People with Disabilities Subject to Restrictive Interventions and Compulsory Treatment and

NDIS:How Will Clinical Services Respond?

Mandy Donley, Practice Leader-Disability,RN, CredMHN

Office of Professional Practice

Department of Human Services

Content

• Role of the Senior Practitioner –Disability

• Restrictive interventions

• Compulsory Treatment

• Chemical restraint

• Dual Disability

• NDIS

• For consideration

Guiding Legislation in Victoria • Disability Act 2006

• Only applicable to funded disability services (i.e. NOT schools, hospitals, aged care etc.)

• Created the position of Senior Practitioner

• Defines restrictive interventions

• Sets out legal boundaries for when you can limit a person‘s Human Rights

• Victorian Charter of Human Rights and Responsibilities Act 2006

• Sets out 20 human rights that are protected in Victoria

• ‗Right Bearers‘ and ‗Duty Bearers‘

• Act compatibly or give proper consideration to a human right

• United Nations Convention on the Rights for Persons with Disabilities

• Reaffirms people with disabilities must enjoy all human rights and freedoms

• Staff need to recognise, interpret and apply rights and obligations

Role of the Senior Practitioner Protects:

• The rights of people with a disability

• Especially those with restrictive

interventions and compulsory treatment

(section 23(2)(a))

Ensures:

• That appropriate standards in relation

to restrictive interventions and

compulsory treatment are complied

with (section 23(2)(a))

Develops:

• Guidelines and standards (section

24(1)(a))

• Links with professional bodies and

academic institutions (section24(1)(f))

Provides:

• Education and information to

disability services (section 24(1)(b)

• Information about rights (section

24(1)(c))

• Advice to improve practice (section

24(1)(d))

• Direction in relation to restrictive

interventions and compulsory

treatment (section 24(1)(e))

Evaluates and Monitors:

• The use of restrictive interventions

(section 24(1)(h))

Powers of the Senior Practitioner (section 27(2)&(3))

• Visit premises where a disability service is being provided

• See any person who is subject to restrictive intervention (RI) or compulsory treatment (CT)

• Investigate, audit & monitor the use of RI & CT

• Inspect or take copies of documents relating to a person subject to a RI or CT

• See any person involved in the development of a RI or CT

• Request information from a disability service provider relating to a RI or CT

• Authorise by written order the use of an RI

• Discontinue or alter practice

• To observe or carry out a practice

• Provide assistance if required to discontinue or alter practice

When Can You Use Restrictive Interventions? (section 140)

• To prevent the person from causing physical harm to themselves or any other

person (section 140(a)(i))

• To prevent the person from destroying property where to do so could involve the

risk of harm to themselves or any other person (section 140(a)(ii))

• If the use and form of the restraint and seclusion is the option which is the least

restrictive of the person as possible in the circumstances (section 140(b))

(c) if the use and form of restraint or seclusion—

(i) is included in the person's behaviour support plan; and

(ii) is in accordance with the person's behaviour support plan; and

(iii) is only applied for the period of time that has been authorised by the

Authorised Program Officer; and

Restrictive Interventions

• Chemical Restraint

• Mechanical Restraint

• Seclusion

• Physical Restraint

• Other

Compulsory Treatment of People with Disabilities (Part 8)

Compulsory treatment allows for the detainment of a person for the purpose of Treatment

Supervised Treatment Orders (s191 - 193): Civil order made by Victorian Civil and Administrative Tribunal (VCAT)

Residential Treatment Orders (s 152): The person has been charged and is subject to an order allowing compulsory treatment in a Residential Treatment Facility

Supervised Treatment Orders

• ID, residential service, Plan approved by Senior Practitioner

• Violent and dangerous behaviour causing significant harm

• Can‘t be reduced in less restrictive ways

• Benefit to the person

• Can‘t consent

• Necessary to detain

Residential Treatment Orders

• Sentencing, Corrections, Crimes (MIUT), Serious Sex Offenders Monitoring Acts, Transfer from prison

• ID, serious risk of violence, less restrictive, facility can provide services, Senior Practitioner notified

Criteria for a Supervised Treatment Order

Criteria as set out in section 191 (6)

a) The person has previously exhibited a pattern of violent or dangerous behaviour causing serious harm to another person or exposing another person to a significant risk of serious harm

b) There is significant risk of serious harm to another person which cannot be substantially reduced by using less restrictive means

c) The services to be provided to the person in accordance with the Treatment Plan will be of benefit to the person and substantially reduce the significant risk of serious harm to another person

d) The person is unable or unwilling to consent to voluntarily complying with a Treatment Plan to substantially reduce the significant risk of serious harm to another person

e) It is necessary to detain the person to ensure compliance with the Treatment Plan and prevent significant risk of serious harm to another person.

148. Reports

(2) A report required under sub-section (1) must—

(a) be provided within 7 days after the end of the interval advised under sub-section (1);

(b) contain the information required in a report under section 147;

(c) include a record of all instances in which restraint or seclusion has been applied during the period for which the report is prepared;

(d) specify any details required by the Senior Practitioner in respect of each instance included under paragraph (b);

(e) have attached a copy of the person's current behaviour management plan if the use of restraint or seclusion is being continued.

Disability Act 2006 – Section 148

WHEN

WHAT

WHY It’s legislation (and other very good reasons to be explained next)

Prev. month reported in the first week of the current month

Episodes of restrictive intervention for the previous month, including emergencies not defined in a current BSP, along

with each reported person’s current BSP

How do services report?

Restrictive Intervention Data System - RIDS e-BSP

DHS CSOs

Accomm.

Day

Program

Accomm.

Person with a

Disability

RIDS e-BSP

--------------- --------------- --------------- ---------------

------------------------------------------------

-

E-BSP ------------------------ --------------

E-BSP ------------------------ --------------

e-BSPs ------------------------ --------------

Episodes of RI 01/03/2013 ----------------- 01/04/2013 ----------------- :

Person’s

record TEMPLATES

Security Layer E-Business

The Problems with Restrictive Interventions:

There is no evidence to support their use

Have short term impact

Don‘t teach adaptive skills

Limit human rights and dignity

Don‘t address the function of the behaviour

Have inherent risks for people with disabilities themselves

May result in injury to others

There is evidence for:

Functional assessment of behaviour

Improving adaptive skills

Positive Behaviour Support

Restrictive Interventions – Chemical Restraint

"chemical restraint" means the use, for the

primary purpose of the behavioural control of a

person with a disability, of a chemical substance to

control or subdue the person but does not include

the use of a drug prescribed by a registered

medical practitioner for the treatment, or to enable

the treatment, of a mental illness or a physical

illness or physical condition

(Disability Act 2006, section 3)

Treatment for mental illness or chemical restraint?

Chemical restraint reduction strategy 2007-2012

Mental Health/Disability Services Project (CFBS)

[D]

Individual Client reviews (x15) Dr Sullivan

[E]

Anti-libidinal Medications Project

(CFBS) [F]

Capacity Building for Area Mental Health

Services (CFBS) [G]

Education for Disability Support Workers

(VDDS) [H]

Kew Residential Services (CDDHV)

[A]

Medication Matrix

(CDDHV) [B]

Independent Psychiatric

Review (34) [C]

Clinicians

Roundtable (RANZCP)

[I]

Education Modules

for Psychiatrists (x3)

(RANZCP) [J]

Institutions Wider Disability Population

Chemical restraint use in shared support accommodation (Hayward et al., 2012)

Antipsychotics are the most common chemical restraint for adults with intellectual disabilities in supported accommodation in Victoria.

The move to second generation antipsychotic use is represented in this data however first generation antipsychotics are still widely used.

Daily dosage of risperidone in adults with ASD as chemical restraint much higher than in those with psychosis (Hayward & Pridding, 2012)

0%

20%

40%

60%

80%

100%

Routine

PR

N

Routine

PR

N

Routine

PR

N

Routine

PR

N

Routine

PR

N

Routine

PR

N

Routine

PR

N

5-14 15-24 25-34 35-44 45-54 55-64 65+

Risperidone Ziprasidone Haloperidol Olanzapine Quetiapine Pericyazine

Chlorpromazine Aripiprazole Amisulpride Trifluoperazine Zuclopenthixol Paliperidone

18

What we know about Mental Ill-Health in Intellectual Disability

• Adults with ID experience high rates of mental ill-health: prevalence approx. 40% (Cooper & van der Speck, 2009) compared with Australian general population prevalence of 20% (ABS, 2007)

• Elderly people with ID have a greater prevalence of psychiatric morbidity than younger adults (Cooper, 1997)

• The overall prevalence of psychiatric disorders is greater in children with ID than for peers without ID (Whitaker & Read, 2006), young people with ID have been found to have levels of psychopathology 3 to 4 times higher (Einfeld et al., 2006)

• Rate of mental illness is higher in children and adults with more severe intellectual disabilities (Whitaker & Read, 2006)

19

Provision of Mental Health Services to People with Disabilities

―The separation of mental health from intellectual disability services has led to a

serious underestimation of the prevalence of dual [disability], with clinicians

ill-equipped to treat individuals‖ (Morgan et al., 2008)

Little robust evidence for chemical restraint use in adults with intellectual

disability

(Brylewski & Duggan, 2004; Tyrer et al. (2009)

What do we know about Dual Disability? Morgan, V. A., Croft, M. L., Valuri, G. M., Zubrick, S. R., Bower, C., McNeil, T.

F., & Jablensky, A. V. (2012).

Intellectual disability and other neuropsychiatric outcomes in high-risk children

of mothers with schizophrenia, bipolar disorder and unipolar major

depression.

The British Journal of Psychiatry, 200(4), 282-289.

Paper suggests shared vulnerabilities...

Complex familial, inherited and social variables to analyse

20

Cumulative Risk Factors in Behaviours of Concern and Mental Ill-Health

(From: Allen, 2008)

22

Barriers to Treatment of People with Dual Disability

• Lack of expertise and experience in both mental health and disability professionals

• Issues in practice implementation and systems - disability support professionals inadequately trained and supported

• Generally, mental health professionals are unfamiliar and untrained to support and work with persons with IQ < 50

• Wide spectrum of mental health problems in people with intellectual disability = diagnostic overshadowing

―HIT THE BALL BACK‖ - ―REVOLVING DOOR‖ PROBLEM

23

Prescribing Guidelines people with an Intellectual Disability Deb et al. (2009). International guide to prescribing psychotropic medication

for the management of problem behaviours in adults with intellectual

disabilities, World Psychiatry, 8: 181-186.

Autism spectrum disorders:

While autism is not correlated with increased prevalence of mental health

problems compared to those with ID in general, there is a greater likelihood

of being on psychotropic medication and less recovery for those with

problem behaviours (Melville et al, 2008)

Hayward, B, (2009). A Proposed Framework for the Medical Review of

Children and Young People with Autism Spectrum Disorders and Behaviours

of Concern, Paper presented at Child 2009, Royal Australian and New

Zealand College of Psychiatrists - Faculty of Child and Adolescent

Psychiatry, Queenstown, New Zealand, 6-9 September.

Review of 200 random RIDS clients

0

20

40

60

80

100

120

140

160

180

200

Pharmacist Psychiatrist Independent

Reviewer

Yes

No

Unable to Determine

Payment for Psychiatric Reviews

• Short term discretionary funding through justice plans etc

• Paid as part person‘s ISP

• Paid out of the person‘s own pocket

• Medicare

▪ 10 sessions through GP surgery

▪ Assessment for mental illness

▪ Review of medication prescribed for mental illness

NDIS

• There will be no diminution of existing clients‘ choice and control over their

supports or support arrangements.

• There will be no diminution of Victoria‘s quality assurance system and

safeguards.

• The launch will build on Victoria‘s existing engagement with mainstream

services through the work of the Office for Disability and capacity building

initiatives.

• There will be a seamless response for clients contacting either the National

Disability Insurance Agency or Victorian Government Services, including

Services Connect.

Bouras & Holt (2009)

Effective dual disability service includes:

• organising services around client wishes /needs,

• good interagency communication,

• high level of awareness of mental health issues by support staff and primary

care staff,

• multidisciplinary composition,

• ability to provide consultation, assessment and treatment,

• provision of community-based interventions,

• access to local specialist and generic community and inpatient assessment,

treatment, forensic, and rehabilitation facilities,

• adequate resources,

• clear coordination of inputs, staff training, and measurement of outcomes.

A Functioning System • A unified agency or brokerage model ?

• Inpatient and outpatient settings

• Funding likely to be justified

• Individual care packages likely cost more than Secure Extended Care Unit

placements

• Multiple partnerships

- Policy and legislative development

- Relationship development

- Staffing

- Capacity building

31

Conclusion

• The history of treatment of those with intellectual disability has deprived a

vulnerable group of good care

• Dual disability exposes gaps in both health and disability

• The forensic / justice / complex care system is plugging the gap, but...

... Poor service delivery is costly and inhumane

... A fundamental change is urgently needed

Will NDIS help or hinder?

References

• Allen, D. (2008). The relationship between challenging behaviour and mental ill-health in people with intellectual disabilities, Journal of Intellectual Disabilities, 12(4): 267-294.

• Australian Bureau of Statistics (2007). National Survey of Mental Health and Wellbeing: Summary of Results. ABS Cat No. 4326.0. Canberra: ABS

• Borthwick-Duffy, S. (1994). Prevalence of destructive behaviours: a study of aggression, self-injury and property destruction, in T. Thompson & D.B. Gray (eds) Destructive Behaviour in Developmental Disabilities, Thousand Oaks, CA: Sage.

• Bouras, N. & Drummond, C. (1992). Behaviour and psychiatric disorders of people with mental handicaps living in the community, Journal of Intellectual Disability Research, 36: 349-357.

• Brylewski, J. & Duggan, L. (2004). Antipsychotic medication for challenging behaviour in people with learning disability, Cochrane Database of Systematic Reviews, CD000377.

• Cooper, S. (1997). Epidemiology of psychiatric disorders in elderly compared with younger adults with learning disabilities, British Journal of Psychiatry, 170: 375-380.

• Cooper, S. & van der Speck, R. (2009). Epidemiology of mental ill health in adults with intellectual disabilities, Current Opinion in Psychiatry, 22: 431-436.

• Deb, S. et al. (2001a). Mental disorder in adults with intellectual disability I: prevalence of functional psychiatric illness among a community-based population aged between 16-24 years, Journal of Intellectual Disability Research, 45(6): 484-505.

• Deb, S et al. (2001b). Mental disorder in adults with intellectual disability II: the rate of behaviour disorders among a community-based population aged between 16-24 years, Journal of Intellectual Disability Research, 45(6): 506-514.

• Einfeld, S.L. et al. (2006). Psychopathology in young people with intellectual disability, Journal of the American Medical Association, 296(16): 1981-1989.

• Felce, D. & Hastings, R.P. (2009). A general practice-based study of the relationship between indicators of mental illness and challenging behaviour among adults with intellectual disabilities, Journal of Intellectual Disability Research, 53(3): 243-254.

• Holden, B. & Gitlesen, J.P. (2003). Prevalence and psychiatric symptoms in adults with mental retardation and challenging behaviour, Research in Developmental Disabilities, 24: 323-332.

• Melville et al. (2008). The prevalence and incidence of mental ill-health in adults with autism and intellectual disabilities, Journal of Autism and Developmental Disorders, 38: 1676-1688.

• Morgan, V.A. et al. (2008). Intellectual disability co-occurring with schizophrenia and other psychiatric illness: population-based study, British Journal of Psychiatry, 193: 364-372.

• Tyrer, P. et al. (2009). Neuroleptics in the treatment of aggressive challenging behaviour for people with intellectual disabilities: a

randomised controlled trial (NACHBID). Health Technology Assessment, 13(21): 1-76.

• Whitaker, S. & Read, S. (2006). The prevalence of psychiatric disorders among people with intellectual disabilities: an analysis of the literature, Journal of Applied Research in Intellectual Disabilities, 19: 330-345.

Further Information

Office of Professional Practice

Senior Practitioner – Disability

T. 9096 8427

E. seniorpractitioner@dhs.vic.gov.au

The Disability Act 2006 and the Charter of Human Rights

and Responsibilities Act 2006 can be accessed online at:

www.legislation.vic.gov.au