Prevalence and associated factors of problem behaviours among older adults with intellectual disabilities in Ireland

Challenging behaviors in adults with autism spectrum disorder and intellectual disability: A differential analysis from a transdiagnostic approach

This study aimed at analyzing the differences in challenging behaviors between adults with intellectual disability and ASD and those who only had intellectual disability, as well as to explore associations between transdiagnostic and clinical variables to these differences. Therapists and educators of 163 adults with intellectual disability (83 with additional ASD diagnosis) completed the test battery. Mean difference analysis and univariate analyses of covariance were performed to determine the impact of clinical variables and transdiagnostic variables on the frequency and severity of challenging behaviors. Results showed that adults with ASD and intellectual disability presented higher frequency and severity of these behaviors. A significant effect of the diagnosis of ASD on the frequency and severity of self-injuries and stereotypies was found. Also, some transdiagnostic variables influencing the presence of these behaviors were highlighted. These factors should be considered when planning and designing interventions for behavioral problems in this population.

Stakeholder views on the barriers and facilitators of psychosocial interventions to address reduction in aggressive challenging behaviour in adults with intellectual disabilities

Success of psychosocial interventions in reducing aggressive challenging behaviour is likely to be related not only to mechanistic aspects but also to therapeutic and system factors. The study aims to examine the facilitators and barriers that influence whether psychosocial interventions for aggressive challenging behaviour in adults with intellectual disabilities lead to positive change. We conducted 42 semi-structured interviews with adults with intellectual disabilities who display aggressive challenging behaviour, family/paid carers, and professionals engaged in or delivering a psychosocial intervention across the UK. Data were analysed thematically using a framework approach. Stakeholders considered therapeutic and supportive relationships and personalised care as facilitating factors in addressing aggressive challenging behaviour. The operational structure of community intellectual disability services and conflicting expectations of professionals and carers were the main contextual barriers that impeded the implementation of psychosocial interventions in adults with intellectual disabilities. Findings highlight the valued components that maximise positive change in adults with intellectual disabilities who display aggressive challenging behaviour. Several operational adjustments including referral criteria, roles of professionals and workforce issues need to be addressed in services to maximise the implementation of psychosocial interventions leading to reduction in aggressive challenging behaviour in this population.

Stakeholder perspectives on intensive support teams for adults with intellectual disabilities who display behaviour that challenges in England

BACKGROUND

Adults with intellectual disabilities often display behaviour that challenges that is a result of biological differences, psychological challenges, and lack of appropriate social support. Intensive Support Teams (IST) are recommended to support the care needs of this group and avoid hospitalisation. However, little attention has been paid to the perspectives of stakeholders who manage, work in, or use ISTs.

METHOD

Interviews and focus groups were conducted with 50 stakeholders (IST service managers and professionals, adults with intellectual disabilities, and family and paid carers) of ISTs. Services operated according to one of two service models previously identified in ISTs in England (enhanced or independent).

RESULTS

Thematic analysis identified accessible and flexible support, individualised care, and the involvement of carers and other relevant agencies in management plans and reviews as features of good IST care highlighted by all stakeholder groups. IST managers and professionals described the key challenges of current IST provision as unclear referral criteria, limited interfaces with other local services, and perceived threats associated with funding and staff retention. Findings were similar between the two IST models.

CONCLUSIONS

ISTs are able to offer care and specialist support that is valued by families, service users and other care providers. However, they face several operational challenges that should be addressed if ISTs are to reach their potential along with community intellectual disability services in supporting adults with intellectual disabilities who display behaviour that challenges in the community.

Transitions for older people with intellectual disabilities and behaviours that challenge others: A rapid scoping review

BACKGROUND

People with intellectual disabilities and behaviours that challenge others are living longer. This review aimed to explore what is known about the health and social care needs, experiences, service interventions and resources of and for this population as they transition to different care contexts in the UK.

METHOD

A rapid scoping review of published and unpublished literature was conducted based on collaborative working with key stakeholders and using systematic methods of data searching, extraction and analysis.

RESULTS

Consistent social work support, skilled staff, suitable accommodation, creative engagement with individuals and families to plan ahead, and timely access to quality healthcare are all required to promote successful transitions as people age, and to avoid unwanted/inappropriate transitions at points of crisis.

CONCLUSIONS

More research is needed to assess the types of services that this population can and do access as they age, the quality of those services, and the extent to which local commissioners are planning ahead for people with intellectual disabilities and behaviours that challenge others.

Impact of creative workshops in an institutionalized patient with moderate/severe cognitive impairment with behavioral disorders: A case report

The Hospital Care Unit for individuals with intellectual disabilities and behavioral disorders provides comprehensive care in a controlled and video-surveyed facility that minimizes access to potentially manipulative materials during aggression or pica episodes. The patient was admitted to the unit due to issues including ingestion of non-edible fluids, aggression toward staff and other patients, and self-injury. All patients participated in occupational activities led by an occupational therapist from Monday to Friday from 10 a.m. to 11:30 a.m. In addition, creative workshops such as cinema forums and cooking workshops were held on some afternoons. During the analyzed period from January to June 2022, the patient experienced three episodes of pica, 14 assaults toward staff, and eight toward peers. All of these incidents occurred after dinner and were triggered either by the inability to eat dessert or by refusal to brush teeth afterward. In our case study, the implementation of creative workshops such as cooking had a positive effect on decreasing instances of pica and aggression. These workshops slightly improved participation in other occupational therapy activities and stabilized the patient's behavior, increasing the likelihood of her being able to return to her habitual residence.

Healthy Ageing and Intellectual Disability study: summary of findings and the protocol for the 10-year follow-up study

INTRODUCTION

The Healthy Ageing and Intellectual Disability (HA-ID) study is a prospective multicentre cohort study in the Netherlands that started in 2008, including 1050 older adults (aged ≥50) with intellectual disabilities (ID). The study is designed to learn more about the health and health risks of this group as they age. Compared with the amount of research in the general population, epidemiological research into the health of older adults with ID is still in its infancy. Longitudinal data about the health of this vulnerable and relatively unhealthy group are needed so that policy and care can be prioritised and for guiding clinical decision making about screening, prevention and treatment to improve healthy ageing.

METHODS AND ANALYSIS

This article presents a summary of the previous findings of the HA-ID study and describes the design of the 10-year follow-up in which a wide range of health data will be collected within five research themes: (1) cardiovascular disease; (2) physical activity, fitness and musculoskeletal disorders; (3) psychological problems and psychiatric disorders; (4) nutrition and nutritional state; and (5) frailty.

ETHICS AND DISSEMINATION

Ethical approval for the 10-year follow-up measurements of the HA-ID study has been obtained from the Medical Ethics Review Committee of the Erasmus MC, University Medical Centre Rotterdam (MEC-2019-0562).

TRIAL REGISTRATION NUMBER

This cohort study is registered in the Dutch Trial Register (NTR number NL8564) and has been conducted according to the principles of the Declaration of Helsinki.

Parent-Implemented Behavior Interventions via Telehealth for Older Children and Adolescents

Children and adolescents with intellectual and developmental disabilities (IDD) are more likely to engage in challenging and interfering behavior than their typically developing peers, which has been linked to many negative outcomes. The most effective interventions to address challenging and interfering behavior incorporate function-based assessments, which are used to develop individualized behavior interventions. Functional communication training (FCT) is an evidence-based practice to decrease challenging and interfering behavior that can be taught to parents using behavioral parent training (BPT); however, there are limited skilled professionals who can develop interventions and train parents. Telehealth can enable greater access to these professionals. This study used withdrawal designs to determine whether high parent treatment fidelity resulted in decreased challenging and interfering behavior and increased appropriate replacement behavior. Three participants (8-17 years) were included in the study, and their parents served as interventionists during mealtime, toothbrushing, and room cleaning. Data were analyzed using visual analysis. Each parent achieved high treatment fidelity with one session of BPT and bug-in-ear coaching. All participants had a decrease in challenging and interfering behavior and an increase in functional communication responses (FCRs) upon the introduction of the intervention with reliable reversals. All parents reported high social validity. Results and implications for practice and future research are discussed.

Autism spectrum disorder in older adults with intellectual disability: a scoping review

INTRODUCTION

Ireland has an ageing population of persons with intellectual disability (ID), autism spectrum disorder (ASD) and both (ID/ASD). Despite this, little is known about the prevalence of ASD and its effect on functional outcomes, psychiatric comorbidity or diagnostic issues in an older population with ID. This article reviews the literature on older adults with ID/ASD and identifies opportunities for future research in this population.

METHOD

The authors searched the Medline, Pubmed, Embase, CINAHL and PsychInfo databases using the search terms using key words: (older adults) AND (ID OR mental retardation OR learning disability) AND (autism OR ASD). After excluding articles for relevance, a scoping review was carried out on the results retrieved.

RESULTS

Of the 1227 articles retrieved from the literature on ID and autism/ASD in older adults, 85 articles were relevant to an adult population with ID/ASD. The data were collated and are presented covering domains of diagnosis, prevalence, psychiatric comorbidities and functional outcomes.

CONCLUSIONS

Despite increased prevalence in childhood ASD in the last 20 years, there is a lack of research regarding adults, especially older adults, with ASD, up to half of whom will have some level of ID. The existing literature suggests that older adults with ID/ASD may have reduced functional independence, increased psychiatric comorbidity and psychotropic prescribing and more behavioural presentations than the older population generally or those with ID only. There is a need for longitudinal data to be collected on this ageing population so that care and management needs can be met in the future.

Nature and extent of intellectual disability nursing research in Ireland: a scoping review to inform health and health service research

OBJECTIVES

To capture the extent and nature of intellectual disability nursing publications in Ireland.

DESIGN

Scoping review using Arksey and O'Malley approach.

DATA SOURCES

Six databases (PsycINFO, CINAHL, Medline, Academic Search Complete, Scopus, Embase) were searched along with a web-based search of the eight academic institutions delivering intellectual disability nurse education in Ireland for publications indexed from the earliest available date to the 31 December 2020.

ELIGIBILITY CRITERIA

Publications by an academic, practitioner or student working in intellectual disability practice or education in Ireland relating to intellectual disability nursing, care or education.

DATA EXTRACTION AND SYNTHESIS

Data pertaining to type of paper/design, authors (academic/professional/student), year, collaboration (national/international), topic/content area and title were extracted from each paper. Data were analysed by two authors using Colorafi and Evans content analysis steps where data was tabulated, and a narrative synthesis undertaken.

RESULTS

The reporting of the review is in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) and PRISMA extension for Scoping Reviews Checklist. Database and web-based searching resulting 245 articles meeting the criteria for this review. Through content analysis the 245 articles were mapped onto six themes: supporting inclusion, future planning, aspects of health, interventions, education, professional development and research, and personal and professional accounts of caring.

CONCLUSIONS

This review highlights the extent and nature of intellectual disability publications by academic, practitioner or student working in intellectual disability nursing in Ireland together with opportunities for future growth and development. From the findings it is apparent that there is an ongoing need for intellectual disability nurses to define their role across the full trajectory of health provision and to make visible their role in person-family centred support, inclusion, and contributions in health education, health promotion and health management.

The relationship between antiepileptic drug load and challenging behaviors in older adults with intellectual disability and epilepsy

Antiepileptic drugs (AEDs) may affect mood and behavior in people with epilepsy and intellectual disability. A high AED load, derived from AED polytherapy and/or high doses of AEDs, has been suggested to be a risk factor for behavioral side effects. Data were drawn from Wave 3 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). The Behavior Problems Inventory Short Form (BPI-S) was used to assess challenging behaviors. AED load was calculated and median AED loads obtained. Non-parametric tests and binary logistic regression were performed to determine the relationship between AED load and challenging behaviors. Of participants with a reported diagnosis of epilepsy who were taking a regular AED and had completed BPI-S (n = 142), 62.7% (n = 89) exhibited challenging behaviors. Challenging behavior was found to be more prevalent in those with more severe levels of intellectual disability (p < 0.001). Aggressive/destructive behavior and stereotyped behavior were significantly more likely in participants living in residential/campus settings. For participants with a severe/profound intellectual disability, a significantly higher median AED load was found for participants exhibiting aggressive/destructive behavior and self-injurious behavior (SIB) compared to participants not exhibiting these behaviors, indicating a high AED load may contribute to some behavioral problems in this population group. However, many factors can influence behavioral outcomes, creating difficulties in determining those that are associated and the nature of the association. Careful monitoring of AED load, together with increased vigilance for breakthrough behavioral issues is essential for dealing with these complex cases. Larger studies are needed to account for the potential confounding factors.

Association between epilepsy and challenging behaviour in adults with intellectual disabilities: systematic review and meta-analysis

BACKGROUND

Previous systematic reviews showed no significant association between epilepsy and challenging behaviours in adults with intellectual disabilities.

AIMS

To identify whether there is an association between epilepsy and challenging behaviour in adults with intellectual disabilities by carrying out a systematic review of published data. PROSPERO registration number: CRD42020178092.

METHOD

We searched five databases and hand-searched six journals. Two authors independently screened titles, abstracts and full articles using a standardised eligibility checklist. Several meta-analyses were carried out.

RESULTS

The narrative analysis of data from 34 included articles (14 168 adults with intellectual disabilities, 4781 of whom also had epilepsy) showed no significant association between epilepsy and challenging behaviour. Meta-analysis was possible on data from 16 controlled studies. This showed no significant intergroup difference but after sensitivity analysis meta-analysis of 10 studies showed a significantly higher rate of overall challenging behaviour in the epilepsy group (effect size: 0.16) compared with the non-epilepsy group. Aggression and self-injurious behaviour both showed a statistically significant higher rate in the epilepsy group, with very small effect sizes (0.16 and 0.28 respectively). No significant intergroup difference was observed in the rate of stereotypy.

CONCLUSIONS

The findings are contradictory and must be interpreted with caution because of the difficulty in pooling data from varied studies, which is likely to introduce confounding. Where significant differences were found, effect sizes are small and may not be clinically significant, and there are major methodological flaws in the included studies, which should be addressed in future large-scale properly controlled studies.

Intensive support for adults with intellectual disability and behaviours that challenge: a survey of provision and service typologies in England

BACKGROUND

Approximately 18% of adults with intellectual disabilities living in the community display behaviours that challenge. Intensive support teams (ISTs) have been recommended to provide high-quality responsive care aimed at avoiding unnecessary admissions and reducing lengthy in-patient stays.

AIMS

To identify and describe the geographical distribution and characteristics of ISTs, and to develop a typology of IST service models in England.

METHOD

We undertook a national cross-sectional survey of 73 ISTs. A hierarchical cluster analysis was performed based on six prespecified grouping factors (mode of referrals, size of case-load, use of outcome measures, staff composition, hours of operation and setting of service). A simplified form of thematic analysis was used to explore free-text responses.

RESULTS

Cluster analysis identified two models of IST provision: (a) independent and (b) enhanced provision based around a community intellectual disability service. ISTs aspire to adopt person-centred care, mostly use the framework of positive behaviour support for behaviour that challenges, and report concerns about organisational and wider context issues.

CONCLUSIONS

This is the first study to examine the delivery of intensive support to people with intellectual disability and behaviour that challenges. A two-cluster model of ISTs was found to have statistical validity and clinical utility. The clinical heterogeneity indicates that further evaluation of these service models is needed to establish their clinical and cost-effectiveness.

[Intellectual disabitily, challenging behavior, and care: A systematic literature review]

Introduction and background : People with intellectual disabilities present difficult behaviors, also called problem behaviors or challenging behaviors.Objective : The objective of this study was to describe the state of knowledge in nursing about challenging behaviors in people with intellectual disabilities.Methodology : We performed a systematic literature review based on the use of the keywords "challenging behavior," "intellectual disability," "nurs*," and "problem behavior" on the PubMed and Web of Science websites between 2008 and 2018.Results : Individuals with intellectual disabilities frequently present challenging behaviors, which can give rise to the abuse of psychotropic medication. These behaviors are also stressful for staff. Solutions in terms of staff training exist, as well as assistance in the identification of associated diagnoses that may sometimes be responsible for challenging behaviors. No publications in French on this topic were found.Conclusion : Nurses who work with people with intellectual disabilities should be encouraged to become involved in research so that they can contribute to developing knowledge on challenging behaviors and improve the quality of their care. This will also enable them to further develop their collaboration within the multidisciplinary team in order to promote good practice in terms of the management of challenging behaviors and in particular in terms of promoting a move away from prescribing psychotropic drugs.

Demographic and diagnostic profiles of older people with intellectual disability and prescription of antipsychotics

PURPOSE

To describe demographic and diagnostic profiles in a national cohort of older people with intellectual disability (ID) who were prescribed antipsychotics.

METHODS

Using national registers, we identified people with ID who were 55 + years in 2012 (n = 7936), as well as a subcohort with complete information on demographic factors (sex, year of birth, severity of ID, presence of behavior impairment, and residence in special housing; n = 1151). Data regarding diagnoses and prescription of antipsychotics were added for the time period 2006-2012. The potential effects of demographic factors and diagnoses on the prescription of sedating and less-sedating antipsychotics, respectively, were assessed in separate models by estimating the relative risks (RRs) of prescription.

RESULTS

Of the demographic factors, severe/profound ID (RR 1.17), behavior impairment (RR 1.34), and living in special housing (RR 1.25) were associated with prescription of sedating antipsychotics, whereas only behavior impairment (RR 1.42) was associated with prescription of less-sedating antipsychotics. For both sedating and less-sedating antipsychotics, the diagnoses with the largest association (i.e., highest relative risk) were schizophrenia (RR 2.17 for sedating and RR 1.81 for less-sedating) and ID (RR 1.84 and RR 1.68, respectively), followed by disorders of psychological development (for sedating antipsychotics, RR 1.57) and organic mental disorders (for less-sedating antipsychotics, RR 1.55).

CONCLUSIONS

The associations between prescription of antipsychotics and demographic factors and non-psychotic diagnoses, respectively, suggest that older people with ID may be prescribed antipsychotic medication without thorough psychiatric diagnosing. If so, there is a need for improving the abilities of health care professionals to properly diagnose and manage psychiatric illness in this population.

Prevalence and patterns of antipsychotic use and their associations with mental health and problem behaviours among older adults with intellectual disabilities

BACKGROUND

There are concerns that antipsychotics may be used inappropriately in adults with intellectual disability for problem behaviours in the absence of a diagnosed mental health condition. The aim was to examine the prevalence and patterns of antipsychotic use and their association with problem behaviours and mental health conditions in older adults with intellectual disability.

METHODS

Cross-sectional data were drawn from Wave 2 (2013/2014) of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA). Medication data were available for 95.6% (n = 677). Those who reported antipsychotic use and reported psychotic or other mental health conditions and those who reported problem behaviours were compared.

RESULTS

In total, 45.1% (n = 305) had antipsychotics, and of those with antipsychotic use and diagnosis information (n = 282), 25.9% (73) had a psychotic disorder. 58% of those exposed to antipsychotics reported problem behaviours.

CONCLUSION

Reported use of antipsychotics significantly exceeded reported doctor's diagnosis of psychotic conditions in this study.