Response

We wish to thank McKinnon and colleagues for their interest in our article, their thoughtful comments and their shared concerns about the potential unintended consequences of removing intellectual disability and/or autism (ID/A) from Section 3 of the Mental Health Act (MHA) in England and Wales.

We share their view that for people with ID/A where there are significant associated risks, they could be rendered vulnerable in the absence of Section 3 safeguards. Accurate clinical diagnosis of mental illness in people with ID/A frequently takes time, and the absence of such legislative safeguards may lead to such diagnoses being made in haste, potentially exposing patients to treatments that are less likely to be efficacious than with more time available to render a more well informed clinical diagnosis.

As they suggest, the proposed changes could lead to a greater number of people with ID/A being imprisoned. Though prison can be a stressful environment for anyone, people with ID/A may experience a greater level of impact on their mental health and well-being for a variety of reasons, including both a lack of prison staff training and reasonable adjustments being made to the prison environment to support them.^{Reference McCarthy, Chaplin, Underwood, Forrester, Hayward and Sabet1} Furthermore, as described by Allely and Wood ^{Reference Allely and Wood2} in the context of prisoners with autism, they are more vulnerable to bullying, social isolation, sexual victimisation and exploitation by other prisoners; it is reasonable to suspect that prisoners with intellectual disability may be similarly vulnerable. In comparison, in a hospital setting, such people would be supported by healthcare staff with specialist expertise in ID/A, in an environment better suited to the needs of people with either or both of these conditions.

We agree with McKinnon and colleagues that autism and intellectual disability represent distinctly separate conditions that should be considered separately with respect to legislative change within the context of the MHA. They suggest that considering these conditions together indicates an ideological approach to the suggested changes. This is possible, but the conditions also have a historical association, with the first reported cases of people with autism having co-occurring delayed intellectual development.^{Reference Thurm, Farmer, Salzman, Lord and Bishop3} Furthermore, autism is more prevalent among people with intellectual disability than their peers without intellectual disability,^{Reference Brugha, Spiers, Bankart, Cooper, McManus and Scott4} though it is important to recognise that people with autism exist across all levels of intellectual functioning, from those with co-occurring profound intellectual disability to highly intelligent individuals. We share the view expressed by McKinnon and colleagues that these two conditions should not be conflated, and instead be treated as separate diagnostic entities. It is important that the evidence pertaining to the proposed changes for both conditions are considered independently of one another.