Angela
Browning: We will debate communication disorders in a
minute—something that I seem to be causing myself at the
moment—but I wish to pressthe Minister about the fact
that, listed under the Government’s risk option 2—the
recommendation for a single definition of mental disorder—they
identify the new appropriate treatment test. It will ensure that an
holistic assessment is carried out in each case. I do not disagree with
that. Of course, it is a good thing, but surely there are resource
implications in such an
approach.
Ms
Winterton: I am not quite sure of the hon. Lady’s
point. If we remove the present categories and less tribunal time is
spent arguing about the categories, other parts of the Act have to kick
in, as they do at the moment. It is absolutely right that appropriate
medical treatment is available and that it is part of the conditions of
detention. Half of the Opposition’s argument is that, under the
Government’s proposals, people will not receive treatment.
However, now the hon. Lady is arguing that people will receive too much
treatment under the Government’s
proposals.
Ms
Winterton: I shall give way first to my hon.
Friend.
Chris
Bryant: I think that I will misinterpret the hon. Lady a
little further. She seems to be suggesting that, because we are
changing the definition of mental disorder, each disorder in the ICD 10
list—a long list, as the hon. Member for East Worthing and
Shoreham said—would suddenly fall under the Act and therefore
everyone might be up for detention. The truth is that the vast majority
of those several different layers, both organic and other conditions
that are termed in the ICD 10 list as mental disorders, would not be
recommended for detention at
all.
Ms
Winterton: I give way now to the hon. Member for Tiverton
and
Honiton.
Angela
Browning: I am raising matters that areon the
record in the Government’s own impact assessments under the
heading “risks of option 2”. They themselves have
identified those risks. I am challenging the Minister because I am not
convinced that she has fully estimated in the regulatory impact
assessment the resource implications of the changes. If those changes
have not been properly calculated within the regulatory impact
assessment, there will be long delays for people wanting to access
those parts of the Bill. She herself has identified the
risk.
Ms
Winterton: I want to emphasise that we have
undertaken the regulatory impact assessment. We believe it to be
accurate, and I think that there are lots of counter-balances in that
regard. The hon. Lady says that by advocating tribunals, one increases
the costs. I would also say, as I have said before, that by reducing
the categories, one spends less time quarrelling about them in
tribunals.
Ann
Coffey (Stockport) (Lab): Is my understanding correct? The
category of mental disorder has not been extended. All that has
happened is that the two categories of mental disorder and psychopathic
disorder, which were in the 1983 Act, have been brought together under
the one category of mental disorder, with the term psychopathic
disorder being omitted. Therefore, there is not a new definition of
mental disorder. That is my understanding. I do not see why there
should be any more resource implications than in the 1983
Act.
Ms
Winterton: As I have said clearly, we do not
believe that the change broadens the definition and brings more people
into it. There are small numbers of people who unfortunately fall
outside that definition. However, I suspect that in many cases, ways
will be found to get help to those people.
Therefore, the change that we
propose has generally been welcomed. I hope that the additional
information I have given will reassure Committee members that we do not
intend to increase the numbers of people who are likely to be treated
under the Bill.
Question put and agreed
to. Clause 1
ordered to stand part of the Bill.
Schedule 1 agreed
to.
Clause
2Learning
disability Angela
Browning: I beg to move amendment No. 40, in
clause 2, page 2, line 4, after
‘disability’, insert
‘or an autistic spectrum
disorder’. I am
pleased to speak to the amendment, which is supported by my colleagues.
The subject has been discussed in the pre-legislative scrutiny
Committee and also in another place. The amendment seeks to add
autistic spectrum disorders to those areas that have been modified to
accommodate the needs of people with learning disabilities. The
Minister and I have shared many a conversation about the matter. I am
very grateful that she has agreed to discuss it again on Thursday
privately. I would
like to use the opportunity of moving the amendment to clarify the
reason why the issue is so important. I should begin by declaring my
interest as the vice-president of the National Autistic Society. I also
hold positions on other related autism charities.
The purpose of the amendment is
to ensure that people with autistic spectrum disorders are recognised
in the way that the amended Bill now recognises learning disability. I
am familiar with the Government arguments, both in another place and
elsewhere, about their reluctance to draw up a list of conditions that
are exceptions to the rule. However, given the background on learning
disability—its recognition in the Bill and the way in which it
is dealt with in the 1983 Act, which I will mention in a
moment—this is a special
case. I am sure that
the Minister has heard a lot of special pleading from people who are
concerned about a range of disabilities and believe that there is a
case forthose to be recognised in a Bill, rather than ignored
altogether or tucked into a code of practice. However, I want to make a
case for making a special exception for autistic spectrum disorders.
There are many reasons for that, not just because I have an interest in
the
subject. 11.30
am
Mr.
Boswell: Does my hon. Friend agree that, notwithstanding
my less extensive experience of such conditions, this is a particularly
sensitive matter and certain people with autistic spectrum disorders
may be rather high performers, whether they have Asperger’s
syndrome, and may not, in some definitions—including locally, in
my experience—be regarded as learning disabled on account of
that? However, both in terms of some of their social behaviour and
their need for social support, such people are clearly in this
category, without being mentally disabled in any
sense.
Angela
Browning: My hon. Friend is right. A diagnosis of an ASD
does not mean that someone has a mental disorder, but we all recognise
that there can be a multiple diagnosis. For example, a person with ASD
can have a learning disability and can—frequently,they
do—have a recognised mental illness. Sometimes people have a
combination of all three things: a triple diagnosis is not unknown.
Cases can be complicated and often difficult for the professional
psychiatric services to understand properly.
I should like to put on record
the concern of the National Autistic Society, which understands the
need for a clearer definition of a mental disorder. I do not think that
there is any disagreement about that. However, it is concerned that,
because of the changes and the lack of recognition of how ASD presents
itself—and our greater knowledge of it now, compared to when we
legislated on mental health in 1983—more people with an ASD
could be inappropriately
detained. I remain to
be convinced by the Governmentthat there is a case for people
with an ASD being compulsorily detained for treatment if they are not
mentally ill or, in the context of the clause, they do not
exhibit “abnormally
aggressive or seriously
irresponsible” behaviour.
That is why the recommendation of the Joint Committee on the draft
Bill, of which I was a member, identified ASDs, in addition to the
exclusion for learning disability, as the one condition to which we
felt that the Government should pay due regard. We took evidence from a
lot of people, representing those with a range of quite legitimate
conditions, who made that case. However, autism, which is a complex
condition, is different and I should like to explain why that is
so. Autism is a
lifelong disability. It is a developmental disorder and is not
something that people catch. We do not know yet what causes it,
although there is a lot of research being undertaken in this area, but
we know that, although it is different in every individual, it presents
with three core deficiencies that have a huge impact on people’s
lives and
behaviour. Autism
leads to a lack of understanding of social behaviour and problems
making social relationships. I am putting this in layman’s
language, rather than talking about what we sometimes call the triad of
impairment, which is language that just floats over people’s
heads. For children, that can mean failing to make friends in the
playground. Going to a school for children with autism and seeing them
at play time is quite a shocking thing. One does not see, as normal,
children running around, interacting and playing with each other, or
creating any imaginative play. Lack of imagination, of an ability to
put oneself in somebody else’s mindset, is part of the triad of
impairment. Children in such a school at play time will either stare
into the middle distance or be preoccupied with repetitive
behaviours.
Mr.
Boswell: Does my hon. Friend recall that one of the
celebrated books written by someone who was subject to an
Asperger’s definition was entitled “A Martian in the
Playground”, which makes her
point?
Angela
Browning: Indeed. I began by talking about children
because it is perhaps the one area in which in the past 10 to 15 years
we have started to make some progress. I am not complacent, but we have
started to give recognition in our education system and through social
services departments. First, early diagnosisis important; the
Minister will know how early intervention is key after picking up the
symptoms and signs of autism. Early intervention and management of the
condition are extremely important. Managementof the condition
very often depends on appropriate
resources being available, but certainly in the education scenario we
are in a very different position from that in 1983,
when the previous Mental Health Bill was drafted. I am old enough to
remember that
personally—
Tim
Loughton: Surely
not.
Angela
Browning: My hon. Friend is most kind, but sometimes it is
better to be older and have a longer
memory. Let us recall
that excellent report by Baroness Warnock in the late 1970s, which
looked at the way in which we educate children with learning
disabilities. Back in the early 1970s it was not unknown for children
with learning disabilities, which would have included a wide body of
children with autism, not to be considered suitable for education at
all. The ground-breaking Warnock report led to education legislation
that started to introduce the statementing process and to the formal
recognition in statute of the rights of children with a learning
disability to receive an education appropriate to their ability to
receive it. That was within the lifetime of most of us in this room,
but at the same time as the Mental Health Act 1983 was being drafted.
So, I can fully understand why—although we have a better
knowledge of learning disability per se than back in 1983, when the
Mental Health Act was being drafted—we were only at that point
just getting to grips with how we handle the education of children with
a learning disability, which would have included
autism. Meg
Hillier (Hackney, South and Shoreditch) (Lab/Co-op): It is
a pleasure to serve under your chairmanship, Mr. Cook. I am
very interested in what the hon. Lady has to say—I have been an
advocate for a relative with a learning disability, so it is an area
that greatly interests me. I wonder whether the hon. Lady can answer a
couple of
questions. First, how
many people with autistic spectrum disorders have been detained under
the Mental Health Act 1983? Secondly, is she not effectively arguing
against the amendment? She is saying that our understanding of autism
is so much greater nowadays that the idea of a psychiatrist considering
anyone with autism to have a mental disorder is as remote as their
considering someone with a learning disability to have a mental
disorder. Back in 1983 there would perhaps have been more argument to
have included autistic spectrum disorder in the
Bill.
Angela
Browning: The point that I am trying to make, which I hope
to expand, is that because our understanding is so much
greater—I am beginning with children, but I will move on to
adolescents and adults—we should be looking at the mental health
legislation in a totally different way to how we looked at it in
1983. The hon. Lady
asked me how many people had been detained. There have been two bigger
pieces of research recently, one by the National Autistic Society and
the other a report, from which I will quote in a moment, by the Royal
College of Psychiatrists. We know the figures for people with an
identified autistic spectrum disorder who come within the criminal
court system. However, a
huge number of people in our prisons almost certainly have an ASD. We
are looking at that as a body of work at present. There is a big debate
to be had about how appropriate it is for such people to go into the
criminal justice system. It is difficult to put a number on it in
quantifiable terms. I
know that this has been put to the Minister before, but can she
identify the number of people with an ASD diagnosis who are deemed
potentially dangerous and therefore cannot be treated in the Bill in
the same way as those with a learning disability? At the moment, we
have seen only the tip of the iceberg in terms of adults; as you go up
the age scale, the available statistics are certainly fewer and fewer.
We still have a great many people in the latter half of their lives who
are in the community but as yet undiagnosed. Not until they come before
the criminal justice system, or until there is a huge breakdown in
their mental health, or social services suddenly become involved with
them for some reason are these individual cases picked up. The figures
are not collected so we do not know the exact number, but it is
severely underestimated at present.
Meg
Hillier: Does the hon. Lady really fear that people with
autistic spectrum disorders will be detained under this Mental Health
Bill? Does she want ASD included for completeness’ sake, or is
there a realthreat that a psychiatrist would have such a lack
of understanding of the seriousness and the range of such disorders
that they would section or recommend sectioning somebody, rather than
recognising that the person had autism?
Angela
Browning: Yes, I do believe that there is such a threat. I
raised the first Adjournment debate in this House on Asperger’s
syndrome a few years ago, and followed it up the next year with one on
the psychiatric treatment of people with Asperger’s. Indeed, I
thoroughly welcomed the 2005 report of the Royal College of
Psychiatrists. It is absolutely essential that the professionals get to
grips with that condition, of which there has been only a restricted
understanding until now. The point that the hon. Lady just raised is my
point exactly. However, there are more complexities to it, and I am
coming to them. I
believe that ASD should be recognised alongside learning disability
under clause 2. We are not trying to prevent people with an autistic
spectrum disorder from receiving appropriate mental health services
nor, for that matter, are we saying that they should never be detained
since, like the rest of the population, in certain circumstances they
would need the security of detention. There are behaviours associated
with ASDs that do not have a psychotic base but are normal and
triggered by events.
I turn to a particular example.
Later on, in part 2, we will deal with how the Government are going to
deal with the Mental Capacity Act 2005 to take account of the decision
of the European Court of Human Rights in the Bournewood case. We should
not forget what Bournewood was about. It involved an adult man named HL
with an autistic spectrum disorder—a gentleman whom I have met.
It was quite clear that the episode leading to his detention was
event-triggered rather than an underlying psychosis. His carers had the
perseverance to take the case through every court in
this country and eventually to the European Court of Human Rights, and
as a result the Minister will now amend the law to ensure that the
experience of HL is not replicated and that there is more protection in
future legislation for people in his position. I, of course, support
that and I hope to contribute to that process of amendment when we
reach that clause of the
Bill. 11.45
am I have
personally heard first-hand accounts about how HL went from a day
centre to being detained for a very long time, to his detriment,
without the people who knew him best having an opportunity to explain
to medical professionals why it would have been, in their view, normal
behaviour for him to have presented in the way in which he did when an
event triggered an episode. I remind the Minister that that is how,
very often, even the most able people on the end of the spectrum can
behave in a different set of
circumstances. So what
is autism and why is it different? We know from the figures that, of
the population of working age, there are about 330,000 people with
autism. Of course, there are more children with autism coming through
and people often ask why autism is more prevalent today. Personally, I
believe that it is because we are much more aware of it, have a greater
knowledge of it and there is more early diagnosis.
I have mentioned the fact that
we have had a history of late diagnosis, but why is that? It is because
autism is a spectrum. If we examine our early understanding of
autism—that is what the Mental Health Act 1983 would have
considered—we see that Kanner identified autism in 1943. The
Kanner definition of autism influenced psychiatric understanding in
this country for some years, although it was not until the 1960s that
there was much recognition of the distinction between autism and other
conditions. Perhaps more prevalent in recent years has been the
understanding of Asperger’s syndrome, which is on the more able
end of the spectrum. Asperger identified Asperger’s syndrome at
about the same time in the 1940s as Kanner defined autism, but it was
never really recognised, and it was not part of psychiatric teaching
and training until very
recently. It is the
strange combination of an autistic spectrum disorder with that triad of
impairment that leads to the very distinct diagnosis that is an
autistic diagnosis. However, in the case of Asperger’s syndrome,
it means that there can be people who present who are extremely able
indeed. In fact, from an educational perspective, many can go on to
university degree level, so that gives an idea for the range of
abilities. Indeed, I have been told by the faculties of some of the
Oxford colleges that most of their mathematics and physics departments
are well populated with people who might have, or who might be
diagnosed with, Asperger’s syndrome. There is nothing
detrimental about
that. Furthermore, if
we consider some of the footage that we have seen of the people who
cracked the Nazi codes in the UK during world war two, I recall seeing
what looked like an amusing piece of footage. It showed someone who was
intelligent enough to crack the codes but who would also, every
afternoon at four o’clock,
walk down through the grounds of the HQ to the lake, carrying his cup of
tea, drink his cup of tea and then throw the teacup and saucer into the
lake. That was repeated on a regular
basis. Such behaviour,
one might think, is idiosyncratic, so where is the depth of concern
about that? However, I would say that that is just one example. I will
give another example, again of my own experience—in fact, there
are myriad examples—of a gentleman who lived, undiagnosed, with
his parents into his 40s. When the second parent died, he was left in
the house on his own, completely unsupported, for the first time ever.
It was only at that point that he really came to the attention of the
social services department. The reason that he came to their attention
was because he never went out of the house; the neighbours had seen him
a little, but he had never given them any cause for concern. However,
after his second parent died, the neighbours noticed, to their great
concern, that after it got dark he was to be seen digging up the garden
by torchlight. They were concerned that he was burying something,
because they found him to be an odd person to deal with andto
communicate with, and, therefore, reported his behaviour to the social
services department. When the department intervened, it discovered that
he was digging up the garden at night because he had a passionate
interest in gardening but did not like being around other people. He
found that, when it got dark, people did not lean over the fence and
ask, “What are you planting there?”, to which he would
have to find a reply, and communicate and socialise with them.
Therefore, it suited him to maximise his ambition of gardening by doing
it at night. I am pleased to say that I have met that gentleman, who is
now working under supervision, potting plants in a greenhouse. He has,
therefore, maximised the opportunity to do what he always wanted to
do. On first sight,
some of the people who present in what may seem to society to be an odd
way are intelligent and have other abilities. Despite the idiosyncrasy
of that particular episode, in other circumstances, that gentleman
could present himself as someone who has the capacity to express a view
about what he wants to
do. Ann
Coffey: The hon. Lady is making a good case for more
knowledge about, and understanding of, autism. In relation to this
Bill, she seems to be concerned that those who are autistic will be
diagnosed as having a mental disorder and could be detained in hospital
against their will. However, I am not clear about how making an
exemption will help. If the assessing psychiatrist does not diagnose
people as autistic in the first place, any exemption on the face of the
Bill for autism will not protect them. Surely the way forward is to
ensure that the psychiatrists who undertake mental health admissions
have as extensive a knowledge of autism as possible at the point of
assessment.
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