Lecture 4: Offenders with Intellectual & Developmental Disabilities

- no risk assessment or assessment questions for midterm - Canadian Context only

How Do We Define Intellectual and Developmental Disabilities (IDD)?

• Intellectual impairment (defined by IQ, usually below 70).

• Deficits in social functioning (impaired adaptive behaviour).

• Age of onset (below 18 years old).

IDDs include which other mental health disorders?

• autism spectrum disorder (ASD)

• borderline cognitive functioning

• low literacy

• acquired brain injury

• other cognitive impairments.

5 Assumptions of AAIDD’s Definition

1. Limitations must be seen in the context of an individual’s age peers & culture.

2. Assessment considered cultural & linguistic diversity.

3. Limitations co-exist with strengths.

4. Limitations are identified to help build a profile of needed supports.

5. With personalized supports, the life functioning of a person with ID will improve

DSM-V: Intellectual Developmental Disorder - 3 Criteria must be met:

• Deficits in intellectual functions

• Deficits in adaptive functions that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.

• Onset during the developmental period.

• Four levels

Ex of Deficits in intellectual functions

• reasoning

• problem solving

Deficits in intellectual functions is confirmed by blank & blank

clinical assessment; intelligence testing

Deficits in adaptive functions that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.

• No support = ?

limited functioning in daily life.

DSM-V: Intellectual Developmental Disorder’s onset is during?

developmental period

Canadian Context - An individual has intellectual disability if they meet three criteria:

• IQ is below 70 to 75

• Significant limitations in two or more adaptive areas (skills that are needed to live, work, and play in the community, such as communication or self-care)

• Onsent before the age of 18

Prevalence Rates - Canadian Context

• 1–2% of the general population

  • 0.9% of the Canadian population.

• Context:

  • IQ of 70 & below in 2.8% of males & 6% of females entering federal custody.

  • 25% incoming males (N = 488) presented with some level of cognitive deficit.

  • 2% of the federal prison population presented with developmental disabilities.

  • ~32 years old, low SES.

IDD Individuals may struggle to learn blank skills

age-appropriate

IDD Individuals think in blank

categories

• Labels and concrete situations > abstract concepts

IDD Individuals can find expressing blank & blank challenging

thoughts; feelings

IDD Individuals May have good verbal & social skills but lack?

cognitive understanding

IDD Individuals face difficulties with?

• complex ideas

• reasoning

• analysis

• judgement

everyone with IDDs can learn?

new skills

Difficulties in those with IDD

• Difficulties across their lives

  • ↑rates of physical health problems, poverty, homelessness, stigma, isolation, institutionalization, and communication difficulties

  • ↓rates of social support, independence

  • *compared to non-disabled offenders

• ↑prevalence of mental health issues among individuals with IDD

  • Most common: substance use disorder, depression, antisocial personality disorder

Difficulties in those with IDD - Most common in:

• substance use disorder

• depression

• antisocial personality disorder

Characteristics Related to Offending

Offending Behaviour

• Recruit from services where severe behavioural problems were more likely.

• more likely to engage in offences against a person.

  • Compared to fraud, drug offences, B&Es, or driving offences.

• Offences against persons >

• Most common offence: Aggression (Physical 50%).

• Other common offences: damage to property, inappropriate sexual contact & non-contact.

• Least common offences: Substance abuse, theft, cruelty, or neglect of children, fire‐setting and stalking.

Involvement in Crime

Used by others

• IDD individuals have a desire to please and are more likely to be gullible.

• Lured to help with criminal activities in exchange for support, friendship, and money.

blank & blank is Presented by a significant minority of people with mild IDDs.

anger; aggression

• A major reason for referrals to psychological services for offenders with IDDs.

  • Also for admittance/re-admittance into hospitals

Why does anger & aggression occur for people with mild IDDs?

• Internal distress and thwarted needs.

• Tendency to interpret social situations differently -

  • biased towards attributions of hostility.

blank is preferred over ‘sexual offence’ for people with IDDs

harmful sexual behaviour (HSB)

Prevalence of Sexual Offending IDDs

• Hard to estimate, a minority of cases and underreported.

• Community: ~6% of men with IDDs display HSB.

• Services: ~11% (a higher rate may be due to sampling bias).

• Not over-represented compared to the general population.

Characteristics of Sexual Offending IDDs

• High level of childhood adversity (e.g., abuse)

• Co-occurring condition (e.g., autism, personality disorders)

• Victims are most commonly children, people with IDDs

• Sexual knowledge: poorer than non-IDD offenders, but the same as other IDD offenders.

  • Maybe a mix of naive and deviant pathways.

Two Groups of Offenders with IDDs

• Individuals who are legally and diagnostically defined IDD and are already known to or supported by the developmental service sector

• Individuals who do not have a legally or diagnostically defined IDD, BUT are socially and cognitively disadvantaged compared to the general population

What happens if individuals with IDDs go undiagnosed?

• at risk of adverse outcomes, including mental health issues and involvement with the criminal legal system.

• May see uncooperative, behaviourally disordered, affected by substances or psychiatrically disturbed.

• Misdiagnosis may lead to misplacement in a secure unit.

  • Inappropriate placement can contribute to management difficulties when the individual is unable to cope

  • May then generate misleading views about the inmate, who is likely to be reported as being a ‘troublemaker’

What are criminal legal challenges with individuals with IDDs?

• Anxious to fit in and, as a result, are skilled at disguising their disabilities

• ‘‘cloak of competence’’

• ‘‘cheating to lose”

• ‘‘halo effect’’

What happens to those with IDDs who are incarcerated?

• Seldom receive specialized services

• Vulnerable to victimization by other inmates

  • may have their personal belongings stolen

  • be sexually assaulted

  • used by other inmates for acts that violate prison rules, such as hiding contraband

• May have greater difficulty following rules when incarcerated, resulting in longer sentences and a lower likelihood of parole

Two distinct offender groups:

• Larger group committing less serious offences but experiencing frequent incarceration.

• A smaller, high-risk/need group responsible for serious violent or sexual offences

blank is the most common comorbidity in prison populations

depression

current practices focus on blank not disability needs for IDDs individuals who are incarcerated

criminogenic

current practices focus on criminogenic not disability needs

• Mainstream programmes are typically adapted.

• While some IDD criminogenic needs are shared, disability-related ones may not be.

• hard to find programmes created for this population (disability)

Criminogenic Needs

Disability Needs

Adaptations to treatment methods include:

• Simplification of communication and the methods used

• Alterations in the use of recording and assessment techniques

• Promoting motivation in participants

Simplification of communication and the methods used

• Effective communication is essential to any interpersonal process, including therapeutic interactions.

• Thus first requirement is to adapt the processes to allow for understanding and engagement by the patient

  • if they’re not understanding, they’re not gonna get what they need out of the treatment

  • promotes the motivaion for goals

Key differences between regular and adapted programs:

• Duration

  • adaptive programs are longer

• Level of external support

• Focus on behavioural application

• Level of post-treatment follow-up

Cognitive & Communication Adaptations

• Simplified concepts & language → improves comprehension and reduces cognitive load

• Concrete examples → links abstract ideas (e.g. risk, responsibility) to real-life situations

  • illustrating these ideas to help them understand what we’re talking about

Simplifying Language

• not a natural process

• Requires constant adjustment of vocabulary and syntax in addition to continuing self-monitoring

• Basic recommendations:

  • Short sentences that contain a single concept

  • ‘‘the three syllable rule’’- attempt to use words of fewer than three syllables

    • in order to de-complicate

Types of Adaptations

• Cognitive & Communication

• Learning & Engagement

• Behavioural & Skills-Based

Learning & Engagement Adaptations

• Visual supports (pictures, diagrams, symbols) → reinforce understanding and memory

• Multi-modal delivery (visual, verbal, experiential) → accommodates varied learning styles

Old Me, New Me is a blank treatment

multi-modal delivery

what does the ‘New Me’ support?

humanistic values and healthy ways to live their life without offending

Old Me, New Me puts emphasis on blank paired with simple client blank statements

visual images; generated key word

Goals should be toward the “New Me”, not toward?

“avoidance behaviors”

Old Me, New Me - Goals need to be?

realistic, broken into small steps, and understood

Old Me, New Me: Effectiveness

• Using the terms Old Me/New Me were found to be motivating and gave the individual a sense of identity

• Motivation can help offset the discrimination and chronic negative social perception of individuals with developmental disabilities

  • not stigmatizing the ‘Old Me’

Behavioural & Skills-Based Adaptations

• Experiential learning (role-play, rehearsal) → supports skill acquisition through practice

• Focus on generalization → helps transfer skills from treatment to daily life and community settings

Role-Play

• It can be used as a treatment technique.

  • e.g., included in CBT interventions.

• Some pre-planned and can, to some extent, be scripted (e.g., victim empathy),

• Or can be spontaneous in response to patients’ reports of homework (e.g., a situation that went badly).

• Can be recorded and rewatched to give feedback.

• Example:

  • Role-playing anger-provoking situations with feedback led to improvements in treatment targets after a 15-month follow-up

blank is used by most programs

CBT

CBT can be used to target a variety of?

criminogenic needs

Treatment Phase: Key Domains - Core of CBT treatment

• Cognitive restructuring

• Arousal reduction

• Behavioural skills training

In comparison with behavioural treatments, CBT may not be as effective for individuals with IDDs due to?

May not help to develop self-control & coping skills which transfer to other settings.

• needs more heavy adaptations

Anger Management and CBT Example: For chronic, deep-rooted anger that impairs interpersonal functioning and psychological well-being

individualized approach to overcome anxieties about change and resistance to engagement

• CBT, 18 sessions (1-2/ week)

  • Includes homework such as daily anger logs in which the nature, intensity, and frequency of angry incidents are recorded

• Two phases:

  • Preparatory phase

  • Treatment phase

Two phases of CBT

• Preparatory

• Treatment

Treatment Phase: Approaches

• Self-monitoring and recording anger incidents.

• Analyzing and formulating individual anger issues.

• Creating a personal anger provocation hierarchy.

• Cognitive restructuring by altering focus, modifying appraisals, and challenging expectations.

• Developing arousal reduction techniques.

• Training problem-solving through role play.

• Creating personal self-instructions.

• Using stress inoculation to practice coping with anger-provoking scenarios.

Limited case studies on CBT anger treatment for offenders with ID show blank results.

positive

CBT - There were found to be significant improvements in?

women with mild to borderline ID involved in the CJS for violence, both post-intervention and at 15-month follow-up

CBT evaluations lacked measures of blank

controlled effectiveness

Key Recommendation for CBT

adapt programs for individuals with intellectual and developmental disabilities (IDD) by using simplified techniques and role-play, as they may lack the skills to benefit from standard

SPORT Programme - Because of the intellectual limitations of the client group, an emphasis is placed on?

practical exercises rather than discussion or written work

SPORT Programme - Key Elements

SPORT Programme - Effectiveness

• Following treatment, participants:

  • Reported feeling more positive about interpersonal problems

  • Were assessed as being less impulsive and less avoidant in social situations

• These improvements maintained at three month follow-up.

• Despite these positive results, these results can only be considered to be of a preliminary nature

Early interventions for sexual offending focused on blank

behaviour reduction

Behaviour reduction includes:

Aversion therapy to reduce sexual arousal or deviant preferences

Later behavioural methods for sexual offending shifted toward blank approaches

constructional

Constructional Approaches

• Functional communication training, extinction

• Positive reinforcement and overcorrection

Habilitative Programmes for Sexual Offending

• Broad sexual and social skills education

• Problem-solving and self-regulation training

anti-androgens (CPA, MPA) and neuroleptics (e.g. Benperidol)

• Aimed at reducing libido or sexual preoccupation

• Associated with serious side effects and ethical concerns

(anti-androgens (CPA, MPA) and neuroleptics) Small trials reported reductions in sexual thoughts/behaviour, but:

• Low consent rates

• Limited applicability

medication-based interventions persist in some?

prison settings

• including among men with IDD

Men with IDD were largely excluded from early blank programmes for non-disabled men

CBT

Group CBT program for men with IDD.

• Aimed at promoting coping with difficult issues, emotional regulation, and social skills.

• Demonstrated that cognitive distortions are present and modifiable in men with IDD and HSB.

• Adapted blank is effective with men on probation.

  • A longer treatment duration (2 years vs 1 year) is associated with better outcomes.

Common limitations of treatments for sexual offending

• small samples

• few/no control groups

• inconsistent recidivism measures

• focus on mild/borderline ID

Treatment for Sexual Offending - Men with IDDs show large effects for?

reducing cognitive distortions and improving victim empathy

• Moderate effects for sexual knowledge

• Post-treatment HSB rate (~11.5%), comparable to treated non-IDD populations

Many case studies often don’t include?

control gorups

Programs should be blank

dual-focused

• Target both criminogenic and IDD needs.

Programs should be adapted to?

meet the needs of people with IDD

• Ex: simplification, visualization

Programs with blank components seem to be most effective

behavioural

• Ex: role-play

Ethical Issues with treating individuals with IDDs

• Capacity to consent

• Coerced treatment

• Treating IDD offenders as autonomous, human beings

• Avoid being patronizing

• Consent to work with key people in their lives to promote an individual’s autonomy

• Careful use of language

• Confidentiality or sharing of interdepartmental/agency information