Prevalence and types of aggressive behaviour among adults with intellectual disabilities

An analysis of stress, burnout, and work commitment among disability support staff in the UK

Previous research has suggested that challenging behaviour emitted by persons with intellectual and developmental disabilities negatively impacts upon the levels of stress and burnout of those who support and care for them. In the current study a sample of disability support workers in the UK (N=138) reported their levels of perceived stress, burnout, and commitment to their work. The relationship between the frequency and severity of aggressive/destructive behaviours to which they were exposed, and these three measures were examined. Results showed that participants scored lower on measures of burnout in the current study than has been reported by similar research studies in the UK and North America. The results revealed an association between challenging behaviours experienced and participants' perceived stress and emotional exhaustion. Perceived stress and burnout were also associated with participants' commitment to their work. Finally, a series of regression analyses identified a number of predictors of emotional exhaustion, depersonalization, and personal accomplishment among disability support workers. The results and their implications for the consideration of disability support worker wellbeing and future research in this area are discussed.

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities

BACKGROUND

Outwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.

SEARCH METHODS

In April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.

SELECTION CRITERIA

We included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified studies and extracted and assessed the quality of the data.

MAIN RESULTS

We deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.

AUTHORS' CONCLUSIONS

The existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

Psychiatric disorders in adolescents and young adults with Down syndrome and other intellectual disabilities

BACKGROUND

Relative to other aspects of Down syndrome, remarkably little is known about the psychiatric problems experienced by youth and young adults with this syndrome and if these problems differ from others with intellectual disabilities. Yet adolescence and young adulthood are particularly vulnerable time periods, as they involve multiple life transitions in educational, medical, and other service systems.

METHODS

This study compared the psychiatric diagnoses of 49 adolescent and young adult patients with Down syndrome to 70 patients with other intellectual disabilities (IDs). The groups were similar in age, gender, and level of intellectual impairment. The 119 participants, aged 13 to 29 years (M = 21) were evaluated in one of two specialized psychiatric clinics.

RESULTS

In contrast to previous literature, those with Down syndrome versus other IDs had significantly higher rates of psychosis NOS or depression with psychotic features (43% versus 13%). Unlike the ID group, psychosis was predominantly seen in females with Down syndrome. Marked motoric slowing in performing routine daily activities or in expressive language was manifested in 17% of patients with Down syndrome. No group differences were found in anxiety or depressive disorders, and the ID group had significantly higher rates of bipolar and impulse control disorders.

CONCLUSIONS

These preliminary observations warrant further studies on genetic, neurological, and psychosocial factors that place some young people with Down syndrome or other IDs at high risk for severe psychiatric illness.

Characteristics and the trajectory of psychotropic medication use in general and antipsychotics in particular among adults with an intellectual disability who exhibit aggressive behaviour

BACKGROUND

A high proportion of adults with an intellectual disability (ID) are known to receive psychotropic medications for the management of aggressive behaviour in the absence of any psychiatric diagnosis. Despite this widespread use of psychotropic medication in general and antipsychotic medication in particular, no study has reported the trajectory of psychotropic medication use using a prospective design.

METHOD

We have prospectively studied a community, clinic-based sample of 100 adults with ID and aggressive behaviour over a 6-month period for use of psychotropic medication in general and antipsychotics in particular, and compared them with demographic, psychiatric and behavioural variables.

RESULTS

Psychotropic medications were used for 89% of patients at baseline (T1) and 90% at 6 months' (T2) follow-up. Risperidone was the most commonly used antipsychotic medication followed by chlorpromazine, haloperidol, olanzapine, zuclopenthixol and quetiapine. Other commonly used medications were SSRI antidepressants such as citalopram, paroxetine and fluoxetine followed by mood stabilisers such as carbamazepine and sodium valproate. Although in a high proportion of cases carbamazepine and sodium valproate were used to treat epilepsy per se. A high proportion (45%) received more than one (polypharmacy) psychotropic medication at T1; however, this proportion decreased slightly to 41% at T2. As for antipsychotic prescribing specifically, a similar proportion received them at T1 (75%) and T2 (73%), with polypharmacy of antipsychotics remaining similar at T1 (10%) and at T2 (9%). Twenty-three per cent and 20% of patients received over 300 mg/day of chlorpromazine equivalent dose of antipsychotics at T1 and T2 respectively. However, there was an overall significant reduction in the severity of aggressive behaviour between T1 and T2. Higher doses of antipsychotic prescribing were positively correlated with more severe aggressive behaviour, physical aggression towards objects, self-injurious behaviour and increasing age. There was no significant association with other demographic variables, physical health conditions or psychiatric diagnosis. Neither was there any significant correlation between mean aggression severity score change and antipsychotic daily dose change between T1 and T2.

CONCLUSIONS

To our knowledge, this is the first ever comprehensive follow-up study of use of psychotropic medications in general but antipsychotics in particular over a 6-month period in adults with ID and aggressive behaviour, in a clinic-based community setting which also compared the trajectory of severity of aggressive behaviour with that of antipsychotic medication dose. Our study shows that not only the use of psychotropic medication is common among adults with ID who attend psychiatric clinics for aggressive behaviour, the use of polypharmacy of psychotropic medications in general and high dose of antipsychotics in particular are equally prevalent. However, in some cases two antipsychotics may have been prescribed simultaneously as the psychiatrist is in the process of switching from one to another.

Cognitive behavioural anger management intervention for people with intellectual disabilities: costs of intervention and impact on health and social care resource use

BACKGROUND

Anger and aggression among adults with intellectual disability (ID) are associated with a range of adverse consequences for their well-being and that of their family or staff carers. The aims were to evaluate the effectiveness of an anger management intervention for adults with mild to moderate ID and to evaluate the costs of the intervention and its impact on health and social care resource use. This paper is concerned with the latter aim.

METHODS

A cluster-randomised controlled trial was conducted involving day services for adults with ID in Scotland, England and Wales. Incremental costs of delivering the intervention and its impact on subsequent total health and social care package costs were calculated. Full data comparing costs between baseline and follow-up 10 months later were collected for 67 participants in the intervention arm and 62 participants in the control arm. Cost differences between the groups at follow-up, adjusted for baseline levels, were calculated using non-parametric bootstrapping controlling for clustering.

RESULTS

The mean hourly excess cost of intervention over treatment as usual was £12.34. A mean adjusted cost difference of £22.46 per person per week in favour of the intervention group was found but this was not statistically significant.

CONCLUSIONS

The baseline-adjusted cost difference at follow-up would result in a fairly immediate compensation for the excess costs of intervention, provided the difference is not a statistical artefact. Further research is needed to clarify the extent to which it might represent a real saving in service support costs.

Intellectual disability and co-occurring mental health and physical disorders in aggressive behaviour

BACKGROUND

Mental and physical health problems are more prevalent among individuals with an intellectual disability (ID) than in the general population. Studies suggest that there may be significant associations between these co-occurring disorders and aggressive behaviour, but few studies have taken into account multiple mental and physical problems, as well as their level of severity.

OBJECTIVES

The main goal of this study was to identify the associations between different types of aggressive behaviour and various types of physical and mental health problems.

METHODS

These associations were explored through a cross-sectional study of 296 adult men and women with mild or moderate ID living in the community and receiving ID services. Information was gathered through interviews with ID participants, case managers and file review.

RESULTS

The results show that individuals with ID who have more mental and physical health problems have higher odds of displaying aggressive behaviour than those with fewer and less severe physical health problems.

DISCUSSION

These results can help guide future prevention and intervention strategies for persons with ID who display aggressive behaviour or who are at risk of become aggressive.

The role of personality in aggressive behaviour among individuals with intellectual disabilities

BACKGROUND

Aggressive behaviour is associated with certain personality traits in both the general population and among individuals with mental health problems, but little attention has been paid to the relationship between aggressive behaviour and personality among individuals with intellectual disabilities (ID). The aim of this study was to circumscribe personality profiles associated with aggressive behaviour among individuals with ID.

METHOD

In this cross-sectional study of 296 adults with mild or moderate ID, information on mental health, personality and aggressive behaviour was gathered through structured interviews with the ID participants and their case manager, and a review of client files.

RESULTS

The results of the Reiss Profile were submitted to hierarchical cluster analysis method. Subsequently, the distribution of aggressive behaviour, sociodemographic characteristics and clinical characteristics across personality profiles was analysed. The analyses yielded seven distinct personality profiles in relation to patterns of aggressive behaviour: Pacifists, Socials, Confidents, Altruists, Conformists, Emotionals and Asocials.

CONCLUSION

The identification of distinct personality profiles sheds light on the risk factors for aggressive behaviour, and suggests new approaches to improving diagnostic and intervention strategies.

Prevalence of aggressive challenging behaviours in intellectual disability and its relationship to personality status: Jamaican study

BACKGROUND

Both the classification of personality disorder in intellectual disability (ID) and its identification in practice are deemed to be difficult. A simpler approach to classification and its relationship to challenging behaviours were tested in an adult Jamaican population with ID.

METHOD

The study was carried out in Kingston, Jamaica, as part of a programme of field trials to determine the utility of the proposed revision of personality disorders in the 11th Revision of the International Classification of Diseases (ICD-11), in a population of adults with ID living with their families or in supported care homes. Thirty-eight people with borderline (n = 5), mild (n = 16), moderate (n = 14) and severe (n = 3) ID were assessed at face-to-face interview and with relatives or staff using the provisional criteria for severity of personality disorder and its associated domain traits, and challenging behaviour was assessed using the Problem Behaviour Check List (PBCL) (a 5-point, 7-item scale).

RESULTS

Using the severity scale 18 patients (47%) had no personality disorder, 7 (18%) had personality difficulty, 9 (24%) had mild personality disorder, and 4 (11%) had moderate personality disorder. None of the sample had severe personality disorder in which there is high risk of harm to self or others. Of the four major trait domains, provisionally named anankastic, detached, emotional and dissocial, three were evenly distributed in those with personality disturbance with the antagonistic (antisocial) trait less commonly shown (6 only). Scores on the PBCL were higher in those with increasing severity of personality disorder (P = 0.03) and those in the antagonistic personality trait domain had the highest PCL scores.

CONCLUSIONS

Despite previous difficulties in assessing personality disorder in intellectual difficulties the ICD-11 classification was easy to administer in practice in this population, and the higher problem behaviour scores in those with greater severity of personality disturbance support its construct validity.

Caregiver's concerns-quality of life scale (CC-QoLS): development and evaluation of psychometric properties

We have developed a Caregiver's Concerns-Quality of Life Scale (CC-QoLS) for adults with intellectual disabilities (ID) who exhibit aggressive behaviour. The CC-QoLS is a brief (8 items in each subscale, CC and QoL respectively) proxy measure completed by caregivers. This is a specific health related quality of life instrument (HRQoL) combined with measures of caregiver's concerns for use as an outcome measure to assess clinical and cost effectiveness of interventions for aggression in adults with ID. The CC-QoLS was found to have good face validity and very good test-retest reliability with an ICC of 0.81 for CC (range 0.46-0.83 across items) and 0.80 for QoL (range 0.65-0.81 across items). Similarly, the scale had good inter-rater reliability with an ICC of 0.67 for CC (range 0.31-0.63 across items) and 0.63 for QoL (range 0.31-0.65 across items). Internal consistency for each subscale was also good (Cronbach's alpha was 0.85 for CC and 0.80 for QoL; Split-half Spearman-Brown was 0.81 for CC and 0.70 for QoL). Furthermore, the scale showed good concurrent validity with measures of severity of aggressive behaviour, namely Modified Overt Aggression Scale (MOAS) (CC: r=0.4; p≤0.01 and QoL: r=-0.2; p≤0.05) and Aberrant Behavior Checklist-Irritability subscale (ABC-I) (CC: r=0.5; p≤0.01 and QoL: r=-0.02; p≤0.05) as well as Caregiver's Uplift and Burden Scale score (<0.05). We believe that the CC-QoLS is a user friendly, easy to complete, first-ever HRQoL measure for adults with ID and aggressive behaviour with very good psychometric properties.

Shifting impairment and aggression in intellectual disability and autism spectrum disorder

Aggressive behaviour is a major problem in individuals with an intellectual disability (ID) as well as in individuals with an Autism Spectrum Disorder (ASD). There are indications that suggest a link between cognitive shifting and aggression. In this study, reports of aggressive incidents of adolescents and young adults with different clinical diagnoses (ID, ID+ASD, ASD) were collected during 1 year, using the Staff Observation Aggression Scale-Revised. Whether they were diagnosed with ID, ASD or both; individuals who displayed aggression were found to face more cognitive shifting difficulties than non-aggressive individuals, while no significant differences were found on severity of ASD symptoms. Study results support the assumption that a cognition-based model for aggression may be more adequate than a diagnose-based model.

Staff perception of aggressive behaviour in community services for adults with intellectual disabilities

Experiencing aggressive behaviour has been associated with increased stress and turnover among staff who support adults with intellectual disabilities. Incident perception is a strong predictor of psychological outcomes after trauma but has not been studied in this staff group. This study clustered exposure to aggression and endorsement of emotional difficulties among 386 community residential group home staff and evaluated the contribution of four behavioural topographies to staff-rated perceived severity. Staff exposure varied considerably. Perceived severity correlated with subjective emotional difficulties. High perceived severity was associated with daily exposure, aggression towards others causing injury, and property aggression causing injury or damage. Therefore, the role the staff plays, whether a witness or target, may impact their experience.

Self-injury and aggression in tuberous sclerosis complex: cross syndrome comparison and associated risk markers

BACKGROUND

Research reporting prevalence rates of self-injurious and aggressive behaviour in people with tuberous sclerosis complex (TSC) is limited. No studies have compared rates of these behaviours in TSC with those in other syndrome groups matched for degree of disability or investigated risk markers for these behaviours in TSC.

METHODS

Data from the Challenging Behaviour Questionnaire were collected for 37 children, aged 4 to 15 years, with TSC. Odds ratios were used to compare rates of self-injury and aggression in children with TSC with children with idiopathic autism spectrum disorder (ASD), fragile X, Cornelia de Lange and Down syndromes. Characteristics were measured using the Mood Interest and Pleasure Questionnaire, the Activity Questionnaire, the Social Communication Questionnaire, the Repetitive Behaviour Questionnaire, the Wessex Behaviour Schedule and the revised Non-communicating Children Pain Checklist. Mann-Whitney U analyses were used to compare characteristics between individuals with self-injury and aggression and those not showing these behaviours.

RESULTS

Rates of self-injury and aggression in TSC were 27% and 50%, respectively. These are high but not significantly different from rates in children with Down syndrome or other syndrome groups. Both self-injury and aggression were associated with stereotyped and pain-related behaviours, low mood, hyperactivity, impulsivity and repetitive use of language. Children who engaged in self-injury also had lower levels of interest and pleasure and showed a greater degree of 'insistence on sameness' than children who did not self-injure. Aggression was associated with repetitive behaviour. The majority of these associations remained significant when the association with level of adaptive functioning was controlled for.

CONCLUSIONS

Behavioural profiles can be used to identify those most at risk of developing self-injury and aggression. Further research is warranted to understand the influence of such internal factors as mood, ASD symptomatology and pain on challenging behaviour in people with intellectual disability.

The prevalence of aggression in genetic syndromes: a review

Research into behavioural phenotypes identifies both environmental and organic factors as influencing aggression in children and adults with genetic disorders associated with intellectual disability. However, in contrast to self-injury there is a paucity of research that compares aggression across relevant syndromes. The primary aim of this review is to examine the association between aggression and genetic syndromes by analysis of prevalence studies. The review also examines the literature on the form of the behaviour and influence of environmental factors. Results imply that certain syndrome groups (Cri du Chat, Smith-Magenis, Prader-Willi, Angelman, Cornelia de Lange, and Fragile X syndromes; estimates over 70%) evidence a stronger association with aggression than others (e.g. Williams and Down syndromes; estimates below 15%). However, the strength of association is difficult to quantify due to methodological differences between studies. The results from examining form and environmental influences highlight the importance of phenotype-environment interactions. Research employing group comparison designs is warranted and future work on the assessment and intervention of aggression in genetic syndromes should consider the importance of phenotype-environment interactions.

Aggressive behaviour and its prevalence within five typologies

Crucial to understanding an individual, presenting with intellectual disability and the management of their challenging behaviours, is the knowledge of the types of those specific behaviours. The term aggressive behaviour is a universal term that embraces many aspects of behaviour that vary in terms of severity, frequency and seriousness for the individual and those around them. Hence, greater consideration regarding intervention, management, person-centred strategies and prevalence and frequency rates are required in service provision for individuals with intellectual disability and aggressive behaviour. This review presents the context of aggressive behaviour and its prevalence within the five typologies of aggressive behaviour: verbal aggression, aggression against others, sexually inappropriate behaviour, self-injurious behaviour and aggression against property, as identified by Crocker et al. (2007). The focus of this review is to report on the prevalence of aggressive behaviour reported for individuals with intellectual disability and consider the ambiguity in defining aggressive behaviour.

The relationship between challenging behaviour and anxiety in adults with intellectual disabilities: a literature review

BACKGROUND

Anxiety and challenging behaviour (CB) often occur simultaneously in people with intellectual disabilities (ID). Understanding the associations between anxiety and CB may contribute to more accurate diagnoses and management of both anxiety and CB in this population.

AIMS

To examine the relationship between anxiety and CB.

METHODS

A literature review covering the period from January 2000 to January 2012.

RESULTS

Seven studies about the relationship between psychiatric disorders, including anxiety, and CB were identified. These studies confirm the relationship between anxiety and CB in people with ID, although the precise nature of this relationship remains unclear.

CONCLUSIONS

The study points toward the existence of a moderate association between anxiety and CB. Further research is needed to clarify the complex nature of the association between anxiety and CB.

The mediating effect of severity of client aggression on burnout between hospital inpatient and community residential staff who support adults with intellectual disabilities

AIMS AND OBJECTIVES

To compare exposure to client aggressive behaviour, perceived self-efficacy in managing this behaviour and burnout between community residential group home and specialised hospital inpatient staff who provide care for adults with intellectual disabilities (ID). To assess the mediating role of aggression exposure on burnout in these two staff groups.

BACKGROUND

Aggressive behaviour is a common indication for admission to hospital so these staff typically experience more frequent and severe forms compared to staff working in the community. There have been mixed results in few studies examining burnout and perceived self-efficacy between these two groups.

DESIGN

This study used a demographically matched sample of cross-sectional survey data from community residential group home and hospital staff who care for adults with ID in Ontario, Canada.

METHODS

Exposure to aggression, perceived self-efficacy and burnout were compared for 42 matched pairs using descriptive statistics. A mediation analysis was used to examine the role of aggression severity in the relationship between care setting and burnout.

RESULTS

Hospital staff were exposed to more severe client aggression and scored higher in emotional exhaustion (EE). There were no differences in perceived self-efficacy. Severity of aggression was a partial mediator of the higher EE among hospital staff.

CONCLUSIONS

Exposure to more severe forms of client aggression among hospital staff contributes, at least in part, to them feeling more emotionally exhausted. This study contributes to further understanding exposure to aggression in these different settings and the impact it can have on emotional outcomes.

RELEVANCE TO CLINICAL PRACTICE

There may be a role for policy and resource development aimed at reducing aggression and preventing or managing the associated emotional consequences. This is particularly true in hospitals, where aggression is most severe.

Prevalence of psychotropic drug use in adults with intellectual disability: positive and negative findings from a large scale study

The use of psychotropics by categories and the reason for their prescription was investigated in a large scale study of 4,069 adults with ID, including those with autism spectrum disorder, in New York State. Similar to other studies it was found that 58 % (2,361/4,069) received one or more psychotropics. Six percent received typical, while 39 % received atypical antipsychotics [corrected]. There was greater use of antidepressants (23 %), mood stabilizers (19 %), and antianxiety agents (16 %) relative to other studies. The use of anti-impulsives, stimulants and hypnotics was rare (1-2 %). Half of the psychotropics were prescribed for treatment of major psychiatric disorders, 13 % for control of challenging behaviors, and 38 % for both. Results indicated that the major psychiatric disorders, except anxiety disorder and autism, influenced the use of psychotropics and the number of medication used. These findings imply that although practitioners still rely too heavily on the use of antipsychotics in this population, there is a welcome shift in the prescription patterns relative to other studies. The practitioners appeared to use psychotropics primarily to treat diagnosed psychiatric disorders and not just to control aggressive behavior which suggests that evidence-based practice of psychiatry is playing an increasing role in the ID population.

Prevalence and risk factors of inpatient aggression by adults with intellectual disabilities and severe challenging behaviour: a long-term prospective study in two Dutch treatment facilities

Over five years, various types of aggressive incidents by 421 intellectually disabled inpatients were recorded on a daily basis, using an adapted version of the Modified Overt Aggression Scale. Stable patient characteristics (e.g., gender, intelligence, DSM IV classification at the start of treatment) and pre-treatment scores of two treatment outcome measures (e.g., Adult Behavior Checklist and Dynamic Risk Outcome Scale) were used to predict aggression during the treatment. At an overall average of one incident per patient per week, about ten times more aggression occurred on admission compared to resocialisation wards, and the 20% most aggressive individuals caused 50% of the verbal and 80% of the physical incidents. The best predictor of aggressive behaviour was aggression early in treatment, followed by coping skills deficits and impulsiveness. The relevance of the results for the treatment of aggressive behaviour and methodological issues in the recording of inpatient aggression are discussed.

Reliability and utility of the Behaviour Support Plan Quality Evaluation tool (BSP-QEII) for auditing and quality development in services for adults with intellectual disability and challenging behaviour

BACKGROUND

Having an objective means of evaluating the quality of behaviour support plans (BSPs) could assist service providers and statutory authorities to monitor and improve the quality of support provided to people with intellectual disability (ID) who exhibit challenging behaviour. The Behaviour Support Plan Quality Evaluation Guide II (BSP-QEII) was developed to monitor and assess BSPs prepared by teachers to support children with disability in the school system. This study investigated the application of the BSP-QEII to the assessment of BSPs for adults with ID in community support services.

METHOD

The inter-rater reliability of the BSP-QEII was assessed. The utility of the BPS-QEII was then investigated with reference to a time series study of matched pairs of BSPs, developed for the same clients over a period of approximately 3 years. Differences in plan quality measured across a number of service and systemic variables were also investigated.

RESULTS

The BSP-QEII was found to have good inter-rater reliability and good utility for audit purposes. It was able to discriminate changes in plan quality over time. Differences in plan quality were also evident across different service types, where specialist staff had or had not been involved, and in some instances where a statutory format for the plan had or had not been used. There were no differences between plans developed by government and community sector agencies, nor were there any regional differences across the jurisdiction.

CONCLUSIONS

The BSP-QEII could usefully be adopted as an audit tool for measuring the quality of BSPs for adults with ID. In addition to being used for research and administrative auditing, the principles underpinning the BSP-QEII could also be useful to guide policy and educational activities for staff in community based services for adults with ID.

Self-injurious behavior in older adults with intellectual disabilities

Self-injurious behavior (SIB) is a distressing type of problem behavior that may be exhibited in individuals with intellectual disabilities (IDs). This article provides an overview of SIB, its underlying causes and functions, as well as other key variables associated with its manifestation. Adults with IDs are routinely living longer. Given this rapidly emerging and expanding population, special attention is given to SIB in aging adults with IDs that may result from age-related risk factors. Risks include increasing and unresolved health issues, physical changes, declining physical abilities, transitions to new residential environments, and the potential for experiencing loss and bereavement. The article concludes with practice implications for social workers who may encounter older individuals with IDs and SIB.

Risk factors associated with self-injurious behaviors in children and adolescents with autism spectrum disorders

While self-injurious behaviors (SIB) can cause significant morbidity for children with autism spectrum disorders (ASD), little is known about its associated risk factors. We assessed 7 factors that may influence self-injury in a large cohort of children with ASD: (a) atypical sensory processing; (b) impaired cognitive ability; (c) abnormal functional communication; (d) abnormal social functioning; (e) age; (f) the need for sameness; (g) rituals and compulsions. Half (52.3%, n = 126) of the children (n = 241, aged 2-19 years) demonstrated SIB. Abnormal sensory processing was the strongest single predictor of self-injury followed by sameness, impaired cognitive ability and social functioning. Since atypical sensory processing and sameness have a greater relative impact on SIB, treatment approaches that focus on these factors may be beneficial in reducing self-harm in children with ASD.

Prevalence and risk markers of behavior problems among adults with intellectual disabilities: a total population study in Örebro County, Sweden

The aim of the present study was to investigate the prevalence of behavior problems among people with administratively defined intellectual disability (ID) and identify possible risk markers for behavior problems using the Behavior Problems Inventory (BPI). Sixty-two percent of the ID population (n=915) had a behavior problem (self-injurious, stereotyped, or aggressive/destructive behavior) and 18.7% had a behavior problem identified as challenging behavior, resulting in a prevalence of 80.3 per 100,000 in the base population. The most pronounced risk markers for behavior problems were severity of ID, autism, night sleep disturbances, sensory hypersensitivity, communication dysfunction, social deficits, psychiatry involvement, and psychotropic medication. About 50% of people with behavior problems were on psychotropic drugs. Protective markers were Down's syndrome and, to some extent, cerebral palsy. The results were largely consistent with those reported in previous studies. Findings not previously reported were that prevalence of aggressive/destructive behavior peaked among those ≥70 years. Highlighting groups within a population at particular risk has implications for management and treatment of individuals with behavior problems.

Investigating low adaptive behaviour and presence of the triad of impairments characteristic of autistic spectrum disorder as indicators of risk for challenging behaviour among adults with intellectual disabilities

BACKGROUND

Identification of possible personal indicators of risk for challenging behaviour has generally been through association in cross-sectional prevalence studies, but few analyses have controlled for intercorrelation between potential risk factors. The aim was to investigate the extent to which gender, age, presence of the triad of impairments characteristic of autism and level of adaptive behaviour were independently associated with level of challenging behaviour among adults with intellectual disabilities.

METHODS

Five datasets were merged to produce information on challenging behaviour, adaptive behaviour, presence of the triad of impairments, gender and age of 818 adults. Variables were entered into a multivariate linear regression, which also tested the interaction between the presence of the triad of impairments and level of adaptive behaviour.

RESULTS

Presence of the triad of impairments, level of adaptive behaviour, their interaction, and age, but not gender, significantly and independently contributed to the prediction of challenging behaviour. Presence/absence of the triad of impairments moderated the effect of adaptive behaviour on challenging behaviour. The inverse relationship found in the absence of the triad of impairments was virtually removed when present.

CONCLUSIONS

This study has shown that it is necessary to control for intercorrelation between potential risk factors for challenging behaviour and to explore how interaction between them might moderate associations.

Correlates of restraint and seclusion for adults with intellectual disabilities in community services

BACKGROUND

Some individuals with intellectual disabilities (IDs) exhibit aggressive behaviour directed towards themselves, others or the environment. Displaying aggressive behaviour is associated with a number of negative consequences such as the exposure to restrictive interventions. This study aims to identify personal and environmental factors related to the use of restrictive measures among persons with IDs living in the community.

METHODS

Data for 81 adults with IDs were collected through a mail survey. The questionnaires acquired information on demographic variables, physical health and psychiatric diagnoses, medication, residential setting, support worker experience and prevalence of restraint and seclusion. The type and severity of aggressive behaviours were measured by the Modified Overt Aggression Scale.

RESULTS

The prevalence of restrictive measures was 63.0%: 44.4% seclusion, 42.0% physical restraint and 27.2% mechanical restraint. The mode of communication, anxiolytic medication, severity of the aggressive behaviours, presence of a functional assessment on aggressive behaviours, and support workers' experience with persons with IDs were predictors of restrictive measures.

CONCLUSION

The results of this study have several clinical implications for practitioners working with persons with IDs who exhibit aggressive behaviours. More research is needed to expand our understanding of the use of restrictive measures and reduce its frequency.

The age related prevalence of aggression and self-injury in persons with an intellectual disability: a review

The aim of this study was to analyse statistically published data regarding the age related prevalence of aggression and self-injury in persons with intellectual disability. Studies including prevalence data for aggression and/or self-injury broken down by age band were identified and relative risk analyses conducted to generate indices of age related change. Despite conflicting results, the analysis conducted on included studies considered to be the most methodologically robust indicated that the relative risk of self-injury, and to a lesser extent aggression, increased with age until mid-adulthood, with some indication of a curvilinear relationship for self-injury. These conclusions have implications for the understanding of the development of different forms of challenging behaviour and the importance of early intervention strategies.

Burnout among summer camp staff supporting people with intellectual disability and aggression

Studies have shown that there is an association between exposure to people with intellectual disability who are aggressive and burnout in the staff who support them. Little is known, however, about the experience of summer camp staff who work with this population. This study examined the relationship between aggression and burnout in 169 staff members working at summer camps in Ontario, Canada. The questionnaire used included demographic information, exposure to aggression (frequency and severity), and the Maslach Burnout Inventory--Human Services Survey. Results showed that summer camp staff was exposed to frequent and relatively severe aggression. Severe exposure was associated with higher levels of emotional exhaustion and personal accomplishment. Given that summer camp staff is likely to be exposed to at least some aggression in their summer job, and that this aggression is associated with burnout, greater attention should be paid to training and supporting staff for when aggression occurs.

Exposure to client aggression and burnout among community staff who support adults with intellectual disabilities in Ontario, Canada

BACKGROUND

Studies have shown that staff who support adults with intellectual disabilities (ID) are exposed to challenging behaviour in their work including client aggression. Exposure to aggressive behaviour has been associated with staff stress and burnout. Study samples have been small however, and there has been very little data exploring this issue among North American staff.

METHODS

A cross-sectional survey which included demographics, measures of frequency and severity (including perceived severity and a standardised severity score) of exposure to client aggression and the Maslach Burnout Inventory - Human Services Survey (MBI-HSS) was completed by 926 community staff who support adults with ID in Ontario, Canada. Relationships between demographic variables and exposure to aggression were examined with descriptive statistics. Pearson correlations were used to analyse exposure variables and MBI-HSS scores.

RESULTS

Nearly all staff reported being exposed to client aggression in the prior 6 months. Mean MBI-HSS scores were comparable to previously published data in similar populations with the exception of a higher score in the personal accomplishment domain. All measures of exposure to aggression were significantly positively correlated with MBI-HSS scores in the emotional exhaustion and depersonalisation dimensions of burnout.

CONCLUSIONS

The prevalence of burnout in this North American sample is comparable to what has been reported in similar populations in other locations, although these staff may have a higher sense of accomplishment with regard to their work. Findings from this large sample support the evidence that exposure to client aggression affects staff emotional well-being but is by no means the only important factor. Further study is needed to explore the differences and similarities reported here as well as other contributing factors which will guide the implementation of effective strategies to improve staff well-being.

Recent research on aetiology, development and phenomenology of self-injurious behaviour in people with intellectual disabilities: a systematic review and implications for treatment

BACKGROUND

Behavioural interventions conceptualise self-injurious behaviour (SIB) as developing from early repetitive behaviours through acquisition of homeostatic functions in regulating stimulation and subsequent shaping into SIB through socially mediated or automatic operant reinforcement. Despite high success rates, such interventions rarely completely eliminate SIB, and overall effectiveness has not increased since the 1960s.

METHODS

Research (excluding studies of single genetic syndromes) on the early development, functional properties and phenomenology of SIB in persons with intellectual disabilities (IDs) published from 1999 to 2010 inclusive is reviewed.

RESULTS

Despite evidence to support the operant shaping hypothesis, in some cases tissue-damaging SIB, especially head-banging, emerges at a similar or younger age than stereotyped behaviours or 'proto-SIB', often associated with tantrums following frustrative non-reward and/or abrupt situational transitions. Many young children show undifferentiated patterns of responding in functional analyses of SIB, and SIB is associated with aggression and impulsivity as well as with repetitive behaviour.

CONCLUSIONS

One dynamic in the development of SIB may be Pavlovian conditioning of aggression, originally elicited by aversive events or frustrative non-reward, to stimuli associated with such situations. Integration into operant technology of interventions based on Pavlovian principles such as graduated exposure (with or without counterconditioning) to aversive stimuli may enhance the effectiveness of behavioural interventions.

'Too withdrawn' or 'too friendly': considering social vulnerability in two neuro-developmental disorders

In some neuro-developmental disorders, the combined effect of intellectual disability and atypicalities of social cognition may put individuals at increased vulnerability in their social environment. The neuro-developmental disorders Williams syndrome, characterised by 'hypersociability', and autism spectrum disorders, characterised by 'social withdrawal', are at two extremes of atypical social functioning in humans. In this article, we use Williams syndrome and autism spectrum disorders as exemplars to demonstrate how atypicalities of social cognition may contribute to social vulnerability in these populations. The lives of individuals with both these disorders are marred by an increased risk of social isolation, bullying, unsteady relationships, employment difficulties and abuse. While different behavioural interventions have been tried to improve social functioning in these populations, there has been great variability in their success. Finally, we discuss different issues regarding social independence of these individuals; including employment, safety and decision making.

College students' conceptualizations of deficits involved in mild intellectual disability

Precedential rulings in recent capital murder trials may, in some cases, leave it up to a jury to determine whether or not an individual meets criteria for an intellectual disability (ID) and should be spared from the death penalty. Despite the potential for misconceptions about ID to bias decisions, few empirical studies have examined the public's conceptualizations of individuals with ID. This study sought to examine 890 college students' conceptualizations of the deficits involved in mild ID. Students were asked to respond to two online surveys about the cognitive and adaptive behavior deficits that people with mild ID may experience. While most students were correct about basic facts, such as ID is not contagious and not curable, there was no clear consensus regarding beliefs about individuals with ID getting married, having children, or engaging in other mainstream activities of adult living. Students' responses are examined in light of results of studies that identify and examine bona fide deficits and areas of successful mainstreaming among persons with ID. Implications of misconceptions are discussed.

Representation of people with intellectual disabilities in randomised controlled trials on antipsychotic treatment for behavioural problems

BACKGROUND

Behavioural problems are common in people with intellectual disability (ID) and are often treated with antipsychotics.

AIM

To establish the frequency and characteristics of people with ID included in randomised controlled trials (RCTs) on antipsychotic treatment for behavioural problems, and to investigate the quality of these RCTs.

METHODS

A literature search in EMBASE, PubMed and Cochrane was performed and reviewed.

RESULTS

People with ID participated in 27 of the 100 included RCTs. The RCTs were of good quality but smaller compared with trials in patients with dementia or schizophrenia (average sample sizes = 55, 124 and 374). In 13/27 trials no clear definition of ID was given. Over 25 different outcome measures were used to assess behavioural problems.

CONCLUSIONS

Studies in which people with ID are included are of a sufficient quality, but of a small size. The heterogeneity in the characteristics of the ID population included as well as in the applied assessment instruments makes performing meta-analyses unfeasible.

Association of aggressive behaviours with psychiatric disorders, age, sex and degree of intellectual disability: a large-scale survey

BACKGROUND

The link between aggression and mental disorders has been the focus of diverse studies in persons with and without intellectual disabilities (ID). Because of discrepancies in the finding of studies in persons with ID to date, and because of differences in research design, instruments used and the population studied, more research is needed. The purpose of this study was to delineate any significant association between certain psychiatric disorders and specific domains of aggressive behaviours in a large sample of persons with ID controlling for sex, age, autism and degree of ID.

METHOD

Data from the present study were obtained from 47% of all persons with ID receiving services from New York State agencies, using the Institute for Basic Research - Modified Overt Aggression Scale (IBR-MOAS between 2006 and 2007). The IBR-MOAS was completed by the chief psychologists of 14 agencies based on information from the participants' files. Demographic information obtained included the psychiatric diagnosis made by the treating psychiatrist as well as information on age, sex and degree of ID. Data from 4069 participants were analysed.

RESULTS

Impulse control disorder and bipolar disorder were strongly associated with all five domains of aggressive behaviour in the IBR-MOAS. Psychotic disorder was highly associated with four domains except for physical aggression against self (PASLF), which was of borderline significance. Anxiety was most associated with PASLF and verbal aggression against self (VASLF); depression with VASLF; obsessive compulsive disorder with physical aggression against objects (PAOBJ); personality disorders with verbal aggression against others (VAOTH), VASLF and PASLF; and autism with physical aggression against others (PAOTH), PAOBJ and PASLF. Mild to moderate ID was associated with VAOTH and VASLF and severe to profound ID with PAOBJ and PASLF. Female sex was most associated with VASLF.

CONCLUSIONS

Impulse control, mood dysregulation and perceived threat appear to underlie most of the aggressive behaviours reported. Psychosis and depression appeared to have been over-diagnosed in persons with mild to moderate ID and under-diagnosed in persons with severe and profound ID. These findings replicate and extend findings from previous studies. The pattern of associations reported can be used as helpful indicators by professionals involved in the treatment of aggressive behaviours in persons with ID.

Frequency and severity of challenging behaviour in people with profound intellectual and multiple disabilities

The main goals of this study were to determine the prevalence, frequency and severity of challenging behaviour in people with profound intellectual and multiple disabilities (PIMD). Because in the literature several health problems and sensory impairments are associated with the onset and existence of challenging behaviour, this relationship was also examined. This study involved 181 people with PIMD (age: mean: 35; SD: 19, 56% male). The Behaviour Problem Inventory was used to determine prevalence, frequency and severity of self-injurious (SIB), stereotypical and aggressive/destructive behaviour, and an additional questionnaire was used to determine the presence of sensory impairments and health problems among the participants. Results show a prevalence of 82% for SIB and stereotypical behaviour in the sample. Aggressive/destructive behaviour was seen in 45% of the participants. Concerning the frequency, on average SIB occurs on a daily or weekly basis. Stereotypical behaviour is seen on a daily basis and aggressive/destructive behaviour is usually reported once a week. All three types of challenging behaviour also occur on an hourly basis. The severity of challenging behaviour is usually rated by staff as of minor consequence for the person with PIMD. Furthermore, a relationship was found between having visual, tactile or psychiatric problems and the occurrence of challenging behaviour. Participants with visual impairments, tactile impairments or psychiatric problems showed significantly higher mean scores regarding challenging behaviour. Challenging behaviour within the target group of people with PIMD is very common. The prevalence figures are high, but direct support professionals are not inclined to rate such behaviour as of serious consequence.

Measuring attitudes, behaviours, and influences in inner city victims of interpersonal violence (VIVs) - a Swiss emergency room pilot study

Background

Switzerland is confronted with the problem of interpersonal violence. Violence is in the increase and the potential for aggression seems to be rising. Observations by hospitals discern an appalling increase of the severity of the injuries. The aim of this study is to collect accurate information about the social environment, the motivation and possible reasons for violence. We also intend to investigate whether sociocultural, or ethnic differences among male victims exist.

Materials and methods

For the first time in Switzerland, this survey employed a validated questionnaire from the division of violence prevention, Atlanta, Georgia. The first part of the questionnaire addressed social and demographic factors which could influence the risk of violence: age, gender, duration of stay in Switzerland, nationality and educational level. Beside these social structural factors, the questionnaire included questions on experience of violent offences in the past, information about the most recent violent offence and intra and interpersonal facts. The questionnaire itself consists of 27 questions, translated into German and French. In a pilot study, the questionnaire was checked with adolescents for feasibility and comprehensibility.

Results

69 male VIVs were interviewed at two hospitals in the Canton of Bern. Most of the adolescents emphasised that weapons were not used during their confrontations. It is astonishing that all of the young men considered themselves to be victims. Most of the brawls were incited after an exchange of verbal abuse and provocations with unfamiliar individuals. The rivals could neither be classified with the help of ethnic categories nor identifiable groups of the youth scenes. The incidents took place in scenes, where violence was more likely to happen. Interestingly and contrary to a general perception the offenders are well integrated into sport and leisure clubs. A further surprising result of our research is that the attitude towards religion differs between young men with experience of violence and non-violent men.

Discussion

Youth violence is a health issue, which concerns us globally. The human and economic toll of violence on victims and offenders, their families, and on society in general is high. The economic costs associated with violence-related illness and disability is estimated to be millions of Swiss francs each year. Physicians and psychologists are compelled to identify the factors, which cause young people to be violent, to find out which interventions prove to be successful, and to design effective prevention programs. The identification of effective programs depends on the availability of reliable and valid measures to assess changes in violence-related attitudes. In our efforts to create healthier communities, we need to investigate; document and do research on the causes and circumstances of youth violence.

A meta-analysis of intervention effects on challenging behaviour among persons with intellectual disabilities

BACKGROUND

Persons with intellectual disabilities (ID) often show challenging behaviour. We review distinct interventions that are applied to treat these challenging behaviours, and analyse intervention effects and moderating variables.

METHODS

A literature search was conducted using the databases ERIC, PsycINFO, Web of Science and Medline. A random-effects meta-analysis was carried out, supplemented with sensitivity, subgroup, meta-regression and publication bias analyses.

RESULTS

Eighty potential articles were identified, from which 30 contained sufficient data to enable statistical meta-analysis. From these 30 studies, 18 described a biological, 13 a psychotherapeutic and nine a contextual intervention, either applied alone or combined. The overall standardised mean difference was 0.671 (SD = 0.051). As shown by sensitivity analysis, this summary effect size is robust. Assessed through subgroup and meta-regression analysis, all tested moderators showed no statistically significant association with the treatment effects. After applying a funnel plot-, a fail-safe N-, and Duval's and Tweedie's trim and fill-analysis, we conclude that our meta-analysis does not suffer much from publication bias effects.

CONCLUSIONS

Several biological, psychotherapeutic and contextual interventions effectively reduce challenging behaviours among persons with ID.

Aggression and violence against health care workers in Germany--a cross sectional retrospective survey

BACKGROUND

Although international scientific research on health issues has been dealing with the problem of aggression and violence towards those employed in health care, research activities in Germany are still at an early stage. In view of this, the aim of this study was to examine the frequency and consequences of aggressive behaviour towards nurses and health care workers in different health sectors in Germany and to assess the need for preventive measures.

METHODS

We conducted a cross-sectional retrospective survey. Nurses and health care workers from two nursing homes, a psychiatric clinic and a workshop for people with disabilities were interviewed using a standardised questionnaire. The sample covered 123 individuals (response rate 38.8%). The survey assessed the frequency, the type and the consequences of aggressive behaviour, and social support in connection with coping with aggression in the workplace. Odds ratios (OR) and 95% confidence intervals (CI) for putative risk factors which may influence the stress induced by aggression at the workplace were calculated using conditional logistic regression.

RESULTS

During the previous twelve months 70.7% of the respondents experienced physical and 89.4% verbal aggression. Physical aggression more frequently occurred in nursing homes (83.9% of the employees) and verbal aggression was more common in the psychiatric clinic (96.7% of the employees). The proportion of the individuals affected in the workshop for people with disabilities was lower (41.9% and 77.4% respectively). The incidents impaired the physical (55%) and emotional well-being (77.2%) of the employees. The frequency of incidents (weekly: OR 2.7; 95% CI 1.1-6.4) combined with the lack of social support (OR 2.8; 95% CI 1.2-6.6) increased the probability of higher stress due to aggression.

CONCLUSIONS

This study corroborates previous reports of frequent physical and verbal aggression towards care workers in the various areas of health care. The present study highlights differences between various areas of health care in Germany and the aggravating effect of prevention neglect such as missing social support at the workplace. Therefore our data suggest the need for improved target group specific prevention of aggressive incidents towards care workers and the need for effective aftercare in Germany.

Cut-offs, norms and patterns of problem behaviours in children with developmental disabilities on the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT-Part 3)

PURPOSE

Challenging behaviours present major impediments to a young child's life. Being able to properly assess these behaviours can lead to early intervention and remediation.

METHOD

In the present study, the problem behaviours of 644 children 17-37 months of age who were at risk for developmental disabilities were studied using the BISCUIT-Part 3. In study one, norms and cut-off scores were established for this new scale using this sample. In study 2, the frequency and patterns of various challenging behaviours were evaluated.

RESULTS

The majority of developmentally delayed children who had severe challenging behaviours engaged in aggressive/destructive acts. However, severe problem behaviours were in the minority of occurrence.

CONCLUSIONS

Outcomes suggest that these behaviours can be identified at an early age using a validated instrument tool. Implications are that pinpointing emerging problematic behaviours allows for a more accurate assessment of the delayed child's overall functioning. Being able to pinpoint behaviour problems allows for earlier and more effective treatment.

Pharmacotherapy for aggressive behaviours in persons with intellectual disabilities: treatment or mistreatment?

BACKGROUND

Antipsychotic medications have been used extensively to treat aggressive behaviours in persons with intellectual disabilities (ID) when the main psychiatric diagnoses given to them in the past were schizophrenia, childhood psychoses and ID with behaviour problems. Today, antipsychotics are still estimated to comprise 30-50% of all the psychotropics prescribed for persons with ID, although the prevalence of psychotic disorders is only 3% in this population. The overuse of antipsychotics in persons with ID could be justified if their aggressive behaviours were associated with mostly psychotic disorders and not other psychiatric disorders or factors and if the anti-aggressive properties of the antipsychotics have been supported by basic research or reviews of clinical studies. Is that so? This article explores these questions.

METHODS

The literature on aggressive behaviours, their associations with psychiatric disorders and other contributing factors and the past and current treatment options for aggressive behaviours in persons with and without ID was reviewed. Also, the literature on basic research regarding the brain receptors implicated in aggressive behaviours and the basic research and clinical studies on the anti-aggressive properties of antipsychotics was reviewed.

RESULTS

Aggressive behaviours in persons with ID serve different functions and many factors contribute to their initiation, maintenance and exacerbations or attenuation including most of the psychiatric and personality disorders. Genetic disorders, early victimisation, non-enriched and restrictive environments during childhood or later on and traumatic brain injury, which are common in persons with ID, have been associated with aggressive behaviours and with mostly non-psychotic disorders in persons with and without ID. If the factors above and the knowledge derived from studies of domestic violence and premeditated aggression in persons without ID are considered and applied during the evaluation of the most severe aggressive behaviours in persons with ID, more appropriate and effective treatment than antipsychotics can be implemented. Basic research implicates mostly the GABA and the serotonin pre-post synaptic brain receptors influence the initiation, modulation or inhibition of aggression in animals. The anti-aggressive properties of the antipsychotics have not been supported by reviews of clinical studies and basic research is absent. Antipsychotics are the indicated treatment only for psychiatric disorders and for aggressive behaviours associated with psychotic disorders and psychotic features as activation of dopamine receptor leads to defensive aggression.

CONCLUSIONS

Most of the persons with ID and aggressive behaviours do not have a diagnosis of psychotic disorder and there is lack of strong evidence supporting the anti-aggressive properties of the antipsychotics. The overuse of antipsychotics in this population may be explained by the old, faulty notion that aggressive behaviour in persons with ID is mostly associated with psychotic disorders. Given the discrediting of this notion, the use of antipsychotics in persons with ID may, in some cases, be considered mistreatment rather than proper treatment. In order to reverse the practice of over-prescribing antipsychotics for aggressive behaviours in persons with ID, basic research information on aggression must be disseminated, the search for the 'quick fix' must be abandoned and the promotion of antipsychotics as anti-aggressive drugs must be discouraged. Matching the treatment with the variables contributing to the aggressive behaviours, seeking a long-term rather than a short-term solution and avoiding the promotion of only one type of treatment for all types of aggression might change the current practice and improve the quality of life for many persons with ID.

Overcoming the barriers experienced in conducting a medication trial in adults with aggressive challenging behaviour and intellectual disabilities

BACKGROUND

Aggressive challenging behaviour in people with intellectual disability (ID) is frequently treated with antipsychotic drugs, despite a limited evidence base.

METHOD

A multi-centre randomised controlled trial was undertaken to investigate the efficacy, adverse effects and costs of two commonly prescribed antipsychotic drugs (risperidone and haloperidol) and placebo.

RESULTS

The trial faced significant problems in recruitment. The intent was to recruit 120 patients over 2 years in three centres and to use a validated aggression scale (Modified Overt Aggression Scale) score as the primary outcome. Despite doubling the period of recruitment, only 86 patients were ultimately recruited.

CONCLUSIONS

Variation in beliefs over the efficacy of drug treatment, difficulties within multidisciplinary teams and perceived ethical concerns over medication trials in this population all contributed to poor recruitment. Where appropriate to the research question cluster randomised trials represent an ethically and logistically feasible alternative to individually randomised trials.

Analysis of staff reports on the frequency of challenging behaviour in people with severe or profound intellectual disabilities

The main goal of this study was to investigate whether staff members vary in their frequency reports on challenging behaviour concerning the same client. Because staff's approaches of challenging behaviour are affected by a range of staff characteristics, we hypothesised that these staff characteristics could explain this variability between staff members. We used questionnaires to investigate the influence of staff's age, gender, experience in working with people with intellectual disabilities, working hours, professional qualifications, sort of education, and their emotional reactions and beliefs regarding the challenging behaviour. This study involved 152 staff members and 51 clients with severe or profound intellectual disabilities who displayed self-injurious behaviour, stereotyped behaviour, and/or aggressive/destructive behaviour. A part of the variability between staff's reports on the frequency of challenging behaviour was indeed explained by differences between the staff members. Working hours, internal attribution, gender, and experience in working with people with severe or profound intellectual disabilities turned out to be influencing variables. Summarising, staff members differ in their reports on the frequency of challenging behaviour. To get an accurate picture of a client's challenging behaviour, perceptions of several staff members are needed.

Staff variables associated with the challenging behaviour of clients with severe or profound intellectual disabilities

BACKGROUND

Previous research has identified that staff-client interactions play an important role in the origin and maintenance of challenging behaviour. Particularly, the reciprocity between staff behaviour and client behaviour has been considered a key issue. Furthermore, severe challenging behaviour has been found to elicit negative emotional reactions from staff which in turn may influence staff's behaviour. Another variable that has been associated with staff behaviour are staff's attributions regarding clients' challenging behaviour. The present study tested several hypotheses about associations between staff variables and challenging behaviour.

METHOD

Questionnaires were used to investigate associations between the attributions, emotional reactions and behavioural reactions of 51 staff members towards challenging behaviour of clients with severe or profound intellectual disabilities who displayed self-injurious behaviour, stereotyped behaviour and/or aggressive/destructive behaviour.

RESULTS

Staff members reported that reactions to challenging behaviour differed according to the type of challenging behaviour. Negative emotional reactions were positively associated with challenging behaviour. Associations between emotional reactions, staff beliefs and staff reactions were inconsistent.

CONCLUSIONS

The findings suggest that there is a need to look for a better conceptualization and assessment of the variables under investigation.

Assessing the prevalence of intellectual disability among young male prisoners

BACKGROUND

In recent years, academic debate has (re)focused on the extent of the co-occurrence of intellectual disability (ID) and criminality, although findings from prevalence studies examining this link have been inconsistent. In April 2004, a process for transferring responsibility for commissioning healthcare services in UK prisons to Primary Care Trusts (PCTs) commenced. This development meant that it was important for PCTs to ascertain the need for specialist ID services in prisons in their areas. Because there were no reliable prevalence data, this research was commissioned by one such PCT.

METHOD

Using a stratified random sampling frame, data were collected from 185 young adult male prisoners aged 18 and 21 years old. Participants completed a semi-structured research questionnaire, the Kaufman Brief Intelligence Test (Second Edition) (KBIT2) and the Vineland Adaptive Behavior Scales (Second Edition) (VABS2).

RESULTS

Ten per cent had an IQ composite of 69 or below, indicating a significant impairment in cognitive functioning. A further 10% had IQ composite scores between 70 and 74, and 14% between 75 and 79. None of the sample had an Adaptive Behavior Composite (ABC) score of 69 or less, although 15% scored between 70 and 79 on this measure. While none of the sample could be classified as having an ID in strict diagnostic terms, 4% scored 69 or below on the KBIT2 and in the borderline (71-79) range on the VABS2, 4% had borderline ABCs and IQs between 70 and 74; and 3% had borderline ABCs and IQs less than 79. This equates to a point prevalence of borderline ID of 11%.

CONCLUSIONS

Eleven per cent of the sample had borderline ID, supporting suggestions that this group are prevalent--and easily hidden--in mainstream criminal justice settings. Differences between borderline ID inmates and non-ID counterparts are discussed, and implications for service delivery are considered.