Outofhome placement

Generally, people move out of home either for support or for treatment, although the distinction is often blurred. Support

Respite placements allow both individuals and their families some relief from each other and the uninterrupted intimacy of care. Placements also widen social networks and pave the way towards the eventual departure from home.

Social care, eventually necessary, is ideally planned as part of an increasing, adult autonomy. However, it is frequently left until there is a crisis, for example when the person's behaviour or dependency has outstripped their family's resources, too often because of parental infirmity or death.

Placements for educational needs (e.g. in a residential school) become necessary where the person's disabilities (e.g. autism or intractable epilepsy) require specialist skills and settings.

Treatment

The threshold for admission for assessment and treatment will depend on the level of care available in the community. It may becomes necessary for three main reasons.

First, admission may be necessary for the treatment of more complex disorders such as epilepsy or psychosis.

Second, admission may be necessary for the assessment of disturbance where it is difficult to disentangle the relative contributions of environmental and innate factors. For example, a patient's behaviour may be amplified by an exasperated or exhausted family, particularly where disturbed nights have left them short of sleep. The result is a secondary self-perpetuating cycle of disturbance involving the whole house. While this is running it can be impossible to discern the underlying primary disturbance and can be very difficult to interrupt except by changing the cast around the patient, either by moving staff into the home or by moving the patient out.

Third, admission may be necessary for the management of behavioural disturbance in the following circumstances.

1. The carers may be unable to cope for many reasons including the following:

marital disharmony

• the carer's inability to manage others simultaneously, for example single parents who have several children or a placement with several disturbed children

• loss of resilience in the carer

• an adverse or hostile neighbourhood where the carer has to give way in case the patient becomes so noisy that the neighbours complain, or the patient may be the victim of bullying or be led astray by his or her peers.

2. There has been a failure of earlier therapeutic trials and the family is locked in a self-reinforcing cycle.

3. The patient is at risk of harm.

4. The patient presents a substantial risk to others, for example where the person is very violent or is a sexual offender.

5. There is the need for effective control of the patient and his or her behaviour.

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