Severe Mental Impairment and Severe Behavioural Difficulties Test

This section uses terminology such as ‘severe mental impairment’, ‘arrested development’ or ‘severe impairment of intelligence’. We acknowledge that these terms are outdated and have been replaced by terms that are less stigmatising or medicalising. ‘Severe mental impairment’ is a term in regulations that is widely known and well defined and understood in a legal context. The Decision-Making Guidance therefore uses the same terminology in order to avoid any misinterpretations or divergence from the law.

This chapter sets out the severe mental impairment and severe behavioural difficulties test. This test should be applied to determine if an individual is entitled to the higher rate of the mobility component. The test is comprised of the following three elements:

1. Does the individual have a severe mental impairment?
2. Does the individual have severe behavioural difficulties?
3. Does the individual meet the criteria for the highest rate of the care component? (Scottish Adult DLA regs, reg. 8(2)(e))

Individuals must meet all of the above elements in order to meet the criteria for severe mental impairment/severe behavioural difficulties.

Case managers should refer to the Care Component Rates and Criteria chapter to understand if the individual meets the third element of the test for severe mental impairment and severe behavioural difficulties.

If the individual does not meet all of the criteria above, they may still be able to qualify for the higher rate of the mobility component. An individual can qualify if they meet any of the following criteria:

• are unable to walk (Scottish Adult DLA regs, reg. 8(2)(a))
• are virtually unable to walk
• the exertion required to walk would constitute a danger to the individual’s life, or would be likely to lead to a serious deterioration in the individual’s health (Scottish Adult DLA regs, reg. 8(2)(a)
• have no legs or no feet (Scottish Adult DLA regs, reg. 8(2)(b))
• have a severe visual disability (Scottish Adult DLA regs, reg. 8(2)(c))
• are both blind and deaf (Scottish Adult DLA regs, reg. 8(2)(d)).

Case managers should refer to the Higher Rate Mobility Component chapter to determine whether the individual meets any of these criteria.

Each element of the severe mental impairment and severe behavioural difficulties test will be assessed below in turn.

Element 1: Does the individual have a severe mental impairment?

To meet this criterion, the individual must have both (Scottish Adult DLA regs, reg. 8(8)):

• a severe impairment of intelligence
• a severe impairment of social functioning.

This must result from either (Scottish Adult DLA regs, reg.8(8)):

• a state of arrested development caused by a failure of the individual’s brain to grow or develop in the way typically expected
• a deficiency in the functionality of the brain caused by its incomplete physical development.

Whether an individual has “severe impairment of intelligence and social functioning” should be treated as a single test and all the evidence considered as a whole. This is described in subsection “What is severe impairment of social functioning?” below in more detail.

What is severe mental impairment of intelligence?

An IQ of 55 or less is generally accepted as a “severe impairment of intelligence”. However, the individual’s IQ is likely to be only a minor factor in assessing whether the individual has a severe impairment of intelligence. An IQ score alone is likely to give a misleading impression, because an IQ test is designed to be as independent of social context as possible. An individual with a reduced IQ will likely have had a referral to a learning disability or other specialist. Case managers must be careful not to refuse an application because an individual has not been referred to a specialist, as there may be reasons for this.

To understand whether the individual has a ‘severe impairment of intelligence’ the case manager should consider

• supporting information
• advice via a clinical case discussion, if necessary in addition to the application or review form.

The case manager should consider the individual’s ‘useful intelligence’ e.g. their degree of judgment in relation to everyday living. This will include whether the individual:

• has an understanding of the impact of their behaviour
• can understand the risk of danger or hazards
• has no awareness of where they are or of what time it is
• experiences short and long-term memory difficulties.

This list is not exhaustive.

What is severe impairment of social functioning?

Social functioning is what a person can do with their intelligence, for example the social skills they use to build relationships, and the ability to relate to and empathise with others.

Individuals who have a severe impairment of social functioning, as a result of arrested development, or deficiency in the functionality of the brain due to incomplete physical development of the brain may not be able to do these things because of their disability. They may alternatively only be able to acquire a few basic social skills after being shown how to perform them.

It is rare to see impairment of intelligence without an impairment in social functioning. This means there is crossover for considerations for both severe impairment of intelligence and social functioning. This includes an individual’s inability to understand danger or the impact of their behaviour.

An individual may have a severe impairment of social functioning if they either:

• are unable or have limited ability to speak, such as only being able to communicate by gesturing, using simple signs or making sounds
• are unable to read or write, or have very limited ability to read or write
• have either limited or no understanding of the impact of their behaviour on others
• have either limited or no ability to understand danger or hazards, such as eating dangerous objects or touching hot objects
• are incontinent via bowel or bladder
• cannot engage in social activities or co-operate with others
• behave violently and injure themselves or others.

This list is not exhaustive.

If the case manager is unable to reach a determination based on the review form and the available supporting information, they should seek input of a practitioner through the case discussion process.

What is causing the severe impairment of intelligence and social functioning?

After they have established that the individual has a severe impairment of intelligence and social functioning, the case manager must determine if these conditions result from either (Scottish Adult DLA regs, reg. 8(8)):

• a state of arrested development as a result of a failure of the individual’s brain to grow or develop in the way normally expected, or
• a deficiency in the functionality of the brain as a result of its incomplete physical development.

In order to meet this test, the information provided by the individual or in supporting information does not have to confirm a physical defect in the brain. This means that it is not required for the individual to provide results of a brain scan or any other relevant tests. The fact that an individual has not had a scan does not mean that this test cannot be met. An individual may be awaiting further tests. It may also be the case that further tests would unnecessarily distress the individual.

There are also a number of congenital conditions present at birth that impact on the proper development of the brain in the womb and following birth, that may be documented in the individual’s supporting information.

There may be cases where there is no information from a professional to confirm an individual’s incomplete physical development of the brain. Case managers should still consider the information provided by the individual, as well as any other forms supporting information. For more detail on supporting information please see the Gathering Supporting Information chapter. Case managers should use the balance of probabilities to make a determination.

Case managers should consult a practitioner within Social Security Scotland through the case discussion process if supporting information is unclear or incomplete.

Arrested development

Arrested development (Scottish Adult DLA regs, reg. 8(8)(a) ) is separate from incomplete physical development (Scottish Adult DLA regs, reg. 8(8)(b)) of the brain. Therefore, it may apply in cases involving arrested emotional or functional development which has a physical cause.

Common conditions where an individual might meet the criteria for arrested development are:

• trauma, neglect, and/or sexual abuse
• when an individual has a diagnosis of an attachment disorder like Reactive Attachment Disorder or Disinhibited Social Engagement Disorder
• global developmental delay
• in some cases, neurodevelopmental conditions, such as Autism Spectrum Condition and/or ADHD
• some severe cases of mental illness

This list is not exhaustive.

Case managers should always consider the individual’s circumstances and level of needs holistically and base their decision on whether or not the individual meets all three elements of the severe mental impairment and severe behavioural difficulties test, as set out in this chapter.

Whether or not an individual who has one of the conditions listed has arrested development of the brain needs to be considered on a case-by-case basis. For example, just because an individual has experienced trauma doesn’t mean their development will be arrested. However, severe cases of abuse/trauma can affect how an individual’s brain forms and functions.

Deficiency in the functionality of the brain due to incomplete physical development of the brain

Incomplete physical development of the brain involves a failure of the brain to grow properly and focuses on the fact that the brain is not functioning as expected.

Conditions which indicate the brain has not developed as expected include:

• lissencephaly
• microgyria
• holoprosencephaly.

This list is not exhaustive.

Case managers should always consider the individual’s circumstances and level of needs holistically and base their decision on whether or not the individual meets all three elements of the severe mental impairment and severe behavioural difficulties test, as set out in this chapter.

Element 2: Does the Individual have Severe Behavioural Difficulties?

An individual is taken to have severe behavioural difficulties if they exhibit disruptive behaviour which:

• is extreme (Scottish Adult DLA regs, reg. 8(9)(a))
• regularly requires another person to intervene in order to prevent or reduce the likelihood of physical injury to the individual or another person (Scottish Adult DLA regs, reg. 8(9)(b)); and
• is so unpredictable that another person is required to be awake and watching over the individual while the individual is awake (Scottish Adult DLA regs, reg. 8(9)(c)).

Behaviour which is “extreme”

“Extreme”, in relation to disruptive behaviour, means that substantial intervention to respond to or manage challenging behaviour is regularly needed.

The extreme disruptive behaviour does not need to be constant, continuous or present all of the time. However, it must be regular. There is no hard and fast rule on what ‘regular’ means in this context. Case managers must consider each case individually.

The individual’s behaviour may be extreme if they can:

• be disruptive
• not consider their safety with dangerous things
• be aggressive
• injure themselves or others
• be hyperactive
• display persistent body movements
• disrupt the household during the night
• require intensive support, for example, an individual who requires continuous intervention from specialist support staff or a caregiver experienced in their needs to maintain their safety outdoors.

This list is not exhaustive.

Behaviour does not have to be violent to be classed as disruptive. For example, "melt-downs" and sensory overload may all be considered disruptive behaviour.

Behaviour which regularly requires another person to intervene

An individual who exhibits severe behavioural difficulties may require intervention if they show:

• aggression
• destructive behaviour
• hyperactivity
• behaviour that is likely to result in injury

The individual’s unpredictable and destructive behaviour must require the presence of another person to intervene to prevent risk of injury to the individual or others.

In this context, intervention relates to providing either care and support, or treatment of the individual (Scottish Adult DLA regs, reg. 8(10))

Case managers should consider whether the individual is unable to go outside alone in a way that can be done safely. However, they should not focus only on how the individual is outdoors or in a structured safe environment and must consider their need for and the nature of intervention in all environments.

Case managers should consider how often intervention is needed to reach a determination of whether intervention is required in the normal course of the individual’s day.

‘Requires’ in this context means ‘reasonably requires’. This means that it depends on the individual circumstances of each case. The requirement to intervene must be to prevent or reduce the likelihood of physical injury occurring.

Case managers could also consider whether the individual has a positive behaviour support plan. See below for more information. This describes how the individual’s behaviour is challenging and the types of intervention or strategies that are used to help the individual.

Use of physical intervention and medication to calm an individual who experiences challenging behaviour are generally not a good long-term solution. While some individuals may require physical restraint, this is not a requirement. Case managers should consider more generally what strategies are required to prevent or manage episodes of challenging behaviour.

Behaviour which is so unpredictable that another person is required to be awake and watching over the individual while the individual is awake

Examples of behaviour which can be characterised as so unpredictable that another person is required to be awake and watching over the individual include:

• the individual will attempt to leave the house if unattended
• the individual does not have a basic understanding of safety or danger awareness
• the individual might hurt themselves or others
• the individual will lie down or drop in the middle of the road and refuse to walk
• the individual will run out into the road without consideration of their safety
• the individual will engage in impulsive or dangerous behaviours like touching a hot hob or playing with knives
• caregivers use cameras to monitor the individual when they are not in the same room
• there is a need for a specialist evacuation plan in at work, college, residential care, day centres or other regularly attended places in case of emergencies (e.g. fire)
• caregivers will sleep beside the individual, so they are aware if the individual is awake during the night for safety, not for comfort.

These behaviours would occur despite:

• attempts from caregivers to highlight dangers
• caregivers making attempts to stop the individual verbally or physically
• locks and alarm systems (used when the family are inside the house)
• high fences

The behaviour indicates a lack of understanding and comprehension of the consequences of their actions which places the individual at increased risk.

Element 3: Is the Individual Entitled to the Highest Rate of the Scottish Adult DLA Care Component?

The case manager must refer to the Care Component Rates and Criteria chapter in order to determine whether the individual satisfies the criteria for the highest rate of this component.