Forensic Issues in Adolescents with Developmental Disabilities

Ernest Gralton

• Editorial: Jessica Kingsley Publishers
• Año: 2011
• ISBN:
  9780857003461
• Categoría: Psicología
• Categoría: Psicología forense

Adolescents with developmental disabilities are a complex population who require specialised treatment and care. This interdisciplinary text examines the processes involved in working with this client group in forensic settings, and explores the ways in which their needs differ from those of other young people who engage in high risk behaviour or offending.

The book covers assessment, intervention and treatment options for adolescents with a wide range of developmental disabilities, including autism spectrum disorders, acquired brain injury, developmental traumatology, and complex comorbidities. It describes the obstacles, challenges and opportunities to consider when working with this population, and the role played by various professionals, including forensic psychiatry and psychology, occupational therapy, physiotherapy, education, art psychotherapy and social work. The book also outlines the issues to consider when working in secure and community settings as well as the legal aspects of working with this client group, and the complex issues surrounding risk assessment.

The first comprehensive account of forensic issues in adolescents with developmental disabilities, this book will be an indispensible primary resource for a wide range of professionals, including child and adolescent psychiatrists, community psychiatric nurses, developmental paediatricians, social workers and youth workers, lawyers and advocates.

Chapter 1

COMPLEX CO-MORBIDITIES IN ADOLESCENTS WITH DEVELOPMENTAL DISABILITIES AND FORENSIC NEEDS

Ernest Gralton

INTRODUCTION

Adolescents with developmental disabilities who have forensic needs are a complex population presenting unique challenges to those who care for them. Those who are referred to secure psychiatric services often have a variety of co-morbid disorders, some unrecognised for long periods due to difficulties in carrying out comprehensive assessments (Barlow and Turk 2001) or due to the phenomenon of ‘diagnostic overshadowing’ where abnormal behaviours that are the result of developmental disability are attributed to the presence of intellectual disability alone (Mason and Scior 2004).

Psychiatric disorders are up to four times more prevalent in adolescents with intellectual impairment than adolescents without impairment (Emerson and Hatton 2007); however, only a limited proportion of young people receive any form of specialist service (Dykens 2000; Emerson 2003a; Tonge and Einfeld 2001; Wright, Williams and Richardson 2008). Diagnoses amongst this population often include developmental problems like autism and attention deficit hyperactivity disorder (ADHD), developmental dyspraxia/developmental coordination disorder, Tourette’s and tic disorders. In addition to this, a number of environmental insults, notably developmental trauma (including neglect and physical and sexual abuse), head injury and substance misuse, are common. Some have also gone on to develop a variety of formal mental illnesses including atypical affective disorders, anxiety disorders (including complex post-traumatic stress disorder (PTSD) and developmental trauma disorder) and a range of psychoses, although these are not always easy to recognise.

RESEARCH EVIDENCE

The prevalence of most of these aforementioned disorders is increased in delinquent adolescents (Kazadin 2000). Diagnosis can be more difficult and response to psychiatric treatment can be idiosyncratic because of communication impairments and the presence of multiple disorders (Berney and Allington-Smith 2010; Kutscher 2005). Some authors have used aspects of Chaos Theory and metaphors like ‘interweave’ to try to explain the complex interactions of co-morbid disorders in this population and the individuality of each case (Blakemore-Brown 2002). There is a general recognition that more complex models of understanding these young people are now required (Emerson 2003b).

Developmentally disabled adolescents are a particularly difficult group to research as there are complex ethical issues and problems with parental consent, difficulties with control groups and a lack of appropriate specific tools and outcome measures. The research basis on which to develop treatments for adolescents with developmental disorders with forensic needs is therefore still very limited (Hall 2000) and much evidence for interventions is therefore extrapolated from mainstream adolescent or adult developmentally disabled populations.

These young people often find themselves as the ultimate excluded patient population, both from research and from services, on the basis of cognitive impairment, age, instability in terms of accommodation and consistent care. They often find themselves in care at an early age as their complex developmental problems overwhelm the parenting capacity of families, particularly those who are already compromised by parental absence or familial mental disorder. Exclusion from school is three times more common in UK prisoners with developmental disabilities than those without (Talbot 2008). They have significantly more placements outside the family home than their non-disabled peers (Hall 2000).

Developmentally disabled adolescents are significantly overrepresented in populations of adolescent offenders (Hall 2000) but they are often not identified (Ford et al. 2008). Around one in five young offenders probably has an IQ less than 70 (Chitsabesan et al. 2006) but individuals with significant developmental disability are routinely unrecognised even when in custodial settings (Brier 1994; Talbot 2008). They are more problematic to manage in prison settings than their more intellectually able peers (Smith et al. 1990) and the range of available prison-based programmes are not generally adapted to meet their needs. Overall the criminal justice system in the UK comprehensively and routinely fails offenders (including adolescents) with a developmental disability (Talbot 2008).

Mental disorders and their manifestations

The interaction of several developmental and acquired mental disorders produces presentations that are difficult to assess in a single cross-sectional interview as an outpatient (Hall 2000). Key developmental history is often missing in the case of young people who are no longer living with biological parents, particularly those who have had multiple foster and residential placements.

The relationship between ADHD and a higher risk of delinquent behaviour is now well recognised. Adolescents with ADHD are up to five times more likely to be arrested than peers without ADHD (Satterfield et al. 1994). It is likely that the symptoms of impulsivity and hyperactivity (rather than inattention) are linked to antisocial behaviour (Bambinski, Hartsough and Lambert 1999). Although ADHD symptoms tend to improve over time, this is by no means universal or uniform in the population (Marsh and Williams 2004). The majority of individuals with ADHD still have one disabling symptom in early adulthood (Weiss et al. 1985) which means they are likely to retain significant symptoms throughout adolescence.

A common example of complex co-morbidity in this population is ADHD and developmental dyspraxia (also known as developmental coordination disorder – DCD); around half the children with ADHD have this particular co-morbidity (Martin, Piek and Hay 2006). This co-morbidity has a worrying outcome in early adulthood in relation to criminal behaviour, alcohol misuse and personality disorder (Rasmussen and Gillberg 2000). However, the co-morbid diagnosis of DCD is frequently unrecognised (Kadesjö and Gillberg 2003).

Children with DCD obtained significantly poorer scores on measures of attention and learning (reading, writing and spelling) than comparison children. They have a relatively high level of social problems and are at risk for problems in attention, learning and psychosocial adjustment (Dewey et al. 2002).

Deficits in attention, motor control and perception (DAMP), described by Gillberg (2003), affect about 1.5 per cent of the population of school age children. Children classified as having DAMP invariably fulfil criteria for ADHD and DCD and also commonly have symptoms of autistic spectrum disorders (Clarke et al. 1999). Children diagnosed with this disorder unsurprisingly have a higher risk of poor outcomes by early adulthood, including delinquency, and have a higher incidence of intellectual impairment and visual motor perception. Childhood-onset DAMP is associated with an increased incidence of psychiatric disorders and combinations of personality disorder (Hellgren et al.1994).

A number of researchers have shown that many of these developmental disorders tend to cluster together. A large number of medical, psychiatric and motor and behavioural decontrol syndromes are associated with autistic spectrum disorders (Gillberg and Billstedt 2001). ADHD and autism are common co-morbidities with Tourette’s disorder (Kadesjo and Gillberg 2000). Children with ADHD and motor disorders are more likely to have severe ADHD-combined type and other neurodevelopmental and behavioural problems (Tervo et al. 2002).

Other authors have described a very similar group of children with multiple problems with affective and anxiety regulation, poor attention and impulsivity, social impairment, impaired cognitive processing and impaired neuro-maturation that they describe as the ‘multiple complex developmental disorder’ (Ad-Dab’bagh and Greenfield 2001).

There are a range of difficulties in making multiple co-morbid diagnoses, not least is trying to attribute individual symptom clusters to disorders whose symptoms may overlap.

How these developmental disorders influence developing personality and behaviour is a complex and difficult question. There is no question, however, that they can have a significant and adverse impact. Childhood-onset neuropsychiatric disorders, including learning disability, ADHD, tics and autism spectrum disorders, form complex co-morbid patterns with adult personality disorders including psychopathic traits, mood disorders and substance abuse. The results support the notion that childhood-onset social and behavioural problems form a highly relevant psychiatric symptom cluster in relation to pervasive adult violent behaviour (Soderstrom et al. 2004; Vizard et al. 2004). It may be that right hemispheric dysfunction and visuospatial difficulties in particular are a marker for persistent conduct problems (Raine et al. 2002). A significant proportion of adult patients detained in high secure hospitals have childhood-onset neuropsychiatric disorders (Soderstrom and Nilsson 2003). Many of these factors have been identified as being at high risk for developing severe personality disorder in adulthood, and some researchers have proposed a new developmental disorder to describe some of these young people (Vizard et al. 2004).

Alcohol related neurodevelopmental disorders like foetal alcohol syndrome are not uncommon in this group and can affect about one per cent of children in the general population (Sampson et al. 1997) and they are probably the leading known cause of developmental disability in the Western world (Mattson and Riley 1998). They are associated with a wide variety of neuro-behavioural problems (Mattson and Riley 1998). Common associations are hyperactivity and deficits in visuospatial functioning, verbal and nonverbal learning and executive function (Riley and McGee 2005), as well as high rates of birth defects including sensori-neural deafness and visual impairment (Elliott et al. 2008), deficits in adaptive behaviours and social skills (Crocker et al. 2009), and sensory processing abnormalities and problem behaviours (Franklin et al. 2008). Interventions should logically target the clinical and neuropsychological deficits seen most commonly in these conditions but there is still only limited evidence to support specific interventions (Peadon et al. 2009).

There are some genetic disorders that can have behavioural phenotypes or particular clusters of behavioural symptoms, although they are by no means invariable. Velo-cardio-facial syndrome can present with developmental delay and ADHD symptoms (Shprintzen 2000) and significant coordination difficulties (Swillen et al. 1999). Fragile x syndrome can be associated with autistic spectrum disorders (Rogers et al. 2001). William’s syndrome has been associated with problems with attention and concentration, anxiety and social impairment (Udwin and Yule 1991). Cornelia de Lange syndrome can present with mild and borderline intellectual functioning and is associated with hyperactivity, autistic symptoms, aggression and sleep disturbance (Berney, Ireland and Burn 1999). Although these disorders are relatively uncommon in adolescents with developmental disorders and forensic needs, they are worth recognising when they occur and there can be issues around genetic counselling that can involve the wider family. There is still, however, limited evidence around the response to the treatment of individual phenotypes.

This group of young people can also have a range of other neurological disorders including complex sleep disorders (Wiggs and France 2000) and obsessive compulsive disorder, including conditions of autoimmune origin like Paediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS), which can complicate their presentation (Moretti et al. 2008). Young people with complex developmental disorders have a higher incidence of epilepsy (Pellock 2004) and can present with a variety of epilepsy-related psychiatric disorders (Blumer, Montouris and Davies 2004). They also have an increased overall incidence of physical health problems that require specific enquiry and investigation (Boyle, Decoufle and Yeargin-Allsopp 1994; Lennox, Rey-Conde and Faint 2008).

Attachment

Ideas from both attachment theory (Bowlby 1988) and schema therapy (Young, Klosko and Weishaar 2003) can be helpful in describing how a variety of adverse experiences in childhood (including neglect and abuse) can profoundly affect brain organisation and future relationships, and lead to the development of core maladaptive schemas (strongly held pervasive emotional and cognitive beliefs). These then further exacerbate the pre-existing developmental impairments in this population. These schemas are likely to be linked to emotional memories within the hippocampal/amygdala midbrain system which can trigger powerful involuntary emotional responses in individuals (LeDoux 1998). A variety of maladaptive schemas can lead to major problems with the control of arousal and anger in young people. They may have a seemingly disproportionate arousal response to a variety of triggers (which can be minor or even unidentified by the individual). This in itself can sometimes make it particularly difficult to use tools like behavioural analysis to implement appropriate behavioural programmes for this group of impaired young people.

Exposing children to violence (including sexual abuse) has been shown to significantly impair their emotional, behavioural and cognitive development and is associated with anxiety, fear, aggressive and antisocial behaviour, sexual aggression, substance misuse and a failure to acquire social competence (Itzin 2006; Skuse et al. 1998). There are also significant alterations in threat perception demonstrated by studies that show that physically abused children are more sensitised to facial displays of anger (Pollak and Sinha 2002). A history of childhood maltreatment is significantly and consistently associated with violence in delinquent adolescents in recent studies (Lansford et al. 2007; Mersky and Reynolds 2007).

The likely biological mechanisms for the disruption of the process of brain development involve the elevated levels of stress neurohormones (De Bellis et al. 1999b). Catecholaminergic and steroid hormones are known to modulate the overall process of neuronal migration, differentiation and synaptic proliferation. Chronically elevated glucocorticoids cause disruption to dentritic growth and neuronal connections in animal models (Sapolski 2003). Child...

Índice

• Cover Page
• Other Books
• Title Page
• Copyright
• Dedication
• Contents
• 1. Complex Co-morbidities in Adolescents with Developmental Disabilities and Forensic Needs
• 2. Communication: Obstacles and Opportunities
• 3. The Application of Sensory Integration within an Adolescent Forensic Learning Disability Service
• 4. Mental Illness in Adolescents with Developmental Disabilities who Require Secure Care
• 5. Working with the Families of Developmentally Disabled Young People Detained in Secure Settings
• 6. Education in Adolescents with Developmental Disabilities in Secure Settings
• 7. Autistic Spectrum Disorders in Adolescents who Require Secure Care
• 8. Occupational Therapy Input for Adolescents with Developmental Disabilities in Secure Settings
• 9. Physiotherapy in Adolescents with Developmental Disabilities who Require Secure Care
• 10. Risk Assessment in Adolescents with Developmental Disabilities
• 11. Developmental Traumatology: Its Relevance to Secure Settings for Adolescents with Developmental Disabilities
• 12. Genetic Influences in Forensic Adolescent Psychiatry
• 13. Acquired Brain Injury in Adolescents with Forensic Needs
• 14. The Legal Context for Adolescents with Developmental Disabilities: An International Perspective
• 15. Art Psychotherapy for Adolescents with Developmental Disabilities: An Inner World Examined Through Images
• 16. Forensic Issues in Adolescents with Developmental Disabilities in Community Settings
• 17. Models of Secure Inpatient Care for Adolescents with Developmental Disabilities
• Contributors
• Subject Index
• Author Index