Assessment and Treatment of Challenging Behaviour for Individuals with Intellectual Disability: A Research Review

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

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

Measurement tools for behaviours that challenge and behavioural function in people with intellectual disability: A systematic review and meta-analysis of internal consistency, inter-rater reliability, and test-retest reliability

Behaviours that challenge (BtC) are common in people with intellectual disability (ID) and associated with negative long-term outcomes. Reliable characterisation of BtC and behavioural function is integral to person-centred interventions. This systematic review and meta-analytic study quantitatively synthesised the evidence-base for the internal consistency, inter-rater reliability, and test-retest reliability of measures of BtC and behavioural function in people with ID (PROSPERO: CRD42021239042). Web of Science, Embase, PsycINFO and MEDLINE were searched from inception to March 2024. Retrieved records (n = 3691) were screened independently to identify studies assessing eligible measurement properties in people with ID. Data extracted from 83 studies, across 29 measures, were synthesised in a series of random-effects meta-analyses. Subgroup analyses assessed the influence of methodological quality and study-level characteristics on pooled estimates. COSMIN criteria were used to evaluate the measurement properties of each measure. Pooled estimates ranged across measures: internal consistency (0.41-0.97), inter-rater reliability (0.29-0.93) and test-retest reliability (0.52-0.98). The quantity and quality of evidence varied substantially across measures; evidence was frequently unavailable or limited to a single study. Based on current evidence, candidate measures with the most evidence for internal consistency and reliability are discussed; however, continued assessment of measurement properties in ID populations is a key priority.

A systematic review of psychosocial interventions for people with intellectual disabilities and dementia

OBJECTIVES

As the life expectancy of individuals with intellectual disabilities (ID) continues to increase, there is an increased risk of developing dementia. While psychosocial interventions are gaining prominence, evidence is limited for people with both dementia and ID. This review discusses the effectiveness of direct psychosocial interventions and adaptations to facilitate delivery within this population.

METHODS

The review followed the PRISMA guidelines. Five electronic databases, grey literature, and reference lists of included articles were searched for relevant studies. 10 eligible studies were appraised and analysed by narrative synthesis.

RESULTS

Ten distinct interventions were identified and categorised based on their purpose and delivery. All interventions were beneficial in improving a range of outcomes, though some studies were of low quality and most had small samples. Common adaptations included simplification of tasks and material, higher staff-to-client ratio, and alternative communication methods.

CONCLUSION

There is emerging evidence for several psychosocial interventions for people with ID and dementia, though further research is required on effectiveness and generalisability. The adaptations discussed may guide implementation into routine care and contribute to current policies and guidelines on improving ID and dementia care.

Short report on navigating access to care for Medicaid-enrolled autistic youth and young adults: Examining accrual of intellectual disability diagnoses in adolescence

LAY ABSTRACT

What is known? In most states, Medicaid waivers provide individuals with an intellectual disability diagnosis generous healthcare coverage throughout adulthood. By comparison, fewer Medicaid programs are available for autistic individuals, and they are more likely to experience disruptions, or gaps, in Medicaid coverage and subsequently not re-enroll.What this paper adds? One in five autistic individuals with Medicaid coverage between ages 8 and 25 accrued a new intellectual disability diagnosis. The probability of a new intellectual disability diagnosis was higher among those who had previous disruptions in Medicaid coverage.Implications for research and policy. Expanding Medicaid to cover autistic people of all ages could decrease the need for intellectual disability diagnosis accrual. Input from autistic individuals and their families regarding their health insurance access and healthcare experiences is critically important to understanding next steps for research.

Pharmacological treatment for challenging behavior in adults with intellectual disability: Systematic review and meta-analysis

INTRODUCTION

Few evidence on the use of antipsychotics in people with intellectual disabilities and challenging behaviors, generates the need to develop studies that contribute to collect, compare and synthesize the available information. The present systematic review and meta-analysis aims to determine the clinical efficacy of antipsychotic medication in reducing critical episodes in this population.

METHODS

We searched Web of Science, Scopus, EBSCO, Embase, and PubMed for randomized controlled trials of antipsychotic medication versus placebo. Preliminarily yielded 1354 abstracts and citations; six studies with 274 subjects met the inclusion criteria of studies with experimental design, longitudinal type, with pre- and post-intervention measurements.

RESULTS

There is evidence for the use of psychotropic drugs in the acute management of challenging behaviors in patients with intellectual disability (SMD=-0.85; 95% CI=-1.69 to -0.01; p=0.05).

CONCLUSIONS

Our results coincide with the recommendations on the efficacy of the use of antipsychotics. Although our study provides evidence, the limited number of studies included in this research does not allow us to obtain totally conclusive results, although it can be considered as a guide for future studies.

Aligning quality of life and guidelines for off-label psychotropic drugs in adults with intellectual disabilities and challenging behaviour

Introduction

Adults with intellectual disabilities have an increased vulnerability to mental health problems and challenging behaviour. In addition to psychotherapeutic or psychoeducational methods, off-label pharmacotherapy, is a commonly used treatment modality.

Objective

The aim of this study was to establish evidence-based guideline recommendations for the responsible prescription of off-label psychotropic drugs, in relation to Quality of Life (QoL).

Method

A list of guidelines was selected, and principles were established based on international literature, guideline review and expert evaluation. The Delphi method was used to achieve consensus about guideline recommendations among a 58-member international multidisciplinary expert Delphi panel. Thirty-three statements were rated on a 5-point Likert-scale, ranging from totally disagree to totally agree, in consecutive Delphi rounds. When at least 70% of the participants agreed (score equal or higher than 4), a statement was accepted . Statements without a consensus were adjusted between consecutive Delphi rounds based on feedback from the Delphi panel.

Results

Consensus was reached on 4 general:the importance of non-pharmaceutical treatments, comprehensive diagnostics and multidisciplinary treatment. Consensus was reached in 4 rounds on 29 statements. No consensus was reached on 4 statements concerning: freedom-restricting measures, the treatment plan, the evaluation of the treatment plan, and the informed consent.

Conclusion

The study led to recommendations and principles for the responsible prescription - aligned with the QoL perspective - of off-label psychotropic drugs for adults with intellectual disabilities and challenging behaviour. Extensive discussion is needed regarding the issues on which there was no consensus to furthering the ongoing development of this guideline.

Development and validation of a system for the prediction of challenging behaviors of people with autism spectrum disorder based on a smart wearable shirt: A mixed-methods design

Background

Most people with autism spectrum disorder (ASD) present at least one form of challenging behavior (CB), causing reduced life quality, social interactions, and community-based service inclusion.

Objectives

The current study had two objectives: (1) to assess the differences in physiological reaction to stressful stimuli between adults with and without high-functioning ASD; (2) to develop a system able to predict the incoming occurrence of a challenging behaviors (CBs) in real time and inform the caregiver that a CB is about to occur; (3) to evaluate the acceptability and usefulness of the developed system for users with ASD and their caregivers.

Methods

Comparison between physiological parameters will be conducted by enrolling two groups of 20 participants with and without ASD monitored while watching a relaxing and disturbing video. To understand the variations of the parameters that occur before the CB takes place, 10 participants with ASD who have aggressive or disruptive CBs will be monitored for 7 days. Then, an ML algorithm capable of predicting immediate CB occurrence based on physiological parameter variations is about to be developed. After developing the application-based algorithm, an efficient proof of concept (POC) will be carried out on one participant with ASD and CB. A focus group, including health professionals, will test the POC to identify the strengths and weaknesses of the developed system.

Results

Higher stress level is anticipated in the group of people with ASD looking at the disturbing video than in the typically developed peers. From the obtained data, the developed algorithm is used to predict CBs that are about to occur in the upcoming 1 min. A high level of satisfaction with the proposed technology and useful consideration for further developments are expected to emerge from the focus group.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT05340608].

Dietary supplements for aggressive behaviour in people with intellectual disabilities: A randomised controlled crossover trial

BACKGROUND

Aggressive incidents are common in people with intellectual disabilities. Therefore, we aimed to assess whether supplementation of multivitamins, minerals, and omega-3 fatty acids (FA) reduces aggressive incidents.

METHODS

We conducted a randomised, triple blind, placebo controlled, single crossover intervention trial. People with intellectual disabilities or borderline intellectual functioning, between 12 and 40 years of age, and showing aggressive behaviour were included. Participants received either a daily dose of dietary supplements, or placebo. Primary outcome was the number of aggressive incidents, measured using the Modified Overt Aggression Scale (MOAS).

RESULTS

there were 113 participants (placebo, n = 56), of whom 24 (placebo, n = 10) participated in the crossover phase of the trial. All 137 trajectories were included in the analyses. There was no significant difference in mean number of aggressive incidents per day between those assigned to supplements and those who received placebo (rate ratio = 0.93: 95% Confidence Interval [CI] = 0.59-1.45).

CONCLUSION

In this pragmatic trial, we did not find significant differences in the outcomes between the supplement and placebo arms. The COVID-19 pandemic started midway through our trial, this may have affected the results.

Challenging behaviour in children with developmental disabilities: an overview of behavioural assessment and treatment methods

Challenging behaviours often co-occur at high rates among those with autism spectrum disorder and intellectual disability. Challenging behaviours, including self-injury, aggression and property destruction, can be associated with social impairment and increased caregiver demands and stress. These behaviours often arise from and are maintained by a combination of biological and environmental risk factors throughout the lifespan. Given the impact of challenging behaviours on development, function-based assessment and intervention approaches are crucial. The prevalence, risk factors, assessment tools and evidence-based treatment options utilised for individuals with developmental disorders are discussed.

Medicaid Disruption Among Transition-Age Youth on the Autism Spectrum

Enrollment in Medicaid facilitates access to needed services among transition-age youth on the autism spectrum and youth with intellectual disability (ID). There are long-standing programs to ensure that individuals with ID remain enrolled as they age; similar programs for autistic youth are newer, not as widespread, and may not be as effective. We compared Medicaid disenrollment and re-enrollment between transition-age youth on the autism spectrum, youth with ID, and youth with both diagnoses using a national claims-based prospective cohort study from 2008 through 2012. Autistic youth were most likely to disenroll and least likely to re-enroll. Disenrollment peaked for all three groups at ages 19 and 21. Transition-age youth on the autism spectrum experience more disruptions in access to Medicaid-reimbursed services than youth with ID. More equitable Medicaid enrollment options for autistic individuals are needed to ensure their access to critical health care as they age.

Lessons learned from two clinical trials on nutritional supplements to reduce aggressive behaviour

BACKGROUND

Setting up and conducting a randomised controlled trial (RCT) has many challenges-particularly trials that include vulnerable individuals with behavioural problems or who reside in facilities that focus on care as opposed to research. These populations are underrepresented in RCTs.

APPROACH

In our paper, we describe the challenges and practical lessons learned from two RCTs in two care settings involving long-stay psychiatric inpatients and people with intellectual disabilities. We describe five main difficulties and how these were overcome: (1) multisite setting, (2) inclusion of vulnerable participants, (3) nutritional supplements and placebos, (4) assessment of behavioural outcomes, and (5) collecting bio samples.

CONCLUSIONS

By sharing these practical experiences, we hope to inform other researchers how to optimally design their trials, while avoiding and minimising the difficulties that we encountered, and to facilitate the implementation of a trial. Both trials were registered in the Clinical Trials Register (RCT A: NCT02498106; RCT B: NCT03212092).

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Neuropsychiatric and Cognitive Comorbidities in Epilepsy

PURPOSE OF REVIEW

This article discusses psychiatric and cognitive comorbidities of epilepsy over the lifespan and illustrates opportunities to improve the quality of care of children and adults with epilepsy.

RECENT FINDINGS

One in 3 people with epilepsy have a lifetime history of psychiatric disorders, and they represent an important prognostic marker of epilepsy. Contributors are diverse and display a complex relationship. Cognitive comorbidities are also common among those living with epilepsy and are increasingly recognized as a reflection of changes to underlying brain networks. Among the cognitive comorbidities, intellectual disability and dementia are common and can complicate the diagnostic process when cognitive and/or behavioral features resemble seizures.

SUMMARY

Comorbidities require consideration from the first point of contact with a patient because they can determine the presentation of symptoms, responsiveness to treatment, and the patient's day-to-day functioning and quality of life. In epilepsy, psychiatric and cognitive comorbidities may prove a greater source of disability for the patient and family than the seizures themselves, and in the case of essential comorbidities, they are regarded as core to the disorder in terms of etiology, diagnosis, and treatment.

Challenging behaviour in students with intellectual disabilities: the role of individual and classmates' communication skills

BACKGROUND

Children and adolescents with intellectual disabilities (ID) are at increased risk of developing challenging behaviour. Challenging behaviour may be partially explained by low individual communicative competences. However, communication involves at least two partners, thus outcomes may also vary according to each interaction partners' abilities. We therefore investigated the degree to which the interplay between individual and classmates' communication skills predicts changes in challenging behaviour among students with ID.

METHODS

This study used a longitudinal design with two measurement points across one school year. Challenging behaviour and communication skills were measured by teacher reports in 1125 students with ID attending special needs schools. Applying a multilevel approach, we investigated (1) whether higher individual communication skills at the first measurement were related to a subsequent decrease in challenging behaviour and (2) whether this effect was moderated by classmates' levels of communication skills. In addition, we examined (3) if classroom communication skills were indirectly related to a decrease in challenging behaviour by influencing individual communicative abilities.

RESULTS

Higher individual communication skills at the first measurement were significantly related to a decrease in general challenging behaviour over the school year. This effect was not moderated by classroom-level communication skills. However, classmates' communication skills exerted an indirect influence by enhancing individual communicative abilities. Further analyses suggested classroom contextual effects related to a decrease in several sub-domains of challenging behaviour.

CONCLUSIONS

The study results suggest that both individual communicative competences and those of the classroom context are relevant to understanding challenging behaviour development in ID. Perspectives for counteracting such behaviour in light of the present findings are discussed.

Reducing challenging behaviours among children and adolescents with intellectual disabilities in community settings: a systematic review of interventions

Background: Challenging behaviours are common among children and adolescents with intellectual disabilities. Such behaviours often result in poor quality of life outcomes such as physical injury, difficulties with relationships and community integration. Aim: This systematic review aimed to synthesise evidence from studies that assessed the effect of interventions used to reduce/manage challenging behaviour among children with intellectual disabilities in community settings. Methods: Studies published between January 2015 and January 2021 were sought from five electronic databases. The quality of studies was assessed, and a narrative synthesis was conducted. Results: A total of 11 studies were included which utilised various non-pharmacological interventions including multi-model interventions, microswitch technology, cognitive behavioural therapy, art, music and illustrated stories. Microswitch cluster technology was the most used intervention. Studies using pharmacological interventions were not retrieved. Results indicated that a person-centred planning approach was key to offering individualised treatment. Conclusions: The superiority of one intervention or a combination of interventions could not be determined from this review given the heterogeneity of studies. Future research is required to explore the use and effects of pharmacological interventions to compare outcomes and improve quality of care of children with intellectual disabilities.

Should Tactile Defensiveness Exclude a Life-Sustaining Intervention in an Adolescent With Autism?

This Ethics Rounds considers the benefits and burdens of a potentially temporary tracheostomy in an adolescent with autism and severe tactile defensiveness.

Planning Positive Reinforcement Cycles in Behavior Intervention Plans

Behavior analysts partner with educators in schools to support the creation of behavior intervention plans (BIPs). Assessment and intervention planning often focuses on the relational contingencies between the student and their environment, with little attention paid to the relational contingencies contacted by the educator. In this article, we posit that planning should simultaneously include contingencies for both the student and the educator as BIPs are created. Specifically, we aim to explore a dual-pathway intervention plan in which student and educator access to reinforcement is simultaneously designed to increase both educators' implementation of high-quality instruction and students' engagement and performance. Procedural steps outlining the duality of intervention planning for both the student and the educator, as well as a theoretical model for considering contextual and reinforcement contingencies for both parties, will be detailed in a step-by-step guide to support readers' creation and implementation of plans to support improved educator and student performance. Planning for supporting both the educator and student may increase sustained, high-quality instruction and improved student outcomes for students with behavioral support needs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-021-00663-8.

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.

Disruptive Behaviors and Intellectual Disability: Creating a New Script

BACKGROUND

Terms currently used to describe the so-called challenging and disruptive behaviors (CBDs) of children with intellectual disabilities (ID) have different connotations depending on guiding contextual frameworks, such as academic and cultural settings in which they are used. A non-judgmental approach, which does not attempt to establish existing categorical diagnoses, but which describes in a neutral way, is missing in the literature. Therefore, we tried to describe CDBs in youth with ID in an explorative study.

METHODS

Interviews with families investigated the CDBs of five youth with Down syndrome. At home, families tracked youth's sleep/wake behaviors and physical activity. Youth were observed in a summer school classroom. The collected information and suggested explanatory models for observed CDBs were reviewed with the families.

RESULTS

We grouped CDBs as challenging, if they were considered to be reactive or triggered, or unspecified, if no such explanatory model was available. A third category was created for light-hearted CDBs: goofy, acknowledging the right to laugh together with peers. We found some relationships between sleep, physical activity, and CDBs and developed an explorative approach, supporting a child-centered perspective on CDBs.

CONCLUSION

The controversial discussions on terminology and management of CDBs in the literature demonstrate the need for a non-judgmental approach. Such an explorative approach, allowing non-professionals to not label, has been missing. The fact that, up to now, the light-hearted behaviors of an individual with ID have not been integrated in commonly-used behavioral checklists as their natural right, proves our concept and indicates that a paradigm change from judgment-based to exploratory-driven approaches is needed.

Comprehensive Assessment of Triggers for Behaviours of Concern Scale (CATS): Initial Development

Challenging behaviour displayed by people with intellectual disabilities (ID) can be difficult to manage if caregivers do not understand the reasons for the behaviour. Identifying the contextual variables/triggers for the behaviour is likely to help undertake a functional analysis leading to a person-centred positive behaviour support plan. Currently, a limited number of checklists are available for trigger assessment and none were developed using an interview with the family caregivers. This article describes the development and contents of the comprehensive assessment of triggers for behaviours of concern scale (CATS). CATS was developed in two stages. Stage 1 used a ‘bottom-up’ approach, in which caregivers of adults with ID who show aggressive behaviour were interviewed to identify the triggers for aggression. In stage two, using a ‘top-down’ approach, a comprehensive literature review was conducted to gather items from existing trigger checklists. Trigger items from both stages were combined and the duplicates were removed. The final list in CATS consists of 333 contextual triggers categorised under five main domains and 12 subdomains. CATS can be used by caregivers to identify triggers or antecedents of challenging behaviour. Further work is needed to test its psychometric properties, utility, and acceptability.

Speech-language profiles in the context of cognitive and adaptive functioning in SATB2-associated syndrome

SATB2‐associated syndrome (SAS) is a neurodevelopmental disorder caused by heterozygous pathogenic variants in the SATB2 gene, and is typically characterized by intellectual disability and severely impaired communication skills. The goal of this study was to contribute to the understanding of speech and language impairments in SAS, in the context of general developmental skills and cognitive and adaptive functioning. We performed detailed oral motor, speech and language profiling in combination with neuropsychological assessments in 23 individuals with a molecularly confirmed SAS diagnosis: 11 primarily verbal individuals and 12 primarily nonverbal individuals, independent of their ages. All individuals had severe receptive language delays. For all verbal individuals, we were able to define underlying speech conditions. While childhood apraxia of speech was most prevalent, oral motor problems appeared frequent as well and were more present in the nonverbal group than in the verbal group. For seven individuals, age‐appropriate Wechsler indices could be derived, showing that the level of intellectual functioning of these individuals varied from moderate–mild ID to mild ID‐borderline intellectual functioning. Assessments of adaptive functioning with the Vineland Screener showed relatively high scores on the domain “daily functioning” and relatively low scores on the domain “communication” in most individuals. Altogether, this study provides a detailed delineation of oral motor, speech and language skills and neuropsychological functioning in individuals with SAS, and can provide families and caregivers with information to guide diagnosis, management and treatment approaches.

Peer influence on problem behaviors among students with intellectual disabilities

BACKGROUND

Students with intellectual disabilities (ID) exhibit increased rates of problem behaviors compared to those without ID.

AIMS

Given the evidence of peer influence in typical development, we examined the impact of classmates' characteristics on problem behaviors of students with ID. We expected higher levels of problem behaviors in special needs classrooms will influence individual development of such behaviors.

METHODS

A longitudinal design with measurements at the beginning and the end of a school year was applied. Staff reported on problem behaviors of 1125 students with ID (69 % boys; age 11.30 years,SD = 3.75) attending 16 Swiss special needs schools.

RESULTS

The peer influence hypothesis was not supported for an overall problem behavior score. However, exploratory analyses suggested that peer influence did occur for the domains anxiety, problems in relating socially, and communication disturbances (not disruptive/antisocial, self-absorbed and other types of problem behaviors). The influence of classmates on anxiety was lower when there was more variability in anxiety within the classroom. The development of communication skills benefitted from attending a classroom that was heterogeneous in the level of communication problems.

CONCLUSION

Our results suggest that the influence of peers on problem behaviors in special needs schools is not universal but varies between domains and depends on classroom characteristics.

Group climate, aggressive incidents and coercion in a secure forensic setting for individuals with mild intellectual disability or borderline intellectual functioning: A multilevel study

Background

This study examines associations between group climate, aggressive incidents and coercive measures in adults with mild intellectual disability or borderline intellectual functioning (MID‐BIF) of a secure forensic setting.

Method

Participants (N = 248) were interviewed about their perception of group climate utilizing the Group Climate Instrument. Data on aggressive incidents and coercive measures were retrieved from the facilities’ electronic database. A multilevel structural equation model was fitted in which variability in perception of group climate within and between living groups was examined.

Results

An open and therapeutic group climate was associated with lower levels of aggression within and between groups. A higher number of aggressive incidents were significantly associated with a higher number of coercive measures.

Conclusions

The findings have implications for the understanding of how group climate may play a role in reducing aggressive incidents at the living group in treatment of individuals with MID‐BIF in secure forensic settings.

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.

Non-pharmacological interventions for challenging behaviours of adults with intellectual disabilities: A meta-analysis

BACKGROUND

Non-pharmacological interventions are recommended for the treatment of challenging behaviours in individuals with intellectual disabilities by clinical guidelines. However, evidence for their effectiveness is ambiguous. The aim of the current meta-analysis is to update the existing evidence, to investigate long-term outcome, and to examine whether intervention type, delivery mode, and study design were associated with differences in effectiveness.

METHOD

An electronic search was conducted using the databases Medline, Eric, PsychINFO and Cinahl. Studies with experimental or quasi-experimental designs were included. We performed an overall random-effect meta-analysis and subgroup analyses.

RESULTS

We found a significant moderate overall effect of non-pharmacological interventions on challenging behaviours (d = 0.573, 95% CI [0.352-0.795]), and this effect appears to be longlasting. Interventions combining mindfulness and behavioural techniques showed to be more effective than other interventions. However, this result should be interpreted with care due to possible overestimation of the subgroup analysis. No differences in effectiveness were found across assessment times, delivery modes or study designs.

CONCLUSIONS

Non-pharmacological interventions appear to be moderately effective on the short and long term in reducing challenging behaviours in adults with intellectual disabilities.

Psychometric properties of the Neuropsychiatric Inventory for adults with intellectual disability

BACKGROUND

Problem behaviours are common among people with intellectual disabilities (ID), but psychometrically evaluated instruments for assessing such behaviours are scarce. The present study evaluated the psychometric properties of the Neuropsychiatric Inventory-Intellectual Disability (NPI-ID).

METHOD

We assessed 108 residents with intellectual disabilities living in group-homes using the NPI-ID, which included the 12 symptoms of the original NPI-Nursing Home and two supplementary symptoms: self-injurious behaviour and impulsive risk-taking behaviour.

RESULTS

The NPI-ID showed adequate internal consistency (α = 0.76) and test-retest reliability (intraclass correlation coefficient = 0.88). Exploratory factor analysis revealed five factors accounting for 64.1% of the variance. Cluster analysis revealed that residents were clustered in three groups with distinctly different symptom profiles.

CONCLUSIONS

The psychometric properties were satisfactory, supporting the use of the NPI-ID as a screening tool for people with intellectual disabilities. Additional research is needed to further evaluate the utility of the NPI-ID among people with intellectual disabilities.

A Meta-analysis of Challenging Behavior Interventions for Students with Developmental Disabilities in Inclusive School Settings

Challenging behavior is a significant barrier in accessing the general education curriculum for students with developmental disabilities. This necessitates the identification of evidence-based practices for addressing challenging behavior in inclusive settings. The purpose of our meta-analysis is to (a) quantify the magnitude of effect of interventions targeting the reduction of challenging behavior in students with developmental disabilities in inclusive educational settings and (b) determine if participant and intervention characteristics moderate intervention effects. A systematic search of academic databases was conducted to identify studies, which were evaluated for methodological rigor and analyzed for effects using Tau-U. Results indicate a strong overall effect of .94 (95% CI [.87, 1]) and moderating variables associated with behavior topography, interventionist, and intervention components were identified.

Attributional styles of support staff working with people with intellectual disabilities exhibiting challenging behaviour

Background

Attributions are cognitive variables that influence a person's behaviour. Although a large volume of research has been conducted on the attributions of support staff with regard to challenging behaviour (CB) exhibited by people with intellectual disabilities (ID), studies on patterns of attributional dimensions (i.e. attributional styles) are scarce.

Method

Using semi‐structured interviews, 19 support staff members were asked to describe incidents of aggressive, self‐injurious and sexualized challenging behaviour. Data on attributions were analysed using the Leeds Attributional Coding System.

Results

Four attributional styles differed significantly for aggressive, self‐injurious and sexualized challenging behaviour. In addition, support staff members largely attributed these three types of CB to characteristics and behaviour of clients with ID.

Conclusions

The results indicate that it is important to train support staff to recognize and understand the ways in which their attributions and behaviour influence the existence and maintenance of CB.

A systematic review of Functional Communication Training (FCT) interventions involving augmentative and alternative communication in school settings

The purpose of this meta-analysis was to summarize single-case intervention studies in which Functional Communication Training (FCT) involving augmentative and alternative communication (AAC) was implemented in school settings. Overall, the findings suggest that FCT involving AAC was effective in reducing challenging behaviour and promoting aided or unaided AAC use among participants with disability. FCT was more effective for the participants who engaged in less severe forms of challenging behaviour prior to intervention. Additionally, FCT was more effective when informed by a descriptive functional behaviour assessment and delivered within inclusive school settings. Implications for practice and directions for future research related to FCT for students who use AAC are addressed.

Challenging behaviours: Views and preferences of people with intellectual disabilities

Background

Challenging behaviour is a common problem among people with ID and in services for people with ID. This paper aims to provide an overview of the views and preferences of people with ID on challenging behaviour.

Method

Semi‐structured interviews were conducted with thirteen adults with mild to moderate ID and seven proxies (family or close associates of adults with ID who were unable to communicate and/or with severe or profound ID) in the Netherlands. The interviews were audio‐recorded, transcribed and analysed thematically.

Results

People with ID and (a history of) challenging behaviour have clear views and preferences on factors related to challenging behaviour, assessments, non‐pharmacological and pharmacological interventions and health professionals’ approach.

Conclusions

The identified views and preferences of people with ID are not always in accordance with current procedures and treatments for challenging behaviour and should be included in future care processes and research.

Transition-Age Medicaid Coverage for Adolescents With Autism and Adolescents With Intellectual Disability

Although the majority of adolescents with autism spectrum disorder (ASD) rely on healthcare coverage through Medicaid during their transition into adulthood, little is known about their continuing eligibility. This study used Medicaid Analytic Extract (MAX) data to examine Medicaid coverage in a national sample using a cohort of adolescents with ASD ( n = 4,179) and a like-aged cohort with intellectual disability (ID, n = 21,844) over 5 years using survival analysis and Cox regression models. More than 1 in 4 adolescents with ASD lost coverage and fewer than half subsequently regained it. They were more likely to disenroll than adolescents with ID. Similarities in overall patterns among the 2 groups suggest that the experience of adolescents with ASD was characteristic of more general aspects of behavioral health coverage and indicate the need for programmatic reforms.

Recognition and treatment of mood dysregulation in adults with intellectual disability

Mood dysregulation is a common feature in the psychopathology of people with intellectual disability (ID) and co-occurring behavioral/psychiatric disorders. It can present with a host of dangerous behaviors, including aggression, self-injury, and property damage. There are special techniques that are used to assess these behaviors in people with ID, that can eventually inform an appropriate approach to pharmacologic and nonpharmacologic treatment. Two case studies are presented that illustrate the elements in the assessment and treatment of mood dysregulation in ID.

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.

Behavioral disorder in people with an intellectual disability and epilepsy: A report of the Intellectual Disability Task Force of the Neuropsychiatric Commission of ILAE

The management and needs of people with intellectual disability (ID) and epilepsy are well evidenced; less so, the comorbidity of behavioral disorder in this population. "Behavioral disorder" is defined as behaviors that are difficult or disruptive, including stereotypes, difficult or disruptive behavior, aggressive behavior toward other people, behaviors that lead to injury to self or others, and destruction of property. These have an important link to emotional disturbance. This report, produced by the Intellectual Disability Task Force of the Neuropsychiatric Commission of the ILAE, aims to provide a brief review of some key areas of concern regarding behavioral disorder among this population and proposes a range of research and clinical practice recommendations generated by task force members. The areas covered in this report were identified by experts in the field as being of specific relevance to the broad epilepsy community when considering behavioral disorder in persons with epilepsy and ID; they are not intended to be exhaustive. The practice recommendations are based on the authors' review of the limited research in this field combined with their experience supporting this population. These points are not graded but can be seen as expert opinion guiding future research and clinical practice.

Renewal, resurgence, and alternative reinforcement context

Resurgence, relapse induced by the removal of alternative reinforcement, and renewal, relapse induced by a change in contextual stimuli, are typically studied separately in operant conditioning paradigms. In analogous treatments of operant problem behavior, aspects of both relapse phenomena can operate simultaneously. Therefore, the purpose of this study was to examine a novel method for studying resurgence and renewal in the same experimental preparation. An alternative source of reinforcement was available during extinction for one group of rats (a typical resurgence preparation). Another group experienced an operant renewal preparation in which the extinction context was distinguished via olfactory and visual stimuli. A third group experienced alternative reinforcement delivery in the new context, a novel combination of typical resurgence and renewal preparations. Removal of alternative reinforcement and/or a change in context induced relapse relative to an extinction-only control group. When alternative reinforcement was delivered in a novel context, the alternative response was less persistent relative to when extinction of the alternative response took place in the context in which it was trained. This methodology might be used to illustrate shared (or distinct) mechanisms of resurgence and renewal, and to determine how delivering alternative reinforcement in another context may affect persistence and relapse.

Parental Perceptions of the Use of Coercive Measures on Children with Developmental Disabilities

BACKGROUND

Children with developmental disabilities who exhibit challenging behaviour are potentially subject to the use of coercive interventions. The aim of the study was to investigate the prevalence of the use of coercive measures by authorities, according to parents' reports.

MATERIALS AND METHODS

A postal survey was distributed, as a total population study, to 946 Finnish parents of children with developmental disabilities, between the ages of 5 and 15, and who were entitled to the highest disability allowance.

RESULTS

Of the respondents, 54 (22%) answered 'yes' when asked whether their child had been subjected to coercive procedures by authorities. The parents had seldom approved the use of coercive means and often believed that such means had negative effects on their child.

CONCLUSIONS

To protect the children's rights, the use of coercive measures should be regulated more strictly, and positive intervention strategies should be taught to teachers and nurses.

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

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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