Australian Government – Productivity Commission
Issues Paper: Disability Care and Support

Response from Interact Australia
Key Area: Dual Diagnosis i.e. Intellectual Disability and Mental Illness

Interact Australia 
Interact Australia is a not-for-profit community organisation that has been delivering a range of services to people with a disability and people experiencing mental health issues, disadvantage, isolation or marginalisation since 1991.  
Interact has extensive experience working with people with multiple and complex disabilities, predominantly intellectual disabilities (ID)  and people with dual diagnosis. We also have experience working with prisoners while still in corrections and post-corrections to connect them into community support systems and housing.   The organisation emerged from the de-institutionalisation of Kew Cottages in Melbourne, Australia’s largest and oldest Institution for people with an ID. Interact therefore have both expertise and a long history in the provision of services to people with high and complex needs.
Our organisational values are: 
•	a business approach to all that we do, 
•	productive and accountable teams that deliver results, 
•	always seeking better ways to work, 
•	service excellence, 
•	building productive relationships with our participants, partners and each other, and 
•	recognition of performance and the celebration of success. 
The organisation embraces social justice principles and works within the social model of health and human rights frameworks which inform and guide our approach and service provision.  We strive to positively influence community health and wellbeing through collaborations and partnerships with a wide range of sectors and communities and through adopting a variety of interventions and capacity building strategies.
The Community Services division works in partnership with people who need support to maximise their health, wellbeing and opportunities for community participation and social inclusion.  Community Services recognise  that people with a disability have the right to be respected and the right to have equal opportunities to participate in the social, economic, cultural, political and spiritual life of society.  Our model is a self-directed approach, recognising that the person with a disability is at the centre, and to the extent that they are able, is in charge of their planning, funding and support responses. 
Community Services operate in both Queensland and Victoria.  Our services include disability day services, community inclusion programs, employment programs, respite, recreation and lifestyle programs, therapeutic and arts programs, school holiday programs, services for older people, services for young people with dual diagnosis and alcohol and other drug issues and programs for offenders and ex-offenders.  
In Queensland, Interact currently delivers the Bridging the Gap (BTG) program of throughcare for prisoners with cognitive impairment, facilitating a transition back to life in the community.  In Victoria, Interact is a partner in a consortium of four agencies (The Stepping Up Consortium) that deliver the ‘Stepping Up Stepping Out’ (SUSO) program for men whose sentence is ending and are transitioning back into the community after a significant period of incarceration.   
Within our consortium, Interact has also recently been successful in tendering to operate a Supported Transition Accommodation (STA) House for ex-Offenders with an Intellectual Disability.  This is a 13 bed facility and we are currently transitioning in, recruiting staff and putting policies and procedures in place to commence operations in October 2010.  The STA project will provide a supported transitional accommodation and support service for men with a cognitive impairment, specifically an intellectual disability (ID) or acquired brain injury (ABI), who are exiting Victorian correctional facilities into community.   We have also been successful in tendering to deliver behaviour support training packages to Corrections Queensland staff through our Registered Training Organisation (RTO).
Our findings on Dual Diagnosis are:-
There is increasing evidence to support the high prevalence of mental illness in adults with intellectual disability, with some studies suggesting that the prevalence may be greater than that of the general population (Chan, Hudson & Vulic, 2004; Cooper, Smiley, Morrison, Williamson & Allan, 2007; Hatton, 2002; ).  For example, a study undertaken by White, Chant, Edwards, Townsend and Waghorn (2005) found that people with intellectual disability are at high risk of developing  co-morbid serious mental illness.  Dual diagnosis is however, often overlooked due to difficulties associated with establishing a diagnosis of a mental disorder in people with an intellectual disability, a problem which is heightened when the individual's capacity to participate in a clinical assessment is limited.  
Research conducted in Western Australia found that overall, 31.7% of people with an intellectual disability had a psychiatric disorder; and 1.8% of people with a psychiatric illness had an intellectual disability.  Schizophrenia was greatly over-represented among individuals with a dual diagnosis: depending on birth cohort, 3.7–5.2% of those with intellectual disability had co-occurring schizophrenia.  Pervasive developmental disorder was more common among people with a dual diagnosis than among individuals with intellectual disability alone. Down syndrome was much less prevalent among individuals with a dual diagnosis despite being the most predominant cause of intellectual disability. Individuals with a dual diagnosis had higher mortality rates and were more disabled than those with psychiatric illness alone (Morgan, Leonard and Bourke  & Jabkensky, 2008). 
The epidemiology of intellectual disability co-occurring with schizophrenia and other psychiatric illness is poorly understood. The separation of mental health from intellectual disability services has led to a serious underestimation of the prevalence of dual diagnosis, with clinicians ill-equipped to treat affected individuals.  Interact’s experience has been that many individuals with a dual diagnosis including ID are referred inappropriately due to the presence of behaviours of concern such as aggression or criminal offending behaviour.  Many of our clients, particularly in Corrections environments have a dual diagnosis, however due to funding restrictions have to be labelled either as someone with an ID and take one stream of community care or be labelled as someone with a mental health issue and take another care pathway.  Either way, while the care they receive is excellent, it usually only addresses one of their issues.  As posited by Einfeld, Piccinin, Mackinnon, Hofer, Taffe, Gray, Bontempo, Hoffman, Parmenter, and Tonge, (2006), the problem of psychopathology co-morbid with intellectual disability is both substantial and persistent and suggests the need for effective mental health interventions.  Interact believes that given the prevalence of dual diagnosis in people with ID and the accompanying behaviours of concern, there is a real need for:
•	Consultation and meaningful dialogue between the disability and mental health sectors to generate recommendations for future action and funding models;
•	Opportunities for consideration of the needs of specific populations such as offenders and ex-offenders;
•	Research to identify the existing gaps in service delivery;
•	Opportunities for integrated clinical training solutions for practitioners dealing with people with complex behaviours as a result of ID and dual diagnosis;
•	Opportunities for parents, friends and significant others to be involved in consultation and training opportunities;
•	Funding for specialist interventions targeting the population who have an ID and mental issues;
•	Recognition of the need to involve a range of other sectors such as the homelessness and alcohol and other drug sectors due to the high numbers of people dually diagnosed that experience significant disadvantage and that have complex coping mechanisms;
•	More work on shared care pathways, early intervention and collaborative practice

Interact Australia commends the Australian Government for its call to the community to respond to the Issues Paper and give direction on the framing of legislation for a new national disability care and support scheme.

We understand that the Government’s principal objective is to consider a variety of models and how each would interact with Australia’s health, aged care, informal care, income support and injury insurance schemes.

We would therefore like to make a formal submission and also present at a public hearing, so that the community may input to our observations and findings, particularly in the area of Dual Diagnosis.

Interact Australia applauds the Government’s desire to improve disability care and support, consistent with community norms for upholding people’s rights and for social justice, which are not fully recognised in current arrangements. 

We agree that the costs that fall on people with disabilities, their family and carers should be shared amongst a wider group of people, through a form of social insurance as the most equitable and efficient manner of sharing the cost burden.

We look forward to reading the draft report and responding in due course and to the opportunity to attend a public hearing in 2011.

References
Chan, J., Hudson, C., & Vulic, C. (2004).  Services for adults with intellectual disability and mental illness: Are we getting it right?  Australian e-Journal for the Advancement of Mental Health (AeJAMH), Vol 3, Issue 1. Retrieved 20 August 2010 from: www.auseinet.com/journal/vol3iss1/chanhudsonvulic.pdf

Cooper, S., Smiley, E., Morrison, J., Williamson, A., & Allan, L. (2007).  Mental ill-health in adults with intellectual disabilities: Prevalence and associated factors. The British Journal of Psychiatry, 190, 27-35.

Hatton, C. (2002).  Psychosocial interventions for adults with intellectual disabilities and mental health problems:  A review.  Journal of Mental Health,  11, 357 – 374.

Morgan, V.A., Leonard, H., and Bourke, J., & Jablenask, A. (2008).  Intellectual disability co-occuring with schizophrenia and other psychiatric illness: population-based study.  The British Journal of Psychiatry, 193, 364-372.

Einfeld, S.L.,  Piccinin, A.M., Mackinnon, A.,  Hofer, S.M., Taffe, J., Gray, K.M.,  Bontempo, D.A.,  Hoffman, L.R., Parmenter, T., & Tonge, B.J. (2006).  Psychopathology in young people with intellectual disability.  Journal of the American  Medical Association, 296, 1981-1989.

White, P., Chant, D., Edwards, N., Townsend, C., & Waghorn, G. (2005). Prevalence of intellectual disability and comorbid mental illness in an Australian community sample, Australian & New Zealand Journal of Psychiatry, 39, 395-400.