LEARNING DISABILITY (Mental Handicap)

1. Introduction
People with learning disability have a low IQ, and have had this from early life. People
with a learning disability find it difficult to understand new or complex information, to
learn new skills, care for themselves and organise their lives. In a prison, it is easy for
people with a learning disability to become a victim of bullying. It is also hard for them
to learn to do what is expected of them under the prison regime and they may therefore
do poorly on the incentives and earned priviledges sytem.

This leaflet is written for prison staff to help them:

• understand what learning disability is
• better manage some of the problems that prisoners with learning disability pose
• know when to refer a prisoner with learning disability to health care
• know what sort of specialists help may be available.

2. What is learning disability?

`Learning disability' is the current British term for what used to be called `mental
handicap' and is called `mental retardat ion' in other coutries. Sometimes people also use
the terms `learning difficulty', `developmental disability' or `special needs'. The multiple
terms used can be confusing. Learning disability is defined by very low intelligence.
People with learning disability also often mature slowly and have problems with social
skills.

Learning disability is different from `specific learning difficulties' such as dyslexia.

Dyslexia refers to a particular type of difficulty in reading. People with dyslexia may
have normal or high (or low) intelligence.

Some people are more severely learning disabled than others (that is, their IQ is lower)
— Severe learning disability is usually identified before two years of age. People
with severe learning disability are unable to take care of themselve or organise
their lives without help
— Moderate learning disability is usually identified by age three to five. People
with moderate learning disability are able to do simple work with support but need
guidance or support to mana ge their daily activities
— Mild disability is usually identified during the school years. People with a mild
learning disability are limited in what they can achieve at school and need
additional help to learn new skills, but are able to live alone and work at simple
jobs.

3. How common is learning disability?

It is estimated that 2% of people in the UK have a learning disability - about 1 million
people. The majority of these have mild disabilities.

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4. Learning disability and crime
Offending behaviour is found more often in people with mild learning disability (IQ
under 85) than in the rest of the population. People with very severe learning disability
(IQ under 50) are not usually charged with a crime if they behave in anti-social ways, as
they are not considered to be able to think and plan sufficiently to have commited the
crime deliberately (do not have the `capacity to form intent'). Offending behaviour in
people with learning disability consists mainly of offences against the person (mostly
violent), whereas in the general population, offences of property are more common. The
two offence types which cause most concern amongst people with learning disability are
sex offences and fire-setting, but the most common form of severe offending behaviour is
probably aggression and assault.

Because people with learning disability may have difficulty in understanding court
proceedings and some have a tendency to answer `yes' to any question, he or she may
need an appropriate adult or an expert in learning disability to represent them or comment
on the special circumstances of their case in Court.

5. Learning disability and mental illness and other health problems

Learning disability is not itself a mental illness. There are no medications or other
treatments. However, people with learning disabilities are more prone to develop
develop mental disorders which can be treated than the general population - especially
when they are under stress. There are very many reasons for this. People with learning
disabilities usually have fewer experiences of personal success, fewer supportive
relationships and are less likely to be regarded by others with respect - all factors that
protect against mental ill health.

People with learning disability are twice as likely to have a major mental illness such as
schizophrenia, severe depression and manic depression. Other health problems that are
more common in this group include problems with their hearing and with sight, epilepsy
and autism.

People who are autistic are not able to socialise with other people and tend to speak very
little or to have an odd style of speech. They often have a pre-occupation or obsession
with everything being the same. People who have autism as well as learning disability
are especially likely to become involved in criminal behaviour.

Epilepsy can affect behaviour in many ways. For example, people with epilepsy may
become irritable, on edge or aggressive before having a fit. They may become confused
and this might also lead to aggression.

6. Managing a prisoner with learning disability on a wing or unit

The following advice in based on the experience of managing people with learning
disabilities in the community. It is aimed at helping the prisoner to integrate into the
prison regime.

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1. Even more than the average person, people with learning disability need a structure
and daily routine. Left to themselves, they do not have the capacity to organise
themselves. They need help in planning how they spend their day, including work
and education and association. They may need extra support to do their job - for
example, more detailed instruction about what is required in cleaning their cell or
landing. It may help to break complex tasks down into small parts and give
instructions to do one part only at a time. They may need different sorts of activities
to be available during association (for example, manual jobs, drawing, simple puzzles
or painting by numbers). They will also need help with writing letters to those
outside prison.

2. Watch out for exploitation of the individual by others. People with learning
disability like to please others by agreeing with them. They are easily duped by more
dominant people and may be "taxed" (encouraged to "give" tobacco, food or
possessions to others) or be victims of theft. They commonly get into debt without
understanding that loans are expected to be repaid and may also engage in criminal
behaviour at the direction of others. In prison, a fit young adult with learning
disabilities might be used as a "hit man" for others. A less assertive adult with
learning disabilities can easily become a victim of sexual abuse. If exploitation is
identified, consider removing the aggressors or placing them on an anti bulling
regime. If the aggressors cannot be identified, consider protective relocation of the
individual.

3. Remember they learn slowly. People with learning disability have poor concentration
and often don't understand what has been said to them the first time or pick things up
as well as others. Be aware that what may seem to be non-compliance with
instructions may just mean that they haven't understood what is required of them

4. Ensure that all staff are aware of and take account of any problems the prisoner has
with hearing or seeing. Another reason the prisoner may appear to be disobeying
instructions is that he or she may not have heard them.

5. Consider asking one or more reliable prisoners on the residential unit if they will help
teach the individual how to manage on the unit to help him or her to avoid problems
with other prisoners.

6. Beware of a general tendency in some people with learning disability to say `yes' (and
less frequently `no') to any question about their thoughts, feelings or behaviours.
People with a learning disability are frequently very suggestible and eager to please
others. This can affect their replies to questions.

7. Reward effort. Encourage the prisoner to function at the highest level of his or her
ability at education, work and on the unit.

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7. When to seek he lp from health care staff
People with learning disability have more health problems than others (both physical and
mental) but they are less likely to seek help for them themselves.

It can be hard to know when difficult or odd behaviour by a prisoner with learning
disability means that they are mentally unwell and need to be seen by health care staff.

Some signs to look out for include:

• behaving in a very disturbed, excited or bizarre way. This could be a sign that the
prisoner has a psychotic illness, such as schizophrenia. People with learning
disability who have this illness may not admit to hearing "voices".

• Being tearful and/or withdrawn. This could be a sign of depression

• Losing weight for more than a month. This could be a sign of an emotio nal or
psychiatric disorder

• Irritability or aggression. These could be a sign of pain or emotional distress. It may

also be a sign that the prisoner has not been taking his or her medication for epilepsy.

People with a learning disability are also less likely than others to recover normally from
the grief caused by the death of a close family member. They will need extra support at
this time. A mental health `check up' by an appropriately skilled person may help
prevent problems.

8. Learning disability specialists - who are they and what do they do?
It may be useful to understand a little about what specialist health care services for people
with learning disabilities are available. Especially if you manage a unit where a number
of prisoners with learning disabilities have been located (perhaps as `vulnerable prisoners'
or `poor copers'), you may wish (in collaboration with the health care manager) to obtain
specialist advice on how best to run a regime for this group of prisoners.

Doctors who specialise in learning disability are psychiatrists who have an additional
training in learning disability. They are usually specialists in treating epilepsy also. They
are skilled in communicating with people with learning disability and in diagnosing and
treating mental disorders in this group of people. They are often called `psychiatrists of
learning disability'. Nurses who specialise in learning disability are also skilled in
communicating with people with learning disability and have valuable skills in managing
the problem behaviours that this group sometimes displays. People with learning
disability who display particularly `challenging behaviours', such as aggression and
inappropriate sexual behaviour, may live in special `challenging behaviour units'. In the
community, learning disability specialists work in multi-disciplinary teams. The teams
may include psychologists, speech and language therapists, physiotherapists,
occupational therapists and a dietician as well as learning disability nurses and

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psychiatrists. Specialists in learning disability are even more scarce than mental health
specialists.

General health care staff and general psychiatrists (without additional training or
experience in learning disability) may have difficulty in diagnosing and treating mental
disorders in people with learning disability, because of difficulties in communication and
the different ways that the illnesses may present. A small number of establishments have
included some learning disability nurses in their complement of health care staff and have
found this very useful.

Making contact with the local learning disability team may be achieved through the
`NHS prison service lead'. Following the re-organisation of the NHS, these leads are
now (April 2002) based in the Primary Care Trust rather than the Health Authority. The
establishment health care manager and Governor will be involved in local liaison
arrangements with the NHS.

9. Pre -release planning

All prisoners with an IQ of below 70 need follow up care to be organised, if possible,
well before release.

10. Resources for prisoner and primary support group

Mencap 020 7454 0454
Mencap Northern Ireland 02890 6911351; 0345 636227 (Family advisory service)
Down's Syndrome Association 020 8682 4001
The National Autistic Society 020 7833 2299; 0207 903 3555 (helpline)
SPOD (Association to Aid the Sexual and Personal Relationships of People with a
Disability) 020 7607 8851
Respond - 020 7383 0700
services for adults with Learning Disabilities who have been or may have been sexually
abused
Depression in People with a Learning Disability
(Free leaflet available from the Royal College of Psychiatrists) Tel: 020 7235 2351)
Learning disabilities and the family: the teenager with a severe learning disability
Available from the Mental Health Foundation, tel: 020 7535 7400

Books beyond words is a serious of picture books for adolescents and adults who cannot
read. They may be used by parents, carers, GPs, nurses and staff to help communication
about important topics. Titles include: Feeling Blue about depression, You're on Trial, I
can get through it (the story of a woman who is abused) Going to the doctor, Going into
Hospital, When Dad Died and Making Friends. £10 each from the Royal College of
Psychiatrists, 17 Belgrave Square, London, SW1X 8PG. Tel: 020 7235 2351 ext 146.

This leaflet has been adapted from information provided by Dr Gregory O'Brien, Dr E Milne, Mr
Paul Thornton and Graham English from Northgate and Prodhoe NHS Trust, Morpeth,
Northumberland