Profiles and correlates of aggressive behaviour among adults with intellectual disabilities

Profiling Autism and Attention Deficit Hyperactivity Disorder Traits in Children with SYNGAP1-Related Intellectual Disability

SYNGAP1-related ID is a genetic condition characterised by global developmental delay and epilepsy. Individuals with SYNGAP1-related ID also commonly show differences in attention and social communication/interaction and frequently receive additional diagnoses of Autism Spectrum Disorder (ASD) or Attention Deficit Hyperactivity Disorder (ADHD). We thus set out to quantify ASD and ADHD symptoms in children with this syndrome. To assess ASD and ADHD, parents and caregivers of a child with SYNGAP1-related ID (N = 34) or a typically developing control (N = 21) completed the Social Responsiveness Scale-2, the Social Communication Questionnaire with a subset of these also completing the Conners-3. We found that those with SYNGAP1-related ID demonstrated higher levels of autistic traits on both the SRS and SCQ than typically developing controls. On the SRS, those with SYNGAP1-related ID scored highest for restricted repetitive behaviours, and were least impaired in social awareness. On the Conners-3, those with SYNGAP1-related ID also showed a high prevalence of ADHD traits, with scores demonstrating difficulties with peer relations but relatively low occurrence of symptoms for DSM-5 conduct disorder and DSM-5 oppositional defiant disorder. Hierarchical clustering analysis highlighted distinct SYNGAP1-related ID subgroups for both ASD and ADHD traits. These findings provide further characterisation of the SYNGAP1-related ID behavioural phenotype, guiding diagnosis, assessment and potential interventions.

The association between the Patient Protection and Affordable Care Act and healthcare affordability among US adults with intellectual disability

BACKGROUND

Historically, US adults with intellectual disability (ID) experience worse healthcare access than the general population. However, the implementation of the Patient Protection and Affordable Care Act (ACA) may have reduced disparities in healthcare access.

METHODS

Using a pre-ACA 2011-2013 sample and a post-ACA implementation 2014-2016 sample from the National Health Interview Survey data, we examined the association between the ACA's introduction and healthcare access among adults with ID (N = 623). Negative binomial regression models were used to test the association between the ACA and the total number of foregone healthcare services. Binary logistic regression was used to explore whether the ACA's implementation was associated with the increased likelihood of possessing health insurance as well as the decreased likelihood of any and particular measures of foregone healthcare services due to cost.

RESULTS

The study provides evidence that the ACA's implementation was associated with the decreased likelihood of the total number and any foregone care services owing to cost. Findings also revealed that the ACA's implementation was associated with expansion of health insurance coverage and decreasing instances of foregone care services for medical care, dental care, specialist visit and mental care among adults with ID. However, persons with ID were still at a higher risk of foregone prescription medicines, follow-up medical care and eyeglasses due to cost in the post-ACA years.

CONCLUSIONS

The study provides evidence that healthcare access among Americans with ID improved after the ACA's implementation. However, challenges in access to follow-up care, eyeglasses and prescription medicines persist and require policy solutions, which extend beyond the ACA's provisions.

Complex interventions for aggressive challenging behaviour in adults with intellectual disability: A rapid realist review informed by multiple populations

OBJECTIVES

Approximately 10% of people with intellectual disability display aggressive challenging behaviour, usually due to unmet needs. There are a variety of interventions available, yet a scarcity of understanding about what mechanisms contribute to successful interventions. We explored how complex interventions for aggressive challenging behaviour work in practice and what works for whom by developing programme theories through contexts-mechanism-outcome configurations.

METHODS

This review followed modified rapid realist review methodology and RAMESES-II standards. Eligible papers reported on a range of population groups (intellectual disability, mental health, dementia, young people and adults) and settings (community and inpatient) to broaden the scope and available data for review.

RESULTS

Five databases and grey literature were searched and a total of 59 studies were included. We developed three overarching domains comprising of 11 contexts-mechanism-outcome configurations; 1. Working with the person displaying aggressive challenging behaviour, 2. Relationships and team focused approaches and 3. Sustaining and embedding facilitating factors at team and systems levels. Mechanisms underlying the successful application of interventions included improving understanding, addressing unmet need, developing positive skills, enhancing carer compassion, and boosting staff self-efficacy and motivation.

CONCLUSION

The review emphasises how interventions for aggressive challenging behaviour should be personalised and tailored to suit individual needs. Effective communication and trusting relationships between service users, carers, professionals, and within staff teams is essential to facilitate effective intervention delivery. Carer inclusion and service level buy-in supports the attainment of desired outcomes. Implications for policy, clinical practice and future directions are discussed.

PROSPERO REGISTRATION NUMBER

CRD42020203055.

Reactive and Proactive Aggression among Children and Adolescents: A Latent Profile Analysis and Latent Transition Analysis

The present study aimed to explore children’s and adolescents’ profiles of reactive and proactive aggression and the stability of those profiles over a six-month period using latent profile analysis (LPA) and latent transition analysis (LTA). Data were collected at two measurement points from a sample of N = 1468 children and adolescents aged from 9 to 18 years. Results of LPA revealed three distinct profiles, labeled as “Severe Reactively and Proactively Aggressive (S-RA-PA)”, “Highly Reactively and Proactively Aggressive” (H-RA-PA), and “Moderately Low Reactively and Proactively Aggressive” (M-RA-PA). All profiles appeared to be relatively stable over six months, supporting their within-sample consistency. The most stable and largest profile was the “M-RA-PA” profile, while the least stable and smallest profile was the “S-RA-PA” profile. However, there was also some within-person variability in children’s and adolescents’ profile membership because almost 40–50% of the participants of the “S-RA-PA” and “H-RA-PA” profiles transitioned to another profile across six months. In contrast, more than 90% of the participants of the “M-RA-PA” profile remained in their profile. These results provide a dynamic picture of children’s and adolescents’ development of reactive and proactive aggression and bear several implications from a short longitudinal person-oriented perspective.

Assessment of Challenging Behavior Exhibited by People with Intellectual and Developmental Disabilities: A Systematic Review

The assessment of challenging behavior exhibited by people with intellectual and developmental disabilities is essential for the planning of prevention and intervention programs. This review aimed to identify and analyze the standardized instruments that exclusively focus on the assessment of challenging behavior. We identified and organized 141 articles into four categories: original instrument studies, validation studies, relational studies, and intervention studies. The results identified 24 instruments that generally show high-quality psychometric properties and other utilities beyond the observation of the presence of challenging behavior and diagnostic categorization. Age, level of adaptive behavior, disability, presence of autism spectrum disorder, and medication are some of the variables that were found to be possibly related to the occurrence of challenging behavior. Additionally, the results suggest that interventions focused on supporting positive behavior or providing training on behavior to professionals and caregivers significantly reduced the occurrence of these behaviors. Instruments that help us to understand and measure the challenging behavior exhibited by people with intellectual and developmental disabilities are essential for the design of effective evaluation and intervention protocols.

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.

Melatonin-dependent changes in neurosteroids are associated with increased aggression in a seasonally breeding rodent

Aggression is a complex social behaviour that allows individuals to compete for access to limited resources (eg, mates, food and territories). Excessive or inappropriate aggression, however, has become problematic in modern societies, and current treatments are largely ineffective. Although previous work in mammals suggests that aggressive behaviour varies seasonally, seasonality is largely overlooked when developing clinical treatments for inappropriate aggression. Here, we investigated how the hormone melatonin regulates seasonal changes in neurosteroid levels and aggressive behaviour in Siberian hamsters, a rodent model of seasonal aggression. Specifically, we housed males in long-day (LD) or short-day (SD) photoperiods, administered timed s.c. melatonin injections (which mimic a SD-like signal) or control injections, and measured aggression using a resident-intruder paradigm after 9 weeks of treatment. Moreover, we quantified five steroid hormones in circulation and in brain regions associated with aggressive behaviour (lateral septum, anterior hypothalamus, medial amygdala and periaqueductal gray) using liquid chromatography-tandem mass spectrometry. SD hamsters and LD hamsters administered timed melatonin injections (LD-M) displayed increased aggression and exhibited region-specific decreases in neural dehydroepiandrosterone, testosterone and oestradiol, but showed no changes in progesterone or cortisol. Male hamsters also showed distinct associations between neurosteroids and aggressive behaviour, in which neural progesterone and dehydroepiandrosterone were positively correlated with aggression in all treatment groups, whereas neural testosterone, oestradiol and cortisol were negatively correlated with aggression only in LD-M and SD hamsters. Collectively, these results provide insight into a novel neuroendocrine mechanism of mammalian aggression, in which melatonin reduces neurosteroid levels and elevates aggressive behaviour.

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.

The Prevalence and Correlates of Partner Violence Used and Experienced by Adults With Intellectual Disabilities: A Systematic Review and Call to Action

It has been suggested that individuals with intellectual disabilities (IDs) are at increased risk of violence perpetration and victimization. A systematic review was undertaken to identify and critically evaluate the existing empirical research concerning the use and experience of partner violence by adults with IDs. In total, six poor-quality articles were identified: five of which adopted qualitative methods and one of which adopted a mixed-methods approach, comprising a total of 93 participants (48 women, 45 men: 1 perpetrator, 92 victims). The qualitative data were extracted from the studies and synthesized. A partner violence victimization rate of 60% was identified in one nonrepresentative sample. Two superordinate themes emerged from the qualitative data: nature of partner violence experience and help seeking. Children were the cross-cutting theme within the two superordinate themes. Participants reported experiencing a range of physical, emotional, and sexual violence leading to serious injury and psychological consequences. Participants reported experiences of positive and negative help-seeking reactions from professionals and specific requirements of services for victims with IDs. Children were identified as involved in the experience of abuse, the impact of abuse, and decisions to seek help. The findings indicate that training of clinical staff to detect partner violence is needed. In addition, adults with IDs need education concerning healthy relationships. Research is needed to better understand the difference between "challenging behavior" that is behavior displayed by an individual which challenges services, family members, and carers. Such behavior is more common in individuals with a severe ID for whom it would not be appropriate to be dealt with through the criminal justice system, and partner violence, in order to develop appropriate interventions for victims and perpetrators with ID.

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.

Identifying Needs-Based Groupings Among People Accessing Intellectual Disability Services

There is increasing emphasis on needs-led service provision for people with intellectual disability (ID). This study outlines the statistical cluster analysis of clinical data from 1,692 individuals accessing secondary care ID services in the United Kingdom (U.K.) Using objective needs assessment data from a newly developed ID assessment tool, six clusters were identified. These had clinical face validity and were validated using six concurrently (but independently) rated tools. In keeping with previous studies, the clusters varied in terms of overall level of need as well as specific clinical features (autism spectrum disorder, mental health problems, challenging behaviors and physical health conditions). More work is now needed to further develop these clusters and explore their utility for planning, commissioning and optimizing needs-led services.

Estimating the risk of crime and victimisation in people with intellectual disability: a data-linkage study

PURPOSE

People with intellectual disability (PWID) appear more likely to be victims and perpetrators of crime. However, extant evidence pertaining to these risks is limited by methodological weaknesses and the absence of consistent operational definitions. This research aimed to estimate the prevalence of criminal histories and victimisation using a large, well-defined sample of PWID.

METHODS

A case-linkage study was conducted comprising 2220 PWID registered with disability services in Victoria, Australia, whose personal details were linked with a state-wide police database. Criminal charges and reports of victimisation were compared to a non-disabled community comparison sample (n = 2085).

RESULTS

PWID were at increased risk of having a history of criminal charges, particularly for violent and sexual offences. Although the non-disabled comparison group had a greater risk of criminal victimisation overall, PWID had a greatly increased risk of sexual and violent crime victimisation.

CONCLUSIONS

PWID are at increased risk of victimisation and perpetration of violent and sexual crimes. Risk of sex offending and victimisation is particularly elevated, and signalling the need for specialised interventions to prevent offending and to ensure victims is assisted with access to justice, support, and treatment.

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.

Predictors of criminal justice system trajectories of homeless adults living with mental illness

OBJECTIVES

This study examines whether baseline profiles of criminal justice involvement are independently associated with 24-month trajectories of arrests in a sample of homeless adults living with mental illness.

METHODS

Interviews with justice-involved participants from the At Home/Chez soi project, a multisite trial of Housing First in Canada, yielded information related to arrests, as well as demographic, clinical, and contextual predictors of criminal justice system involvement. All potential predictors were entered into logistic and negative binomial regression models to assess their effect on re-arrest.

RESULTS

Of the 584 individuals involved with the criminal justice system at baseline, and for whom follow-up data was obtained, 347 (59%) were re-arrested within two years. Of those, 283 (82%) had an episodic pattern of re-arrest and 64 (18%) had a continuous trajectory of re-arrest. Results indicate that participants involved with the legal system for minor (mostly theft and public order) offenses at baseline were most likely to be repeatedly arrested. Gender, Aboriginal status, and recent victimization were also independently associated with re-arrest.

CONCLUSIONS

These findings have implications for the delivery of police and clinical services alike, as well as for policies that aim to divert vulnerable individuals who commit minor crimes from a long-term trajectory of justice involvement.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Psychometric characteristics of the adult scale of hostility and aggression: reactive/proactive (A-SHARP) and relation to psychiatric features of adults with developmental disabilities

Recently, we described the development of the Adult Scale of Hostility and Aggression: Reactive/Proactive (A-SHARP) (Matlock & Aman, 2011). The A-SHARP was derived by factor analysis of ratings of 512 adults with intellectual and developmental disabilities (IDD), and its resulting five subscales were designated as (1) Verbal Aggression, (2) Physical Aggression, (3) Hostile Affect, (4) Covert Aggression, and (5) Bullying. The items on each subscale are rated first for severity (the Problem scale) and second for "origin" (i.e., to reflect extent to which behaviors are planned or reactive; "Provocation scale"). This study evaluated psychometric characteristics of the A-SHARP in the developmental sample of 512 adults. Mean item-whole subscale correlations ranged from .67 (Physical Aggression) to .78 (Verbal Aggression) on the Problem scale. Interrater reliability (n=39) ranged from .59 to .78 on the Problem subscales and from .54 to .78 on the Provocation subscales. For the entire sample, the correspondence between the Problem and Provocation subscales was low (-0.04 to 0.28), indicating independence between the scales. The A-SHARP Physical subscale was strongly correlated with Behavior Problems Inventory (BPI) Aggression frequency ratings (n=512, r=0.79), and strongly with BPI severity ratings (r=.86). We examined congruent validity between A-SHARP subscale scores on the one hand and four DSM-IV categories and Down syndrome on the other. A number of significant associations were observed between the A-SHARP subscales and diagnostic group, supporting the A-SHARP's congruent validity. Likewise, we examined the correspondence between use of psychoactive medicines and A-SHARP scores and found a number of associations between medication use and higher subscale scores. Overall, these results support the reliability and validity of the A-SHARP, and, as intended, the problem and provocation subscales appear to assess different constructs. However, much more work is needed to determine fully how well each of the subscales performs psychometrically.

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

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

Demographics, clinical characteristics, and treatment of aggressive patients admitted to the acute behavioral unit of a community general hospital: a prospective observational study

OBJECTIVE

Aggressive patients are not uncommon in acute inpatient behavioral health units of general hospitals. Prior research identifies various predictors associated with aggressive inpatient behavior. This prospective observational study examines the demographic and clinical characteristics of aggressive inpatients and the routine medications these patients were receiving at discharge.

METHOD

Thirty-six adults diagnosed with a DSM-IV mental disorder who met 2 of 6 established inclusion criteria for high violence risk and a Clinical Global Impressions-Severity of Illness (CGI-S) scale score ≥ 4 were observed for a maximum of 28 days on the 23-bed case mix acute behavioral health unit of St Luke's University Hospital, Bethlehem, Pennsylvania, from January 2012 to May 2013. Primary outcome measures were the Modified Overt Aggression Scale (MOAS) and CGI-S; secondary measures were symptom outcome measures and demographic and clinical characteristics data. Analysis was conducted using repeated measures methodology.

RESULTS

Younger males with a history of previous violence, psychiatric admissions, and symptoms of severe agitation were more at risk for aggressive behavior. Positive psychotic symptoms, a diagnosis of bipolar disorder, substance use, and comorbid personality disorders also increased risk. Significant improvements from baseline to last visit were observed for the CGI-S and MOAS (P < .001 for both), with a significant correlation between the MOAS and CGI-S at last visit (P < .001). Only the symptom of agitation was significantly correlated to MOAS scores at both baseline and last visit (P < .001).

CONCLUSION

Patients significantly improved over time in both severity of illness and level of aggression.

Aggressive behaviour and its prevalence within five typologies

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

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

RELEVANCE TO CLINICAL PRACTICE

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

Treating Individuals With Intellectual Disabilities and Challenging Behaviors With Adapted Dialectical Behavior Therapy

Approximately one third of adults with intellectual and developmental disabilities have emotion dysregulation and challenging behaviors (CBs). Although research has not yet confirmed that existing treatments adequately reduce CBs in this population, dialectical behavior therapy (DBT) holds promise, as it has been shown to effectively reduce CBs in other emotionally dysregulated populations. This longitudinal single-group pilot study examined whether individuals with impaired intellectual functioning would show reductions in CBs while receiving standard DBT individual therapy used in conjunction with the Skills System (DBT-SS), a DBT emotion regulation skills curriculum adapted for individuals with cognitive impairment. Forty adults with developmental disabilities (most of whom also had intellectual disabilities) and CBs, including histories of aggression, self-injury, sexual offending, or other CBs, participated in this study. Changes in their behaviors were monitored over 4 years while in DBT-SS. Large reductions in CBs were observed during the 4 years. These findings suggest that modified DBT holds promise for effectively treating individuals with intellectual and developmental disabilities.

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.

Suicidality among adults with intellectual disability

BACKGROUND

The objective of the current study is to arrive at a better understanding of individuals with intellectual disability (ID) who threaten or attempt suicide.

METHODS

From a sample of 751 adults with ID who experienced a crisis, demographic and clinical profiles of 39 adults who threatened to commit suicide were compared to 28 adults who attempted suicide. These individuals were then compared to 337 adults who behaved aggressively toward others.

RESULTS

Individuals who attempted suicide appeared similar to those who voiced suicide with the exception that suicide attempters were younger and more likely to visit the emergency department. Females, higher functioning individuals, and persons with a history of self-harm had higher odds of attempting or threatening suicide

LIMITATIONS

Research findings based on informant reported data, so diagnoses and delivery of services in hospital cannot be validated.

CONCLUSIONS

Suicidality does occur in adults with ID, and can result in emergency department visits and hospitalizations. Recognition of variables associated with suicidality among those with ID by clinicians may allow for enhanced assessment, treatment services and ultimately more positive mental health outcomes for this group.

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.

Nursing practices recorded in reports of episodes of seclusion

The purpose of this study is to describe the nursing practices recorded in reports of patient episodes of seclusion, with or without restraints, in a specialized psychiatric facility in Quebec. The reports for all adult patients secluded (n = 4863) in a psychiatric unit between April 1, 2007 and March 31, 2009, were examined. Descriptive analyses were performed. The main reasons for seclusion were agitation, disorganization, and aggressive behaviour. The alternative methods that were attempted included stimulus reduction, extra medication, and working with the patient to find a solution. Few families were notified about their relation's seclusion. More hours of seclusion were reported in the evening and at night. Our results are comparable to those obtained by other investigators. Some of the variables have not been the subject of much research: for example, health conditions during seclusion with or without restraint and partnerships with family members. Our findings also suggest that, in their analyses, studies should differentiate between cognitive-impairment and adult-psychiatry units as well as long-term seclusion and short-term seclusion. The information reported by the nurse makes no distinction between short-stay and long-stay adult psychiatric units. Only one psychiatric facility was investigated in this study, precluding generalization.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Performance in temporal discounting tasks by people with intellectual disabilities reveals difficulties in decision-making and impulse control

The subjective value of rewards declines as a function of the delay to receive them (temporal discounting). Three temporal discounting tasks that assessed preferences between small amounts of money (10 pence) over short delays (60 s), moderate amounts of money (10 pound) over moderate delays (2 weeks), and large amounts of money (1000 pound) over long delays (12 months) were presented to people with intellectual disabilities (Full-Scale IQ < 70) and to a comparison group (ns = 20 for each group). Measures of IQ, financial knowledge, memory, and executive functioning were also obtained. Only a third of the service users were able to perform the temporal discounting tasks consistently, and they tended to respond impulsively. The proportion of participants responding consistently increased following training. Both the initial performance and the effect of training were related to executive functioning but not IQ.

Psychotropic medication use for challenging behaviors in persons with intellectual disabilities: an overview

Challenging behaviors in persons with intellectual disabilities are primary target for treatment in mental health clinics and institutions. Furthermore, an increasing number of people are receiving psychotropic medications for the management of their challenging behaviors. Many people are often treated with high doses of multiple psychotropic medications for extended periods of time with little or no data collected to determine treatment efficacy. Similarly, data demonstrating treatment effectiveness is at best questionable at this time. It is for these reasons that controversy exists regarding the use of psychotropic medication for challenging behaviors. The purpose of this paper was to summarize past and current studies of drug related interventions for challenging behaviors for persons with intellectual disabilities. Based on the results of this review, the effectiveness of psychotropic medications in managing challenging behaviors is best described as minimal and a need exists for controlled studies of higher scientific quality in this area. Considering alternative psychologically based interventions and careful functional assessments appear to be advisable.

Diagnosis and treatment of aggression in individuals with developmental disabilities

Aggressive behavior is a common referral problem for individuals with developmental disabilities (DD), placing them at risk for institutionalization, social isolation, physical restraint, over-use of medication to treat behavior problems, exclusion from services, and becoming a victim of abuse. Aggression strains relationships between individuals being supported and their caregivers, whether professionals or family members. The treatment of aggression is persons with DD, with or without comorbid mental illness, remains a controversial area and changes in practice have been slow to come. The evidence related to pharmacotherapy and psychological treatment is, in general, either lacking or poor. This does not suggest that these treatments are necessarily ineffective but that there is not enough good quality evidence to support their usefulness. This review considers the prevalence and correlates of aggression, as well as possible causative factors. The relationship between mental illness, intellectual disability and aggression is explored. The psychopharmacological and psychological treatment literature is reviewed with implications for clinical care and future research.

Forensic issues in intellectual disability

PURPOSE OF REVIEW

The present paper reviews some of the most significant findings in the field of forensic issues related to intellectual disability over the last 2 years.

RECENT FINDINGS

Recent publications have explored the prevalence and assessment of intellectual disabilities in the criminal justice system, as well as individual characteristics of intellectual disabled offenders. Service by the criminal justice system and treatment of intellectual disabled offenders have also been explored. New insights into violence and sexual offences have been achieved, however identification and evidence-based treatment of intellectual disabled offenders are not widely explored issues.

SUMMARY

Progress in treatment studies, studies of the function of the criminal justice system and risk assessments have resulted in improvements in these aspects during recent years. The wide range of services involved in successful initiatives has been addressed, but some crucial aspects still receive too little attention. Differences between countries and cultures have not been emphasized, and the progress that has been achieved seems to be confined to countries with a clear policy and organized services for offenders with intellectual disabilities.

Aggressive challenging behaviour and intellectual disability

PURPOSE OF REVIEW

The aim of this article is to review reports of aggressive challenging behaviour in individuals with intellectual disability from September 2006 to March 2008.

RECENT FINDINGS

Studies continued to demonstrate the prevalence and significance of aggressive challenging behaviour in persons with intellectual disability. Over half of the population engages in some form of aggression, but only a small number is responsible for frequent or severe acts. A publication that identified aggression profiles offered a promising new approach. Aggressive behaviour in adults often has multiple functions. The most frequently studied interventions were either behavioural or somatic. Parents learned skills to effectively intervene with their aggressive preschool child. Reviews of medication efficacy studies concluded that there was insufficient evidence to recommend a single medication. Psychiatrists agreed that medication should not be the first treatment option. In one study, a class of medication was found to reduce aggression, but not aggression with self-injury, or self-injury alone.

SUMMARY

Research on aggressive challenging behaviour requires assessment instruments that address the topography and severity of aggression. Identifying aggression types may clarify mixed results of previous research and improve treatment effectiveness. Greater access to effective, nonmedication treatments is needed.