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Mainstream & Niche services - Dichotomy vs continuum
Dr Arun Chidambaram DEPUTY MEDICAL DIRECTOR CONSULTANT FORENSIC PSYCHIATRIST 24th FEBRUARY 2017
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Forensic Personality and Autism Spectrum Disorder Assessment and Liaison Team, Cheshire & Mersey - Gatekeeping for MSU & LSU ASD beds Inpatient Autism Team, Merseycare Whalley ( Calderstones) – LD service – Diagnostic assessments, formulation, care plans & Offending interventions for ASD Female Secure services – MSU & LSU for learning disability Operational Delivery Network – Northwest – Transforming care for LD and Autism Centre for Perfect Care, Merseycare
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Scope of presentation Current Pathways for offenders
Biological changes in stress in ASD Offending Social stressors of adulthood Case vignettes Demand management
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Pathways LOCAL COMMUNITY SERVICES Offence Specialist assessment Remand
Specialist prison provisions Court Prison Adaptation of prison interventions Specialist Secure services Mainstream Secure services Offending interventions in community with a legal framework LOCAL COMMUNITY SERVICES
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Stress response
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ASD, significant variability in cortisol confirms heterogeneity in this population
need to individualize interventions even mild social situations can result in heightened and prolonged stress responsivity initial and enduring responses to potential social stressors that may contribute to how children with ASD adapt to the dynamic social world.
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Offending Social deficits Restricted interests Communication Anxiety
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Social Challenges of Adulthood
Moving into adult roles, including work, educational, and social roles. Learning to manage adult life. This aspect includes making housing arrangements, maintaining health, and avoiding negative outcomes such as substance use, mental health problems, and trouble with the legal system. higher education and work roles - limited social skills difficult to hold a job. Problems in interviews/re- employment problem behaviors also may occur; these include involvement in illegal activities or substance abuse. Problems in accessing system supports that are already available
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Leaving home Difficulties in finding employment
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Case vignette 1 Lack of cooperation of prison services
Offence – Single act of violence Remand Prison Specialist hospital service Lack of understanding of index offence/ Lack of progress Adapted interventions in Prison Lack of cooperation of prison services Prison not ideal environment
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Norman Cameron Paranoid pseudo-community Delusional Disorder Seven situations that favoured development of delusional disorder Increased expectation of receiving sadistic treatment Situations that increase distrust and suspicion Social isolation Situations that increase envy and jealousy Situations that lower self esteem Situations that cause persons to see their own defect in others Situations that increase the potential for rumination over probable meanings and motivation
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Problems in shared living
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Case vignette 2 Legal framework Preference for prison
Offence Specialist assessment in a specialist setting Remand Court Specialist Secure service 2 Specialist Secure services Legal framework Preference for prison Lack of engagement
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Difficulty in initiating romantic relationships
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Case vignette 3 Lack of consultation with local services
Offence Specialist assessment Remand Court Prison Prison inreach Specialist Secure services Mainstream Secure services Lack of consultation with local services Valuable time lost in accessing expert reports Lack of beds in specialist provision “High risk” – lack of willingness to assess Lack of community team
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Inability to move on – post breakup
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Case vignette 4 Offence Specialist assessment Remand Court Prison Specialist Secure services assessment Non engagement Community interventions Lack of engagement in specialist service, request for highly specialised service No more scope to extend assessment due to lack of beds Prison and community followup Reoffence
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Re-employment
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Case vignette 5 Lack of victim empathy – stumbling block
Offence – Single act of violence Prison Bail hostel Lack of progress Specialist assessment Parole board Community Asperger team Lack of victim empathy – stumbling block Formulation & recommendation for structured support Couldn’t access planned community intervention as was moved to a different geographical location without specialist service
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Problems in accessing support for finance & daily living
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Specialist assessment
Case vignette 6 Offence Court Prison Social support Community team Specialist assessment No case for offending interventions Lack of prison team to carry out recommendations Lack of community team to provide social support
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Female SU Accessed Tier 4 CAMHS Neuropsychiatric disorder
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Case vignette 7 Good practice Engagement of mainstream services
Violent and public order offences - recurrent Prison Low secure unit (mainstream) Specialist assessment Defined descriptors for hospital Community intervention in mainstream adult service with DOLS Medium secure ( mainstream) – short stay Good practice Engagement of mainstream services Reduced length of stay
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Issues in Prison/CJS Focus on victim empathy
Single violent offence – Effect on risk assessment Expectations of Parole Board – Lack of informants to complete assessments Worsening of core deficits – social isolation, restricted interests Evidencing change in risk Effect of time lapsed on offence related work
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Rigid and inflexible thinking
Risk assessment Deficits in Empathy Rigid and inflexible thinking
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Preoccupation/special interests
Social deficits Communication difficulties Preoccupation/special interests Offending Interventions Comorbidity – Anxiety Sensory needs
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DEMAND MANAGEMENT Can we engage mainstream services? Can we define the role of specialist services?
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Mainstream & Niche services
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Mainstream secure services - adaptation
Prison services - adaptation PERSON CENTRED CARE Mainstream secure services - adaptation Specialist prison& hospital services Potential Solutions Community interventions Engaging Clinicians
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Community interventions
Adaptation within mainstream services Prison and Health Specialist services – Health & Prison
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Questions?
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Thank you Managing demand Improving prison services Mainstream
Adapted interventions Take Home messages Community based interventions Person centred care Thank you
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