Prevalence and types of aggressive behaviour among adults with intellectual disabilities

Systematic Aggression Registration in Forensic Psychiatric Care: A Qualitative Study on Preconditions for Successful Implementation

Available research emphasizes the importance of getting a systematic overview of inpatient aggression in forensic psychiatric care. However, the same research does not focus on how systematic aggression registration should be introduced in clinical practice. To facilitate the use of systematic aggression registration instruments, it is very relevant to gain insight into the perspective of staff members on the introduction of these instruments in daily clinical practice. Additionally, preconditions for achieving a successful implementation can be considered. Therefore, this study aims to gain insight into the perspective of the staff members on the implementation of a systematic aggression registration instrument-that is, the MOAS-in a forensic psychiatric unit. Interviews (n = 8) and a focus group with staff members were carried out. Three main themes: (1) creating the most appropriate context for introduction, (2) choice for the MOAS as relevant instrument, and (3) perpetuating the use of the MOAS in clinical practice are scrutinized. The mentioned preconditions can be used as guidelines when implementing systematic aggression registration in clinical practice. We hope that this paper can inspire other forensic psychiatric facilities to introduce systematic registration of aggressive incidents.

Profound Autism: An Imperative Diagnosis

Profound autism refers to a subset of individuals with autism spectrum disorder who have an intellectual disability with an intelligence quotient less than 50 and minimal-to-no language and require 24-hour supervision and assistance with activities of daily living. The general pediatrician will invariably work with autistic children across the spectrum and will likely encounter youth with profound autism. Awareness of profound autism as a real entity describing autistic children with concomitant intellectual disability and language impairment who require 24-hour care is the first step in developing a solid pediatric home for these youth.

Stimulus Avoidance Assessment: A Systematic Literature Review

Board certified behavior analysts are ethically required to first address destructive behavior using reinforcement-based and other less intrusive procedures before considering the use of restrictive or punishment-based procedures (ethics standard 2.15; Behavior Analyst Certification Board, 2020). However, the inclusion of punishment in reinforcement-based treatments may be warranted in some cases of severe forms of destructive behavior that poses risk of harm to the client or others. In these cases, behavior analysts are required to base the selection of treatment components on empirical assessment results (ethics standard 2.14; Behavior Analyst Certification Board, 2020). One such preintervention assessment is the stimulus avoidance assessment (SAA), which allows clinicians to identify a procedure that is likely to function as a punisher. Since the inception of this assessment approach, no studies have conducted a systematic literature review of published SAA cases. These data may be pertinent to examine the efficacy, generality, and best practices for the SAA. The current review sought to address this gap by synthesizing findings from peer-reviewed published literature including (1) the phenomenology and epidemiology of the population partaking in the SAA; (2) procedural variations of the SAA across studies (e.g., number of series, session length); (3) important quality indicators of the SAA (i.e., procedural integrity, social validity); and (4) how the SAA informed final treatment efficacy. We discuss findings in the context of the clinical use of the SAA and suggest several avenues for future research.

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.

Evaluations of heart rate during functional analyses of destructive behavior

Previous research has examined the predictive validity of heart rate on destructive behavior; however, such research has yet to improve clinical practice or enhance our understanding of the relation between physiology and destructive behavior. The purpose of this study was to examine the predictive validity of heart rate on varying topographies and functions of destructive behavior while controlling antecedent and consequent events through functional analysis. We first demonstrated the reliability of the Polar H10 heart rate monitor and assessed the feasibility of its use in simulated functional analysis sessions. However, across four consecutively enrolled patients, heart rate was not found to be a reliable predictor of destructive behavior, regardless of its topography or function. Instead, functional reinforcer presence and absence was sufficient to predict socially reinforced destructive behavior. This study may provide a framework for the future assessment of other biological measures in relation to destructive behavior occurrence and nonoccurrence.

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

BACKGROUND

Outwardly directed aggressive behaviour in people with intellectual disabilities is a significant issue that may lead to poor quality of life, social exclusion and inpatient psychiatric admissions. Cognitive and behavioural approaches have been developed to manage aggressive behaviour but the effectiveness of these interventions on reducing aggressive behaviour and other outcomes are unclear. This is the third update of this review and adds nine new studies, resulting in a total of 15 studies in this review.

OBJECTIVES

To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly directed aggressive behaviour compared to usual care, wait-list controls or no treatment in people with intellectual disability. We also evaluated enhanced interventions compared to non-enhanced interventions.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was March 2022. We revised the search terms to include positive behaviour support (PBS).

SELECTION CRITERIA

We included randomised and quasi-randomised trials of children and adults with intellectual disability of any duration, setting and any eligible comparator.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were change in 1. aggressive behaviour, 2. ability to control anger, and 3. adaptive functioning, and 4.

ADVERSE EFFECTS

Our secondary outcomes were change in 5. mental state, 6. medication, 7. care needs and 8. quality of life, and 9. frequency of service utilisation and 10. user satisfaction data. We used GRADE to assess certainty of evidence for each outcome. We expressed treatment effects as mean differences (MD) or odds ratios (OR), with 95% confidence intervals (CI). Where possible, we pooled data using a fixed-effect model.

MAIN RESULTS

This updated version comprises nine new studies giving 15 included studies and 921 participants. The update also adds new interventions including parent training (two studies), mindfulness-based positive behaviour support (MBPBS) (two studies), reciprocal imitation training (RIT; one study) and dialectical behavioural therapy (DBT; one study). It also adds two new studies on PBS. Most studies were based in the community (14 studies), and one was in an inpatient forensic service. Eleven studies involved adults only. The remaining studies involved children (one study), children and adolescents (one study), adolescents (one study), and adolescents and adults (one study). One study included boys with fragile X syndrome. Six studies were conducted in the UK, seven in the USA, one in Canada and one in Germany. Only five studies described sources of funding. Four studies compared anger management based on cognitive behaviour therapy to a wait-list or no treatment control group (n = 263); two studies compared PBS with treatment as usual (TAU) (n = 308); two studies compared carer training on mindfulness and PBS with PBS only (n = 128); two studies involving parent training on behavioural approaches compared to wait-list control or TAU (n = 99); one study of mindfulness to a wait-list control (n = 34); one study of adapted dialectal behavioural therapy compared to wait-list control (n = 21); one study of RIT compared to an active control (n = 20) and one study of modified relaxation compared to an active control group (n = 12). There was moderate-certainty evidence that anger management may improve severity of aggressive behaviour post-treatment (MD -3.50, 95% CI -6.21 to -0.79; P = 0.01; 1 study, 158 participants); very low-certainty evidence that it might improve self-reported ability to control anger (MD -8.38, 95% CI -14.05 to -2.71; P = 0.004, I2 = 2%; 3 studies, 212 participants), adaptive functioning (MD -21.73, 95% CI -36.44 to -7.02; P = 0.004; 1 study, 28 participants) and psychiatric symptoms (MD -0.48, 95% CI -0.79 to -0.17; P = 0.002; 1 study, 28 participants) post-treatment; and very low-certainty evidence that it does not improve quality of life post-treatment (MD -5.60, 95% CI -18.11 to 6.91; P = 0.38; 1 study, 129 participants) or reduce service utilisation and costs at 10 months (MD 102.99 British pounds, 95% CI -117.16 to 323.14; P = 0.36; 1 study, 133 participants). There was moderate-certainty evidence that PBS may reduce aggressive behaviour post-treatment (MD -7.78, 95% CI -15.23 to -0.32; P = 0.04, I2 = 0%; 2 studies, 275 participants) and low-certainty evidence that it probably does not reduce aggressive behaviour at 12 months (MD -5.20, 95% CI -13.27 to 2.87; P = 0.21; 1 study, 225 participants). There was low-certainty evidence that PBS does not improve mental state post-treatment (OR 1.44, 95% CI 0.83 to 2.49; P = 1.21; 1 study, 214 participants) and very low-certainty evidence that it might not reduce service utilisation at 12 months (MD -448.00 British pounds, 95% CI -1660.83 to 764.83; P = 0.47; 1 study, 225 participants). There was very low-certainty evidence that mindfulness may reduce incidents of physical aggression (MD -2.80, 95% CI -4.37 to -1.23; P < 0.001; 1 study; 34 participants) and low-certainty evidence that MBPBS may reduce incidents of aggression post-treatment (MD -10.27, 95% CI -14.86 to -5.67; P < 0.001, I2 = 87%; 2 studies, 128 participants). Reasons for downgrading the certainty of evidence were risk of bias (particularly selection and performance bias); imprecision (results from single, often small studies, wide CIs, and CIs crossing the null effect); and inconsistency (statistical heterogeneity).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that cognitive-behavioural approaches such as anger management and PBS may reduce outwardly directed aggressive behaviour in the short term but there is less certainty about the evidence in the medium and long term, particularly in relation to other outcomes such as quality of life. There is some evidence to suggest that combining more than one intervention may have cumulative benefits. Most studies were small and there is a need for larger, robust randomised controlled trials, particularly for interventions where the certainty of evidence is very low. More trials are needed that focus on children and whether psychological interventions lead to reductions in the use of psychotropic medications.

The Association between Physical Environment and Externalising Problems in Typically Developing and Neurodiverse Children and Young People: A Narrative Review

The physical environment is of critical importance to child development. Understanding how exposure to physical environmental domains such as greenspace, urbanicity, air pollution or noise affects aggressive behaviours in typical and neurodiverse children is of particular importance given the significant long-term impact of those problems. In this narrative review, we investigated the evidence for domains of the physical environment that may ameliorate or contribute to the display of aggressive behaviours. We have considered a broad range of study designs that include typically developing and neurodiverse children and young people aged 0-18 years. We used the GRADE system to appraise the evidence. Searches were performed in eight databases in July 2020 and updated in June 2022. Additional articles were further identified by hand-searching reference lists of included papers. The protocol for the review was preregistered with PROSPERO. Results: We retrieved 7174 studies of which 67 are included in this review. The studies reported on green space, environmental noise and music, air pollution, meteorological effects, spatial density, urban or rural setting, and interior home elements (e.g., damp/sensory aspects/colour). They all used well validated parent and child reported measures of aggressive behaviour. Most of the studies were rated as having low or unclear risk of bias. As expected, noise, air pollution, urbanicity, spatial density, colour and humidity appeared to increase the display of aggressive behaviours. There was a dearth of studies on the role of the physical environment in neurodiverse children. The studies were heterogeneous and measured a range of aggressive behaviours from symptoms to full syndromes. Greenspace exposure was the most common domain studied but certainty of evidence for the association between environmental exposures and aggression problems in the child or young person was low across all domains. We found a large knowledge gap in the literature concerning neurodiverse children, which suggests that future studies should focus on these children, who are also more likely to experience adverse early life experiences including living in more deprived environments as well as being highly vulnerable to the onset of mental ill health. Such research should also aim to dis-aggregate the underlying aetiological mechanisms for environmental influences on aggression, the results of which may point to pathways for public health interventions and policy development to address inequities that can be relevant to ill health in neurodiverse young people.

Basic and applied research on extinction bursts

Discontinuation of the contingency between a response and its reinforcer sometimes produces a temporary increase in the response before its rate decreases, a phenomenon called the extinction burst. Prior clinical and basic studies on the prevalence of the extinction burst provide highly disparate estimates. Existing theories on the extinction burst fail to account for the dynamic nature of this phenomenon, and the basic behavioral processes that control response bursting remain poorly understood. In this paper, we first review the basic and applied literature on the extinction burst. We then describe a recent refinement of the concatenated matching law called the temporally weighted matching law that appears to resolve the above-mentioned issues regarding the extinction burst. We present illustrative translational data based conceptually on the model. Finally, we discuss specific recommendations derived from the temporally weighted matching law regarding procedures clinicians could implement to potentially mitigate or prevent extinction bursts.

Acceptance and potential clinical added value of biocueing in forensic psychiatric patients with autism spectrum disorder and/or intellectual disability

Autism spectrum disorder (ASD) and intellectual disability (ID) are prevalent in forensic psychiatric samples. People with ASD and/or ID often experience difficulties in emotion processing which can lead to aggressive or self-harming behavior. The use of biocueing (using wearable technology to constantly monitor and provide feedback on bodily changes) shows promise for improving emotion processing and, thus, potentially reducing aggressive behavior in this population. Both qualitative and quantitative methods were used to examine the feasibility and acceptance of Sense-IT, a biocueing application, in a sample of forensic psychiatric patients with ASD and/or ID and their forensic psychiatric nurses. To our knowledge, the current study is the first to examine first-person experiences with biocueing in forensic psychiatric patients with ASD and/or ID. Results show that, in general, participants experienced the biocueing application as positive and are willing to use biocueing. This is an important finding since forensic patients are often unmotivated to engage with therapeutic techniques. An exploration of trends in aggression and self-harm prior to and during the use of biocueing showed no significant changes. Future research should focus on the way biocueing can be implemented in clinical practice.

Behaviours that challenge in adults with intellectual disability: overview of assessment and management

Up to a fifth of people with intellectual disabilities display challenging behaviour that has a significant impact on their health and quality of life. Psychotropic medication does not appear to confer any clinical benefits beyond risk reduction in acute situations. However, very few non-pharmacological treatments have clear evidence of clinical and cost-effectiveness and there is therefore often a dearth of advice as to which components or interventions would be helpful. To our knowledge no single model has been developed to provide a clear path from understanding the behaviour to the implementation of a therapeutic approach for such a complex clinical problem. In this article we describe a stepped-care model that needs to be further operationalised in the assessment and management of behaviours that challenge in adults with intellectual disabilities.

The behavioural phenotype of SATB2-associated syndrome: a within-group and cross-syndrome analysis

Background

SATB2-associated syndrome (SAS) is a multisystem neurodevelopmental disorder characterised by intellectual disability, speech delay, and craniofacial anomalies. Although the clinical presentation of SAS is well-delineated, behaviours associated with SAS are less well-defined. Given the varied social profile reported in SAS of a ‘jovial’ predisposition and autistic behaviours, there may be phenotypic overlap with both Angelman syndrome (AS) and non-syndromal autism. This study aimed to describe behaviours in SAS in relation to chronological age and level of ability and contrast aspects of the behavioural phenotype with AS and non-syndromal autism.

Methods

Informant report questionnaire measures of behaviour, emotion, and autism characteristics were completed for 81 individuals with SAS (aged 1–36 years; 43 male). Within-group associations were analysed, and categorical data were compared between pre-school (1–5 years), school-age (6–15 years), and adolescent and adult SAS sub-groups (16 years and over). Cross-syndrome subscale and item-level analyses were conducted for 63 individuals with SAS (aged 1–27 years; 31 male), who were matched according to age and level of ability to 63 individuals with AS (aged 2–25 years; 32 male) and 63 individuals with non-syndromal autism (aged 3–26 years; 53 male).

Results

In SAS, higher rates of overactivity were moderately associated with lower self-help ability, and higher general anxiety scores were reported for males compared with females. Cross-syndrome subscale analyses uncovered several significant differences (p < .01), with comparatively low rates of stereotyped behaviour, overactivity, insistence on sameness and positive affect, and comparatively greater interest and pleasure and compulsive behaviour in individuals with SAS. Item-level analyses revealed a distinct profile of repetitive and autistic behaviours.

Limitations

Developmental analysis was based on a cross-sectional rather than a longitudinal research design, the contribution of pain and sleep to behaviour was not explored, and molecular genetic testing to determine genotype–phenotype behavioural relationships was not possible.

Conclusions

This study highlights the importance of behavioural comparisons to well-delineated groups and the utility of fine-grained item-level analyses to elucidate aspects of behaviour that might be syndrome related or shared across neurodevelopmental disorders. Future research is needed to further describe the distinctive repetitive and autistic behavioural phenotype in SAS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11689-022-09426-0.

Prevalence and correlates of aggressive behavior in psychiatric inpatient populations

Aggressive behavior in patients with psychiatric disorders is attracting increasing research interest. One reason for this is that psychiatric patients are generally considered more likely to be aggressive, which raises a related question of whether diagnoses of psychiatric disorders predict the prevalence of aggressive behavior. Predicting aggression in psychiatric wards is crucial, because aggressive behavior not only endangers the safety of both patients and staff, but it also extends the hospitalization times. Predictions of aggressive behavior also need careful attention to ensure effective treatment planning. This literature review explores the relationship between aggressive behavior and psychiatric disorders and syndromes (dementia, psychoactive substance use, acute psychotic disorder, schizophrenia, bipolar affective disorder, major depressive disorder, obsessive-compulsive disorder, personality disorders and intellectual disability). The prevalence of aggressive behavior and its underlying risk factors, such as sex, age, comorbid psychiatric disorders, socioeconomic status, and history of aggressive behavior are discussed as these are the components that mostly contribute to the increased risk of aggressive behavior. Measurement tools commonly used to predict and detect aggressive behavior and to differentiate between different forms of aggressive behavior in both research and clinical practice are also reviewed. Successful aggression prevention programs can be developed based on the current findings of the correlates of aggressive behavior in psychiatric patients.

Pharmacogenomic Studies in Intellectual Disabilities and Autism Spectrum Disorder: A Systematic Review

BACKGROUND

Individuals with intellectual disability (ID) and autism spectrum disorder (ASD) often receive psychotropic medications such as antipsychotics and antidepressants to treat aberrant behaviors and mood symptoms, frequently resulting in polypharmacy and drug-related adverse effects. Pharmacogenomic (PGx) studies with ASD and/or ID (ASD/ID) have been scarce despite the promise of optimizing treatment outcomes. We reviewed the literature on PGx studies with antipsychotics and antidepressants (e.g., treatment response and adverse effects) in ASD/ID.

METHODS

We performed a systematic review using MEDLINE, Embase, and PsycINFO, including peer-reviewed original articles in English referring to PGx in the treatment of ASD/ID in any age groups (e.g., treatment response and adverse effects).

RESULTS

A total of 28 PGx studies using mostly candidate gene approaches were identified across age groups. Notably, only 3 studies included adults with ASD/ID while the other 25 studies focused specifically on children/adolescents with ASD/ID. Twelve studies primarily investigated treatment response, of which 5 and 6 studies included patients treated with antipsychotics and antidepressants, respectively. Most interesting results for response were reported for 2 sets of candidate gene studies, namely: (1) The DRD3 Ser9Gly (rs6280) polymorphism was examined in patients treated with risperidone in 3 studies, 2 of which reported an association with risperidone treatment response and (2) the SLC6A4 5-HTTLPR polymorphism and treatment response to antidepressants which was investigated in 4 studies, 3 of which reported significant associations. In regard to side effects, 9 of 15 studies focused on hyperprolactinemia in patients treated with risperidone. Among them, 7 and 5 studies examined the impact of CYP2D6 and DRD2 Taq1A polymorphisms, respectively, yielding mostly negative study findings.

CONCLUSIONS

There is limited data available on PGx in individuals with ASD/ID and in particular in adults. Given the potential for PGx testing in improving treatment outcomes, additional PGx studies for psychotropic treatment in ASD/ID across age groups are warranted.

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.

Shining a Light on the Challenging Behaviors of Adolescents with Comorbid Diagnoses: Use of Pictorial Concurrent Operant Preference Assessment

Currently, there are no published studies that have used the concurrent operant preference assessment procedure to identify functions of challenging behaviors displayed by individuals with comorbid diagnoses. Four participants (aged 11–16 years) with comorbid diagnoses who displayed multiple challenging behaviors were referred to this study. We modified the standard concurrent operant preference assessment and used the new modified version, the pictorial concurrent operant preference assessment, to identify the functions of the challenging behaviors. Utilizing the triangulation mixed-methods design, we compared the indirect functional behavioral assessment (FBA) and the direct FBA with the pictorial concurrent operant preference assessment. The results obtained successfully demonstrated the concordance among these assessments in identifying the behavioral function for each participant. The results further showed that (1) the preferences served the same functional effects on both the challenging behaviors and the adaptive behaviors and (2) the pictorial concurrent operant preference assessment can be used independently to identify potential behavioral function and to specify the reinforcing potency of each behavioral function. The significance of the study results, limitations of this study, and directions for future research and clinical practice are discussed.

A Study Into the Severity of Forensic and Civil Inpatient Aggression

Aggressive incidents occur frequently in health care facilities, such as psychiatric care and forensic psychiatric hospitals. Previous research suggests that civil psychiatric inpatients may display more aggression than forensic inpatients. However, there is a lack of research comparing these groups on the incident severity, even though both frequency and severity of aggression influence the impact on staff members. The purpose of this study is to compare the frequency and severity of inpatient aggression caused by forensic and civil psychiatric inpatients in the same Dutch forensic psychiatric hospital. Data on aggressive incidents occurring between January 1, 2014, and December 31, 2017, were gathered from hospital files and analyzed using the Modified Overt Aggression Scale, including sexual aggression (MOAS+). Multilevel random intercept models were used to analyze differences between forensic and civil psychiatric patients in severity of aggressive incidents. In all, 3,603 aggressive incidents were recorded, caused by 344 different patients. Civil psychiatric patients caused more aggressive incidents than forensic patients and female patients caused more inpatient aggression compared with male patients. Female forensic patients were found to cause the most severe incidents, followed by female civil psychiatric patients. Male forensic patients caused the least severe incidents. The findings have important clinical implications, such as corroborating the need for an intensive treatment program for aggressive and disruptive civil psychiatric patients, as well as emphasizing the importance of gender-responsive treatment.

Resurgence Following Traditional and Interdependent Differential Reinforcement of Alternative Behavior

Clinicians frequently prescribe functional communication training (FCT) as a treatment for severe destructive behavior. Recent research has shown that FCT treatments are susceptible to treatment relapse in the form of resurgence of destructive behavior when individuals contact periods in which reinforcers are unavailable. Results of preliminary studies suggest that teaching multiple response alternatives can mitigate the resurgence of target behavior. The current evaluation serves as a preliminary study in which we used a laboratory arrangement to evaluate the effects of a novel approach to training multiple alternative responses on the resurgence of target behavior. Findings showed that multiple-response training did not decrease resurgence of target responding consistently; however, it increased the total amount of target and alternative responding observed during the resurgence phase and decreased the overall probability of the target response.

The Use of Demand Assessments: A Brief Review and Practical Guide

It is important for practitioners to first conduct an indirect demand assessment to identify appropriate stimuli to include during the direct demand assessment. Information obtained from an indirect demand assessment is useful not only for identifying which demands to evaluate during the direct assessment but also for selecting stimuli associated with each demand. Conducting an indirect demand assessment with caregivers provides practitioners the opportunity to identify whether specific demand stimuli are associated with more challenging behavior (e.g., writing with a pen vs. a pencil) and whether demand presentation may be an establishing operation for challenging behavior (e.g., presenting one math problem at a time vs. presenting an entire math worksheet). The purpose of this article is to review the current literature on demand assessment procedures and to provide practitioners with a practical guide for conducting demand assessments in clinical settings. We provide a summary of our findings along with a brief description of the procedures used for implementing the indirect and direct demand assessments. Further, we created a decision-making guide to help practitioners select which type of demand assessment to conduct with their clients.

The effectiveness of functional training on impulsiveness of females with intellectual disability

The aim of this study was to determine the effectiveness of Functional Training (FT) on impulsiveness of female students with Intellectual Disability (ID). The research method was pretestposttest- with a control group. The statistical population consisted of all female students with ID in elementary school of Shiraz studying under the auspices of the Special Education Organization in 2018-2019. The participants included 30 female students with ID selected through convenience sampling and randomly assigned to the experimental (n=14) and control (n=14) groups. The experimental group received the functional training for 15 sessions, while the control group did not receive any intervention. The Barratt Impulsiveness Scale Version 11 (BIS-11) was used for measuring the impulsiveness. The Impulsiveness pre-test was performed for both experimental and control groups. The experimental group received the FT for 15 sessions, while the control group did not receive any intervention. At the end of the intervention, post-test was performed for both groups. Mann-Whitney U test was used to analyze the data. The results showed that the mean scores of impulsivities and its subscales (motor impulsiveness, attentional impulsiveness and nonplanning impulsiveness) in the experimental group were significantly reduced. The results showed that FT had a significant effect on impulsiveness of female students with ID (p<0.001). Therefore, it is recommended to design and implement a FT program to improve impulsiveness in people with ID.

The use of pasung for people with mental illness: a systematic review and narrative synthesis

Background

Pasung is the term used in Indonesia and a number of other countries for seclusion and restraint of people with mental illness in the community, usually at home by their family. While pasung has been banned because it is contrary to human rights, its practice continues to exist within the community, particularly where community mental health services are limited, and in the absence of adequate social support, and pervasive negatives beliefs about mental illness. It is essential to understand the reasons for the ongoing use of pasung and to examine potential solutions.

Methods

A systematic review and narrative synthesis of peer-reviewed international literature was conducted to identify the socio-cultural contexts for pasung use, and interventions to address it. The analysis draws on the socio-ecological framework, which focused on relationships between the individual and their environment.

Result

Fifty published articles were included in the review; all studies were conducted in Asia and Africa, with 32 undertaken in Indonesia. Most studies were qualitative (n = 21). Others included one case–control study, one cross-sectional study, and seven surveys; only four studies examined the application of an intervention, and each used a pre and post methodology. Of these, two studies tested psychoeducational interventions which aimed to overcome family burden due to pasung, and each suggested a community mental health approach. The remaining two studies evaluated the intervention of ‘unlocking’; one study used a community-based culturally sensitive approach, and the other used a community-based rehabilitation program. Reasons for pasung given by family appear to be as a last resort and in the absence of other supports to help them care for the person with severe mental illness.

Conclusion

The findings highlight that a mixture of individual, interpersonal, community and policy interventions are needed to reduce the use of pasung. While consumer and carer involvement as part of a socio-ecological approach is understood to be effective in reducing pasung, an understanding of how to elaborate this in the management of pasung remains elusive.

Review Registration CRD42020157543: CRD

Behavioural, psychiatric and psychosocial factors associated with aggressive behaviour in adults with intellectual disabilities: A systematic review and narrative analysis

Background

Aggressive behaviour is prevalent in people with intellectual disabilities. To understand the aetiology, it is important to recognize factors associated with the behaviour.

Method

A systematic review was conducted and included studies published between January 2002 and April 2017 on the association of behavioural, psychiatric and psychosocial factors with aggressive behaviour in adults with intellectual disabilities.

Results

Thirty‐eight studies were included that presented associations with 11 behavioural, psychiatric and psychosocial factors. Conflicting evidence was found on the association of these factors with aggressive behaviour.

Conclusions

The aetiology of aggressive behaviour is specific for a certain person in a certain context and may be multifactorial. Additional research is required to identify contributing factors, to understand causal relationships and to increase knowledge on possible interaction effects of different factors.

Addressing Aggression in the Residential Setting for Juveniles with Mild Intellectual Disability through Training in Non-Violent Resistance

Background

Levels of aggression are high in residential settings for juveniles with Mild Intellectual Disability (MID). As a result, treatment is less effective, aggression causes injury, traumatic experiences and longer inhabitation for juveniles. Additionally, inpatient aggression has been linked to burnout and stress among group workers, which has negative consequences such as less job satisfaction or poorer work performance

Objective

Therefore, it is crucial to diminish aggressive incidents in these settings and to find a way for staff how to respond to aggression properly.

Methods

As there is no intervention method which tackles all of the referred problems efficiently, a new method Non-violent Resistance for MID was introduced into three residential settings for juveniles with MID, in a quasi-experimental stepped wedge design. Reports of aggressive incidents were assessed seven times before, during and after the training in NVR-MID on group level. Multilevel analyses were carried out in order to assess the development of the aggressive incidents over time.

Results

Aggressive incidents decreased significantly in time during and after training in NVR-MID, this decrease is seen in all three institutions. Thus, regardless of resident’s age, gender or IQ, NVR-MID seemed successful in diminishing aggressive incidents. Furthermore, a significant interaction effect was found between institution and time, indicating that regardless if incidents of aggression were relatively high at baseline, decrease in incidents was similar to institutions where incidents were relatively low on baseline.

Conclusions

Implementing NVR-MID into residential settings for juveniles with MID and comorbid behavioral problems might help to decrease aggressive incidents.

Triggers of Aggressive Behaviors in Intellectually Disabled Adults and Their Association with Autism, Medical Conditions, Psychiatric Disorders, Age and Sex: A Large-Scale Study

Aggressive behaviors in those with intellectual disability (ID) and autism (ASD) have been linked to a variety of factors including ID level, age, sex, psychiatric disorders, and medical conditions but these factors have not been studied, in large samples, in terms of how they affect the stimuli that trigger aggression. In this survey of 2243 adults, four triggers of aggression associated with frustration, discomfort, change in the physical/social environment, and defensive reactions were analyzed for their relation to ID level, ASD, age, sex, number of psychiatric diagnoses, sleeping problems, seizures, visual impairment, ear infections and gastrointestinal problems. All four triggers were associated with increasing number of psychiatric disorders, with frustration, discomfort, and change intolerance commonly linked to sleeping problems and ASD. Implications for assessment and intervention are discussed.

Toward Actionable Practice Parameters for "Dual Diagnosis": Principles of Assessment and Management for Co-Occurring Psychiatric and Intellectual/Developmental Disability

PURPOSE OF REVIEW

Although treatment algorithms and parameters for best practice are readily available for all major syndromes of psychiatric impairment, the occurrence of psychiatric syndromes in individuals with intellectual and developmental disability (IDD) invokes serious contextual challenges for interpretation of symptoms, diagnosis, and optimization of treatment, both for clinicians and for the service sectors in which care and support of individuals with IDD are delivered. Recognizing that there exist very few definitive resources for best practice under the circumstance of this form of "dual diagnosis," the Missouri Department of Mental Health convened an expert panel to conduct a focused review and synthesis of the relevant scientific literature from which to develop guidance in the form of decision support to clinicians. This article summarizes the findings for three of the most common and impairing clusters of psychiatric symptoms that co-occur with IDD-aggression, depression, and addictions.

RECENT FINDINGS

Individuals with IDD are at high risk for the development of psychiatric symptoms (PS), which often manifest uniquely in IDD and for which evidence for effective intervention is steadily accruing. Interventions that are commonly implemented in the IDD service sector (e.g., functional communication training and positive behavioral support planning) are capable of mitigating severe behavioral impairment, yet rarely invoked when dual diagnosis patients are seen in the psychiatric service sector. Conversely, state-of-the-art interventions for traumatic stress, pharmacotherapy, and psychotherapy have proven capable of improving behavioral impairments in IDD but are typically restricted to the psychiatric service sector, where there exist significant barriers to access for patients with IDD, including limitations imposed by diagnostic eligibility and practitioner experience. Bridging these gaps in knowledge and clinical capacity across the respective IDD and PS service sectors should be of very high priority in strategizing the care and support of IDD patients with serious co-occurring psychiatric conditions.

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.

Predicting aggression in adults with intellectual disability: A pilot study of the predictive efficacy of the Current Risk of Violence and the Short Dynamic Risk Scale

BACKGROUND

Structured assessments have been shown to assist professionals to evaluate the risk of aggression in secure services for general offender populations and more recently among adults with intellectual disabilities. There is a need to develop intellectual disability sensitive measures for predicting risk of aggression in community samples, especially tools with a focus on dynamic variables.

METHODS

The study prospectively followed 28 participants for up to 2 months to test whether the Current Risk of Violence (CuRV) and Short Dynamic Risk Scale (SDRS) were able to predict verbal and physical aggression in a community sample of adults with intellectual disability.

RESULTS

CuRV and SDRS ratings significantly predicted verbal and physical aggression over a 2-month period.

CONCLUSIONS

The current study supports the use of the CuRV with adults with intellectual disability living in community settings. The CuRV and SDRS are worthy of future development and evaluation in independent investigations.

Changes in heart rate and skin conductance in the 30 min preceding aggressive behavior

Aggressive behavior of inpatients threatens the safety and well-being of both mental health staff members and fellow patients. It was investigated whether heart rate and electrodermal activity can be used to signal imminent aggression. A naturalistic study was conducted in which 100 inpatients wore sensor wristbands during 5 days to monitor their heart rate and electrodermal activity while staff members recorded patients' aggressive incidents on the ward. Of the 100 patients, 36 displayed at least one aggressive incident. Longitudinal multilevel models indicated that heart rate, skin conductance level, and the number of nonspecific skin conductance responses per minute rose significantly in the 20 min preceding aggressive incidents. Although psychopathy was modestly correlated with displaying aggression, it was not a significant predictor of heart rate and skin conductance preceding aggression. The current findings may provide opportunities for the development of individual prediction models to aid acute risk assessment and to predict aggressive incidents in an earlier stage. The current results on the physiological indicators of aggression are promising for reducing aggression and improving both staff as well as patient safety in psychiatric mental health institutions.

Assessments and Interventions to Address Challenging Behavior in Individuals with Intellectual Disability and Autism Spectrum Disorder in Japan: A Consolidated Review

Intellectual disability and autism spectrum disorder are neurodevelopmental disorders that emerge during the developmental period. A significant barrier that impedes the social adaptation of individuals with these disorders is the exhibition of problem behaviors, such as self-injurious, stereotyped, and aggressive/destructive behaviors. In recent years, these problem behaviors have been collectively referred to as "challenging behavior," in accordance with the contention that they result from an interaction between the individual and his or her social environment. Evidence-based psychosocial interventions that adopt the functional approach to treating challenging behavior are increasing. However, in order to effectively implement such interventions in educational settings and welfare facilities, it is essential to develop staff training programs and usable psychometric assessments. Accordingly, a brief overview of research studies on challenging behavior that have been conducted in Japan, as well as the various support systems that are available to individuals who exhibit challenging behavior, are presented in this article. The discussion makes it apparent that, in order to improve treatment systems in Japan that are aimed at addressing challenging behavior, it is necessary to establish not only better staff training programs, but also reliable and valid assessments measuring challenging behavior that can be readily used by teachers and parents. On the basis of this discussion, it is proposed that technological advancements must be applied to psychosocial approaches in the study of problem behaviors, in order to develop assessment system using software applications and automatic measurement system of target behaviors using sensing technology.

Burnout symptoms in forensic mental health nurses: Results from a longitudinal study

Burnout in nursing staff is a major cause for turnover and absenteeism. Identifying risk and protective factors may be helpful in decreasing burnout symptoms. Moreover, research indicates that ambulatory assessments of the autonomic nervous system might be helpful in detecting long-term stress and burnout symptoms. One hundred and ten forensic nursing staff members completed questionnaires measuring experiences with aggressive behaviour, emotional intelligence, personality, and job stress during four waves of data collection across a 2-year period. Multilevel analyses were used to test the predicted associations and moderation effects with (the development of) burnout symptoms. Burnout was predicted by a combination of emotional intelligence, job stress, aggression, personality factors, and skin conductance, but no moderation effects over time were found. Over a period of 2 years, the model approximately predicts a change in one burnout category on the Maslach Burnout Inventory. The amount of burnout symptoms in nurses might be used as an indicator to predict turnover and absenteeism considering the increase in symptoms over time. Nursing staff who experience severe aggression and who have relatively low levels of emotional intelligence and altruism and high levels of neuroticism and job stress should be monitored and supported to decrease the risk of burnout. Staff members can be trained to increase their emotional intelligence and relieve stress to decrease their burnout symptoms and turnover and absenteeism on the long term. Ambulatory assessment might be helpful as a nonintrusive way to detect increasing levels of burnout.

Guardianship and Predatory Crimes among Incapacitated Persons in Kentucky

Purpose: Guardianship is a legal process intended to aid incapacitated persons unable to fully care for themselves. Guardianship in the state of Kentucky ranges from total observation (24-hour care) to informal care (such as a group home) and also includes persons who are no longer being supervised but should be. One intent of guardianship includes preventing incapacitated persons from engaging in criminal acts. However, no research has been conducted on incapacitated persons currently in guardianship and the prevalence for committing predatory crimes such as murder, fire starting, or assault.Method: In this study, the authors examine guardianship supervision levels and predatory crimes in the state of Kentucky. Logistic regression analysis was used to determine the variables that significantly contributed to the model.Results: They find that unsupervised incapacitated persons are at higher odds of committing predatory crimes, leading to important policy recommendations for Kentucky guardians.

Risk factors and topographies for self-injurious behaviour in a sample of adults with intellectual developmental disorders

BACKGROUND

Self-injurious behaviour (SIB) is a prevalent form of challenging behaviour in people with intellectual developmental disorders (IDD). Existing research has yielded conflicting findings concerning the major risk factors involved, and in addition, SIB shows multiple topographies and presentations. Although presence of autism spectrum disorders (ASD) and severity of intellectual disability (ID) are known risk factors for SIB, there are no studies comparing SIB topographies by severity degrees of ID and ASD. The purpose of the present paper has been to identify risk factors and topographies for SIB in a representative, stratified and randomised sample of adults with IDD.

METHOD

This study was conducted on the basis of data collected by the POMONA-ESP project, in a sample of 833 adults with IDD. Data concerning demographic and health information, ASD symptoms, psychopathology and ID, have been analysed to determine the presence of risk factors for SIB among participants and to explore the occurrence and topographies of SIB across different severity levels of ID and ASD symptoms.

RESULTS

Self-injurious behaviour prevalence in the sample was 16.2%. Younger age, oral pain, greater severity of ID, presence of dual diagnosis, psychiatric medication intake and higher scores on Childhood Autism Rating Scale were risk factors for SIB among participants, whereas number of areas with functioning limitations, place of residence, diagnosis of epilepsy and sex were not. SIB was more frequent in participants with ASD symptoms regardless of its severity level, and they displayed a higher number of different topographies of SIB. People with profound ID without co-morbid ASD symptoms showed similar results concerning SIB prevalence and topographies.

CONCLUSIONS

Knowledge on risk factors and topographies of SIB might play a vital role in the development of prevention strategies and management of SIB in people with IDD. The mere presence of ASD symptoms, regardless of its severity level, can be a crucial factor to be taken into account in assessing SIB. Accordingly, the presence of SIB in people with ID, especially when presented with a varied number of topographies, might provide guidance on ASD differential diagnosis.

Mechanisms Underlying Aggressive Behavior Induced by Antiepileptic Drugs: Focus on Topiramate, Levetiracetam, and Perampanel

Antiepileptic drugs (AEDs) are effective against seizures, but their use is often limited by adverse effects, among them psychiatric and behavioral ones including aggressive behavior (AB). Knowledge of the incidence, risk factors, and the underlying mechanisms of AB induced by AEDs may help to facilitate management and reduce the risk of such side effects. The exact incidence of AB as an adverse effect of AEDs is difficult to estimate, but frequencies up to 16% have been reported. Primarily, levetiracetam (LEV), perampanel (PER), and topiramate (TPM), which have diverse mechanisms of action, have been associated with AB. Currently, there is no evidence for a specific pharmacological mechanism solely explaining the increased incidence of AB with LEV, PER, and TPM. Serotonin (5-HT) and GABA, and particularly glutamate (via the AMPA receptor), seem to play key roles. Other mechanisms involve hormones, epigenetics, and “alternative psychosis” and related phenomena. Increased individual susceptibility due to an underlying neurological and/or a mental health disorder may further explain why people with epilepsy are at an increased risk of AB when using AEDs. Remarkably, AB may occur with a delay of weeks or months after start of treatment. Information to patients, relatives, and caregivers, as well as sufficient clinical follow-up, is crucial, and there is a need for further research to understand the complex relationship between AED mechanisms of action and the induction/worsening of AB.

Burnout symptoms in forensic psychiatric nurses and their associations with personality, emotional intelligence and client aggression: A cross-sectional study

WHAT IS KNOWN ON THE SUBJECT?: Client aggression in forensic psychiatry is associated with burnout symptoms in nursing staff. It is unclear what mechanisms contribute to this relationship. The type and severity of aggression might be of importance in the association between client aggression and burnout symptoms, but also the personality characteristics and emotional intelligence of nursing staff. It is unknown whether wearable devices that measure arousal can be used to detect chronic stress and burnout symptoms. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: Especially, physical aggression as experienced by nursing staff is associated with staff's burnout symptoms (e.g., emotional exhaustion and depersonalization). Further research on the aggression questionnaire is necessary. The stress management skill of nursing staff is an important factor to consider in the association between burnout symptoms and client aggression. The wearable device was not useful for detecting burnout symptoms. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Nursing staff who experience (physical) aggression should be carefully monitored and should receive social support from their management to aid their well-being. Contrary to intuition, nurses who reported a higher number of stress management skills might have to be monitored more closely if necessary.

ABSTRACT

Introduction Aggressive behaviour of forensic clients is associated with burnout symptoms in nursing staff. The role of staff characteristics as moderators is unclear. Aim We explored the association between type and severity of aggressive behaviour as experienced by nursing staff and staff's burnout symptoms. In addition, the moderating roles of personality characteristics and emotional intelligence (EI) were studied. Moreover, the usefulness of ambulatory skin conductance assessments in detecting arousal related to burnout symptoms was studied. Method A total of 114 forensic nursing staff members filled out questionnaires and wore an ambulatory device. Results Experiencing physical aggression was positively associated with staff's burnout symptoms. Stress management skills, a subscale of EI, but not personality, moderated this relationship. Skin conductance was not associated with burnout symptoms. Remarkably, the association between aggression and burnout symptoms was highest for staff reporting a higher number of stress management skills. Discussion Longitudinal research is necessary to establish causality between client aggression and staff burnout symptoms. In addition, further research is necessary on the validity of the aggression measure used in the current study. Implication for practice Nursing staff who experience physical aggression frequently should receive social support for this, and staff who report high stress management skills should be monitored more carefully after having been confronted with aggression.

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

A growing number of adults with intellectual disabilities (ID) are reaching old age, however, little is known about epidemiology of problem behaviours (PBs) in this population. The aim was to identify the prevalence and associated factors of PBs among older adults with ID in Ireland. Data was generated from Wave 2 of the Intellectual Disability Supplement to the Irish Longitudinal Study on Ageing (IDS-TILDA), a nationally representative sample of adults with ID aged ≥40. Data on PBs was available for 683 (98.3%) of individuals. Over half (53%; n = 362) reported displaying any PB (verbal aggression, physical aggression, destruction, self-injury, or "other" PB). Multivariate analyses indicated PBs were independently associated with moderate or severe/profound ID, living in a community group home or residential centre, experiencing a greater number of life events in the last year, taking psychotropic medication, and reporting a doctor's diagnosis of a psychiatric problem. A considerable number of older adults with ID in Ireland display PBs, which may hinder their opportunities to engage in community based activities and form meaningful social connections. High rates of psychotropic medication and doctor's diagnosis of psychiatric conditions and their associations with PBs were highlighted. Future research should examine mechanisms underlying these linkages.

Restraint, Restrictive Intervention, and Seclusion of People With Intellectual and Developmental Disabilities

Restraint, restrictive interventions, and seclusion are hotly contested practices with inconclusive evidence of their effectiveness. Because the use of restraint and seclusion on people with intellectual and developmental disabilities (IDD) is controversial and its effectiveness doubtable, this study was conducted to explore if and how they were permitted in Medicaid HCBS 1915(c) waivers, the largest providers of long-term services and supports (LTSS) for people with IDD. To do so, 111 fiscal year 2015 IDD waivers from across the nation were examined to determine if and how states permitted restraint, restrictive interventions, and seclusion. Findings revealed an overwhelming majority of waivers permitted the use of restraint (78.4%) and restrictive interventions (75.7%). A smaller proportion (24.3%) allowed the use of seclusion.

How effective are risk assessments/measures for predicting future aggressive behaviour in adults with intellectual disabilities (ID): A systematic review and meta-analysis

BACKGROUND

Risk assessments assist professionals in the identification and management of risk of aggression. The present study aimed to systematically review evidence on the efficacy of assessments for managing the risk of physical aggression in adults with intellectual disabilities (ID).

METHODS

A literature search was conducted using the databases PsycINFO, EMBASE, MEDLINE, Web of Science, and Google Scholar. Electronic and hand searches identified 14 studies that met the inclusion criteria. Standardised mean difference effect sizes Area Under Curve (AUC) were calculated for studies. Random effects subgroup analysis was used to compare different types of risk measures (Actuarial, Structured Professional Judgment and dynamic), and prospective vs. catch-up longitudinal study designs.

RESULTS

Overall, evidence of predictive validity was found for risk measures with ID populations: (AUC)=0.724, 95% CI [0.681, 0.768]. There was no variation in the performance of different types of risk measures, or different study design.

CONCLUSIONS

Risk assessment measures predict the likelihood of aggression in ID population and are comparable to those in mainstream populations. Further meta-analysis is necessary when risk measures are more established in this population.

'It's a matter of your personality more than anything else'

The impact on full-time carers of children with intellectual disabilities who exhibit challenging behaviour has been well researched (e.g. Lach et al., 2009; Shah et al., 2010; Wodehouse and McGill, 2009), however, there is to date no published research into the impact of behaviour that challenges on seasonal carers. Five participants who had been employed in summer playschemes for children and young people (up to the age of 18) were interviewed about their experiences of behaviour that challenges. The transcripts were analysed using interpretative phenomenological analysis, which revealed six superordinate themes: the belief in and sanctuary of temporary work, emotional impact, personality and gender, strength through knowledge, communication difficulties and the belief in integration. Seasonal workers discussed suppressing their emotions in order to stay in control of a challenging situation, using coping styles developed through experience or based on personal skills; it is suggested that formalized training, particularly regarding non-verbal communication, would support playscheme workers in the management of and adaption to challenging behaviour.

Using Adapted Dialectical Behavioral Therapy to Treat Challenging Behaviors, Emotional Dysregulation, and Generalized Anxiety Disorder in an Individual With Mild Intellectual Disability

Individuals with intellectual disability (ID) are at increased risk of presenting challenging behaviors and comorbid mental illness. Preliminary findings show decreased challenging behaviors and overall increased functioning in individuals with ID and mental health problems who receive adapted dialectical behavior therapy (DBT). However, more research and documentation on how to adapt DBT in this population is warranted given that DBT is a promising intervention in individuals with ID. This article presents the case of an individual with mild ID who received adapted DBT for the treatment of challenging behaviors, emotional dysregulation, and generalized anxiety disorder. Treatment lasted 1 year and was conducted in a residential facility for individuals with ID. Improvement of symptoms and decrease in frequency of challenging behaviors were observed throughout the case. This case study demonstrates the potential utility of adapted DBT for individuals with ID and underscores the importance of teaching skills to clients with ID to help them become agents of their own change.

Changes in Heart Rate Variability Recorded in Natural Situation with T-Shirt Integrated Sensors and Level of Observed Behavioral Excitation: A Pilot Study of Patients with Intellectual Disabilities and Psychiatric Disorders

BACKGROUND

The present study investigates the possibilities of using heart rate variability (HRV) parameters as physiological markers that precede increase in observed behavioral excitation of intellectually disabled individuals. The ability to recognize or predict such patterns, especially in patients showing unpredictable reactions and language deficiencies, might be a major step forward in clinical research.

METHOD

Thirteen volunteers with intellectual disabilities, who had suffered of at least one event of overt aggression in the preceding 3 months, participated to the study. The protocol consists in the acquisition of continuous electrocardiogram (ECG) throughout approximately two times of 8 h in natural situation, using a T-shirt integrated with sensors. Simultaneously, an observer evaluates the patient's level of overt excitation from calm (level 1) to extremely tense (level 5) and send online via Bluetooth these triggers into the ECG signals. The HRV indexes were then estimated offline on the basis of the inter-beat intervals recorded by the ECG, independently for the 30 min preceding each behavioral tension marking point, averaged, and compared through non-parametric Wilcoxon matched-pairs test. Of these, the RMSSD and LF/HF calculations were used to observe the fluctuations of inhibitory activity and cardiovagal balance through different tension states.

RESULTS

Seven individuals have sufficient reliable data for analysis. They have reached at least a level 3 of behavioral excitation (moderately tense) or more (very to extremely tense, level 4 and 5) and have been retained for further analysis. In sum, a total of 197 periods of tension were kept, made up of 46 periods of slight excitation (level 2), 18 of moderate excitation (level 3), 10 of high excitation (level 4), and 5 of extreme agitation (level 5). Variations in the HRV as a function of degree of excitation are observed for RMSSD index only (inhibitory parasympathetic activity). The changes from calm to increasing levels of excitation are characterized by a significant downfall in RMSSD index when patients were evaluated to be in a very high level of tension (level 4).

CONCLUSION

The presence of precursors to agitation, reflected in the falling-off of parasympathetic activity, offers potentially interesting prospects for therapeutic development.

Identification and Analysis of Factors Contributing to the Reduction in Seclusion and Restraint for a Population with Intellectual Disability

BACKGROUND

A cohort of 11 patients with an intellectual disability and a psychiatric diagnosis present severe behavioural disorders in psychiatric hospital of Quebec in 2009. Control-measure use for this clientele has now been reduced. How do management personnel, families and care teams explain the changes? What clinical interventions did management and care providers implement that contributed to the reduction?

METHOD

A retrospective case study was conducted. Five focus groups were held with people involved in their care, and the patient files were examined.

RESULTS

The factors contributing to this change were the cohesion of the care providers, the involvement of the families and the efforts to determine the function of the behaviour.

IMPLICATIONS

This study may inspire other care teams to try new approaches in dealing with patients with severe behavioural disorders. Also, the model of factors and interventions supporting a reduction in seclusion and restraint measures may inspire future studies.

Correlates of direct care staffs' attitudes towards aggression of persons with intellectual disabilities

BACKGROUND AND AIM

To explain direct care staff's attitudes (responsive or rejecting) towards aggression of clients with intellectual disability (ID), data were collected about client characteristics as well as individual and team characteristics of 475 direct care staff members, working in 71 teams.

METHOD AND RESULTS

Multilevel analyses revealed that a positive team climate was positively associated with both a rejecting and responsive attitude towards aggression. Senior staff members and females showed a less responsive attitude towards aggression, whereas a relatively high percentage of females in a team and a positive attitude towards external professionals were associated with a more responsive attitude towards aggression. Unexpectedly, staff who experienced less verbal and/or physical aggressive incidents of their clients with ID showed a more rejecting attitude towards aggression. Finally, characteristics of the clients with ID accounted for the largest part of the variance in the attitude towards aggression of direct care staff, in particular psychiatric diagnoses.

CONCLUSIONS AND IMPLICATIONS

Further research is necessary in order to understand how team processes affect the attitude towards aggression of direct care staff. Further it is recommended to provide direct care staff with knowledge about mental disorders in clients with ID.

The Structured Assessment of Violence Risk in Adults with Intellectual Disability: A Systematic Review

BACKGROUND

While structured professional judgement approaches to assessing and managing the risk of violence have been extensively examined in mental health/forensic settings, the application of the findings to people with an intellectual disability is less extensively researched and reviewed. This review aimed to assess whether risk assessment tools have adequate predictive validity for violence in adults with an intellectual disability.

METHODS

Standard systematic review methodology was used to identify and synthesize appropriate studies.

RESULTS

A total of 14 studies were identified as meeting the inclusion criteria. These studies assessed the predictive validity of 18 different risk assessment tools, mainly in forensic settings. All studies concluded that the tools assessed were successful in predicting violence. Studies were generally of a high quality.

CONCLUSIONS

There is good quality evidence that risk assessment tools are valid for people with intellectual disability who offend but further research is required to validate tools for use with people with intellectual disability who offend.

Factors associated with reported challenging behavior in young people with epilepsy and neurodevelopmental problems: Data from a specialist epilepsy center

Reported incidents of challenging behavior over a 6‐month period (December 2011–May 2012) were systematically recorded in young people (8–23 years) with epilepsy (n = 125), and a comparison group of young people without epilepsy (n = 64) at a specialist epilepsy center in the United Kingdom. Factors associated with such incidents were analyzed via regression analysis. The presence of epilepsy was not a significant predictor of recorded challenging behavior. Factors associated with increases in recorded challenging behavior on multivariable analysis in the epilepsy sample were the use of medication for behavioral/psychiatric conditions (p < 0.05) and attending the center on a residential basis (p < 0.001). In the total sample, use of medication for behavioral/psychiatric conditions (p < 0.05), younger age (p < 0.01), IQ < 50 (p < 0.01), and residential status (p < 0.001) were associated with increases in recorded challenging behavior. The presence of depression was associated with reduced challenging behavior in the total sample (p < 0.05).The association between the use of psychopharmacology and increased challenging behavior in those with epilepsy and nonepilepsy could indicate a difficult to treat behavioral/psychiatric burden, lack of treatment efficacy, and/or an increased side effect profile and needs further examination.

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.

An Exploration of Costs of Community-Based Specialist Health Service Provision for the Management of Aggressive Behaviour in Adults with Intellectual Disabilities

BACKGROUND

In the UK, people with intellectual disabilities who exhibit aggressive behaviour often receive community-based specialist health services from a community learning disability team (CLDT). Our aim was to estimate costs associated with this provision and to identify predictors of higher costs.

METHOD

Costs were estimated for 60 adults with intellectual disabilities and aggressive behaviour who attended specialist psychiatric outpatient clinics in the West Midlands region of the UK, including contact time with members of the CLDT and use of psychotropic medication over a 12-month period.

RESULTS

Mean total cost of 12-month service provision was £418 (95% confidence interval [CI] £299-557). Mean total cost of 12-month psychotropic medication was £369 (95% CI £256-492). Amongst individual members of the CLDT, mean costs were highest for psychiatrists (£181) and relatively lower for community nurses (£70) and clinical psychologists (£30), and lowest for physiotherapists (£13). Male sex, presence of expressive verbal communication and presence of epilepsy were independently associated with 12-month medication and service use costs, accounting for 23% of the variance in cost.

CONCLUSIONS

It seems that in terms of costs, there is an overreliance on medication and psychiatrists and a relatively lesser reliance on other CLDT members such as community nurses and clinical psychologists for the management of aggressive behaviour in adults with intellectual disabilities within community settings. Health commissioners may wish to explore this relative cost discrepancy further and try to redress the balance where appropriate.

Injuries Reported and Recorded for Adults with Intellectual Disabilities Who Live with Paid Support in Scotland: a Comparison with Scottish Adults in the General Population

BACKGROUND

Providers of supported living services to adults with intellectual disabilities (IDs) in the United Kingdom have procedures in place to monitor injuries; this provides opportunity to learn about the injuries being reported and recorded. The aim was to determine the incidence, causes and types of injuries experienced by 593 adults with intellectual disabilities who live with paid support in a 12-month period.

METHOD

Injury data, collected via a standard electronic injury monitoring system, were compared with data collected for a matched sample of the general population in the same year.

RESULTS

The adults with intellectual disabilities experienced a higher rate of injury. Falls were the commonest cause of injury for both samples, but significantly more so for the adults with intellectual disabilities.

CONCLUSIONS

The higher rate of injuries, particularly minor injuries, being reported suggests a culture of injury reporting and recording within these supported living services. Electronic injury monitoring is recommended for organizations providing supported living services for adults with intellectual disabilities.

Adverse events and the relation with quality of life in adults with intellectual disability and challenging behaviour using psychotropic drugs

BACKGROUND

Psychotropic drugs are prescribed to approximately 30-40% of adults with intellectual disability (ID) and challenging behaviour, despite the limited evidence of effectiveness and the potential of adverse events.

AIMS

To assess the prevalence of adverse events in association with psychotropic drug use in adults with ID and challenging behaviour and to examine the relation of these adverse events with the person's quality of life.

METHOD

The presence of adverse events was measured with a questionnaire that had to be filled in by the physicians of the participants. Movement disorders were measured separately with a standardised protocol. The strength of the association between adverse events and Intellectual Disability Quality of Life-16 (IDQOL-16), and daily functioning was investigated using linear regression analyses, taking into account the severity of disease (CGI-S) as potential confounder.

RESULTS

Virtually all of 103 adults with ID and challenging behaviour had at least one adverse event (84.4%) and almost half had ≥3 adverse events (45.6%) across different subclasses. Using psychotropic drugs increased the prevalence of adverse events significantly. Respectively 13% of the patients without psychotropic drugs and 61% of the patients with ≥2 psychotropic drugs had ≥3 adverse events. Having adverse events had a significantly negative influence on the quality of life.

CONCLUSIONS

A large majority of all patients had at least one adverse event associated with psychotropic drug use. More attention is needed for these adverse events and their negative influence on the quality of life of these patients, taking into account the lack of evidence of effectiveness of psychotropic drugs for challenging behaviour.

Crime and Legal Issues among Intellectually Disabled Individuals

Intellectual Disability (ID) can be caused by a variety of factors, which may lead to a variety of signs and symptoms. Individuals with ID are living in societies where during the past decade there is a steady increase in the amount of research focused on civil law, criminal law and mental health. In this chapter, there will be a theoretical presentation of the research on ID regarding criminal law and the different forms of aggressive behavior such as sexual violence, homicide, theft, arson and alcohol-drug abuse. There will be information on research regarding civil law and the most common problems for individuals with ID, such as financial capacity and capacity for medical consent. Finally, there will be a section for the most important issues regarding the trial and conviction for individuals with ID and a presentation of a recent research on attitudes toward ID and legal issues. The above will be examined through the prism of current neuropsychological data, while cross-cultural restrictions will be discussed.