Challenging behavior, functioning difficulties, and quality of life of adults with intellectual disabilities

Nurses' experiences on the use of Positive Behaviour Support in the management of challenging behaviour in adults with a dual diagnosis of a mental health disorder and an intellectual disability

INTRODUCTION

Individuals who have a dual diagnosis of both a psychiatric disorder and an intellectual disability (ID) are more likely to exhibit challenging behaviour than the general population. Clinicians globally have been encouraged to use positive approaches such as Positive Behaviour Support (PBS) when managing challenging behaviour.

AIM

To explore nurses' views, opinions and perceptions on the use of positive behaviour support, as an adjunctive therapy, in the management of challenging behaviour in adults with a dual diagnosis of a mental health disorder and an intellectual disability within a mental health setting.

METHOD

A descriptive qualitative study was undertaken to identify registered nurses' experiences of using PBS in managing challenging behaviour. Data were collected from ten participants via semi-structured interviews and analysed using thematic analysis.

RESULTS

Two themes were constructed; 1) Being involved from the beginning and 2) Impact on adults with a dual diagnosis.

DISCUSSION

Nurses' involvement from the onset was fundamental in maximising the potential of PBS. Benefits of PBS were identified. Having a meaningful relationship with clients and a good knowledge of their behaviours was integral to the success of PBS.

IMPLICATIONS FOR PRACTICE

Participants emphasised the importance of continuous education around PBS. Nurses should be included in the formulation of PBS plans. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: RELEVANCE STATEMENT.

Emotional Reactions of Professionals to Challenging Behaviors in People with Intellectual and Developmental Disability

Professionals working with people with intellectual and developmental disability (IDD) can be exposed to challenging behaviors (CBs), which may result in professionals exhibiting emotional reactions that can impact their practices. This study examined these reactions and analyzed how they are influenced by the individual characteristics of people with IDD (gender, age, and level of IDD) and the variables related to CB (type of behavior and its frequency and behavioral function). A total of 125 professionals assessed 293 people with IDD who exhibited CBs. The professionals were asked to complete the Behavior Problems Inventory-Short Form, the Emotional Reactions to Challenging Behavior Scale, and the Questions About Behavior Function measure. It was revealed that positive emotional reactions predominated over negative ones. Significant results were found regarding the level of disability and the age of people with IDD. Emotional reactions were related to the severity of CBs, especially self-injurious and aggressive/destructive behavior, as well as certain behavioral functions. The severity of CBs and the age of people with IDD emerge as key predictors of the emotional reactions of professionals. In short, these reactions vary according to different variables, highlighting the importance of interventions that address professionals' emotional needs.

Integrative Care for Challenging Behaviors in People with Intellectual Disabilities to Reduce Challenging Behaviors and Inappropriate Psychotropic Drug Prescribing Compared with Care as Usual: A Cluster-Randomized Trial

People with intellectual disabilities (IDs) often present with challenging behaviors (CBs) mostly due to inappropriate environments and mental and physical disorders. Integrative care is recommended to address CBs. However, in clinical practice, psychotropic drugs are often prescribed off-label for CBs, although the effectiveness is unclear, and side effects frequently occur. We conducted a cluster-randomized controlled study to investigate the effect of integrative care provided by a collaboration of an ID specialized mental healthcare team and participants' own ID service providers' care team on reducing CBs and inappropriate off-label psychotropic drug prescriptions compared with care as usual. Participants (N = 33, aged 19-81 years) had a moderate, severe, or profound intellectual disability and used off-label psychotropic drugs. The primary outcome measures were the Aberrant Behavior Checklist and the total dose of psychotropic drug prescriptions. At the study endpoint of 40 weeks, we found no effect of the intervention on the total ABC score and on the total dose of psychotropic drug prescriptions. In the intervention group, however, the psychotropic drug dose decreased significantly, while CBs did not change. The small sample size and not-completed interventions due to organizational problems may have affected our findings. This study illustrates the difficulties in the implementation of integrative care.

Real-time stress detection based on artificial intelligence for people with an intellectual disability

People with severe intellectual disabilities (ID) could have difficulty expressing their stress which may complicate timely responses from caregivers. The present study proposes an automatic stress detection system that can work in real-time. The system uses wearable sensors that record physiological signals in combination with machine learning to detect physiological changes related to stress. Four experiments were conducted to assess if the system could detect stress in people with and without ID. Three experiments were conducted with people without ID (n = 14, n = 18, and n = 48), and one observational study was done with people with ID (n = 12). To analyze if the system could detect stress, the performance of random, general, and personalized models was evaluated. The mixed ANOVA found a significant effect for model type, F(2, 134) = 116.50, p < .001. Additionally, the post-hoc t-tests found that the personalized model for the group with ID performed better than the random model, t(11) = 9.05, p < .001. The findings suggest that the personalized model can detect stress in people with and without ID. A larger-scale study is required to validate the system for people with ID.

Families' experiences of the Low Arousal Approach: a qualitative study

Background

Parents and carers supporting a family member presenting with behaviors of concern experience heightened stress. The Low Arousal Approach is a crisis management strategy which recognizes that stress, or physiological arousal, can be expressed through behaviors of concern. This approach aims to equip parents and carers to manage behaviors in a person-centered and non-confrontational way. There is a paucity of published research exploring the experiences of families applying this approach.

Methods

Seventeen parents who had received training in the Low Arousal Approach were interviewed to gain their perspectives on supporting their family members using this approach.

Results

Thematic analysis revealed themes relating to parental stress, which was related to external pressures, isolation, family stress, and challenges in their caring role. They described encountering negative narratives relating to self-criticism and negative judgments from others. Training in the Low Arousal Approach was related to being empowered through access to evidence, increased confidence, and increased ability to advocate for their family member's needs. Low Arousal was described as a "lifestyle" that enabled increased coping for the family unit as a whole.

Discussion/conclusion

Findings indicate that it is vitally important to recognize the views of parents and carers, and these are equally as important as the views of professionals. We must understand parents' and carers' needs in order to provide adequate support.

A review of the use of psychotropic medication to address challenging behaviour in neurodevelopmental disorders

Engagement in challenging behaviour (e.g., aggression, self-injury) is reported to occur in neurodevelopmental disorders such as intellectual disabilities (ID), autism spectrum disorder (ASD), and fragile X syndrome (FXS). Common interventions to address these behaviours include both behavioural and pharmacological approaches. Although psychotropic medications are commonly used to address challenging behaviour in ID, ASD, and FXS, demonstration of the effectiveness of treatment is limited. Furthermore, research examining interaction effects between psychotropic medication, challenging behaviour, and environmental events within specific neurodevelopmental disorders such as ID, ASD, and FXS is scarce. The purpose of this chapter is to provide an overview of challenging behaviour within ID, ASD, and FXS and of the effectiveness of psychotropic medication as an intervention for challenging behaviour within these neurodevelopmental disorders. Finally, research examining how psychotropic medication may impact the relationship between challenging behaviour and environmental events is reviewed.

Difficulties in Addressing Diagnostic, Treatment and Support Needs in Individuals with Intellectual Disability and Persistent Challenging Behaviours: A Descriptive File Study of Referrals to an Expertise Centre

Service providers may experience difficulties in providing appropriate care to optimize the functioning of individuals with intellectual disability and challenging behaviour. External consultation to identify and address the unmet support needs underlying the behaviour may be beneficial. Applying the multidimensional American Association Intellectual and Developmental Disabilities (AAIDD) model may facilitate this approach. We aimed to describe the content and outcomes of consultation for individuals with intellectual disability and challenging behaviour referred to the Dutch Centre for Consultation and Expertise in relation to the AAIDD model. Interventions were based on the clients' diagnostic, treatment, and support needs and were categorized according to the five dimensions of the AAIDD model. Outcomes of the consultations were assessed based on reports in the file and rated as 'clear improvement', 'improvement' or 'no improvement or deterioration'. In two-thirds of the 104 studied files, consultees were satisfied with the improvement in functioning. Interventions targeted the difficulties of the service providers in supporting their clients and were most often applied within the Health and Context dimensions of the AAIDD model. We may conclude that consultation of an expert team may be valuable to support the care providers, and the use of the AAIDD model may be helpful to address the unmet needs to improve the functioning of individuals with challenging behaviour.

Grandparent-Implemented Interventions to Reduce Challenging Behavior of an Adult With Autism: A Pilot Telehealth Case Study

Adults with autism spectrum disorder (ASD) often engage in challenging behavior that requires individualized intervention to remediate. However, access to high-quality services is limited for adults, leaving this population without necessary behavioral healthcare. This study addressed the needs of a 22-year-old man with ASD and intellectual disability (ID) who lived with his grandmother and engaged in tangibly maintained challenging behavior. The interventionist coached his grandmother via telehealth in the implementation of two behavior analytic interventions: signaled multiple schedule arrangement and a modified contingency contract. The effects of the interventions were evaluated using an alternating treatments design with baseline. While both interventions were effective at decreasing challenging behavior when compared to baseline, the signaled multiple schedule arrangement resulted in zero instances of challenging behavior. Both the participant and the grandparent completed post-intervention social validity assessments and reported overall positive satisfaction with the interventions. Practice recommendations are presented.

Community Living, Intellectual Disability and Extensive Support Needs: A Rights-Based Approach to Assessment and Intervention

People with intellectual disability (ID) and extensive support needs experience poorer quality of life than their peers whose disability is not as severe. Many of them live in residential settings that limit community participation and prevent them from exercising control over their lives. This work analyzes the extent to which professional practices are aimed at promoting the right to community living for people with ID and extensive support needs, as well as the rights that are particularly linked to it, such as the right to habilitation and rehabilitation and the right to privacy. A specific questionnaire was designed and administered to 729 adults with intellectual disability (M = 37.05; DT = 12.79) living in different settings (family home, residential facilities and group homes). Measurement and structural models were estimated using exploratory structural equation modeling. Results obtained reveal that people with extensive support needs receive less support in terms of guaranteeing their right to independent living and privacy, especially when they live in disability-related services. This study highlights the need to implement and monitor, using valid and reliable indicators, mesosystem strategies that guarantee the right to live and participate in the community, especially for individuals with ID and extensive support needs.

Caring for Persons With Intellectual Disabilities and Challenging Behavior: Staff Experiences With a Web-Based Training Program

Background: Clear and effective communication is a prerequisite to provide help and support in healthcare situations, especially in health, and social care services for persons with intellectual disabilities, as these clients commonly experience communication difficulties. Knowledge about how to communicate effectively is integral to ensuring the quality of care. Currently, however, there is a lack of such knowledge among staff working in the disabilities sector, which is exacerbated by challenges in the competence provision in municipal health and social care services. Therefore, the aim of the study was to explore staffs' experience of web-based training in relation to their professional caring for persons with intellectual disabilities and challenging behavior. The intention is to move toward well-evaluated and proven web-based training in order to contribute to competence provision in this specific context. Methods: Fourteen semi-structured interviews were carried out with individual staff members to gather data regarding their experiences with web-based training in relation to their profession. The collected data were analyzed using qualitative content analysis with a focus on both manifest and latent content. Results: The staff's experiences with the web-based training program were presented as a single main theme: "Web-based training for staff initiates a workplace learning process by promoting reflections on and awareness of how to better care for persons with intellectual disabilities and challenging behavior." This theme contained three categories which are based on eight sub-categories. Conclusion and clinical implications: The benefits of web-based training for workplace learning could clearly be observed in the strengthening of professional care for persons with intellectual disabilities and challenging behavior. Staff members claimed to have gained novel insights about how to better care for clients as well as about the importance of interactions in their encounters with clients. Professional teamwork is crucial to providing effective care for persons with intellectual disabilities and challenging behavior. Hence, future research aimed at investigating the views of other healthcare professionals, such as registered nurses, is recommended to improve the competence provision within municipal health and social care services and thereby enhance the quality of care.