Background Peoplewith learning disability who exhibitchallenging

Declaration of interest The authors are orhavebeenpartofthe clinicalteamat the specialistunitevaluated. National Health Service (NHS) and social services expenditure on adults with learning disability is approximately £3000 million per annum (Department of Health, 2003) from which the costs of meeting the needs of those who are aggressive are estimated at £50–140 million (Netten et al, 2001). Changes in legislation and service provision have led to the resettlement of people with learning disability into the community, but challenging behaviour and particularly a forensic history can be an obstacle to resettlement for some. A significant proportion of people with learning disability and challenging behaviour are excluded from ordinary services (Vaughan et al, 2000), are treated out of area (Vaughan, 1999; Kearns, 2001) and face delayed discharge due to lack of specialist placements (Watts et al, 2000). An offender ‘tag’ may further segregate care pathways for this group, with those who offend entering statutory care earlier than those who do not (Alborz, 2003) and facing exceptionally long periods of in-patient admissions (Holland et al, 2002). This implies that community services are especially reluctant to accommodate people with learning disabilities who offend. However, this situation is unlikely to meet need; it contravenes human rights, government policy and recommendations; and increases the burden on the NHS (Home Office, 1990, 1995; Department of Health & Home Office, 1992; Department of Health, 1993, 2001). Thus people with learning disability who a have forensic history are subject to inequalities in access to health care and service provision. The reason for the exclusion of this group of people from services is unclear, but may be based on the assumption that they are likely to be more violent and/or less responsive to treatment than others. However, there is no evidence to substantiate whether people with learning disabilities who are suspected or convicted of offending differ from their counterparts who do not come into contact with the criminal justice system. Previous studies have evaluated an in-patient service for people with learning disability and challenging behaviour (Murphy & Clare, 1991; Murphy et al, 1991; Clare & Murphy, 1993; Gaskell et al, 1995) and reported positive short-term outcomes (Xenitidis et al, 1999). However, it is unknown if offenders with learning disability within non-forensic in-patient services have a different presentation in terms of types of aggression or treatment outcome. We therefore compared patients with learning disability admitted to our assessment and treatment unit because of behaviour labelled as either ‘challenging’ or ‘forensic’ to determine whether there are between-group differences in presentation of aggressive behaviour during admission and in discharge placement.