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Barrett BF, Wehmeyer M, Kolb J, Ostermann T, Sappok T. Impact of the emotional development approach on psychotropic medication in adults with intellectual and developmental disabilities: a retrospective clinical analysis. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2024; 68:941-953. [PMID: 38545626 DOI: 10.1111/jir.13136] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 02/05/2024] [Accepted: 03/01/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Compared with the general population, adults with an intellectual developmental disorder (IDD) are more likely to develop mental health problems and to receive high levels of psychotropic medication, particularly antipsychotics. The emotional development (ED) approach may help to better understand the nature of challenging behaviour (CB) and tailor treatment and support accordingly. The aim of this retrospective study was to investigate the impact of the ED approach on the prescription of psychotropic medication during inpatient psychiatric treatment. METHODS The clinical data of 1758 patients were analysed within a retrospective study design over a period of 12 years. ED level was assessed (1) for the first time (INITIAL-SEO), (2) during a previous hospital stay (PAST-SEO) or (3) not at all (NO-SEO). The effects of the ED assessment and the respective intervention during the current admission on the number of psychotropics and the number and dosage of antipsychotics were analysed for the total sample, including those with CB, autism spectrum disorders and psychosis. Group differences were analysed by a chi-square test and a one-factorial analysis of variance. For analysing the impact of the application of the ED approach on psychotropic medication, a covariance model was applied. Changes between the subsamples were analysed by t-tests for dependent samples. RESULTS The ED approach had a significant impact on reducing the overall amount of psychotropic medication and the dosage of antipsychotics in all patients with IDD. These effects were mainly attributable to those showing CB. In patients with autism spectrum disorders, the developmental approach reduced the number of antipsychotics. No effects could be observed in patients with psychosis; in this subsample, both the number and dosage of antipsychotics increased. CONCLUSIONS The application of the ED approach in the current hospital stay reduced the number of psychotropic drugs and the number and dosage of antipsychotics, especially in those patients with IDD and CB, but also in those with autism spectrum disorders.
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Affiliation(s)
- B F Barrett
- Liebenau Kliniken, St. Lukas Klinik, Liebenau, Germany
| | - M Wehmeyer
- Department of Pedagogy and Rehabilitation, Faculty of Psychology and Pedagogy, Ludwig Maximilians University, Munich, Germany
| | - J Kolb
- Liebenau Kliniken, St. Lukas Klinik, Liebenau, Germany
| | - T Ostermann
- Department of Psychology and Psychotherapy, Faculty of Health, University of Witten/Herdecke, Witten, Germany
| | - T Sappok
- University Clinic for People with Neurodevelopmental Disorders, Mara, University Hospital OWL, Bielefeld University, Bielefeld, Germany
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Friedman C, Luxama CM. Mental and Behavioral Health, and Crisis Services for People with Intellectual and Developmental Disabilities in Medicaid Home- and Community-Based Services. J Autism Dev Disord 2024:10.1007/s10803-024-06441-z. [PMID: 38951311 DOI: 10.1007/s10803-024-06441-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/03/2024]
Abstract
People with intellectual and developmental disabilities (IDD) often have higher rates of comorbid mental health conditions compared to the general population. Yet, many people with IDD also have unmet needs for mental and behavioral health services. The aim of this study was to examine how states provided mental and behavior health, and crisis services to people with IDD in their Home- and Community-Based Services (HCBS) programs, the largest funding mechanism for Long-Term Services and Supports (LTSS) for people with IDD in the United States. We analyzed fiscal year (2021) Medicaid HCBS waivers for people with IDD from across the United States to examine if and how they provided mental and behavior health, and crisis services. States projected spending $968.9 million for mental and behavior health, and crisis services for 190,299 people with IDD. Applied behavior analysis services were provided at greater rates than positive behavior supports and other forms of behavior interventions. While most states provided mental and behavior health, and crisis services in their waivers, there were vast inconsistencies in how they did so, across states, waivers, and services. HCBS are a crucial safety net to ensure people with IDD, especially those who also have mental health disabilities, can live and thrive in their communities.
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Affiliation(s)
- Carli Friedman
- The Council on Quality and Leadership (CQL), 100 West Road, Suite 300, Towson, MD, 21204, USA.
| | - Carine M Luxama
- College of Nursing and Health Services, University of Massachusetts at Boston, 100 Morrissey Blvd, Boston, MA, 02125, USA
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Korb L, Tromans S, Perera B, Khan N, Burrows L, Laugharne R, Hassiotis A, Allgar V, Efron D, Maidment I, Shankar R. The potential for medicinal cannabis to help manage challenging behaviour in people with intellectual disability: A perspective review. J Psychopharmacol 2023; 37:1201-1208. [PMID: 37937428 PMCID: PMC10714688 DOI: 10.1177/02698811231209192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
BACKGROUND Around 2% of the population have intellectual disabilities. Over one-third people with intellectual disabilities (PwID) present with 'challenging behaviour', which nosologically and diagnostically is an abstract concept. Challenging behaviour is influenced by a range of bio-psycho-social factors in a population, which is unable to suitably comprehend and/or communicate concerns. This predisposes to poor health and social outcomes. There is no evidence-based treatments for managing challenging behaviour. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are being trialled for a range of disorders, which are over-represented in PwID and provoke challenging behaviours, such as severe epilepsy, spasticity, post-traumatic stress disorder, social phobia, pain, etc. METHODS This perspective review explores the different conditions, which benefit from medicinal CBD/THC preparations, by analysing recent literature from neurobiological, pre-clinical and clinical studies related to the topic. The evidence is synthesised to build an argument of the therapeutic benefits and challenges of medicinal cannabis to manage severe challenging behaviour in PwID. RESULTS There is developing evidence of medicinal CBD/THC improving psychiatric and behavioural presentations in general. In particular, there is emergent proof in certain key areas of influence of medicinal CBD/THC positively supporting challenging behaviour, for example in children with neurodevelopmental disorders. However, there are significant challenges in employing such treatments in vulnerable populations such as PwID. CONCLUSION Further clinical research for the considered use of medicinal CBD/THC for challenging behaviour management in PwID is needed. Strong co-production with experts with lived experience is needed for further testing to be done in this exciting new area.
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Affiliation(s)
- Laura Korb
- Haringey Learning Disability Partnership, Barnet Enfield and Haringey Mental Health NHS Trust, London, UK
| | - Samuel Tromans
- Department of Population Health Sciences, University of Leicester, Leicester, UK
- Adult Learning Disability Service, Leicestershire Partnership NHS Trust, Leicester, UK
| | - Bhathika Perera
- North East London NHS Foundation Trust, London, UK
- Division of Psychiatry, University College London, London, UK
| | - Nagina Khan
- Centre for Addiction and Mental Health, Toronto, Canada
| | | | - Richard Laugharne
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
| | | | - Victoria Allgar
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Truro, UK
| | - Daryl Efron
- Royal Children’s Hospital, Melbourne, Australia
- Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Ian Maidment
- College of Life and Health Sciences, Aston School of Pharmacy, Aston University, Birmingham, UK
| | - Rohit Shankar
- Cornwall Intellectual Disability Equitable Research (CIDER), University of Plymouth Peninsula School of Medicine, Truro, UK
- Peninsula Clinical Trials Unit, Faculty of Health, University of Plymouth, Truro, UK
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Prior D, Win S, Hassiotis A, Hall I, Martiello MA, Ali AK. Behavioural and cognitive-behavioural interventions for outwardly directed aggressive behaviour in people with intellectual disabilities. Cochrane Database Syst Rev 2023; 2:CD003406. [PMID: 36745863 PMCID: PMC9901280 DOI: 10.1002/14651858.cd003406.pub5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Outwardly directed aggressive behaviour in people with intellectual disabilities is a significant issue that may lead to poor quality of life, social exclusion and inpatient psychiatric admissions. Cognitive and behavioural approaches have been developed to manage aggressive behaviour but the effectiveness of these interventions on reducing aggressive behaviour and other outcomes are unclear. This is the third update of this review and adds nine new studies, resulting in a total of 15 studies in this review. OBJECTIVES To evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly directed aggressive behaviour compared to usual care, wait-list controls or no treatment in people with intellectual disability. We also evaluated enhanced interventions compared to non-enhanced interventions. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was March 2022. We revised the search terms to include positive behaviour support (PBS). SELECTION CRITERIA We included randomised and quasi-randomised trials of children and adults with intellectual disability of any duration, setting and any eligible comparator. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were change in 1. aggressive behaviour, 2. ability to control anger, and 3. adaptive functioning, and 4. ADVERSE EFFECTS Our secondary outcomes were change in 5. mental state, 6. medication, 7. care needs and 8. quality of life, and 9. frequency of service utilisation and 10. user satisfaction data. We used GRADE to assess certainty of evidence for each outcome. We expressed treatment effects as mean differences (MD) or odds ratios (OR), with 95% confidence intervals (CI). Where possible, we pooled data using a fixed-effect model. MAIN RESULTS This updated version comprises nine new studies giving 15 included studies and 921 participants. The update also adds new interventions including parent training (two studies), mindfulness-based positive behaviour support (MBPBS) (two studies), reciprocal imitation training (RIT; one study) and dialectical behavioural therapy (DBT; one study). It also adds two new studies on PBS. Most studies were based in the community (14 studies), and one was in an inpatient forensic service. Eleven studies involved adults only. The remaining studies involved children (one study), children and adolescents (one study), adolescents (one study), and adolescents and adults (one study). One study included boys with fragile X syndrome. Six studies were conducted in the UK, seven in the USA, one in Canada and one in Germany. Only five studies described sources of funding. Four studies compared anger management based on cognitive behaviour therapy to a wait-list or no treatment control group (n = 263); two studies compared PBS with treatment as usual (TAU) (n = 308); two studies compared carer training on mindfulness and PBS with PBS only (n = 128); two studies involving parent training on behavioural approaches compared to wait-list control or TAU (n = 99); one study of mindfulness to a wait-list control (n = 34); one study of adapted dialectal behavioural therapy compared to wait-list control (n = 21); one study of RIT compared to an active control (n = 20) and one study of modified relaxation compared to an active control group (n = 12). There was moderate-certainty evidence that anger management may improve severity of aggressive behaviour post-treatment (MD -3.50, 95% CI -6.21 to -0.79; P = 0.01; 1 study, 158 participants); very low-certainty evidence that it might improve self-reported ability to control anger (MD -8.38, 95% CI -14.05 to -2.71; P = 0.004, I2 = 2%; 3 studies, 212 participants), adaptive functioning (MD -21.73, 95% CI -36.44 to -7.02; P = 0.004; 1 study, 28 participants) and psychiatric symptoms (MD -0.48, 95% CI -0.79 to -0.17; P = 0.002; 1 study, 28 participants) post-treatment; and very low-certainty evidence that it does not improve quality of life post-treatment (MD -5.60, 95% CI -18.11 to 6.91; P = 0.38; 1 study, 129 participants) or reduce service utilisation and costs at 10 months (MD 102.99 British pounds, 95% CI -117.16 to 323.14; P = 0.36; 1 study, 133 participants). There was moderate-certainty evidence that PBS may reduce aggressive behaviour post-treatment (MD -7.78, 95% CI -15.23 to -0.32; P = 0.04, I2 = 0%; 2 studies, 275 participants) and low-certainty evidence that it probably does not reduce aggressive behaviour at 12 months (MD -5.20, 95% CI -13.27 to 2.87; P = 0.21; 1 study, 225 participants). There was low-certainty evidence that PBS does not improve mental state post-treatment (OR 1.44, 95% CI 0.83 to 2.49; P = 1.21; 1 study, 214 participants) and very low-certainty evidence that it might not reduce service utilisation at 12 months (MD -448.00 British pounds, 95% CI -1660.83 to 764.83; P = 0.47; 1 study, 225 participants). There was very low-certainty evidence that mindfulness may reduce incidents of physical aggression (MD -2.80, 95% CI -4.37 to -1.23; P < 0.001; 1 study; 34 participants) and low-certainty evidence that MBPBS may reduce incidents of aggression post-treatment (MD -10.27, 95% CI -14.86 to -5.67; P < 0.001, I2 = 87%; 2 studies, 128 participants). Reasons for downgrading the certainty of evidence were risk of bias (particularly selection and performance bias); imprecision (results from single, often small studies, wide CIs, and CIs crossing the null effect); and inconsistency (statistical heterogeneity). AUTHORS' CONCLUSIONS There is moderate-certainty evidence that cognitive-behavioural approaches such as anger management and PBS may reduce outwardly directed aggressive behaviour in the short term but there is less certainty about the evidence in the medium and long term, particularly in relation to other outcomes such as quality of life. There is some evidence to suggest that combining more than one intervention may have cumulative benefits. Most studies were small and there is a need for larger, robust randomised controlled trials, particularly for interventions where the certainty of evidence is very low. More trials are needed that focus on children and whether psychological interventions lead to reductions in the use of psychotropic medications.
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Affiliation(s)
- David Prior
- Forensic Intellectual and Neurodevelopmental Disabilities (FIND) Community Team South London Partnership, Oxleas NHS Foundation Trust, London, UK
| | - Soe Win
- Services for People with Learning Disabilities (Luton), East London NHS Foundation Trust, London, UK
| | | | - Ian Hall
- Hackney Integrated Learning Disability Service, East London NHS Foundation Trust, London, UK
| | - Michele A Martiello
- More Ward, Goodmayes Hospital, North East London NHS Foundation Trust, London, UK
| | - Afia K Ali
- Unit for Social and Community Psychiatry, East London NHS Foundation Trust, London, UK
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Reyes-Martín J, Simó-Pinatella D, Font-Roura J. Assessment of Challenging Behavior Exhibited by People with Intellectual and Developmental Disabilities: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:8701. [PMID: 35886552 PMCID: PMC9324269 DOI: 10.3390/ijerph19148701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Juliana Reyes-Martín
- Facultat de Psicologia, Ciències de l’Educació i de l’Esport, Blanquerna, Ramon Llull University, 08022 Barcelona, Spain;
- Fundació Vallparadís, Mutua Terrassa, 08221 Barcelona, Spain
| | - David Simó-Pinatella
- Facultat de Psicologia, Ciències de l’Educació i de l’Esport, Blanquerna, Ramon Llull University, 08022 Barcelona, Spain;
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Wang HI, Wright BD, Bursnall M, Cooper C, Kingsley E, Le Couteur A, Teare D, Biggs K, McKendrick K, de la Cuesta GG, Chater T, Barr A, Solaiman K, Packham A, Marshall D, Varley D, Nekooi R, Gilbody S, Parrott S. Cost-utility analysis of LEGO based therapy for school children and young people with autism spectrum disorder: results from a randomised controlled trial. BMJ Open 2022; 12:e056347. [PMID: 35039300 PMCID: PMC8765033 DOI: 10.1136/bmjopen-2021-056347] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/07/2021] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To assess the cost-effectiveness of LEGO-based therapy compared with usual support. DESIGN Cost-utility analysis alongside randomised control trial. SETTING Mainstream primary and secondary schools in the UK. PARTICIPANTS 248 children and young people (CYP) with autism spectrum disorder (ASD) aged 7-15 years. INTERVENTION LEGO-based therapy is a group social skills intervention designed specifically for CYP with ASD. Through play, CYP learn to use the skills such as joint attention, sharing, communication and group problem-solving. CYP randomised to the intervention arm received 12 weekly sessions of LEGO-based therapy and usual support, while CYP allocated to control arm received usual support only. MAIN OUTCOME MEASURES Average costs based on National Health Service (NHS) and personal social services perspective and quality-adjusted life years (QALYs) measured by EQ-5D-Y over time horizon of 1 year were collected during the trial. Incremental cost-effectiveness ratio (ICER) was calculated, and non-parametric bootstrapping was conducted. The uncertainty around the ICER estimates was presented using cost-effectiveness acceptability curve (CEAC). A set of sensitivity analyses were conducted to assess the robustness of the primary findings. RESULTS After adjustment and bootstrapping, on average, CYP in LEGO-based therapy group incurred less costs (incremental cost was -£251 (95% CI -£752 to £268)) and gained marginal improvement in QALYs (QALYs gained 0.009 (95% CI -0.008 to 0.028)). The CEAC shows that the probability of LEGO-based therapy being cost-effective was 94% at the willingness-to-pay threshold of £20 000 per QALY gained. Results of sensitivity analyses were consistent with the primary outcomes. CONCLUSION Compared with usual support, LEGO-based therapy produced marginal reduction in costs and improvement in QALYs. Results from both primary and sensitivity analyses suggested that LEGO-based therapy was likely to be cost-effective. TRIAL REGISTRATION NUMBER ISRCTN64852382.
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Affiliation(s)
- Han-I Wang
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Barry Debenham Wright
- Department of Health Sciences, University of York, York, North Yorkshire, UK
- COMIC Research Team, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Matthew Bursnall
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - Ellen Kingsley
- COMIC Research Team, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Ann Le Couteur
- Sir James Spence Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Biggs
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - Kirsty McKendrick
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | | | - Tim Chater
- Liverpool Clinical Trials Centre, University of Liverpool, Liverpool, Merseyside, UK
| | - Amy Barr
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - Kiera Solaiman
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - Anna Packham
- Clinical Trials Research Unit, ScHARR, The University of Sheffield, Sheffield, UK
| | - David Marshall
- Centre for Reviews and Dissemination, University of York, York, North Yorkshire, UK
| | - Danielle Varley
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Roshanak Nekooi
- COMIC Research Team, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, North Yorkshire, UK
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