Angela
Browning: The hon. Lady has made a good point, and
psychiatrists’ knowledge about this group of people is a matter
that I have raised in debate many times. Despite the 2005 report of the
royal college, it remains true that we are fortunate in some of
ourinner cities, as we have a resource of psychiatrists who
understand autism and who work with people who have
learning disabilities. The run-of-the-mill provincial
psychiatrist—if I may use that terminology—does not
experience enough of these cases to get sufficient working knowledge of
what is and is not appropriate behaviour.
The point about the Mental
Health Act 1983 does not relate to the sort of situation that I have
just described, involving my gardening friend. I raised that example to
illustrate the breadth of the situation. However, when these people are
in crisis, it is not because they have a mental illness—and if
they have a mental illness, of course they should be entitled to the
same treatment and services as everyone else—but because the
nature of having an autistic spectrum disorder means that many people,
including those with a high intelligence quotient, sometimes present in
a challenging way, or in a way that may be regarded as
inappropriate. At this
point, it would be a good idea to quote from the report of the Royal
College of Psychiatrists, which I have referred to many times. I am
conscious that I have been critical of psychiatrists over the years,
not least because there is a prevalence of people with autistic
spectrum disorders who present in a challenging way being admitted as
in-patients, sometimes even when they have an autistic spectrum
disorder clearly diagnosed by another professional. Psychiatrists
commonly believe that those people have schizophrenia, and all too
often medicate them accordingly. Given the nature of the drugs used to
treat schizophrenia, what happens next is that they start to go through
the list. If the first drug does not work, they move on to the next. By
the time someone is on their fourth or fifth drug, and that still does
not work, it is very difficult to unscramble the situation to get a
clear view of whether the initial or ongoing behaviour is a psychosis,
or whether it is autistic behaviour, which, if they were harming
themselves or others, I quite agree would need
intervention. If I
may, I would like to quote from a report by the Royal College of
Psychiatrists. It is an excellent report that
indicates why, when these people are inappropriately detained or
brought within the ambit of mental health services inappropriately, it
is not only an injustice in terms of human rights, but is detrimental
to the way in which they recover from the incident that caused it. The
Royal College of Psychiatrists report states
that “Autistic-spectrum
disorders are not an illness but a disability that can have a major
impact on the development, presentation and management of psychiatric
disturbance.” The
following point is one that I would particularly like the Minister to
understand, because it explains why those people are different from
other
groups: “They
fall into a limbo between the various psychiatric specialties, their
ability putting them outside learning disability contracts but with
developmental disabilities that, once they have outgrown child and
adolescent services, may be unfamiliar to the various specialties
dealing with adult mental health or else fall outside their remit.
These issues are touched on in the Council report on services for
individuals with mild or borderline learning disability (Royal College
of Psychiatrists, 2003). This report emphasised that the defining
criterion for acceptance by the services provided by learning
disability psychiatry should continue to be a measured overall
intelligence quotient of less than 70. At the same time it recognised
that individuals with an autistic-spectrum disorder were a group who,
at times, might be better served by learning disability
services.”
The link with the way in which
such people present is not unfamiliar to people who deal with learning
disabilities, but at the same time you are dealing with people who do
not necessarily have an IQ of under 70. In most cases, if you have an
IQ under 70, you are regarded as being learning
disabled. I want to
draw the Minister’s attention to the point that the prevalence
of behaviour and the way in which it is managed is not that far
distanced from learning disability, despite the variation in IQ and
people’s potential, particularly those who are at the
moreable end.
The Government have produced a
White Paper, which I certainly welcome. It is called “Valuing
People: A New Strategy for Learning Disability for the 21st
Century”. When the Government first produced that paper, because
of the benchmark of an IQ of 70 or under to indicate learning
disabilities, they excluded people with Asperger’s from
accessing services from the social services learning disability teams.
As a result of a number of people—not only me, but a number of
others—jumping up and down when we read this, the Department of
Health then issued a
circular. I carry
these documents around with me to this day. Every time I give a talk on
autism, people come up to me afterwards and say, “Let me have a
copy of that Government circular”. I have several copies of
this, which I give out. The Government realised, to their credit, that
to deny people with Asperger’s syndrome the right to access
services through the learning disability team was
doing those people a grave disservice. They put out guidelines that
said: “This
guidance focuses mainly on action to implement the proposals for
improving the lives of all adults with learning
disabilities—those with severe and profound learning
disabilities through to those with moderate or mild learning
disabilities. Adults with Asperger's Syndrome or higher functioning
autism”— those
with an IQ of over 70, of which there are a great
number— “are not
precluded from using learning disability services, and may, where
appropriate, require an assessment of their social functioning and
social skills in order to establish their level of
need.” In other
words, our knowledge of how people with Asperger’s syndrome
function in practice, on a day-to-day basis, is something that we know
far more about now than we did when the Mental Health Act 1983
was drafted. It is also something that the Government have picked up
on, sometimes with a bit of prompting, as they start to legislate in
other
areas. 12
noon If the Bill
is to last another 20 years, we should consider our knowledge of how
autistic spectrum disorders are managed and how people with an ASD
function in their day-to-day lives, particularly when they come into
contact with services, especially mental health services. We should
recognise that there is a correlation; it is not that people with an
ASD are necessarily learning-disabled, but there is read-across in
respect of how we treat people with a learning disability. The point is
that they are different. They may have an IQ of more than 70, but they
behave differently from how one would expect people with such an IQ to
behave.
It is such behaviour that
unfortunately all too often brings those people into contact with the
mental health services and professionals who do not understand and
cannot disaggregate what I would call normal autistic behaviour and a
psychotic basis for their
behaviour.
Dr.
Gibson: The hon. Lady obviously has an intense interest in
the subject and a deep knowledge of it. Having talked to people in the
field, can she speculate about how research work is progressing? Such
research might relate to genetic causes, for example, and might
alleviate some problems. What is likely to happen in that field over
the next 20 years is pertinent, as she
said.
Angela
Browning: I will send the hon. Gentleman details of an
excellent Medical Research Council paper that deals extensively with
the subject. Having been asked that question, I shall put on record my
view of some of the various theories about the causal basis of autism,
which I have declined to do before, primarily
because—
The
Chairman: Order. Anxious as I am to maintain the technical
nature of this debate, it is important that we focus our minds on the
points in sequence. We are discussing our ability to include autistic
spectrum disorder in the clause. We will do ourselves a favour if we
concentrate on that, rather than on research which might, or might not,
take place in the future.
Angela
Browning: Thank you, Mr. Cook. I will speak to
the hon. Member for Norwich, North privately on the subject as he has
shown such an interest in it. You may have noticed, Mr.
Cook, that I have an interest in it. I frequently feel that I must
apologise for my fixation on it, and for talking about it ad
nauseam.
Chris
Bryant: Is that a
disorder?
Angela
Browning: Yes, indeed. Many hon. Members know that I have
a 35-year-old with Asperger’s syndrome and I sometimes say
jokingly to other members of my family when they go on too much about
the cricket, for example, “Just remember there is autism in the
family.” I think it has a genetic base.
May I move on, Mr.
Cook?
Angela
Browning: I want to make the case for the Bill to treat
learning disability and ASD in the same light, despite the
differentials in the two conditions, and to move on to the legal
aspects of psychiatry in relation to people who have them. I shall draw
from council report 136 of the Royal College of Psychiatrists entitled,
“Psychiatric services for adolescents and adults with Asperger
syndrome and other autistic-spectrum disorders”, which was
published in April 2006, not 2005 as I said earlier. I very much
welcome the report, which particularly informs this debate. In the
section headed “Legal aspects of psychiatry”, the
psychiatrists
say: “Most
individuals with autistic-spectrum disorders are keen to avoid trouble
with the law and most do not offend.”
That is absolutely
right. There is no propensity for them to offend more than the rest of
society. The report continues:
“This law-abiding
respect for rules can be offset by a number of predispositional factors
that make the individual more
vulnerable.” There is a
vulnerability to such conditions that needs to be recognised as well.
As I mentioned earlier, social naivety and misrepresentation of
relationships can lead such people into problems with the criminal
justice system. The report argues
that “misinterpreting
rules, particularly social ones, whereby individuals can find
themselves unwittingly embroiled in
offences” and behaviour
in which they are led on by others has consequences for them with the
criminal justice system. I would also argue that in certain
circumstances their behaviour might well bring them to the attention of
psychiatric services.
In particular, the report
states that “impulsivity,
sometimes violent, that may be a component of a comorbid
attention-deficit disorder, a state of anxiety turning into panic or a
confusing blend of both. The result is a response that is out of
proportion to the
situation”— I
would argue that that was the situation in the detention of HL in the
Bournewood case. For example, what in children could be regarded as a
tantrum, could in an adolescent or adult be believed to be a
threatening episode. That is why it is very difficult to explain what I
mean by normal behaviour. Clearly, nobody wants anyone to be exposed to
a threat, and neither do we want people to self-harm.
More often than not, however,
such tantrum-like behaviour in adults with autism is event-influenced,
rather than psychotically influenced, as I have said before. I shall
give the Committee an example of how such behaviour might present
itself. We know that people with autism often follow ritualistic
routines. For example, some feel that they must eat at a certain time
of day. I know of one young man who, every Sunday, takes two bus
journeys to eat at the same restaurant. Most of us would get thoroughly
bored with that routine, but for somebody with autism it is a security
indicator—they know that next Sunday will be the same as this
Sunday. If followed, that pattern provides comfort and
security—next Sunday will be
predictable.
Tim
Loughton: Some MPs do
that.
Angela
Browning: Indeed. We will see who eats everyday at 6
o’clock in the Members’ Dining
Room. That
predictability might seem pretty benign, but if disrupted by external
circumstances, such people do not just have a tantrum in the same way
as a small child might if deprived of sweets. In the mind of somebody
with autism, such disruption is a major event, and a third party might
interpret their response as out of proportion. However, it is a really
serious matter for the autistic person that totally undermines how they
had reckoned that the day would turn out. As a consequence, for an
adult, their response to something as minor as having their routine
being disrupted in such a way would come across as totally
unreasonable. It is particularly difficult for people with whom the
autistic person does not have a confident relationship—there
will be very few with whom they do—to rationalise and negotiate
their way out of such a situation.
Ann
Coffey: It is, of course, terrible that people are
misdiagnosed, whether for physical illnesses or mental health problems,
because there can be a stream of consequences for their treatment that
put them at a disadvantage and make their condition much worse.
However, I do not understand how the hon. Lady’s amendment would
prevent psychiatrists who do not understand autism from diagnosing
somebody, in a mental health assessment, as suffering from a mental
disorder when in fact they suffer from autism. I just cannot see how
the amendment would help. We cannot protect through an exclusion unless
the mental health professional making the assessment understands that
they are dealing with somebody with
autism.
Angela
Browning: The hon. Lady is right, and that is not actually
the basis of what I am saying. What she has just expounded is exactly
what happens in some cases. Having been critical of psychiatric
services, I must say that I am convinced that the royal college is
getting to grips with the problem through training and so on.
The behaviour of people with
ASD may well have a qualifying basis. If we are to make an exception
for somebody with a learning disability—an IQ of less than
70—unless, as the Bill states, it
is “associated with
abnormally aggressive or seriously irresponsible conduct on his
part”, the same should
apply to autism because of the way in which it presents itself. It is
very different from any other condition, except that one can measure it
as a learning disability. There can therefore be quite a read-across,
as interventions for those with learning disabilities can apply
equally, if resources are available, to those with
ASD. The royal
college’s report mentions the services for individuals with a
learning disability, and again one can see the comparator used between
how we treat people with learning disabilities and those with autism.
It
states: “Increasingly,
services for individuals with a learning disability have become
familiar with autistic-spectrum disorders, and where there is a
significant intellectual disability, they are ready to engage with
these individuals. When disturbed, their management is often a matter
of improving communication, their environment and their level of
support rather than of more traditional individual psychiatric
treatment.” In other
words, as we learn more about the management of people with ASD we can
see some of the lessons that we have learned from the management of
people with learning disabilities. We do not just lock them up when
they are “having an episode” unless, as the Bill states
and I support, they
demonstrate “abnormally
aggressive or seriously irresponsible
conduct”. So there is
quite a read-across in the management of people. It is not about
locking up people who might suddenly in one way present as potentially
having a mental disorder, because they might not have a mental disorder
any more than does someone with a learning disability who is behaving
in the same way. The test for psychiatrists is to disaggregate the two
set of behaviour, which is why the matter is difficult and there is a
need for specialisms. In some of our hospitals in London and other
large cities there are psychiatrists who specialise in autism or in
learning disabilities, so they can disaggregate types of behaviour and
understand clearly what the appropriate treatment is.
The royal college report
continues: “These
issues, while familiar to learning disability psychiatry, also apply to
individuals of normal cognitive ability, although their ability may
well bar their acceptance by an element of the learning disability
service”. We have
discussed that in relation to the Government’s health White
Paper. The report also
states: “There
is therefore the risk that such vulnerable patients fall between
contracts despite their statutory entitlement to psychiatric
services”. 12.15
pm The situation,
particularly for adults and adolescents who present behaviour that is
treated by psychiatric services, is only as good as the knowledge of
the people treating them. In managing behavioural episodes, it is clear
that although we make allowances for people with learning disabilities,
we do not for people with autism because they do not present in the
same way or because they have a higher IQ.
Psychiatrists understand that
somebody might have great ability in one area of their life but behave
in a certain way because they are autistic, not because they have a
psychiatric condition. That is why we should recognise in the Bill the
fact that that group of people is different. I cannot think of another
group who would present in such a way in certain circumstances
andyet not have a psychotic base. Very often such people
present themselves as intelligent, and despite what people say about
autism, they can be quite articulate—sometimes inappropriately
so. They are different from other sets of people and we should
recognise that. The
Bill is making provisions for the future. It has to look forward and
not simply deal with our assessment of how things are now. We already
recognise in other parts of government that we have a
better understanding of autism than we had 20 years ago, and that
should be reflected in the Bill. The fact that it was not recognised in
the 1983 Act is no argument. We know from the casework around the
country that more and more people will fall within this grouping who
need the attention of services. When it is psychiatric services that
they require, they need more equality, not
less. More and more
cases of people with autism who have been denied access to appropriate
services or treatment are coming before tribunals and the courts. The
HL case is a classic case in point. People are starting to ask
themselves, very often with legal backing, “Is this right in
terms of civil liberties? Is this right in terms of what we understand
these people need and the sort of attention they should be
receiving?” More often than not, particularly when I look at my
social services casework, once one has cut to the chase and challenged
the social services on behalf of someone with autism, they settle out
of court. The
Government would do well to recognise that our knowledge and awareness
of autism and what is and is not an appropriate treatment or package of
support are increasingly such that when we challenge social services,
the courts tend to rule in our favour. The Government should take that
on board, because to deny it at the stage at which legislation is being
introduced is not merely negligent, but a concession that they know
this but are not going to do anything about it. That is indefensible
behaviour towards a vulnerable group of people. All the statistics show
that
as a group they are not an increased risk to other
people, but people who themselves need support and appropriate
services. The Royal
College of Psychiatrists points out in its report the need to address
inappropriate detention under the mental illness category, detention of
this group in inappropriate settings and detention for longer than is
absolutely necessary. This group of people is already discriminated
against. If that is what psychiatrists identify as the problem,
specifically with regard to the interaction of such people with mental
health services now, surely the Bill should aim to improve their lot in
future. We cannot do anything about the past, but we can do something
about the future. The information is there; it is on the
record. That is why I
am asking the Minister—colleagues will be pleased to hear that I
am concluding my remarks—to think again about whether those with
an ASD are different. I believe that they are, and I hope that the
examples that I have given show how and why they are and, in
particular, why the Bill, rather than the code of practice, should
associate the appropriate treatment of their needs by mental health
services with the conditions identified for people with learning
disabilities. The
hon. Member for Stockport identified the need for better and more
specialist services and for better recognition, which is an issue that
I discuss all the time. Although we can do nothing about such issues in
the Bill, we can ensure that it recognises people with ASD, and I
stress that they are people—people who, as a result of whatever
fate has befallen them, will live with this condition for the rest of
their lives. However, although they are born with it and will die with
it, we can make a difference to what happens in between. We need to do
more to improve their quality of life and the way in which they are
treated between the time they are born and the time they die. At the
moment, we are nowhere near getting that
right.
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