs detection of passive movements at the human thumb

Activity in both muscle spindle endings and cutaneous stretch receptors contributes to the sensation of joint movement. The present experiments assessed whether muscle pain and subcutaneous pain distort proprioception in humans. The ability to detect the direction of passive movements at the interphalangeal joint of the thumb was measured when pain was induced experimentally in four sites: the flexor pollicis longus (FPL), the subcutaneous tissue overlying this muscle, the flexor carpi radialis (FCR) muscle and the subcutaneous tissue distal to the metacarpophalangeal joint of thumb. Tests were conducted when pain was at a similar subjective intensity. There was no significant difference in the ability to detect flexion or extension under any painful or non-painful condition. The detection of movement was significantly impaired when pain was induced in the FPL muscle, but pain in the FCR, a nearby muscle that does not act on the thumb, had no effect. Subcutaneous pain also significantly impaired movement detection when initiated in skin overlying the thumb, but not in skin overlying the FPL muscle in the forearm. These findings suggest that while both muscle and skin pain can disturb the detection of the direction of movement, the impairment is site-specific and involves regions and tissues that have a proprioceptive role at the joint. Also, pain induced in FPL did not significantly increase the perceived size of the thumb. Proprioceptive mechanisms signalling perceived body size are less disturbed by a relevant muscle nociceptive input than those subserving movement detection. The results highlight the complex relationship between nociceptive inputs and their influence on proprioception and motor control.

Risk assessment in offenders with intellectual disability: a comparison across three levels of security

In mainstream offender samples, several risk assessments have been evaluated for predictive validity. This study extends this work to male offenders with intellectual disabilities. Participants from high-, medium-, and low-security settings, as well as community settings, were compared on a range of risk assessments. The Violence Risk Appraisal Guide, HCR-20-Historical Scale, the Risk Matrix 2000-C (combined risk), and the Emotional Problems Scales-Internalising discriminated between groups, with participants from high security having higher scores than those in medium security, who had higher scores than those in the community. The Violence Risk Appraisal Guide, all HCR-20 scales, the Short Dynamic Risk Scale, and the Emotional Problems Scales (Internalising and Externalising) showed significant areas under the curve for the prediction of violence. The Static-99 showed a significant area under the curve for the prediction of sexual incidents. The discussion reviews the value of these various scales to intellectual disability services.