Preventive approaches

There are three types of preventive activity. Primary prevention involves stopping the offending behaviour occurring. Secondary prevention entails providing treatment to a young offender in order to prevent a recurrence. Tertiary prevention focuses on the group who continue to present a high risk of offending despite interventions and so requires attention to their appropriate care, with the careful planning of specialist services.

To undertake preventive approaches with this group we need to understand the factors that lead to offending behaviour. Hall outlines the characteristics of young offenders with a learning disability. These factors include socio-economic deprivation, temperament problems, originating from large families, impaired social and communication skills, presence of psychiatric disorder and having experienced a number of placements outside the family home. Primary prevention needs to focus on children with low abilities from impoverished backgrounds. Longitudinal studies have shown a link between early risk factors of behavioural problems in childhood and later antisocial behaviour (Reference RobinsRobins, 1978). The impact of early intervention to reduce delinquency is found to be strongest where the programmes are concerned with social and emotional development, as well as intellectual development, and include parental involvement (Reference Zigler, Taussing and BlackZigler et al, 1992).

Another group to target is those looked after children with a learning disability in the care system who experience a number of placements. The health needs of those young people in care is addressed as a priority in recent documentation from the Department of Health (1998).

Once a young person has committed an offence, then the approach is mainly one of assessment and management of the risk. A good practical review of the assessment of risk in adolescents is provided by Sheldrick (1999). The up-to-date thinking is not to look at all-or-nothing long-term predictors, but to undertake short-term frequent decisions about risk, which can assist in the management of the individual and their environment. The other key area of prevention for mental health services is the treatment of mental disorder, with conduct and mood disorders being the most common problems.

Service developments

A strategic approach to service development is required in order to develop a comprehensive range of coordinated services for young offenders with a learning disability. These services must be considered in the wider commissioning of other child and adolescent mental health services for young people with a learning disability. A multi-agency group involving learning disability specialist health services, forensic adolescent services, education authorities, Social Services, primary health services, youth offending teams and the probation service needs to be set up to develop a local strategy in order to plan services effectively. There need to be available in-patient, out-patient and day services closely working with other agencies providing for young people.

It is important to have links through the tiers of service, from highly specialist in-patient services to those providing at Tier 1 non-specialist level, such as social workers, teachers and GPs. This is necessary not only in the process of assessment and treatment, but also in the rehabilitation of young people requiring discharge into the community. For the majority of young people with learning disability who offend, the child care system is more appropriate than in-patient hospital treatment. Hall gives a comprehensive list of possible residential placements for this group. Factors that determine which services are used include the type of psychiatric diagnosis and its severity and prognosis, as well as the range of therapeutic services available.

Personal experience during the opening in 1998 of the first and only low secure unit in the National Health Service for adolescents with learning disability showed the need to plan carefully in advance for appropriately trained professionals. It has been most fruitful working with local forensic adolescent services providing a route to shared expertise and skills across the multi-professional team. In addition, building up links with adult forensic learning disability services is also necessary, as a number of young people may need treatment and care well into early adult life.

One practical issue which needs emphasising, and which is discussed by Hall in the section of his review entitled ‘Clinical pathways’, is the complex subject of providing treatment for this group using the appropriate legislation. It is important to have clear both the treatment and care objectives for the young person when considering use of the Mental Health Act 1983 and the Children Act 1989. A very good concise guide on aspects of the law for young people is found in Williams & White (1996). The principles also apply to young people with a learning disability, although the issue of mental capacity and compliance needs more careful consideration.

This is a fascinating area of clinical practice in which there is a dearth of research. Hopefully, the recent work by Hall will put the needs of these young people more clearly in the minds of clinicians, researchers and managers.