Prevalence of, and factors associated with, problem behaviors in adults with intellectual disabilities

Challenging behaviour, the application of restrictive measures and psychotropic drug prescription in people with intellectual disabilities

BACKGROUND

Prescribing of psychotropic drugs (PDs) and applying restrictive measures are both frequently used in managing challenging behaviour of people with intellectual disabilities (ID), which is not always according to guidelines or good clinical practice.

AIMS

This study aimed to investigate the potential triangular relationship between challenging behaviour, the application of restrictive measures and PD prescription.

METHODS AND PROCEDURES

In this cross-sectional study, data on challenging behaviour, PD prescription and restrictive measures were collected. We defined and compared four mutually exclusive groups of participants.

OUTCOMES AND RESULTS

Challenging behaviour in the group in whom one or more PD were prescribed as a restrictive measures (PDRM) was more severe than in the other three groups. More severe challenging behaviour, a higher number of antipsychotics, antidepressants and anxiolytics/hypnotics prescriptions, a lower dosage, and more application of domotics as restrictive measure was shown in the PDRM compared to the group in whom PDs were prescribed according to guidelines (PDNRM).

CONCLUSIONS AND IMPLICATIONS

We did not find indications for a triangular relationship of challenging behaviour, the application of restrictive measures and PD prescriptions. Future longitudinal research is needed to better understand this complex relationship and should investigate the indication and the effect of treatment. WHAT THIS PAPER ADDS?: This study is a first exploration of the potential triangular relationship between symptoms of challenging behaviour, psychotropic drug (PD) prescription, and the application of restrictive measures. Prescribing PDs and applying restrictive measures are two interventions which are commonly used to manage challenging behaviour in people with intellectual disabilities. Both have been subject of research separately in recent years. However, it is conceivable that the PD prescription in treatments for challenging behaviour could be a substitute for another form of a restrictive measure, for example a physical or mechanical restraint. For this purpose, we defined and compared four mutually exclusive groups of participants. We found no indication for this triangular relationship. On the other hand, we found the highest severity of challenging behaviour in the group who used PDs as restrictive measure next to other restrictive measures. Our results may suggest that both prescribing PDs and applying non-pharmacological restrictive measures are used simultaneously in managing challenging behaviour, are not sufficiently implemented or effective.

IDcare - a longitudinal register study of pre-pandemic and pandemic health care utilization and diagnostic profiles among people with intellectual disabilities in southern Sweden

The aim of the creation of this cohort was to investigate patterns of health and health care utilisation before and during the COVID-19 pandemic, overall and in relation to specific diagnoses, among people with intellectual disabilities (ID) compared to the general population. People living in Skåne, the southernmost region of Sweden, on 1st of January 2014 with at least one diagnosis of ID (ICD-10 codes F70-F79) or Down syndrome (DS; Q90), or support and/or services according to the LSS act comprised the ID cohort (n = 14 716). People living in the same family and/or household as a person in the ID cohort constituted the ID family cohort (n = 31 688), and those remaining comprised the general population cohort (gPop; n = 1 226 955). Data has been collected for all three cohorts from several national and regional registers. These include registers for health care (2014-2021), deaths (2014-2021), COVID-19-related health care (vaccinations, intensive care, palliative care, 2020-2021). The prevalence of ID was 1.2%. In the ID cohort, 77.9% had at least one measure of support, 5.8% at least one Q90-diagnosis and 63.8% had at least one F7-diagnosis (26.9% mild (F70), 7.4% moderate (F71), 2.8% severe (F72), 1.4% profound (F73), and 25.4% other/unknown (F78/F79)). Compared to the gPop there were more people in the younger age groups in the ID cohort. At this point, no additional collection of data will be carried out. However, there is a possibility to add data from the registers to include years after 2021 or from additional registers. Future publications will explore relevant research questions and report key findings in relation to health among people with ID. Future results will be used to inform policy and practice on people with ID.

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.

Who is at risk? Adults with intellectual disability at risk of admission to mental health inpatient care

BACKGROUND

NHS England's Transforming Care agenda aims to reduce the number of adults with intellectual disabilities and autistic adults in mental health hospitals. The aim was to understand the demographic and clinical characteristics of those most at risk of admission.

METHOD

A cohort, retrospective study of adults using community intellectual disability services in the North West of England from 2018 to 2022 was undertaken.

RESULTS

We compared 211 adults at imminent risk of admission to a mental health hospital and 249 at significant (but not imminent) risk on a validated risk stratification tool. Individuals at significant risk were more likely to have moderate intellectual disability. Individuals at imminent risk were more likely to have diagnoses of mild intellectual disability, autism, personality disorder, or psychosis.

CONCLUSION

By furthering our understanding of the clinical characteristics of those most at risk of admission, the findings inform more appropriate targeting of resources.

Training support workers about the overmedication of people with intellectual disabilities: an Australian pre-post pilot study

BACKGROUND

There is evidence that psychotropic medications are overprescribed and overused to manage behaviours of concern for people with intellectual disabilities. Disability support workers and support staff lack education and training on the administration and safety of psychotropic medication use. This study aimed to test the applicability and preliminary efficacy of SPECTROM, an education programme developed in the UK, in an Australian context.

METHODS

The training comprises two parts: Module 1 encompasses psychotropic medications, their use and side effects. Module 2 focuses on non-pharmacological interventions for supporting people with behaviours of concern. Thirty-three participants attended the training course and completed pre-training and post-training surveys on the Psychotropic Knowledge Questionnaire and Management of Aggression and Violence Attitude Scale-Revised at four time points: pre-training, 2 weeks, 3 months and 5 months post-training.

RESULTS

Psychotropic Knowledge Questionnaire scores showed statistically significant post-training improvement at all post-training time points (P < 0.05). Management of Aggression and Violence Attitude Scale-Revised scores were high at pre-training and did not change significantly at any of the post-training survey time points. A 2-week post-training feedback questionnaire reported 80% agreement that the training programme was appropriate, useful and valid. Only 36% of participants completed questionnaires at all time points.

CONCLUSIONS

SPECTROM training increased staff knowledge of psychotropic medications, yet loss of participants was high. Further refinement of the applicability of the training for the Australian context and evaluation of the feasibility of implementation, clinical and cost-effectiveness of the programme are required.

Use of psychotropic medications in adults with intellectual disability: A systematic review and meta-analysis

OBJECTIVE

This study presents the proportion of adults with intellectual disability using psychotropic medications including antipsychotics, antidepressants, anxiolytics, hypnotics and sedatives, and psychostimulants.

METHODS

A search was performed in PubMed, Embase, PsycINFO, Web of Science, and Scopus up to 31 December 2021. Articles were included if they reported the proportion of adults with intellectual disability using psychotropic medications. Frequency of use was estimated using a random effects meta-analysis. Meta-regression analysis was used to assess the association between study-level characteristics and variability in estimates, when heterogeneity was considerable.

RESULTS

Twenty-four articles were included in pooled analysis. The pooled prevalence of psychotropic medications was 41% (95% confidence interval: 35-46%). Pooled prevalences of subclasses were as follows: antipsychotics 31% (27-35%), antidepressants 14% (9-19%), anxiolytics 9% (4-15%), hypnotics/sedatives 5% (2-8%), and psychostimulants 1% (1-2%). Heterogeneity was considerable between studies, except for psychostimulants. There was no significant association between assessed characteristics and variability in prevalence estimates.

CONCLUSION

Two-fifths of adults with intellectual disability were prescribed psychotropic medications. Antipsychotics and antidepressants were used by one-third and one-seventh of adults, respectively. There was considerable variability between studies, and further investigation is required to determine the source of variability. More studies are needed to better characterise prescribed psychotropic medications, including effectiveness and adverse effects, to ensure appropriate use of these drugs.

The Effect of Progressive Resistance Exercise Training on Cardiovascular Risk Factors in People with Intellectual Disabilities: A Study Protocol

Progressive resistance exercise training (PRET) reduces cardiovascular risk factors (CVRF) in the general population. It is unknown if PRET also reduces these risk factors in adults with intellectual disabilities (ID). The aim is to present the protocol of an intervention study that investigates the effect of PRET on CVRF in adults with ID. We will use a repeated time series design with one study group. Adults with mild-to-moderate ID and at least two CVRF are eligible (Netherlands Trial Register, NL8382). During a 12-week baseline period, measurements take place at a 6-week interval. After this, the PRET programme starts for 24 weeks, after which all measurements will be repeated. We will use hierarchical regression models, adjusted for sport activity and medication use, to estimate the effect of PRET. After the intervention, the participants will be followed-up for 12 weeks. We will evaluate factors for successful implementation of exercise in daily life. Primary outcomes are: hypertension, obesity, hypercholesterolemia, diabetes, metabolic syndrome. Secondary outcomes are: physical fitness, sarcopenia, physical activity, activities of daily living, falls, challenging behaviour. If our results show that the PRET programme is effective, it may be a promising non-pharmacological intervention to reduce CVRF in adults with ID.

Aggressive behaviour of psychiatric patients with mild and borderline intellectual disabilities in general mental health care

PURPOSE

Little is known about the associations between mild intellectual disability (MID), borderline intellectual functioning (BIF) and aggressive behaviour in general mental health care. The study aims to establish the association between aggressive behaviour and MID/BIF, analysing patient characteristics and diagnoses.

METHOD

1174 out of 1565 consecutive in-and outpatients were screened for MID/BIF with the Screener for Intelligence and Learning Disabilities (SCIL) in general mental health care in The Netherlands. During treatment, aggressive behaviour was assessed with the Staff Observation Aggression Scale-Revised (SOAS-R). We calculated odds ratios and performed a logistic and poisson regression to calculate the associations of MID/ BIF, patient characteristics and diagnoses with the probability of aggression.

RESULTS

Forty-one percent of participating patients were screened positive for MID/BIF. Patients with assumed MID/BIF showed significantly more aggression at the patient and sample level (odds ratio (OR) of 2.50 for aggression and 2.52 for engaging in outwardly directed physical aggression). The proportion of patients engaging in 2-5 repeated aggression incidents was higher in assumed MID (OR = 3.01, 95% CI 1.82-4.95) and MID/BIF (OR = 4.20, 95% CI 2.45-7.22). Logistic regression showed that patients who screened positive for BIF (OR 2,0 95% CL 1.26-3.17), MID (OR 2.89, 95% CI 1.87-4.46), had a bipolar disorder (OR 3.07, 95% CI 1.79-5.28), schizophrenia (OR 2.75, 95% CI 1.80-4.19), and younger age (OR 1.69, 95% CI 1.15-2.50), were more likely to have engaged in any aggression. Poisson regression underlined these findings, showing a SCIL of 15 and below (β = 0.61, p<0.001) was related to more incidents.

CONCLUSIONS

We found an increased risk for aggression and physical aggression in patients with assumed MID/BIF. We recommend screening for intellectual functioning at the start of treatment and using measures to prevent and manage aggressive behaviour that fits patients with MID/BIF.

Approaches used to prevent and reduce the use of restrictive practices on adults with learning disabilities: Protocol for a realist review

Introduction

The use of restrictive practices has significant adverse effects on the individual, care providers and organisations. This review will describe how, why, for whom, and in what circumstances approaches used by healthcare organisations work to prevent and reduce the use of restrictive practices on adults with learning disabilities.

Methods and analysis

Evidence from the literature will be synthesised using a realist review approach - an interpretative, theory-driven approach to understand how complex healthcare approaches work in reducing the use of restrictive practices in these settings. In step 1, existing theories will be located to explore what approaches work by consulting with key topic experts, holding consultation workshops with healthcare professionals, academics, and experts by experience, and performing an informal search to help develop an initial programme theory. A systematic search will be performed in the second step in electronic databases. Further searches will be performed iteratively to test particular subcomponents of the initial programme theory, which will also include the use of the CLUSTER approach. Evidence judged as relevant and rigorous will be used to test the initial programme theory. In step three, data will be extracted and coded inductively and deductively. The final step will involve using a realist logic of analysis to refine the initial programme theory in light of evidence. This will then provide a basis to describe and explain what key approaches work, why, how and in what circumstances in preventing and reducing the use of restrictive practices in adults with learning disabilities in healthcare settings.

Results

Findings will be used to provide recommendations for practice and policymaking.

Registration

In accordance with the guidelines, this realist review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 4^th December 2019 (CRD42019158432).

Intellectual Disability Profiles, Quality of Life and Maladaptive Behavior in Deaf Adults: An Exploratory Study

Individuals who are prelingually deaf and have intellectual disabilities experience great challenges in their language, cognitive and social development, leading to heterogeneous profiles of intellectual and adaptive functioning. The present study describes these profiles, paying particular attention to domain discrepancies, and explores their associations with quality of life and maladaptive behavior. Twenty-nine adults with prelingual deafness (31% female) and mild intellectual functioning deficits (mean IQ = 67.3, SD = 6.5) were administered the Vineland Adaptive Behavior Scales-II (VABS-II) and an adapted sign language version of a quality of life scale (EUROHIS-QOL 8). Intellectual disability domain discrepancies were characterized as at least one standard deviation difference between the social domain and IQ and the practical domain and IQ, and a significant difference, according to the VABS-II manual, between the social and practical domains. Domain discrepancies were found between intellectual functioning and both the practical (58.6%) and social domain (65.5%). A discrepancy between intellectual and social functioning was significantly associated with a higher level of internalizing maladaptive behavior (T = 1.89, p < 0.05). The heterogeneous profiles highlight the importance of comprehensive assessments for adequate service provision.

The role of physical environmental characteristics and intellectual disability in conduct problem trajectories across childhood: A population-based Cohort study

BACKGROUND

The paucity of research investigating the role of the physical environment in the developmental progression of conduct problems and the potential moderating effects of intellectual disability (ID) is surprising, given the clinical relevance of elucidating environmental determinants of disruptive behaviours.

AIMS

To use data from a large UK cohort study to assess associations between physical environmental exposures, ID, and conduct problem trajectories.

METHOD

The sample included 8168 Millennium Cohort Study children (1.9% with ID). Multilevel growth curve modelling was used to examine the role of physical environment characteristics in the developmental trajectories of conduct problems after adjustments for ID status.

RESULTS

Exposure to external environmental domains was not associated with differences in children's conduct problems across development. Alternatively, internal aspects of the household environment: spatial density (b = 0.40, p < .001) and damp problems (b = 0.14, p < .001) were both significantly associated with increased trajectories. Various individual and familial covariates were positively associated with conduct problems over time, including: presence of ID (b = 0.96, p < .001), autism spectrum disorder (b = 1.18, p < .001), male sex (b = 0.26, p < .001), poverty (b = 0.19, p < .001), maternal depression (b = 0.65, p < .001), and non-nuclear family structure (b = 0.35, p < .001). Positive ID status appeared to moderate the effects of internal household spatial density, reporting a non-linear negative association with spatial density and conduct problems across development (b = -1.08, p < .01).

CONCLUSIONS

Our findings highlight the potential harmful consequences of poor internal residential conditions on children's development of disruptive behaviours.

Behavioural phenomena in persons with an intellectual developmental disorder according to the level of emotional development

BACKGROUND

Challenging behaviours in people with an intellectual developmental disorder (IDD) are complex and often difficult to understand. The developmental perspective may provide additional insights into the specific behavioural patterns and underlying motives in different emotional reference ages.

METHODS

The behaviours of 185 adults with IDD who were admitted to psychiatry were systematically assessed with the Aberrant Behaviour Checklist (ABC) and the Modified Overt Aggression Scale (MOAS). The association of the different behaviours with various emotional reference age groups as assessed with the Scale of Emotional Development - Short (SED-S) was analysed to deduce behavioural patterns typical for a certain level of functioning.

RESULTS

Overall, the severity of challenging behaviours decreases in higher emotional reference age groups. Physical aggression was most prevalent in persons in the second phase of emotional development (7-18 months reference age). In SED-S-1 (reference age 0-6 months), the persons appeared to be searching for physical comfort and showed high scores in social withdrawal, stereotypies and aggression towards the self. Persons functioning in SED-S-2 (reference age 7-18 months) scored highest in irritability and physical aggression (searching for security), while those in SED-S-3 (19-36 months) exhibited the searching for autonomy type characterised by defiant and socially inappropriate behaviours. Persons with an emotional reference age of 4-7 years (SED-S-4) showed inappropriate speech, verbal self-regulation and depressive-like behavioural aspects (searching for identity).

CONCLUSIONS

The behavioural phenomena exhibited in a certain emotional reference age may support the clinician to differentiate behavioural problems from psychopathological symptoms to yield the proper diagnosis.

Support staff liaising effectively with family caregivers: Findings from a co-design event and recommendation for a staff training resource

A high proportion of people with intellectual disabilities (ID) and autism spectrum disorder (ASD) are prescribed psychotropic medications such as antipsychotics, antidepressants etc., outside their licensed indications, primarily for the management of behaviors that challenge (BtC) in the absence of a psychiatric disorder. Examples of BtC are aggression to people and property or self-injury. BtC could be challenging to manage and may cause the person with ID/ASD and their caregivers distress, breakdown of community placement leading to hospitalization, and restrictive practices such as restraint or inappropriate medication use. Caregivers play a pivotal role in the prescribing process. However, many family caregivers feel that they have not been fully involved in the shared decision-making process about the care planning of their relatives with ID/ASD. To address the public health concern regarding the overuse of off-license prescribing in people with ID/ASD, we have recently developed a training programme called SPECTROM (Short-term Psycho-Education for Carers To Reduce OverMedication of people with intellectual disabilities) for direct care staff who support people with ID/ASD within community settings. We used co-production and a modified Experience-Based Co-Design (EBCD) method to develop SPECTROM, which involved a literature review, four focus groups and a co-design event day involving 26 stakeholders. Recommendations from the co-design event day were analyzed by a Programme Development Group (PDG) consisting of 21 stakeholders who made the final recommendations to the project team regarding the contents and the format of SPECTROM, which was finalized after receiving feedback from further 59 stakeholders. SPECTROM has web-based resources introduced through two core modules in face-to-face workshops/training. A small field test found SPECTROM was effective in improving staff's knowledge of psychotropic medications and attitude toward BtC and people with ID (p < 0.05). One of the 14 STOMP modules is "Effective liaison with family carers and advocates". In this paper, we have presented data from the co-design event day recommendations for this particular module. The group recommended ways to improve collaborative working and effective shared decision-making with family caregivers and people with ID/ASD.

Short-Term Psycho-Education for Caregivers to Reduce Overmedication of People with Intellectual Disabilities (SPECTROM): Development and Field Testing

People with intellectual disabilities (PwID) are at a higher risk of developing challenging behaviours (CB). Despite the poor evidence for the effectiveness of medications in managing CB, they are used widely among PwID (50–63%). The aims of our study were to develop a training programme, SPECTROM for support staff to help reduce overmedication in PwID and carry out field testing of SPECTROM including a process evaluation. We developed SPECTROM using the Experience-based co-design method that included four focus groups and a one-day co-design event. Twenty trainees received SPECTROM training. We used the Management of Aggression and Violence Attitudes Scale-Revised-Intellectual Disabilities (MAVAS-R-ID) and the Psychotropic knowledge questionnaire. A semi-structured interview and a feasibility questionnaire were used for process evaluation. SPECTROM website contains 14 modules, resources, and face-to-face training. MAVAS-R-ID scores showed change in staff attitude to ‘medication management’ domain was statistically significant (p < 0.05). Psychotropic knowledge questionnaire showed statistically significant post-training improvement in correct responses (p < 0.05). Process evaluation data showed that SPECTROM was acceptable, applicable, practical, and relevant to staff practice, and helped to improve self-reflection, knowledge, and support to PwID. SPECTROM is a useful training that helps to change the support staff’s attitude toward CB and improve their knowledge of psychotropic medications.

Antipsychotics withdrawal in adults with intellectual disability and challenging behaviour: study protocol for a multicentre double-blind placebo-controlled randomised trial

BACKGROUND

In people with intellectual disability (ID) and challenging behaviour, antipsychotics (AP) are often used off-label and for a long period. Despite a lack of evidence for efficacy for challenging behaviour and concerns about common and clinically relevant side effects, complete withdrawal often fails. We postulate three possible hypotheses for withdrawal failure: 1. Influence of subjective interpretation of behavioural symptoms by caregivers and family; 2. Beneficial effects from AP treatment on undiagnosed psychiatric illness, through improvement in sleep or a direct effect on behaviour; and 3. Misinterpretation of withdrawal symptoms as a recurrence of challenging behaviour.

METHODS

To investigate our hypotheses, we have designed a multicentre double-blind, placebo-controlled randomised trial in which AP (pipamperone or risperidone) are withdrawn. In the withdrawal group, the AP dose is reduced by 25% every 4 weeks and in the control group the dose remains unaltered. Behaviour, sleep, psychiatric disorders, withdrawal symptoms and side effects will be measured and compared between the two groups. If drop-out from the protocol is similar in both groups (non-inferiority), the first hypothesis will be supported. If drop-out is higher in the withdrawal group and an increase is seen in psychiatric disorders, sleep problems and/or behavioural problems compared to the control group, this suggests effectiveness of AP, and indications for AP use should be reconsidered. If drop-out is higher in the withdrawal group and withdrawal symptoms and side effects are more common in the withdrawal group compared to the control group, this supports the hypothesis that withdrawal symptoms contribute to withdrawal failure.

DISCUSSION

In order to develop AP withdrawal guidelines for people with ID, we need to understand why withdrawal of AP is not successful in the majority of people with ID and challenging behaviour. With this study, we will bridge the gap between the lack of available evidence on AP use and withdrawal on the one hand and the international policy drive to reduce prescription of AP in people with ID and challenging behaviour on the other hand.

TRIAL REGISTRATION

This trial is registered in the Netherlands Trial Register (NTR 7232) on October 6, 2018 ( www.trialregister.nl ).

Challenging behaviors among students with severe developmental disabilities in Saudi Arabia: Impact of socio-demographic differences

This study aimed to explore the prevalence of challenging behaviors (CBs) associated with students with severe developmental disabilities (SDDs) as rated by their teachers. The study also attempted to examine whether the occurrence and intensity of CBs might depend on certain socio-demographic variables. Data was collected using a questionnaire to rate the prevalence of CBs in 687 students with SDDs. Results indicate that social problems, stereotypical behaviors, and disobedient behaviors were estimated to be the most prevalent of CBs among such students. Positive correlations were confirmed between the type of disability, gender, age, school grade, educational placement, and the prevalence of CBs among students with SDDs. Implications for educational practice and recommendations for future research are discussed.

Factors affecting the relationship between adaptive behavior and challenging behaviors in individuals with intellectual disability and co-occurring disorders

Previous studies have reported an inverse relationship between adaptive behavior and challenging behaviors in individuals with ID. However, it is unclear which characteristics might influence this relationship in individuals with ID and co-occurring conditions. We found a positive correlation between adaptive behavior (Vineland-II) and challenging behaviors (Nisonger Child Behavior Rating Form) in a study of 105 individuals who presented with mostly severe to profound ID and comorbid physical and mental health conditions. These results might be the consequence of the individual participant characteristics. Therefore, participants were separated out into two groups representing the top (n = 24) and bottom quartiles (n = 28) for presence of challenging behaviors. The participants with the highest levels of challenging behaviors had higher levels of adaptive behavior, higher frequency of intermittent explosive/conduct disorder, but lower frequency of epilepsy and cerebral palsy. All participants with the highest levels of challenging behaviors lived in an institutional setting; whereas, those with the lowest level of challenging behaviors lived in either an institutional setting or with their family. In participants with severe/profound ID and multiple co-occurring disorders, a minimum level of adaptive behavior seems to be necessary for the expression of challenging behaviors.

Psychiatric symptoms, challenging behaviour and utilization of psychiatric services among adults with intellectual disabilities in Turkey

BACKGROUND

The aim of this study was to investigate the prevalence of and the factors associated with psychiatric symptoms (PS) and challenging behaviour (CB) in adults with intellectual disabilities, and the utilization of psychiatric services in Turkey.

METHOD

Psychiatric Assessment Schedule for Adults with Developmental Disorders Checklist-Revised was used for PS and a structured form for other variables in 771 participants.

RESULTS

Of the participants, 50.1% had PS and 36.4% presented with CB. Multivariate analysis revealed that a higher level of needs, better verbal ability, residential living, incontinence and CB, and lifetime suicidal ideation/attempt were independently associated with PS. For CB, it emerged as male carer, PS, lifetime suicidal attempt/ideation, lower level of verbal ability and autism spectrum disorder. Barriers were experienced by 64.7% of participants within the previous year.

CONCLUSIONS

Psychiatric symptoms and CB seem to be problems for a significant proportion of adults with intellectual disabilities in Turkey, and there are certain barriers to psychiatric services.

Communication difficulties in adults with Intellectual Disability: Results from a national cross-sectional study

BACKGROUND

People with an intellectual disability (ID) are vulnerable to communication impairments, with consequences for employment, education, and social participation.

AIMS

To identify the communication skills of a population of adults (40+ years) with ID and explore relationships between individual and environmental factors and communication skills.

METHODS AND PROCEDURES

Data from a sample of 601 adults with ID was selected from the Intellectual Disability Supplement to The Irish Longitudinal Study on Ageing (IDS-TILDA) addressing communication characteristics, demographics, co-morbidities, challenging behaviours, and social participation. A multiple regression model and a decision-making tree were built to identify factors related to communication abilities.

OUTCOMES AND RESULTS

Overall, 57.9 % of participants experienced communication difficulties, with 23.5 % reporting severe difficulties. Only 75.1 % of participants communicated verbally; more than half found communicating with professionals and non-familiar partners difficult. Level of ID, low social participation, challenging behaviours, and diagnosis of Down syndrome were significantly associated with communication difficulties.

CONCLUSIONS AND IMPLICATIONS

Communication difficulties are prevalent in adults with ID and are influenced by complex factors. Interventions to enhance interaction and quality of life of individuals with ID should consider communication opportunities, needs, and barriers.

Prevalence of Challenging Behaviour in Adults with Intellectual Disabilities, Correlates, and Association with Mental Health

Purpose of Review

To summarise findings about the prevalence and correlates of challenging behaviour in adults with intellectual disabilities from robust research. We also describe findings on the interplay between challenging behaviour and mental health.

Recent Findings

Recent studies that have utilised psychometrically evaluated tools, with clear operational definitions, show similar findings on the prevalence of challenging behaviour of about 1 in every 5–6 adults known to services. We describe common correlates identified such as communication impairments, severity of intellectual disability, and living in institutional settings or congregate care. We also describe the complex and multifaceted relationship between challenging behaviour and mental health.

Summary

Based on recent studies, we propose a revised framework model to help understand challenging behaviour. We propose a number of areas where more research is required, particularly the development of risk tools clinicians can utilise in practice.

The Effect of Fun Physical Activities on Sarcopenia Progression among Elderly Residents in Nursing Homes: a Randomized Controlled Trial

Introduction: Immobilization in the elderly can reduce the size and strength of muscle mass and ultimately lead to sarcopenia, the severity and progression of which can be prevented by exercise. However, due to physical and mental conditions, the elderly may be unable to take full advantage of regular exercise. Therefore, fun exercise through motivation and effective participation of older adults is likely to have positive effects on decreasing the volume and power of muscle mass. The aim of this study was to determine the effect of fun physical activities on the progression of sarcopenia among elderly residents in nursing homes.

Methods: This study was a two-group randomized controlled trial conducted in 2014. Sixty three older adults were recruited by the random sampling. The elderly in the fun physical exercise group did the exercise for 8 weeks, three times a week for 20 minutes at a time, and in the control group, the adults did the routine exercises. The Berg Balance Scale, a dynamometer, and the Six-Minute Walk Test were used to measure sarcopenia criteria (balance, muscle strength, distance traveled).The statistical analysis was done by SPSS version 13.

Results: The results showed that the mean score of the sarcopenia criterion (balance, distance walked, muscles strength) was significantly increased in the fun physical exercise group than in the control group.

Conclusion: The fun physical activity reduces sarcopenia progression through improving balance, increasing distances walked, and strengthening muscles.

Who's challenging who training for staff empathy towards adults with challenging behaviour: cluster randomised controlled trial

BACKGROUND

One in five adults with intellectual disabilities (ID) known to services display challenging behaviours (CBs), and these individuals are at risk for restrictive practices and poor care. Staff attitudes may contribute to the development and/or maintenance of CBs. We investigated the effectiveness of co-produced Who's Challenging Who? training delivered by people with ID to staff.

METHOD

This study involved a cluster randomised controlled trial (RCT) of Who's Challenging Who? training with follow-up at six and 20 weeks post-randomisation.

PARTICIPANTS

two staff from each of 118 residential care settings for adults with ID at least one of whom displayed aggressive CB.

PRIMARY OUTCOME

Self-reported Staff Empathy for people with Challenging Behaviour Questionnaire.

ANALYSIS

intention to treat of all randomised settings. ISCRTN registration: ISRCTN53763600.

RESULTS

118 residential settings (including 236 staff) were randomised to either receive training (59 settings) or to receive training after a delay (59 settings). The primary analysis included data from 121 staff in 76 settings (51% of staff, 64% of settings). The adjusted mean difference on the transformed (cubed) Staff Empathy for people with Challenging Behaviour Questionnaire score at the primary end point was 1073.2 (95% CI: -938.1 to 3084.5, P = 0.296) in favour of the intervention group (effect size Cohen's d = .19).

CONCLUSIONS

This is the first large-scale RCT of a co-produced training course delivered by people with ID. Findings indicated a small positive (but statistically non-significant) effect on increased staff empathy at 20 weeks, and small to moderate effects for staff reported secondary outcomes in favour of the intervention group.

Challenging behavior in adults with epilepsy and intellectual disability: An analysis of epilepsy characteristics

PURPOSE

The study aimed to describe the frequency and severity of self-injurious, stereotyped, and aggressive/destructive behavior in adults with both epilepsy and intellectual disability (ID) who reside at a tertiary epilepsy center and to investigate the associations between challenging behavior and epilepsy and ID characteristics.

METHOD

The frequency and severity of self-injurious, (motoric) stereotyped, and aggressive/destructive behavior among 189 patients was assessed using the Behavior Problem Inventory. Comparisons were made with an adult reference population with ID, based on gender, to determine whether the behavior was clinically deviant. Epilepsy characteristics, including age at onset, epilepsy type, seizure types, seizure frequency, and use of antiepileptic drugs (AEDs), were retrieved from patient files. The level of ID was classified using the Diagnostic and Statistical Manual of Mental Disorders - Fifth Edition (DSM-5) and an ID domain discrepancy was allocated if there was a substantial difference between two domains of adaptive behavior within a subject.

RESULTS

Self-injurious behavior was present in 35% of subjects, stereotyped behavior in 60%, and aggressive/destructive behavior in 63%. The behavior exceeded clinical norms in 7%, 18%, and 12%, respectively. Aggression was the behavior evaluated most often as being problematic, despite its reported frequency being the lowest. When adjusting for level of ID and use of psychotropic medication, logistic regression analyses showed that self-injurious behavior was significantly associated with a lower number of AEDs (odds ratio (OR) = 0.4); that stereotyped behavior was significantly associated with a higher number of seizure types (OR = 1.4) and a lower number of AEDs (OR = 0.4); and that aggression was significantly associated with the presence of an ID domain discrepancy (OR = 3.1).

CONCLUSION

Challenging behavior is a serious issue among adults with epilepsy and ID. Although some of the epilepsy and ID characteristics seemed to contribute independently to these types of challenging behavior, the effects of epilepsy-related characteristics are modest when compared with ID.

Self-Injurious Behavior in People with Intellectual Disabilities and Co-Occurring Psychopathology using the Self-Harm Scale: A Pilot Study

Self-injurious behavior (SIB) is one of the most detrimental behaviors for the person showing it, as well as for their environment. Nevertheless, structured clinical assessments of SIB are scarce. Staff completed a Self-Harm Scale (SHS) every time they witnessed SIB in clients with an intellectual disability (ID) and co-occurring psychopathology (N = 33). Descriptive statistics were conducted to explore the nature of the incidents of SIB and the characteristics of the people involved in the incidents. In 41 weeks, 104 SIB incidents were reported for 8 out of 33 clients (24%). Incidents were most prevalent on Mondays (23%). As far as the methods of SIB concerned, cutting was the most used method (63%). Clients who showed SIB differed significantly from clients who did not on gender, having a personality disorder and communicative abilities. This study was one of the few that used an incident-based record form to report SIB by direct observation. It is hoped that the SHS helps to gain more information about SIB, to improve individualized interventions. Further research is necessary to determine the psychometric properties and clinical utility of the scale.

A population-based, cross-sectional study of the prevalence and correlates of sedentary behaviour of adults with intellectual disabilities

BACKGROUND

High levels of sedentary behaviour have a negative impact on health and well-being. There is limited evidence on the prevalence and correlates of sedentary behaviour of adults with intellectual disabilities (ID).

METHODS

A population-based sample of adults with ID were invited to take part in a comprehensive health check programme. Demographic and health data were collected during a structured interview and physical examination. Screen time was used as a proxy measure of sedentary behaviour. Bivariate and multivariate statistical modelling examined correlates of screen time.

RESULTS

Fifty per cent of the 725 participants reported four or more hours of screen time per day. Male gender, higher levels of intellectual ability, mobility problems, obesity, not having hearing impairment and not having epilepsy were all significantly associated with higher screen time in the final multivariate model (R²  = 0.16; Hosmer-Lemeshow goodness of fit statistic P = 0.36).

CONCLUSIONS

This is the first study to publish population-based data on the prevalence and correlates of sedentary behaviour in adults with ID. Compared with adults who do not have ID, adults with ID have higher levels, and different correlates, of sedentary behaviour. A better understanding of the social context of sedentary behaviour will inform the design of effective behaviour change programmes for adults with ID.

Effectiveness of the 'Who's Challenging Who' support staff training intervention to improve attitudes and empathy towards adults with intellectual disability and challenging behaviours: study protocol for a cluster randomised controlled trial

Background

Findings suggest approximately one in six people with intellectual disability engage in ‘challenging behaviours’, which include aggression towards others/property and self-injurious actions. In residential settings, actions of staff members can make challenging behaviours more likely to occur, or make these behaviours worse. In particular, negative attitudes from members of staff and lack of understanding about the reasons for challenging behaviour are contributory factors. ‘Who’s Challenging Who?’ (WCW) training is designed to emphasise the role of staff in residential settings as a challenge also to people with intellectual disability. The course is delivered jointly by a trainer with intellectual disability who has been labelled as having challenging behaviour, along with a trainer without intellectual disability.

Methods

This is a cluster randomised two-arm trial of WCW training versus a waiting list control. Overall, 118 residential settings will be recruited and randomised on a 1:1 ratio. Within each setting, two members of staff will be invited to take part in the trial. Participants will complete assessments at baseline and at 6 and 20 weeks. WCW is a half day initial training course with some follow-on coaching to ensure implementation. The primary outcome is changes in staff empathy towards people with challenging behaviour. Secondary outcomes at the staff level include confidence, attitudes and work-related well-being. Secondary outcomes at the residential setting level include recorded incidents of aggressive challenging behaviour, and use of any restrictive practices.

Discussion

If the results of the cluster randomised trial are positive, we will disseminate the findings widely and make all training manuals and materials freely available for anyone in intellectual disability services (and beyond) to use. Our training approach may have wider implications in other areas of social care. It may also provide a generally applicable model for how to train people with intellectual disability to act as co-trainers in intellectual disability social care settings. People with intellectual disability and challenging behaviour have already been involved centrally with the design, development and pilot evaluation of WCW and will also be fully involved throughout this trial.

Trial registration

Registered on the International Standard Randomised Controlled Trial Number registry on 8th December 2015: ISRCTN53763600.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2175-1) contains supplementary material, which is available to authorized users.

Prevalence of psychotropic medication use and association with challenging behaviour in adults with an intellectual disability. A total population study

BACKGROUND

There is a high prevalence of psychotropic medication use in adults with Intellectual Disabilities (ID), often in the absence of psychiatric disorder, also associated with challenging behaviour. Previous research has focused on specific sample frames or data from primary care providers. There is also a lack of consistency in the definition of challenging behaviour used.

METHODS

We adopted a total population sampling method. Medication data on 265 adults with ID were classified according to the Anatomical Therapeutic Chemical classification system. The Behaviour Problems Inventory - short form classified challenging behaviours. We examined the association between challenging behaviour and the use of psychotropic medication, and whether any association would still be present after accounting for socio-demographic and clinical characteristics.

RESULTS

70.57% of adults with ID were prescribed at least one class of any medication (mean per person =2.62; range 0-14). Psychotropic medications were used by 37.73% of participants with antipsychotics the commonest type used by 21.89% of individuals. Polypharmacy and high dosages were common. Generalised Linear Models indicated significant associations between psychotropic medication and the presence of a psychiatric diagnosis, challenging behaviour, older age and type of residence. Male gender was additionally associated with antipsychotic medication.

CONCLUSIONS

The use of a total population sample identified via multiple routes is less likely to overestimate prevalence rates of medication use. Current challenging behaviour was a predictor of medication use after controlling for other variables. Data indicate that there may be differences in prescribing patterns associated with different topographies of challenging behaviours.

Risk factors associated with challenging behaviour in people with profound intellectual and multiple disabilities

BACKGROUND

Several factors that correlate with the onset or continuation of challenging behaviour are mentioned in research. These are factors related to persons with ID, but also to direct support professionals and the context. Although many of these factors seem to affect the onset or continuation of challenging behaviour in people with ID in general, results are often inconclusive and have little focus on people with profound intellectual and multiple disabilities (PIMD). The present study aimed to assess the extent to which known factors related to challenging behaviour are also applicable to a group of 198 people with PIMD.

METHOD

To determine which factors were associated with challenging behaviour, univariate analyses on associations between known risk factors and challenging behaviour were conducted. The associated factors were then subject to a regression analysis to determine the extent to which they explain the prevalence of challenging behaviour and can thus be seen as factors associated with challenging behaviour.

RESULTS

The results show that, in particular, factors concerning the personal characteristics of people with PIMD, such as sleeping problems and auditory problems, were related to the variance in mean frequency of challenging behaviour. Only one factor related to the direct support professionals was found: when these professionals had been offered training on the subject of challenging behaviour in people with intellectual disabilities in general, they identified significantly more withdrawn behaviour. We found no contextual factors related to challenging behaviour.

CONCLUSION

These findings are generally consistent with findings reported in other studies, especially concerning the personal characteristics of people with PIMD. Further research should focus on the effects of providing safe auditory environments and appropriate sleep schedules for people with PIMD on the occurrence of challenging behaviour.

"Intellectual developmental disorders": reflections on the international consensus document for redefining "mental retardation-intellectual disability" in ICD-11

PURPOSE

The debate as to whether intellectual disability (ID) should be conceptualized as a health condition or as a disability has intensified as the revision of World Health Organization's (WHO's) International Classification of Diseases (ICD) is being finalized. Defining ID as a health condition is central to retaining it in ICD, with significant implications for health policy and access to health services. The purpose of this paper is to include some reflections on the consensus document produced by the first WHO Working Group on the Classification of MR (WHO WG-MR) and on the process that was followed to realize it. The consensus report was the basis for the development of official recommendations sent to the WHO Advisory Group for ICD-11.

DESIGN/METHODOLOGY/APPROACH

A mixed qualitative approach was followed in a series of meetings leading to the final consensus report submitted to the WHO Advisory group. These recommendations combined prior expert knowledge with available evidence; a nominal approach was followed throughout with face-to-face conferences.

FINDINGS

The WG recommended a synonym set ("synset") ontological approach to the conceptualisation of this health condition underlying a clinical rationale for its diagnosis. It proposed replacing MR with Intellectual Developmental Disorders (IDD) in ICD-11, defined as "a group of developmental conditions characterized by a significant impairment of cognitive functions, which are associated with limitations of learning, adaptive behaviour and skills". The WG further advised that IDD be included under the parent category of neurodevelopmental disorders, that current distinctions (mild, moderate, severe and profound) be continued as severity qualifiers, and that problem behaviours removed from its core classification structure and instead described as associated features.

ORIGINALITY/VALUE

Within the ID/IDD synset two different names combine distinct aspects under a single construct that describes its clinical as well as social, educational and policy utilities. The single construct incorporates IDD as a clinical meta-syndrome, and ID as its functioning and disability counterpart. IDD and ID are not synonymous or mirror concepts as they have different scientific, social and policy applications. New diagnostic criteria for IDD should be based on a developmental approach, which accounts for the complex causal factors known to impact the acquisition of specific cognitive abilities and adaptive behaviours. The paper focuses on a new clinical framework for the diagnosis of IDD that also includes and complements the existing social, educational and policy components inherent in ID.

Pharmacological interventions for challenging behaviour in children with intellectual disabilities: a systematic review and meta-analysis

BACKGROUND

Psychotropic medications are frequently used to treat challenging behaviour in children with intellectual disabilities, despite a lack of evidence for their efficacy. This systematic review and meta-analysis aimed to determine the safety and efficacy of pharmacological interventions for challenging behaviour among children with intellectual disabilities.

METHODS

Electronic databases were searched and supplemented with a hand search of reference lists and trial registries. Randomised controlled trials of pharmacological interventions for challenging behaviour among children with intellectual disabilities were included. Data were analysed using meta-analysis or described narratively if meta-analysis was not possible. For quality assessment, the Cochrane Risk of Bias tool and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach were used.

RESULTS

Fourteen studies including 912 participants met inclusion criteria. Antipsychotic medication reduced challenging behaviour among children with intellectual disabilities in the short-term (SMD = -1.09, p < 0.001 for risperidone; SMD = -0.64, p <0.001 for aripiprazole). However, there were significant side-effects including elevated prolactin levels (SMD = 3.22, p < 0.001) and weight gain (SMD = 0.82, p < 0.001). Evidence was inconclusive regarding the effectiveness of anticonvulsants and antioxidants for reducing challenging behaviour. The quality of all evidence was low and there were no long term follow up studies.

CONCLUSIONS

Antipsychotic medications appear to be effective for reducing challenging behaviour in the short-term among children with intellectual disabilities, but they carry a risk of significant side effects. Findings from this review must be interpreted with caution as studies were typically of low quality and most outcomes were based on a small number of studies. Further long-term, high-quality research is needed to determine the effectiveness and safety of psychotropic medication for reducing challenging behaviour.

Multiple physical and mental health comorbidity in adults with intellectual disabilities: population-based cross-sectional analysis

BACKGROUND

Adults with intellectual disabilities have increased early mortality compared with the general population. However, their extent of multimorbidity (two or more additional conditions) compared with the general population is unknown, particularly with regards to physical ill-health, as are associations between comorbidities, neighbourhood deprivation, and age.

METHODS

We analysed primary health-care data on 1,424,378 adults registered with 314 representative Scottish practices. Data on intellectual disabilities, 32 physical, and six mental health conditions were extracted. We generated standardised prevalence rates by age-groups, gender, and neighbourhood deprivation, then calculated odds ratio (OR) and 95 % confidence intervals (95 % CI) for adults with intellectual disabilities compared to those without, for the prevalence, and number of condition.

RESULTS

Eight thousand fourteen (0.56 %) had intellectual disabilities, of whom only 31.8 % had no other conditions compared to 51.6 % without intellectual disabilities (OR 0.26, 95 % 0.25-0.27). The intellectual disabilities group were significantly more likely to have more conditions, with the biggest difference found for three conditions (10.9 % versus 6.8 %; OR 2.28, 95 % CI 2.10-2.46). Fourteen physical conditions were significantly more prevalent, and four cardiovascular conditions occurred less frequently, as did any cancers, and chronic obstructive pulmonary diseases. Five of the six mental health conditions were significantly more prevalent. For the adults with intellectual disabilities, no gradient was seen in extent of multimorbidity with increasing neighbourhood deprivation; indeed findings were similar in the most affluent and most deprived areas. Co-morbidity increased with age but is highly prevalent at all ages, being similar at age 20-25 to 50-54 year olds in the general population.

CONCLUSIONS

Multi-morbidity burden is greater, occurs at much earlier age, and the profile of health conditions differs, for adults with intellectual disabilities compared with the general population. There is no association with neighbourhood deprivation; people with intellectual disabilities need focussed services irrespective of where they live, and at a much earlier age than the general population. They require specific initiatives to reduce inequalities.

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.

Practice nurse health checks for adults with intellectual disabilities: a cluster-design, randomised controlled trial

BACKGROUND

Adults with intellectual disabilities have substantial health inequalities and poor access to health care. We assessed whether practice nurse-delivered health checks could improve the health of adults with intellectual disabilities compared with standard care.

METHODS

In this cluster-design, single-blind, randomised controlled trial, we included general practices in Scotland, UK. From June to December, 2011, we randomly assigned (1:1) these general practices to either health checks plus standard care (health-checks group), or standard care only (control group), and we recruited the patients from these practices. Randomisation was done with stratification by number of GPs per practice and number of registered patients with intellectual disabilities (<20 or ≥20). Two research assistants were masked to allocation, and undertook the review of 9 month medical records and interviews. Participants and carers were not masked. The intervention was one health check designed especially for people with intellectual disabilities delivered by a practice nurse. The objective was improvement in health and health care 9 months after randomisation, and the primary outcome was the incidence of newly detected health needs being met by this timepoint. Whether needs were met was established by the investigators being masked to group allocation. The analysis was by intention to treat. This trial is registered with Current Controlled Trials, number ISRCTN43324841.

FINDINGS

Between June 26 and Dec 20, 2011, we recruited 38 practices. 85 participants (from 16 practices) were randomly assigned to intervention and 67 (from 17 practices) to standard care; five of the identified practices did not supply any participants. 83 intervention and 66 standard care participants completed the trial. More newly detected health needs were met in the intervention group than in the control standard care group (median 1 [range 0-8], 76·4% met [SD 36·5] vs 2 [0-11], 72·6% met [35·4]; odds ratio [OR] 1·73 [95% CI 0·93-3·22], p=0·085), although this difference was not significant. Significantly more health monitoring needs were met in the intervention group than standard care (median 2 [0-20], 69·9% [SD 34·2] vs 2 [0-22], 56·8% [29·4], OR 2·38 [95% CI 1·31-4·32, p=0·0053]). The probability that health checks are cost effective was between 0·6 and 0·8, irrespective of the cost-effectiveness threshold level. Costs per patient were -£71·48 for health checks and -£20·56 for standard care. The difference (-£50·92) was not significant [95% CI -434 to 362]. No adverse events were attributable to the intervention.

INTERPRETATION

Health checks given by practice nurses to adults with intellectual disabilities produced health-care improvements that were more conducive to longer-term health than standard care given to this population. The intervention dominated standard care, being both cheaper and more effective. Health-check programmes might therefore be indicated for adults with intellectual disabilities.

FUNDING

Scottish Government Change Fund, NHS Greater Glasgow and Clyde Research and Development.

Mental health for people with intellectual disability: the impact of stress and social support

A large, nationally representative sample from a preexisting dataset, the National Core Indicators, was used to examine the impact of stress and social support on the mental health of adults with intellectual disability (ID). Stress was significantly correlated with both mental illness and severity of behavior problems, with each additional stressor increasing the odds of poor mental health by 20%. This relationship held, even after controlling for level of ID, gender, and place of residence. Lack of social support was associated with having a mental illness; individuals who lacked social support were twice as likely to have a mental illness. The importance of considering these factors in the prevention, diagnosis, and treatment of mental health in this population is discussed.

RETRACTED: Functional variables of challenging behavior in individuals with intellectual disabilities

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief, after review by an independent panel of experts, due to evidence of a compromised peer review process and the failure of one author to disclose significant conflicts of interest. An independent peer-review process is a cornerstone of scientific integrity that allows for research to be scrutinized before publication to ensure that conclusions are anchored in sound methodology and objective interpretation of the results. Equally important is that the readership of research is fully informed about any potential competing interests that may have influenced the research process. This article is being retracted because it did not include a declaration of a conflict of interest of one author in relation to diagnostic tools which the paper endorses. The same author was also the Editor in Chief of the journal at the time of publication and evidence indicates that the paper was accepted without any independent peer review by external reviewers. The article is therefore retracted in accordance with the ethical guidelines of Elsevier: https://www.elsevier.com/about/policies/publishing-ethics and the Committee on Publication Ethics (COPE) https://publicationethics.org/files/retraction-guidelines.pdf.

The association between behavioural and emotional problems and age in adults with Down syndrome without dementia: Examining a wide spectrum of behavioural and emotional problems

The literature on the association between behavioural and emotional problems and ageing in adults with Down syndrome (DS) without dementia is limited and has generally not reported on a wide range of behavioural and emotional problems. This research aimed to extend the field by examining the associations between age and a wide spectrum of behavioural and emotional problems in adults with DS without dementia. A preliminary analysis of the association between potential covariates and behavioural and emotional problems was also undertaken. Parents and caregivers completed a questionnaire on behavioural and emotional problems for 53 adults with DS aged between 16 and 56 years. Twenty-eight adults with DS and their caregivers were part of a longitudinal sample, which provided two time points of data approximately four years apart. Additionally, 25 participants with DS and their caregivers were from a cross sectional sample, which provided one time point of data. Random effects regression analyses were used to examine the patterns in item scores for behavioural and emotional problems associated with age. No significant associations between age and the range or severity of any behavioural and emotional items were found. This suggested a more positive pattern for ageing adults with DS than has been previously described. Given that behavioural and emotional problems were not associated with age, investigation into other factors that may be associated with the behavioural and emotional difficulties for adults with DS is discussed.

A systematic review on the effect of exercise interventions on challenging behavior for people with intellectual disabilities

BACKGROUND

Challenging behavior, such as aggressive or self-injurious behavior, is a major concern for the health and well-being of people with intellectual disabilities (ID) and for their relatives, friends, and caregivers. The most common contemporary treatments have drawbacks, such as the adverse side effects of antipsychotics. Exercise interventions could be a good alternative, but little is known about its beneficial effects on challenging behavior in people with ID yet.

METHOD

A systematic review of the literature was done and methodological quality of the selected studies has been judged on four points. With one-way Analysis of Variance (ANOVA), the effect of exercise interventions on challenging behavior was studied. The effect of low versus high intensity exercise interventions was studied with independent samples T-test using mean improvement scores.

RESULTS

Twenty studies studying the effects of exercise interventions on challenging behavior in people with ID have been found. A quantitative evaluation of the results showed a significant decrease in challenging behavior after participating in an exercise intervention (M=30.9%, 95% CI: 25.0, 36.8). Furthermore, no significant difference was found between high (M=32.2%) and low (M=22.9%) intensity exercise interventions.

CONCLUSIONS

The found decrease in challenging behavior shows that exercise seems to be recommendable as an effective treatment for people with challenging behavior and ID. However, most studies were of low methodological quality and more research is needed to optimize recommendations about the exact intensity, duration, frequency, and mode (group or individual) of exercise interventions for this group of people.

Antecedent events as predictive variables for behavioral function

Challenging behavior is one of the largest barriers to ensuring that people with intellectual disabilities (ID) are able to participate in the community. These difficulties have become one of the main causes of social exclusion. The research into and treatment of challenging behavior has usually involved the identification of its function and the manipulation of the events or environmental conditions that influence its occurrence (antecedent variables). The present research explores the relationship between antecedents and behavioral function and the extent to which antecedent variables may act as predictors of behavioral function. This relationship is explored using two standardized instruments: Questions About Behavioral Function and Contextual Assessment Inventory. Data from the validation of these instruments for the Spanish population involved 300 participants with ID and 328 challenging behaviors. The results suggest that social/cultural variables are most related to challenging behavior, whereas biological variables seem to only be related to physically maintained behavior.

The French version of the Reiss Screen for Maladaptive Behavior: factor structure, point prevalence and associated factors

The main aims of the present study were to examine the factor structure and the internal consistency of the factors in the French version of the Reiss Screen of Maladaptive Behavior in a French-speaking European sample. The prevalence of psychopathology and the influence of associated factors were also examined. The Reiss Screen was administered to 467 adults (age range: 18-73) with intellectual disability living in the French-speaking regions of Switzerland and Belgium. A confirmatory factor analysis was performed to replicate the original factor structure. Internal consistency was examined by using Cronbach's alpha. Analyses of variance were computed to study the influence of gender, age and Down syndrome etiology. The original factor structure of the Reiss Screen was replicated. The overall rate of psychopathology in the sample was 37%. No linear relationship between age and psychopathology was found. However, adults aged less than 26 years had lower scores than older adults on several psychopathological domains. Males had higher scores than females on the Autism and the Avoidant Disorder subscales. Participants with Down syndrome had lower scores on all domains, with the exception of the Autism subscale. The results of this study suggest that the French version of the Reiss Screen can be a useful tool to detect psychopathology in adults with intellectual disability.

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 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.

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.

Physical conditions and challenging behaviour in people with intellectual disability: a systematic review

BACKGROUND

Challenging behaviour is a major problem among people with intellectual disabilities. Physical factors may be an important cause. The aim of the present systematic review was to determine the physical conditions associated with challenging behaviour.

METHODS

A literature search was conducted in PubMed and the Cochrane systematic review database for empirical studies published between 1990 and 2008. The quality of all the studies that met the inclusion criteria was assessed using the SIGN-50 methodology checklists.

RESULTS

The search identified 45 studies, which looked at general medical conditions, motor impairment, epilepsy, sensory impairment, gastrointestinal disease, sleep disorders, dementia and others. There were four high-quality observational studies, seven well-conducted observational studies, 21 observational studies of low methodological quality and 13 non-analytical studies. There were significant and independent associations between challenging behaviours and urinary incontinence, pain related to cerebral palsy and chronic sleep problems, and between self-injurious behaviour and visual impairment. No association was found with hearing impairment, bowel incontinence, mobility impairment or epilepsy. Many other physical conditions were not addressed at all.

CONCLUSION

Medical conditions can play a role in challenging behaviour, and this should be evaluated in the clinical setting. So far, the level of evidence is generally low, and longitudinal studies are completely lacking. We recommend a systematic approach to research examining the role of physical conditions in challenging behaviour, the ultimate aim being to establish a basis for the development of clinical guidelines.

What is the evidence for environmental causes of challenging behaviors in persons with intellectual disabilities and autism spectrum disorders?

An extensive literature on the causes of challenging behaviors has been developed, primarily in the applied behavior analysis literature. One hundred and seventy-three empirical studies were reviewed where functional assessment serves as the primary method of identifying these causes. Most of the studies were able to identify a clear function or functions. Most commonly established causes were attention, the efforts to acquire tangibles, negative reinforcement in the form of escape from tasks or environments, and sensory stimulation, also described as an alone condition. Examples are provided regarding how these conditions are investigated across studies. Biological and cognitive causes have also been demonstrated. However, to date the empirical literature is limited with the bulk of studies being correlational. Considerably more research is needed, but some causes and methods to identify them are beginning to emerge.