Editorial
Article Type: Editorial From: Advances in Mental Health and Intellectual Disabilities, Volume 7, Issue 6.
Welcome to the last issue of Advances in Mental Health and Intellectual Disabilities for 2013. We hope that you have enjoyed reading the papers over the last year, found them interesting and that they have helped to inform your practice. We have certainly enjoyed editing the journal and we would like to thank all the authors who have put a great deal of time and effort into producing the papers and also to those who took the time to review them for us. We are always looking for high-quality papers on the mental health needs of people with intellectual disabilities, including research papers, innovations in service provision, policy perspectives and case reports. If you would like to make a submission for a future issue please get in touch.
It has been well established for some years now that the use of applied behavioural analysis and positive behaviour support is the recommended intervention pathway for people whose behaviour is described as challenging. However, the use of psychotropic medication in this area is still widely reported and remains a contentious area. This issue presents three papers looking at various aspects of psychotropic medication usage: its use in the management of challenging behaviours; the experience of care staff and an audit on the use of PRN (as and when required) medication. Bamidele and Hall provide an insightful paper which explores the place of medication in the management of challenging behaviour. They view its use in the context of the whole system around the person and by considering the challenges of implementing best practice guidance and they make recommendations to reduce the use of medication.
Many people with intellectual disabilities are supported by care staff with little or no training in the use of psychotropic medication. Lalor and Poulson completed a study that examined the experiences of, and impact on, care staff in relation to psychotropic medication usage in adults with intellectual disabilities living in long-term residential care. They found several areas of concern for staff, including the negative impact upon the service users’ quality-of-life, ethical implications and a significant lack of training.
As and when required (PRN) medication is often prescribed to people with intellectual disabilities for an array of reasons such as emergency management of epileptic seizures, pain and for incidents of challenging behaviour or crises management. Delafon and colleagues carried out a study which aims included identifying “PRN” psychotropic medication being prescribed for people with an intellectual disability, the indications and frequency of use. The study also sought to identify individual and environmental factors associated with prescribing. They looked at a cohort of individuals using inpatient services, respite and long stay homes managed by a NHS Trust. They found that 25 per cent of the cohort received PRN medication during the measured period and the most common indications for PRN prescribing were aggression and agitation. Male gender and a history of challenging behaviour were found to be significant factors associated with prescribing. The study recommends regular multi-disciplinary reviews of PRN medication and to explore the relationship between availability of staffing levels, their skills and training in relation to the use of PRN medication.
A small but significant number of people with intellectual disabilities are detained in high secure services and like other detained individuals may have neuropsychological deficits which may inhibit their ability to benefit from psycho-educational materials. On the basis of these difficulties Lowings and colleagues reviewed neuropsychological activity at one high secure hospital. Patient files from both mental health and intellectual disability services were examined in order to identify the volume of neuropsychological assessment previously undertaken and the make up of the neuropsychological test batteries administered. Psychologists were also surveyed to assess their knowledge of patients within that service who to their knowledge had previously suffered an acquired brain injury or had suffered a significant neurological illness likely to have resulted in cognitive impairment. They found a significant amount of neuropsychological assessment was being undertaken, albeit in an unstructured way which led to delays in the care pathway. There was considerable variance on when a patient was tested, ranging from one month to 14 years and the size of the test battery used, with the number of tests conducted per patient ranging between one single test to 16 tests during a patient's stay at the hospital. They concluded that there were opportunities to more appropriately place patients based upon their abilities and that this could be achieved if the hospital were to adopt a policy of conducting neuropsychological assessments, including cognitive functioning, for all patients upon admission to the hospital. A proportion of patients were known to have had a traumatic or acquired brain injury or a significant illness likely to have resulted in cognitive impairment. Their study cohort was considered to be an underrepresentation and a through history specifically covering traumatic and acquired brain injury and specific illnesses known to have an impact on cognitive ability and behaviour was recommended. The study also makes a case for including neuropsychological screening as part of the admission process.
It may have been over two years since the BBC's Panorama programme aired its documentary on the abuse and neglect that occurred at Winterbourne View but the repercussions will continue to be felt and quite rightly influence service provision for many years to come. Wright provides us with a literature review focusing on the precipitants of physical and psychological abuse in an attempt to understand why mistreatment continues to be prevalent. In particular, the importance of contributing factors such as challenging behaviour and lack of staff training are explored in order to identify areas that could be improved. The UK government's response to Winterbourne View has led to a number of policy, good practice and commissioning guidance which we hope to review in a future issue of the journal.
Steven Hardy
