Self-injury and violence in people with severe learning disabilities

Predictors for attacks on people after deinstitutionalization

BACKGROUND

The deinstitutionalization movement is presently spreading in Europe, but studies evaluating the effects of deinstitutionalization on behaviour disturbances among people with intellectual disability (ID) are inconclusive. The prevalence of aggressive behaviour among people with ID is high in both institutions and in community. Aggression and attacks on people are a significant problem for people with ID in both institutions and society. In the present paper, the authors focus on individuals who started attacking people after deinstitutionalization.

METHOD

The authors studied individual and environmental characteristics before and after deinstitutionalization to look for individual and environmental predictors for the development of aggression with the hope that some could be possible intervention points for preventive action. In an institution for people with ID, all who did not attack people before deinstitutionalization were included. The individuals who started attacking others after deinstitutionalization (n = 22) were the study group (group A) and those who did not (n = 42) comprised the control group (group B). The population was examined before and after deinstitutionalization. As far as possible the same methods were used at both occasions. The covariates included individual ones, such as mental health, behaviour disturbances and behaviour deficits, and environmental ones, such as caretaker education, caretaker:patient ratio, housing and leisure activities. Psychiatric disorders were identified in 1987 and 1995 with the Psychopathology Instrument for Mentally Retarded Adults (PIMRA), which was filled in by the caretakers.

RESULTS

Group A showed significantly more self-injurious behaviour (SIB) than group B in 1987. The sum of behaviour disturbances shown in the past year, attacks on property, SIB and other disruptive behaviours were also significantly higher in group A than in group B. The soundness scores on the PIMRA for the people in group A were lower than for the people in group B. Group A contained significantly fewer people without behavioural problems in the past year. The authors could not find any differences on other individual characteristics such as aetiologies of ID and behaviour deficits in 1987. The caretakers' evaluations of the clients need for help, based on behaviour disturbances and mental health problems, were significantly higher in group A. The people in this study differed in age, gender and degree of ID from those in most other studies on ID and challenging behaviour.

CONCLUSION

The individual predictors for starting to attack others after deinstitutionalization were SIB, a slight load of other behaviour problems and a low soundness score on the PIMRA. The only environmental predictor was the caretakers' evaluation of the subjects' need for help caused by behaviour problems and mental illness. The authors could not identify possible preventive intervention points, neither individual or environmental, and therefore, further studies are needed.

A survey of the prevalence of stereotypy, self-injury and aggression in children and young adults with Cri du Chat syndrome

The aim of the present study was to determine the prevalence and frequency of stereotypy, self-injurious behaviour (SIB), and aggression in children and adults with Cri du Chat syndrome (CCS), and to investigate the relationship between SIB, aggressive behaviour and stereotypy in these individuals. Sixty-six families of children and adults diagnosed with CCS completed the Behaviour Problems Inventory. Additional information relating to gender, chronological age, type of school/post-school occupation and medication was also included in the survey. Stereotyped behaviour was reported for 82% of subjects, more than half the sample displaying it on a daily basis. The occurrence percentage of 15 topographies of SIB suggested that head banging, hitting the head against body parts, self-biting and rumination are the most frequently occurring behaviours in CCS. Aggressive behaviour was reported for 88%, with a statistically significant negative correlation between age and the number of aggressive behaviours reported. The present findings suggest that specific types of stereotypy and SIB are observed frequently in CCS.

Self-injurious behaviour before and after deinstitutionalization

The deinstitutionalization movement is presently spreading in Europe. Studies evaluating the effects of deinstitutionalization on behaviour disturbances among people with intellectual disability (ID) have been inconclusive. The present paper focuses on people without self-injurious behaviour (SIB) who developed SIB after deinstitutionalization. The present authors studied individual and environmental characteristics before and after deinstitutionalization to look for factors associated with the development of SIB which could also be possible intervention points for preventive action. All those individuals in an institution for people with ID who did not have SIB before deinstitutionalization were included in the present study. The individuals who developed SIB after deinstitutionalization (n = 15) formed the study group (group A) and those who did not (n = 53) comprised the control group (group B). The population was examined both before and after deinstitutionalization. As far as possible, the same methods were used at both occasions. The covariates were both individual (e.g. mental health, behaviour disturbances and behaviour deficits) and environmental (e.g. caretaker education, caretaker:patient ratio, housing and leisure activities). Psychiatric disorders were identified in 1987 and 1995 with the Psychopathology Instrument for Mentally Retarded Adults, which was filled in by the caretakers. In 1987, the people in group A who acquired SIB had lower developmental quotients, used wheelchairs more often and had trouble with moving around without help. They also had a greater frequency of epileptic seizures, and hearing and communication impairment. In 1995, there were only minor environmental differences between groups A and B. There were significantly more individuals involved in the rotation period and more unskilled caretakers working with the people in group A than group B. The present authors found no differences between the two groups on variables such as global mental health and behaviour disturbances, or in the use of neuroleptics before or after deinstitutionalization. Groups A and B did not show differences in behaviour disturbances or psychiatric disorders in 1987. In both 1987 and 1995, there were no differences between groups A and B on variables such as accommodation, caretaker:patient ratio, the number of caretakers involved in direct care, the caretakers' education, or the time spent in structured activities before and after deinstitutionalization. The individual characteristics indicating that a person may acquire SIB are behaviour deficits which are suggestive of central nervous system dysfunction or damage, even if the results are inconclusive. The development of SIB may also be facilitated by communication deficits or by reinforcement of a incidentally occurring SIB if the staff includes many unskilled caretakers in the rotation period.

Self-injurious behaviour: a kindling phenomenon?

Self-injurious behaviour continues to be a drain on the resources for rehabilitation of the children with developmental disabilities. Pathogenesis and therapy seems fragmentary, with virtually every major neurotransmitter system being identified as the putative substrate for self-injurious behaviour. This phenomenon as it cuts across the diagnostic boundaries, although it is suggestive of a heterogeneous neurochemical basis, should call for the exploration of the biological event preceding the neurochemical cascade resulting in the behaviour. The authors argue that kindling is the preceding neurophysiological event resulting in self-injurious behaviour and, thus, can be effectively prevented pharmacologically.

Epidemiology of self-injurious behaviour in adults with learning disabilities

BACKGROUND

There have been few epidemiological studies of the disabling and poorly understood disorder self-injurious behaviour among adults with learning disabilities.

METHOD

Interviews were undertaken with the carers of adults known to the Leicestershire Learning Disabilities Register (n = 2277). The Disability Assessment Schedule was used and information was also collected on demographic characteristics, developmental and physical status.

RESULTS

Self-injurious behaviour was present in 17.4% of the population. In 1.7% self-injurious behaviour occurred frequently and was severe. There was no gender difference between those with and without self-injurious behaviour. Both the chronological age and developmental quotient of individuals with self-injurious behaviour were lower than those of individuals without self-injurious behaviour. Autistic symptoms were more common among those with self-injurious behaviour. The association of self-injurious behaviour with a wide range of other maladaptive behaviours was highly significant. Logistic regression analysis retained age, developmental quotient, hearing status, immobility and number of autistic symptoms as explanatory variables for self-injurious behaviour.

CONCLUSIONS

Self-injurious behaviour is a prevalent and disabling disorder among adults with learning disabilities.