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The Future of Learning Disability Inpatient Secure Services

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Head injury amongst referral ... Often complicated by other psychiatric disorders ... Beagles & rats exposed to electric shock without chance to escape ... – PowerPoint PPT presentation

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Title: The Future of Learning Disability Inpatient Secure Services


1
The Future of Learning Disability Inpatient
Secure Services
Dr Ernest Gralton Forensic Psychiatrist in
Developmental Disabilities Malcolm Arnold
House St Andrews Healthcare
2
Key issues- we need to adapt to new evidence
  • Complex co-morbidities
  • Head injury
  • Complex co-morbid Autism/DAMP
  • Developmental Traumatology
  • Rehabilitation systems/philosophy
  • Right brain treatments
  • Diet
  • Touch
  • Exercise
  • Pharmacology

3
Complex and Diverse population
  • Autistic Spectrum Disorders
  • DAMP
  • Tourettes Disorder
  • PTSD Developmental Trauma
  • Affective Disorders (atypical)
  • Schizophrenia/Schizoaffective
  • Attachment disorders
  • Paraphillias
  • Brain injury/Executive function deficits
  • Conduct Disorder
  • Substance misuse

4
Head injury
  • Head injury amongst referral population common
  • In a significant minority- developmentally normal
    prior to serious head injury
  • Often complicated by other psychiatric disorders
  • Requires neuro-psychology input with brain injury
    expertise
  • Can lead to a range of offending behaviours
    including serious sexual offending- executive
    function deficits

5
Attachment issues/Developmental Traumatology
  • High levels of disordered attachment
  • Increased levels of neglect and abuse
  • Early entry into care
  • Multiple short term failed placements

6
Animal models
  • Seligman
  • Learned Helplessness 1967
  • Beagles rats exposed to electric shock without
    chance to escape
  • Originally considered a model for depression now
    more likely for PTSD (especially Chronic PTSD)
  • Massive outpourings of stress neurohormones
  • Animals exposed to varieties of chronic stress
    (including primates)- demonstrate impairments in
    learning and memory
  • Associated with alterations in structure-
    temporal lobe, amygdala and hippocampus

7
Anxiety Bell Curve
  • Anxiety increases to a level where performance
    decreases
  • Speech centres shut down, increased blood flow
    motor areas
  • Over-arousal can quickly lead to aggression

8
Stress Plasticity in Limbic System (Sapolsky
2003)
  • Damage by Glucocorticoids-
  • Decrease in length retraction of dendritic
    processes
  • Loss of branch points, neuronal atrophy/death
  • Growth is promoted (rodents/primates)
  • a) Reduction in glucocorticoids (stress)
  • b) Environmental enrichment
  • c) Exercise

9
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10
Autism
  • A high proportion of young people with LD
    requiring inpatient care have co-morbid autism
  • Dislike change, find transitions very difficult

11
Mixed Disorders
  • Symptoms of ADHD 1846
  • Comorbid disorders
  • DAMP syndrome

12
Sensory Sensitivities
  • Significant proportion of autistic patients have
    sensory sensitivities- that may adversely
    influence behaviour

13
Robert
  • 17 year old adolescent in mild LD range
  • Developmental History consistent with PDD/ADHD/
    Developmental dyspraxia
  • Aggressive toward sibs- punitive parenting
    strategies
  • Multiple foster care placements from age 4
  • Sexual abuse history from age 7, head injury aged
    8
  • Erratic education/ no peer relationships bullied
  • Multiple childrens homes from age 9
  • Arson and sexual offending against younger
    children
  • Social Services Secure Accommodation-
    consistently aggressive, needing continuous
    restraint

14
Care Pathway
  • Conventional mental health rehabilitation
    pathway models are often unsuitable

15
The developmental perspective
  • Young people still rapidly developing
  • Challenges- more complex difficult to meet
    needs
  • Opportunity- to make a much greater impact on
    their development and outcome
  • Unlikely single interventions will be sufficient
  • Programme of intervention should be comprehensive
    covering all developmental domains
  • Improvements in one area impact on others
  • More difficult to distinguish contribution of
    individual interventions

16
Hierarchy of interventions
  • They need to be safe basic needs met
  • Level of arousal/aggression needs to be reduced
  • Only then can move on to other interventions
  • Every interaction has the potential to be
    therapeutic

17
EMDR
  • Number of theories as to mechanism of effect
  • Difference between hippocampal/amygdala may
    initially worsen PTSD and lead to increased risk
    of self harm
  • neocortical memories- conversion one to other
  • Good evidence for single trauma PTSD in adults
  • Delivering it to patients (especially
    adolescents) with complex PTSD is not straight
    forward
  • If dissociate cannot co-operate with procedure
  • Highly reliant on feedback of SUD score
  • Needs to be supported with other anxiety
    management techniques and medication

18
Neurobiology of EMDR
  •  EMDR stimulation (visual, auditory and tactile)
    brings about a constant alternating shifting of
    attention- cholinergic surge.
  • The cholinergic surge starts the REM processing
    system.
  • Pontine Genticulate Occipital (PGO) Waves occur
    in REM EMDR
  • The REM system activates areas of the anterior
    cingulate, - link between (cognitive) neocortex
    and (emotional) limbic areas - facilitating the
    integration of traumatic memory into neocortex.
  • Inhibition of both hippocampal episodic memories
    amygdaloid mediated negative affect of PTSD.

19
Solution Focused Model
  • Widely used individual intervention for
    difficult to treat populations -good evidence
    efficacy
  • Widened use into a Model of Care
  • Crosses multi-professional boundaries
  • Simple principles easy to teach- quick to apply
  • Integrates with CPA
  • Future focussed- acknowledges individual
    preferred future
  • Draws on existing strengths
  • Avoids confrontational relationships

20
Diet
20 of neuronal wall is made up of Essential
Fatty acids DHA is essential for the operation of
ion channels Essential for neuronal growth
21
Pharmacotherapy
  • Low dose Risperidone for CD/LD/Autism
  • SSRI- act via serotonergic mechanisms, can
    trigger rapid cycling affective disorders
  • Benzodiazepines- can increase dissociation
  • Antiepileptics- Carbemazepine and Valproate open
    label evidence
  • Antiadrenergic agents Propranolol Clonidine (NIMH
    CT trial underway)

22
Be prepared!
  • Young people need lots of preparation to make a
    transition into a new placement
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