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Services for people with intellectual disabilities, in the UK as elsewhere, have changed dramatically over the last 30 years; deinstitutionalisation has probably been the largest experiment in social policy in our time. The vast majority of people with intellectual disabilities, their families and carers have benefited from having a better quality of life as a result of deinstitutionalisation. However, much still needs to be done to integrate this population more into society and to ensure they are offered the appropriate supports to meet their needs.

The aim of this study was to investigate co-morbid psychopathology and clinical characteristics of adults with ID living across different types of residential settings. All participants were first time referrals to specialist services in South-East London who lived either with their family (N = 375) or in supported residence (N = 280) or independently (N = 95). Psychiatric diagnoses were based on ICD 10 criteria following clinical interviews with key informants and patients. Logistic regression analyses showed that personality disorders were more likely to be diagnosed in people who lived independently or in supported residence, while anxiety disorders were more likely in those living with their family. Overall, those who lived in independent residence had higher rates of co-morbid psychopathology. These effects were independent of ID level and age differences. Younger adults were more likely to live with their families while those with higher ID level were about 17 times more likely to live independently. The largest proportion of referrals to outpatients lived in independent residence although there were no significant differences in other care pathways. The findings are discussed in terms of implications for service planning and development.

We investigated the relationship between challenging behavior and co-morbid psychopathology in adults with intellectual disability (ID) and autism spectrum disorders (ASDs) (N=124) as compared to adults with ID only (N=562). All participants were first time referrals to specialist mental health services and were living in community settings. Clinical diagnoses were based on ICD-10 criteria and presence of challenging behavior was assessed with the Disability Assessment Schedule (DAS-B). The analyses showed that ASD diagnosis was significantly associated with male gender, younger age and lower level of ID. Challenging behavior was about four times more likely in adults with ASD as compared to non-ASD adults. In those with challenging behavior, there were significant differences in co-morbid psychopathology between ASD and non-ASD adults. However, after controlling for level of ID, gender and age, there was no association between co-morbid psychopathology and presence of challenging behavior. Overall, the results suggest that presence of challenging behavior is independent from co-morbid psychopathology in adults with ID and ASD.

Accessible summary • This paper looks at how care is given to people with intellectual disability who have mental health problems. • The paper looks at care since Valuing People came out in 2001. • It shows there are not enough services for people with intellectual disability who have mental health problems. • It shows there are not enough services for people who have autism and mental health problems. • Lots of people feel that mainstream mental health services are not good enough for people with intellectual disability. Lots of people feel mainstream services could be better. • The paper looks at how people can get help and support in their local area and not having to move away to get help. • The paper looks at what services might be needed in the future. What can be done to make services better? • The people who pay for services are called commissioners. They should think about how they can make local services better for with intellectual disability and mental health problems. • Commissioners should work more together with those who support people with intellectual disability to improve services. • People with intellectual disability should be happy with the services they have in their local places. • Services need to remember that people change as they get older. • Services need to remember that what people want. This can change when they get older. Summary The commissioning and provision of mental health services for people with intellectual disability is often complex and characterised by different service delivery models. This paper looks at the current situation 7 years after the White Paper, Valuing People (From words into action: London learning disabilities strategic framework, Department of Health, London), within the context of the National Service Framework for Mental Health (Establishing responsible commissioner; draft guidance. HSC draft, Department of Health, London). It sets out to illustrate problems faced in providing local services in the United Kingdom for those with intellectual disability and other neurodevelopmental disorders. This paper proposes new ways of working and introduces the concept of a neurodevelopmental model designed to address gaps and inequalities within services by offering solutions that embrace joint working.

Accessible summary • This research was about people with learning disabilities who went into hospital when they had mental health problems. • We looked at when they went into ordinary mental health units and also into a special unit for people who also have learning disabilities. • We looked at what their mental health problems were and how long they stayed for. We looked at what types of places they were living in before they went to hospital and where they went to live afterwards. We found some differences in what happened to the people depending on where they stayed. • This research will help to find out where people with learning disabilities who also have mental health problems should be treated if they need to go to hospital. Summary This study aimed to compare the characteristics of service users with intellectual disabilities and mental health problems admitted to either a specialist or a generic inpatient unit in an area of South London. Socio-demographic and clinical characteristics of consecutive admissions over a 5.5-year period were recorded using a questionnaire. Key differences in psychiatric diagnosis, residence type and discharge destination were found between individuals using generic and specialist provision. Length of stay was significantly longer for specialist unit admissions. Admissions to the specialist unit were significantly more likely to reside with family prior to admission and admissions to generic units were significantly more likely to come from ‘other’ forms of residence such as hostels, prison and ‘no fixed abode’. At discharge the proportion of those admitted to the specialist unit who resided with their families reduced. At the same time the proportion of those living in supported accommodation increased although compared with those admitted to generic units they were still significantly more likely to return to the family home. Significantly, more adults admitted to generic units were diagnosed with an affective disorder. Specialist inpatient provision may be crucial in helping mainstream services meet the needs of individuals with intellectual disabilities and mental health problems.

There are high rates of emotional, behavioural and psychiatric problems (Cooper et al, 2007) in the learning disability population. This paper describes the Mental Health in Learning Disabilities (MHiLD) service for adults with learning disabilities in four South London boroughs. This service has been in operation in two South East London boroughs from 1982, and was extended to a third in 1999 and a fourth in 2006.

There is sparse information upon which to recommend a return to activity after foot surgery. The purpose of this study was to determine whether six weeks is sufficient time for the emergency brake response time to return to preoperative levels after a first metatarsal osteotomy for symptomatic hallux valgus.We conducted a prospective, observational study to assess the effect of surgery on emergency brake response time in a group of twenty-eight patients undergoing a unilateral first metatarsal osteotomy on the right side for symptomatic hallux valgus. A custom-made driving simulator was used to assess total brake response time, reaction time, and brake time. Patients were assessed preoperatively and at two and six weeks postoperatively. A control group of twenty-eight individuals matched for age, driving status, and sex was included for baseline comparison.Total brake response time, reaction time, and brake time were significantly lower for the control cohort compared with the preoperative values recorded in the study cohort (p0.05). Only seven of the twenty-eight study patients were able to complete the assessment at two weeks; the remainder were not able to complete it because of postoperative pain. All patients were able to comfortably complete the study at six weeks. In the study cohort, the total brake response time, reaction time, and brake time had significantly improved compared with preoperative recordings (p0.05).By six weeks after surgery, emergency braking time in patients undergoing a first metatarsal osteotomy is similar to that of healthy individuals.

Associations between demographic and clinical variables and severe behavioural problems in people with intellectual disabilities were examined in a cross-sectional survey of 408 adults consecutively referred to a specialist mental health service. Severe behavioural problems were present in 136 (33.3%) of the sample. The demographic and clinical predictors of severe behavioural problems in this sample were identified by logistic regression. Age and gender were not associated with severe behavioural problems. The presence of severe ID independently predicted the presence of severe behavioural problems. Schizophrenia spectrum disorders and personality disorders independently predicted the presence of severe behavioural problems, whereas the presence of an anxiety disorder independently predicted their absence. There is an increasing evidence base of relationships between mental disorders and behavioural problems in people with ID although the pattern of these relationships remains unclear.

Background Although research is starting to identify those factors that predict contact with mental health services in individuals with intellectual disabilities, very little is known about the patterns of service use following referral. Yet, this information is vital for effective service planning and development. We therefore examined the factors associated with service consumption. Methods We constructed a service consumption index based on the number of outpatient clinics attended, contacts with the community psychiatric nurses, home visits by a psychiatrist and the number of admissions. This consumption index was used to divide the sample (n = 115) into two groups: heavy and light service users. Results and conclusions Logistic regression analysis indicated that, after controlling for the length of service contact, individuals with a diagnosis of schizophrenia spectrum disorder and those with a greater number of affective/neurotic symptoms were more likely to be heavy service users. Age, living situation and the degree of intellectual disabilities were not found to be significant predictors of service consumption. The results also suggest that a small proportion of service users consumed almost half of the service resources.

Background Although there is already information available about caring for someone with a mental health problem, there is very little written for families and carers of people with intellectual disabilities. Materials and methods This paper describes the development of a Guide as such a resource. The consultation stage involved interviews and focus groups with families, service users and paid carers (n = 20) to highlight their needs and preferred format. Additional carers (n = 12) completed structured questionnaires to evaluate the Guide. Results The initial consultation showed that an easily accessible and user-friendly information resource was needed. The evaluation showed that family carers were satisfied with the Guide, finding it easy to read and covering most of the information required. However, they did highlight areas that needed further detail. Conclusions The involvement of carers in the development of such resources is essential, emphasizing the benefit of carers’ knowledge and experience to professionals.

We examined behaviour management problems as predictors of psychotropic medication, use of psychiatric consultation and in-patient admission in a group of 66 adults with pervasive developmental disorder (PDD) and intellectual disability (ID) and 99 controls matched in age, gender and level of ID. Overall, people with PDD had higher rates of most DAS behaviour problems and more frequent use of anti-psychotics than matched controls. Logistic regression analyses showed that physical aggression and problems such as pestering staff independently predicted use of anti-psychotics. Physical aggression and overactivity predicted further involvement of psychiatric services. PDD diagnosis predicted admission to an in-patient unit. The results suggest that externalizing problem behaviours in adults with autism can predict type of treatment intervention.

Background Assertive community treatment (ACT) has been applied to a number of disorders in the adult population, such as schizophrenia, with some degree of success; its use in the treatment of people with intellectual disability (ID) and mental illness has received little attention. Despite the high costs of ID in health and social care, there has been very little evidence-based practice for people with ID and mental illness, and it remains a neglected area of research. Aims The aims of this study were an exploratory comparison of the effectiveness of an ACT model for the treatment of mental illness in people with ID (ACT-ID) with a standard community treatment (SCT-ID) approach. Method A Randomized controlled trial design was adopted and allocation was made by stratified randomization by an independent statistician. The prognostic factors used in the randomization were gender and psychiatric diagnosis (psychosis vs. affective). Service users were randomly allocated to either ACT-ID or SCT-ID. Results There were no statistically significant differences between ACT-ID and SCT-ID in terms of the level of unmet needs, carer burden, functioning and quality of life, but borderline evidence of a difference between treatment groups in quality of life in favour of SCT-ID. Both SCT-ID and ACT-ID groups decreased level of unmet needs and carer burden, and increased functioning. SCT-ID also led to a small increase in quality of life.

BackgroundThe development of reliable, valid measures of psychopathology in people with intellectual disabilities is an important task. However, independent replication studies are rarely reported.AimsTo report data on the psychometric properties of the Psychiatric Assessment Schedule for Adults with Developmental Disabilities (PAS–ADD) Checklist.MethodThe PAS–ADD Checklist was completed for 226 adults as part of the assessment process for a specialist mental health service for people with intellectual disabilities.ResultsInternal consistency was acceptable. Factor analysis revealed one main factor that was characterised by items related to mood. The Checklist was sensitive to differences between diagnostic groups and had an overall sensitivity of 66%; its specificity was 70%.ConclusionsThe PAS–ADD Checklist is a quick and easy to use screening tool. Although at present it is the best measure available, it should not be the only method used to identify psychiatric disorders in people with intellectual disabilities.

Background Although there is an increased risk of schizophrenia-spectrum psychoses (SSP) in people with intellectual disability (ID), there is a paucity of research evidence into clinical presentation of the disorder in comparison with research into SSP in people without ID. Aims The aims of the study were to compare clinical, functional, and social factors in patients with mild ID (ICD-10: F70) and SSP (ICD-10: F20–9) attending a specialist mental health service for people with ID, with a control group of patients without ID but with SSP attending a generic adult mental health (GAMH) outpatient clinic. Method A total of 106 patients with SSP (53 with ID and 53 from GAMH) were assessed on psychopathological symptoms, functioning scales and quality of life. They were compared using chi-squared and regression analysis where appropriate. Results People with ID and SSP appear to be more debilitated by the co-occurring disorder than those with the same disorder but without ID. Increases in observable psychopathology and ‘negative’ schizophrenic symptoms, and decreased functional abilities were observed in the group with ID when compared to the GAMH group. The clinical implications of these findings are discussed.

This article considers variables associated with the presence of a psychiatric diagnosis in those referred to a specialist mental health service for people with mental retardation (MR). Data were collected on 752 newly referred clients. The presence of a psychiatric diagnosis was assessed by two psychiatrists based on International Classification of Diseases, 10th Revision, criteria. A series of binary logistic regression analyses were conducted. Older age, mild MR, admission to an inpatient unit, referral from generic mental health services, and detention under current mental health legislation were associated with an increased presence of any psychopathology. Severe MR, the presence of epilepsy, and residence with the family were associated with a lower incidence of any psychopathology. Findings relating to specific psychiatric diagnoses on the whole supported previous research. Clear service arrangements are necessary for people with mild MR who have a high incidence of psychiatric disorders.

Background When adults with intellectual disabilities (ID) require a psychiatric admission, general adult mental health units are often used. Specialist units have emerged recently as a care option but there is only limited evidence of their effectiveness. Thus this study aims to describe and evaluate the effectiveness of a specialist inpatient unit and report on the utilization of generic and specialist inpatient services. Method All patients admitted to a specialist ID psychiatric unit were evaluated on admission and immediately after discharge on a number of outcome measures. In addition, they were compared with those admitted to general adult mental health units covering the same catchment area. Results Significant improvements were demonstrated within the specialist unit cohort on measures including psychopathology, global level of functioning, behavioural impairment and severity of mental illness. The specialist unit patients had a longer length of inpatient stay but were less likely to be discharged to out-of-area residential placement. Conclusions Specialist units are an effective care option for this group of people.

Background The Specialist Mental Health Service for people with an intellectual disability (ID) and psychiatric disorder (referred to throughout this paper as ‘the Service’) has been in operation in south-east London for the last 18 years, during which time two local, long-stay institutions have closed. Aims To measure the number of referrals to the Service from 1983 to 2001 and identify trends. Methods Data were recorded on 752 new referrals using the assessment and information rating profile. Diagnoses according to the International Classification of Diseases (10th edition) were made by two psychiatrists. Referrals for a one off consultation or assessment, or with an IQ > 70 were excluded from analysis. Results Over time more non-white clients and more clients with mild ID were referred. More referrals were made in later years, and a greater proportion came from primary care. Later referrals were also more likely to have a psychiatric diagnosis than those in earlier years. Conclusion Significant trends in referrals were identified, which may be explained by various external factors.

Atypical antipsychotics are the first-line treatment for psychosis and are commonly used for behavioural problems in people with intellectual disabilities (ID), but a comprehensive evidence base for this approach is lacking. We studied prescription trends and the clinical effectiveness of risperidone and olanzapine in people with ID in a clinical, naturalistic setting. The results suggest that both drugs are well tolerated and effective in treating target symptoms across a range of diagnoses and ID. Both risperidone and olanzapine appear to reach full efficacy within 3 months, after which improvement reaches a plateau, as reflected in the Clinical Global Impression-Improvement scale. Compliance with both drugs is high. Olanzapine tended to be prescribed mostly for psychotic disorders, and showed good rates of response, whereas risperidone was prescribed mostly for people with behavioural disturbance associated with a psychiatric diagnosis. Furthermore, approximately one-quarter of the risperidone group were prescribed the medication for a behavioural disorder associated with a pervasive developmental disorder. Again, the medication was broadly effective in treatment. Both medications were also used to effectively treat affective disorders in a small percentage of patients. This study appears to indicate that both medications could be of significant clinical benefit for people with ID across a wide range of diagnoses and level of ID, although further controlled trials are required.

The present study was designed to monitor the use of atypical antipsychotics in adults with intellectual disability and to evaluate the clinical effectiveness of these drugs. Twenty-one patients were commenced on an atypical antipsychotic: 12 on Olanzapine and nine on Risperidone. The ICD-10 diagnoses of the subjects were mild (13 cases) or moderate (8 cases) mental retardation, and psychiatric disorders (17 cases) with significant impairment of behaviour in 10 cases. Tolerability was good for 15 patients experiencing minimum or no side-effects, and medication was only stopped as a result of side-effects in one case. Clinical global outcome was rated as minimally improved or better for 16 cases. The present findings suggest that the atypical antipsychotics Olanzapine and Risperidone are well tolerated by patients with intellectual disability and psychiatric disorders, and are broadly effective against target symptoms.

The present paper discusses the application of the 'matrix model' to mental health services for people with intellectual disability. There is great variability between the service models in this area, which makes comparisons and conclusions difficult. The present model facilitates the breaking down of these complexities into understandable parts so that future directions for research, service planning and delivery can be logical, coherent and evidence-based.

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.

Changes have occurred in the pattern of services for people with learning disabilities and mental illness and/or challenging behaviour over recent years, with the development of a variety of service models across the UK. In SE London, residential services are based predominantly on a supported housing model and the strong philosophical premise that people should not be excluded from a community residential service because they have complex physical, behavioural or mental health needs. Local services, therefore, are supporting individuals with a wide range of need. This paper describes the development of specialist mental health and challenging needs services in support of this model. The issues raised are outlined, together with a list for action and priorities to overcome the difficulties encountered, including the maintenance of an effective infrastructure.

The challenge facing services for people with learning disabilities is to create the environment in which clients have the best quality of life without preconception. The heterogenous nature of people with learning disabilities requires diversity of care provisions sensitive to their individual needs. The different demonstration and presentation of their mental health needs has influenced the development of services and different models of specialist services have emerged with local variations. There is still, however, a great deal of confusion on both ideological and service delivery level. Although services for people with learning disabilities have succeeded in resettling people in the community and supporting them in developing adaptive skills, unfortunately these successes are not matched by equally effective and efficient services to those with mental health needs.

The functioning of people with intellectual disability (ID) is affected by many factors. As well as their ID, their ability to communicate with others, their social competency, personality, life experiences and circumstances, and their health (including mental health) also influence their behaviour and adjustment. This chapter focuses on the development and provision of services for adults with ID who have additional psychiatric and behavioural disorders. Developments have taken place in various parts of the world in recent years and a wide range of services has emerged.

Service provision in the United Kingdom (UK) for those individuals with intellectual and developmental disabilities (IDD) and coexisting mental health problems remains unfunded and under-developed. Heavily determined by widespread and enduring dualistic thinking, leading patients to bounce between mental health and IDD services. Community services in the UK for people with IDD and coexisting mental health problems, particularly for older adults, remain non-standardised, not researched based and with limited evaluations of clinical outcomes and cost effectiveness. Future research into the effectiveness of community services for people with IDD needs to focus on service components rather than whole-service models.

Researchers have paid increasing attention to mental health issues in adults with autism spectrum disorders (ASDs) over the last decades. However, little is known about how rates of clinical referrals, types of mental health diagnoses and treatment in adults with ASDs and intellectual disability have changed. We examined patterns of change in referral trends to specialist mental health services in south London from 1983 to 2000 ( N = 137). The majority of the cases (58.4%) did not have a diagnosable psychiatric disorder. Schizophrenia was the most frequent psychiatric diagnosis followed by depression, adjustment reaction and anxiety. There was a significant change in the rate of referrals, an increase in the diagnosable psychiatric disorders over time and a significant reduction of medication at time of referral. There were no significant changes in the use of other therapeutic interventions. The proportion of participants living independently increased. Implications for services and future research are discussed.

Background Although gender differences in psychopathology among the general psychiatric population appear to be well documented, such differences have been either ignored or inconsistently investigated among people with intellectual disability (ID). Methods The study examined psychiatric co- morbidity in 295 men and 295 women with ID and significant social impairments living in community settings. The sample was drawn from consecutive clinical referrals to a specialist mental heath service of South-East London. Psychiatric diagnoses were based on ICD-10 criteria. Results Personality disorder was more common among men, although dementia and adjustment reaction were more common among women. There were also gender differences in marital status, with a larger percentage of women being either married or in a stable relationship. Gender differences in the source of referral were also observed, with more women being referred through primary care and more men being referred through generic mental health services. Conclusions Female patients seem to have at some extent different mental health needs from male patients. Such differences should be taken into account in the design and delivery of clinical service for people with ID.

There have been few studies of psychopathology in adult with autism. This study examined psychiatric co-morbidity in 147 adults with intellectual disability (ID) and autism and 605 adults with ID but without autism. After controlling for the effects of gender, age, psychotropic medication and level of ID, people with autism and ID were no more likely to receive a psychiatric diagnosis than people with ID only. People with autism were less likely to receive a diagnosis of personality disorder. These findings cast doubts on the hypothesis that adults with ID and autism are more vulnerable to certain psychiatric disorders than non-autistic adults with ID.

Information on admission to psychiatric inpatient units is lacking from the literature on contemporary services for people with intellectual disability and mental health needs. Here we report on predictors of admission for a cohort of 752 adults from this population living in community settings; 83 were admitted. We also report on two subsamples of this cohort for whom different psychometric measures concerned with psychiatric symptoms and behavior had been completed. Schizophrenia spectrum disorders and mild intellectual disabilities independently predicted admission for the total cohort. The presence of symptoms associated with psychosis and the presence of physical aggression predicted admission in the subsamples.

Services for people with learning disabilities have been transformed since the late 1960s by the move from institutional to community care. (Learning disabilities is the term currently used in the UK in preference to mental retardation, developmental disabilities and mental handicap.) Important changes include the progress towards integration, participation, inclusion and choice for people with learning disabilities, which have occurred in the context of the broader civil and human rights movements. It is time to examine the services delivered to people with learning disabilities and comorbid psychiatric disorders (mental illness, personality disorders, behavioural problems with aggression) and the evidence for their effectiveness.

• Many, and in some countries most, health care professionals receive little training in the assessment, treatment and management of mental health problems in people with ID. • In the UK, ID is a compulsory component of the training of psychiatrists. This is not the case in the USA, Canada, Australia and Austria. • ID is included in some training programmes for psychologists, but clinical experience in the field is less available, is optional and usually post-qualifications. • Primary car physicians in all the countries reviewed receive little or no exposure to the health care needs of people with ID, including mental health, at both an undergraduate and postgraduate level. • Positive developments in training were evident in all the countries reviewed. these often are linked to charismatic individuals who pioneer the initiatives. • An infrastructure is necessary to support training, including national standards of care for people with ID and mental health problems, to drive accreditation and certification of courses, together with secure career paths.

Part I. Assessment and Diagnosis: 1. Diagnosis of mental disorders in people with intellectual disabilities Peter Sturmey 2. Mental health assessment and monitoring tools for people with intellectual disabilities Caroline Mohr and Helen Costello 3. Interdisciplinary multi-modal assessment for mental health problems in people with intellectual disabilities Jean O'Hara 4. The relationship between challenging behaviour and psychiatric disorders in people with severe intellectual disabilities Collin Hemmings 5. The interface between medical and psychiatric disorders in people with intellectual disabilities Nick Lennox Part II. Psychopathology and Special Topics: 6. The psychopathology of children with intellectual disabilities Bruce Tonge 7. Depression, anxiety and adjustment disorders in people with intellectual disabilities Chrissoula Stavrakaki and Yona Lunsky 8. Schizophrenia spectrum disorders in people with intellectual disabilities David Clarke 9. Personality disorder W. Lindsay 10. Dementia and mental ill health in older people with intellectual disabilities Sally-Anna Cooper and Anthony J. Holland 11. People with intellectual disabilities who are at risk of offending Glynis Murphy and Jonathan Mason 12. Behavioural phenotypes: growing understandings of psychiatric disorders in individuals with intellectual disabilities Robert Hodapp and Elizabeth Dykens 13. Mental health problems in people with autism and related disorders Celine Saulnier and Fred Volkmar 14. Self-injurious behaviour John Hillery and Philip Dodd 15. Mental health and epilepsy among adults with intellectual disabilities Sumitro Deb 16. Neuroimaging and intellectual disabilities Max Pickard and Dene Robertson Part III. Treatment and Therapeutic Interventions: 17. Treatment methods for destructive and aggressive behaviour in people with severe developmental and intellectual disabilities R. Matthew Reese, Jessica Hellings and Stephen Schroeder 18. Behavioural approaches to treatment: principles and practices Betsy Benson, Susan Havercamp 19. The psychopharmacology in intellectual disabilities Bryan King 20. Psychosocial interventions for people with intellectual disabilities Dave Dagnan 21. Psychodynamic approaches to people with intellectual disabilities: individuals, groups/systems, and families Georgina Parkes and Sheila Hollins Part IV. Policy and Service Systems: 22. Mental health and intellectual disabilities: the development of services Stuart Cumella 23. Clinical services for people with intellectual disabilities and psychiatric or severe behaviour disorders Philip Davidson and Jean O'Hara 24. Staff supporting people with intellectual disabilities and mental health problems Chris Hatton and Fiona Lobban 25. Professional training for those working with people with intellectual disabilities and mental health problems Helen Costello and Geraldine Holt, Nancy Caine, Elspeth Bradley, Jennifer Torr, Robert Davis, Niki Edwards and Nicholas Lennox.

This article describes some of the areas which have been noted to cause stress in community mental handicap teams. Each area is discussed in turn and suggestions are made as to how the stress might be resolved.

Diogenes' syndrome is characterized by marked self-neglect, domestic squalor, social withdrawal and hoarding of rubbish (syllogomania). The syndrome has been reported to occur in association with a wide variety of conditions, but the present authors were unable to find any previous reports of Diogenes' syndrome in patients with intellectual disability.

The concept of autism has widened from the typical, classic or nuclear autism of Kanner (1943), to include those with the ‘triad of social impairments’ (Wing & Gould, 1979); that is impaired social interaction, communication and imagination which is associated with narrow, stereotyped, repetitive patterns of behaviour. These features make up the ‘autistic spectrum disorders’ and include Kanner's and Asperger's syndromes (Box 1).