Epidemiology of self-injurious behaviour in adults with learning disabilities

Autism spectrum disorder in older adults with intellectual disability: a scoping review

INTRODUCTION

Ireland has an ageing population of persons with intellectual disability (ID), autism spectrum disorder (ASD) and both (ID/ASD). Despite this, little is known about the prevalence of ASD and its effect on functional outcomes, psychiatric comorbidity or diagnostic issues in an older population with ID. This article reviews the literature on older adults with ID/ASD and identifies opportunities for future research in this population.

METHOD

The authors searched the Medline, Pubmed, Embase, CINAHL and PsychInfo databases using the search terms using key words: (older adults) AND (ID OR mental retardation OR learning disability) AND (autism OR ASD). After excluding articles for relevance, a scoping review was carried out on the results retrieved.

RESULTS

Of the 1227 articles retrieved from the literature on ID and autism/ASD in older adults, 85 articles were relevant to an adult population with ID/ASD. The data were collated and are presented covering domains of diagnosis, prevalence, psychiatric comorbidities and functional outcomes.

CONCLUSIONS

Despite increased prevalence in childhood ASD in the last 20 years, there is a lack of research regarding adults, especially older adults, with ASD, up to half of whom will have some level of ID. The existing literature suggests that older adults with ID/ASD may have reduced functional independence, increased psychiatric comorbidity and psychotropic prescribing and more behavioural presentations than the older population generally or those with ID only. There is a need for longitudinal data to be collected on this ageing population so that care and management needs can be met in the future.

Association between epilepsy and challenging behaviour in adults with intellectual disabilities: systematic review and meta-analysis

BACKGROUND

Previous systematic reviews showed no significant association between epilepsy and challenging behaviours in adults with intellectual disabilities.

AIMS

To identify whether there is an association between epilepsy and challenging behaviour in adults with intellectual disabilities by carrying out a systematic review of published data. PROSPERO registration number: CRD42020178092.

METHOD

We searched five databases and hand-searched six journals. Two authors independently screened titles, abstracts and full articles using a standardised eligibility checklist. Several meta-analyses were carried out.

RESULTS

The narrative analysis of data from 34 included articles (14 168 adults with intellectual disabilities, 4781 of whom also had epilepsy) showed no significant association between epilepsy and challenging behaviour. Meta-analysis was possible on data from 16 controlled studies. This showed no significant intergroup difference but after sensitivity analysis meta-analysis of 10 studies showed a significantly higher rate of overall challenging behaviour in the epilepsy group (effect size: 0.16) compared with the non-epilepsy group. Aggression and self-injurious behaviour both showed a statistically significant higher rate in the epilepsy group, with very small effect sizes (0.16 and 0.28 respectively). No significant intergroup difference was observed in the rate of stereotypy.

CONCLUSIONS

The findings are contradictory and must be interpreted with caution because of the difficulty in pooling data from varied studies, which is likely to introduce confounding. Where significant differences were found, effect sizes are small and may not be clinically significant, and there are major methodological flaws in the included studies, which should be addressed in future large-scale properly controlled studies.

The Persistence of Self-injurious and Aggressive Behavior in Males with Fragile X Syndrome Over 8 Years: A Longitudinal Study of Prevalence and Predictive Risk Markers

Self-injurious and aggressive behaviors are common in fragile X syndrome (FXS). However, little is known about the persistence of these behaviors and associated risk markers. We established the prevalence and persistence of self-injurious and aggressive behaviors over eight years in males with FXS, and associations with risk markers. Results showed 77% and 69% persistence rates for self-injurious and aggressive behavior, respectively. Baseline levels of repetitive behavior predicted persistent self-injurious behavior. Chronological age, impulsivity and overactivity were associated with persistent aggressive behavior but only impulsivity predicted persistence. This is the first study to document the persistence of self-injurious and aggressive behavior in FXS over the medium to long term and to identify behavioral risk markers that might facilitate targeted early intervention.

Resolution of self-injurious behavior in a nonverbal and developmentally delayed patient after surgical treatment of a blind painful eye

Changes in behavioral patterns can be the only indication of the presence of pain in nonverbal patients. Phthisis bulbi results in shrinking, disorganization, and sometimes severe inflammation of the ocular globe and can occur after eye injury or multiple eye surgeries. Chronic tearing, frequent eye rubbing, and self-injurious behavior focused around the eye and periocular region may indicate ocular discomfort in nonverbal patients. In eyes that become painful and refractory to medical treatment, ocular evisceration or enucleation can provide immediate pain relief. An ocular prosthesis provides excellent cosmetic results to restore normal facial appearance after surgery.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

Refractive error and ocular findings among infants and young children with severe problem behavior and developmental disabilities

The prevalence of refractive error and ocular disorders among infants and young children with severe behavioral problems and developmental disorders is not well defined, particularly in developing countries. We performed a retrospective review of ophthalmic examinations performed during a National Institutes of Health-funded cohort study of very young children in Peru with behavioral problems and at risk for developmental disorders. 222 children between the ages of 0 and 4 years (mean 2.2 ± 0.9 years) were examined and 100 (45.0%) had an abnormal ocular exam. Overall, the prevalence of refractive error was 33.3%, nystagmus was 12.2%, and strabismus was 10.9%. Among children with Down syndrome, refractive error ranged from 46.2% at age 2 to 85.7% at age 4. Refractive error and ocular disorders are highly prevalent even at a young age in children with behavioral problems and developmental disorders. Much of the visual impairment in this population is treatable; early identification and intervention can have a lifelong positive impact on neurodevelopment.

A guide to intellectual disability psychiatry assessments in the community

Psychiatric assessment in the community is an important part of both the initial assessment process and delivery of follow-up care in adult intellectual disability services in the UK. This article examines how such assessments can be carried out safely and explores the clinical skills required to perform them effectively. Use of the psychiatric interview and mental state examination to elicit information is discussed. Communication difficulties experienced by people with intellectual disabilities and strategies that may be employed to address these in the assessment process are also explored. The article is directed at psychiatrists, in particular specialty trainees, and other healthcare professionals who work with intellectually disabled people.

Epidemiology of mental health problems in adults with learning disability: an update

Epidemiological studies measuring prevalence rates and factors associated with mental health problems in adults with learning disability have produced very different and sometimes contradictory results, mainly because of methodological problems. Consequently, much of the epidemiology of mental health problems in this population is still unknown, although improved methodology and additional information are emerging. This article describes the methodological difficulties of studies, the reported prevalence rates in the context of these difficulties and what is currently known about the factors associated with mental health problems in this population.

Unusual devastating self-injurious behaviour in a patient with a severe learning disability: treatment with citalopram

Physicians caring for people with severe learning disabilities are frequently faced with the problem of self-injurious behaviour, which often takes a chronic course. Among neurotransmitter systems the serotonergic system in particular is thought to be involved in the initiation and maintenance of self-injurious behaviour, and pharmacological treatment with serotonin enhancers or serotonin reuptake inhibitors has been shown to reduce impulsive aggressive behaviour.

Overcoming the oral aspects of -self-mutilation: description of a method

BACKGROUND/AIM

Self-injurious behavior (SIB) is a serious and chronic condition frequently seen in special needs populations, affecting 10% to 17% of individuals diagnosed with intellectual and/or developmental disabilities. A 2.5-year-old infant with SIB, whose presenting symptoms were severe tongue and lip lacerations accompanied by much hemorrhage, is presented here to illustrate the problem and to show how this may be prevented.

MATERIALS AND METHODS

An appliance is described which effectively limits the damage caused by SIB and permits rapid healing of existing injuries.

RESULTS

The method provides for a stable, retentive, and comfortable device on the infant's undererupted and largely nonretentive crowns of the deciduous teeth as well as for all permanent teeth in children, adolescents, and adults.

CONCLUSIONS

The appliance has been successfully employed for the past 10 years in patients with SIB who have attended for treatment in the Special Needs Clinic in our Department.

Pharmacological interventions for self-injurious behaviour in adults with intellectual disabilities: Abridged republication of a Cochrane systematic review

We aimed to determine clinical effectiveness of pharmacological interventions for self-injurious behaviour in adults with intellectual disability. We searched the following databases: CENTRAL; MEDLINE; EMBASE; PsycINFO; CINAHL; SCI; SSCI; Conference Proceedings Citation Index - Science; Conference Proceedings Citation Index - Social Science and Humanities; ZETOC; World Cat .We also searched ClinicalTrials.gov,ICTRP and the reference lists of included trials. We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour. We found five double-blind, placebo-controlled trials, which included a total of 50 people. Four trials compared the effects of naltrexone versus placebo and one trial clomipramine versus placebo. We did not identify any relevant placebo-controlled trials for other drugs. We presented a narrative summary, as meta-analysis was not appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures. There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating self-injurious behaviour. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.

Pharmacological interventions for self-injurious behaviour in adults with intellectual disabilities

BACKGROUND

Self-injurious behaviour among people with intellectual disability is relatively common and often persistent. Self-injurious behaviour continues to present a challenge to clinicians. It remains poorly understood and difficult to ameliorate despite advances in neurobiology and psychological therapies. There is a strong need for a better evidence base in prescribing and monitoring of drugs in this population, especially since none of the drugs are actually licensed for self-injurious behaviour.

OBJECTIVES

To determine clinical effectiveness of pharmacological interventions in management of self-injurious behaviour in adults with intellectual disability.

SEARCH METHODS

We searched the following databases on 19 February 2012: CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL, Science Citation Index, Social Science Citation Index, Conference Proceedings Citation Index - Science, Conference Proceedings Citation Index - Social Science and Humanities, ZETOC and WorldCat. We also searched ClinicalTrials.gov, ICTRP and the reference lists of included trials.

SELECTION CRITERIA

We included randomised controlled trials that examined drug interventions versus placebo for self-injurious behaviour (SIB) in adults with intellectual disability.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias for each trial using a data extraction form. We present a narrative summary of the results is presented. We did not consider meta-analysis was appropriate due to differences in study designs, differences between interventions and heterogeneous outcome measures.

MAIN RESULTS

We found five double-blind placebo-controlled trials that met our inclusion criteria. These trials assessed effectiveness and safety of drugs in a total of 50 people with intellectual disability demonstrating SIB. Four trials compared the effects of naltrexone versus placebo and one trial compared clomipramine versus placebo.One of the naltrexone versus placebo trials reported that naltrexone had clinically significant effects (≥ 33% reduction) on the daily rates of three of the four participants' most severe form of SIB and modest to substantial reductions in SIB for all participants; however, this study did not report on statistical significance. Another trial reported that naltrexone attenuated SIB in all four participants, with 25 mg and 50 mg doses producing a statistically significant decrease in SIB (P value < 0.05). Another trial (eight people) indicated that naltrexone administration was associated with significantly fewer days of high frequency self injury and significantly more days with low frequency self injury. Naltrexone had different effects depending on the form and location of self injury. Another trial with only 26 participants found that neither single-dose (100 mg) nor long-term (50 and 150 mg) naltrexone treatment had any therapeutic effect on SIB.Comparison of clomipramine versus placebo found no statistically significant benefit for any outcome measure, which included SIB rate and intensity, stereotypy and adverse events. However, it showed clinically significant improvement in the rate and intensity of SIB and stereotypy.There were very few noteworthy adverse events to report in any of the four trials in which these were reported.All trials were at high risk of bias, apart from one trial (Lewis 1996), which was probably at low risk of bias. The short period of follow-up was a significant drawback in the design of all five trials, as it did not allow long-term assessment of behaviour over time.We were unable to examine the efficacy of antidepressants other than clomipramine, antipsychotics, mood stabilisers or beta-blockers as we did not identify any relevant placebo-controlled trials.

AUTHORS' CONCLUSIONS

There was weak evidence in included trials that any active drug was more effective than placebo for people with intellectual disability demonstrating SIB. Due to sparse data, an absence of power and statistical significance, and high risk of bias for four of the included trials, we are unable to reach any definite conclusions about the relative benefits of naltrexone or clomipramine compared to placebo.

The age related prevalence of aggression and self-injury in persons with an intellectual disability: a review

The aim of this study was to analyse statistically published data regarding the age related prevalence of aggression and self-injury in persons with intellectual disability. Studies including prevalence data for aggression and/or self-injury broken down by age band were identified and relative risk analyses conducted to generate indices of age related change. Despite conflicting results, the analysis conducted on included studies considered to be the most methodologically robust indicated that the relative risk of self-injury, and to a lesser extent aggression, increased with age until mid-adulthood, with some indication of a curvilinear relationship for self-injury. These conclusions have implications for the understanding of the development of different forms of challenging behaviour and the importance of early intervention strategies.

Self-injurious behaviour in individuals with autism spectrum disorder and intellectual disability

BACKGROUND

Autism spectrum disorder (ASD) has been identified as a risk marker for self-injurious behaviour. In this study we aimed to describe the prevalence, topography and correlates of self-injury in individuals with ASD in contrast to individuals with Fragile X and Down syndromes and examine person characteristics associated with self-injury across and within these groups.

METHOD

Carers of individuals with ASD (n = 149; mean age = 9.98, SD = 4.86), Fragile X syndrome (n = 123; mean age = 15.32, SD = 8.74) and Down syndrome (n = 49; mean age = 15.84, SD = 12.59) completed questionnaires relating to the presence and topography of self-injury. Information was also gathered regarding demographic characteristics, affect, autistic behaviour, hyperactivity, impulsivity and repetitive behaviour.

RESULTS

Self-injurious behaviour was displayed by 50% of the ASD sample: a significantly higher prevalence than in the Down syndrome group (18.4%) but broadly similar to the prevalence in Fragile X syndrome (54.5%). Self-injury was associated with significantly higher levels of autistic behaviour within the Down and Fragile X syndrome groups. Within the ASD group, the presence of self-injury was associated with significantly higher levels of impulsivity and hyperactivity, negative affect and significantly lower levels of ability and speech.

CONCLUSIONS

Self-injurious behaviour is prevalent in individuals with ASD and the presence of ASD phenomenology increases the risk of self-injury in individuals with known genetic disorders but without a diagnosis of idiopathic autism. Person characteristics associated with self-injury in ASD indicate a role for impaired behavioural inhibition, low levels of ability and negative affect in the development of self-injurious behaviour.

Identification of Emerging Self-Injurious Behavior in Young Children: A Preliminary Study

Self-injurious behavior (SIB) is a chronic disorder that often begins in early childhood; however, few studies have examined the onset of SIB in young children. This preliminary study reports on the identification, assessment and observation of SIB in 32 children who had begun to engage in SIB within the previous 6 months. Participants were ages birth to 5 years and presented with or were at risk for intellectual and/or developmental disabilities. Assessment measures included parental interviews, developmental and language measures, standardized measures of problem behavior, and direct observations conducted in the home. Results indicated that for most children, SIB emerged prior to age 1 year, and multiple topographies of SIB and other problem behaviors developed in most children. Multiple measures were useful in identifying SIB and in characterizing the behavior by topography, frequency, and severity. Findings from the examination of child communication in relation to SIB were inconclusive. Results are discussed in relation to theories of SIB emergence, and previous observational studies of young children with SIB.

Physical conditions and challenging behaviour in people with intellectual disability: a systematic review

BACKGROUND

Challenging behaviour is a major problem among people with intellectual disabilities. Physical factors may be an important cause. The aim of the present systematic review was to determine the physical conditions associated with challenging behaviour.

METHODS

A literature search was conducted in PubMed and the Cochrane systematic review database for empirical studies published between 1990 and 2008. The quality of all the studies that met the inclusion criteria was assessed using the SIGN-50 methodology checklists.

RESULTS

The search identified 45 studies, which looked at general medical conditions, motor impairment, epilepsy, sensory impairment, gastrointestinal disease, sleep disorders, dementia and others. There were four high-quality observational studies, seven well-conducted observational studies, 21 observational studies of low methodological quality and 13 non-analytical studies. There were significant and independent associations between challenging behaviours and urinary incontinence, pain related to cerebral palsy and chronic sleep problems, and between self-injurious behaviour and visual impairment. No association was found with hearing impairment, bowel incontinence, mobility impairment or epilepsy. Many other physical conditions were not addressed at all.

CONCLUSION

Medical conditions can play a role in challenging behaviour, and this should be evaluated in the clinical setting. So far, the level of evidence is generally low, and longitudinal studies are completely lacking. We recommend a systematic approach to research examining the role of physical conditions in challenging behaviour, the ultimate aim being to establish a basis for the development of clinical guidelines.

Reviewing risk for individuals with developmental disabilities

There are many categories of risky behaviors that are of interest to individuals, agencies, and institutions interested in care for developmentally disabled persons. These include challenging behaviors such as aggression and self-injury, psychiatric diagnoses, medical problems, criminal behaviors, and victimization. The literature in this area is difficult to digest due to a number of methodological problems. This paper reviews the research on one of these behaviors, self-injury, and provides a framework that can be applied to other research on predicting risk. Additionally, it attempts to organize the findings in such a way as to maximize the utility to providers and suggest useful directions for future research.

Self-injury among a community cohort of young children at risk for intellectual and developmental disabilities

OBJECTIVE

To identify risk factors for self-injurious behavior in young children with developmental delay and to determine whether that group is also more likely to exhibit other challenging behaviors.

STUDY DESIGN

A retrospective chart review of 196 children < 6 years of age referred for comprehensive neurodevelopmental evaluations. We analyzed child developmental level, receptive and expressive communication level, mobility, visual and auditory impairment, and co-morbid diagnoses of cerebral palsy, seizure disorders, and autism.

RESULTS

Sixty-three children (32%; mean age = 42.7 mo, 63% male) were reported to engage in self-injurious behavior at the time of the evaluation. Children with and without self-injurious behavior did not differ on overall developmental level, expressive or receptive language level, mobility status or sensory functioning, or in rates of identification with cerebral palsy, seizure disorders, or autism. However, the self-injurious behavior group was rated significantly higher by parents on destructive behavior, hurting others, and unusual habits.

CONCLUSIONS

Although self-injurious behavior was reported to occur in 32% of the cohort, the modal frequency was monthly/weekly and the severity was low. No significant differences were found for risk markers reported for adults, adolescents, and older children with intellectual and developmental disabilities. However, self-injurious behavior was comorbid with other behavior problems in this sample.

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.

Children with autism spectrum disorders: a comparison of those who regress vs. those who do not

OBJECTIVE

While autism spectrum disorders (ASD) constitute a group of similar conditions, considerable heterogeneity in symptoms of these neurodevelopmental disorders have been noted. One of the most important, yet least studied, of these factors is developmental regression.

METHODS

One-hundred and twenty-five children were studied and broken down into the following three groups: ASD children with and without substantial regression and typically developing children. In study one, the three groups were compared on global measures of ASD symptomatology, comorbid psychopathology, challenging behaviour and social skills. In study two, the two ASD groups were compared on each individual item from the dependent measures.

RESULTS

Mean age when regression occurred was 27.76 months. The ASD children as a whole differed from the typically developing controls, showing more symptoms of ASD, as would be expected, and poorer social skills, while differences were also noted between the two ASD groups.

CONCLUSIONS

It was determined that children with ASD who regress present with a distinct behavioural profile when compared to children with ASD who do not regress, which included greater levels of impairment on global measures of ASD symptomatology, comorbid psychopathology, challenging behaviour and social skills.

Adults with intellectual disabilities: prevalence, incidence and remission of self-injurious behaviour, and related factors

BACKGROUND

Self-injurious behaviour (SIB) is a serious condition, with implications for the person, their family and financial costs to the state providing care. The previously reported prevalence of SIB has ranged from 1.7% to 41%, or 1.7%-23.7% in community studies. There has been little study of remission rate, and incidence has not previously been reported. SIB has been reported to be individually associated with lower ability, autism and communication impairments, but given the inter-relationships between these three factors, it is not known whether they are independently associated with SIB. This study investigates the point prevalence, incidence and remission rates of SIB among the adult population with intellectual disabilities (ID), and explores which factors are independently associated with SIB.

METHOD

A prospective cohort study design was used in a general community setting. The participants were all adults (16 years and over) with ID in a defined geographical area. Individual assessments were conducted with all participants.

RESULTS

The point prevalence of SIB (as defined by DC-LD) was 4.9%, the two-year incidence was 0.6%, and two-year remission rate was 38.2%. Independently related to SIB were: lower ability level, not living with a family carer, having attention deficit hyperactivity disorder, visual impairment, and not having Down syndrome. Other factors, including communication impairment, autism, and level of deprivation of the area resided within, were not related.

CONCLUSIONS

SIB is not as enduring and persistent as previously thought; a significant proportion gains remission in this time period. This should provide hope for families, paid carers and professionals, and reduce therapeutic nihilism. Our study is a first tentative step towards identifying risk-markers for SIB, and developing aetiological hypotheses for subsequent testing. The extent to which SIB may be a relapsing-remitting (episodic) condition requires further investigation, so does further hypothesis-based investigation of factors that might be predictive of incidence of, and remission from, SIB.

Self-injurious behavior and tuberous sclerosis complex: frequency and possible associations in a population of 257 patients

Self-injurious behavior (SIB) has been observed in people with tuberous sclerosis complex (TSC), although the frequency of SIB in TSC is largely unknown. SIB is associated with intellectual and developmental disabilities, but there is no single cause of SIB. We retrospectively examined the frequency of SIB in a population of 257 patients with TSC and determined possible associations with SIB. We found a 10% frequency of SIB in our TSC population. When compared with patients without psychiatric symptoms, we identified a significantly higher rate of electroencephalographic interictal spikes in the left frontal lobe and a significantly lower number of tubers in the left occipital, parietal, and posterior temporal lobes. We also found that frequency of TSC2 mutation, history of infantile spasms, history of seizures, mental retardation, and autism are significantly associated with SIB.

Clinical predictors of severe behavioural problems in people with intellectual disabilities referred to a specialist mental health service

Associations between demographic and clinical variables and severe behavioural problems in people with intellectual disabilities were examined in a cross-sectional survey of 408 adults consecutively referred to a specialist mental health service. Severe behavioural problems were present in 136 (33.3%) of the sample. The demographic and clinical predictors of severe behavioural problems in this sample were identified by logistic regression. Age and gender were not associated with severe behavioural problems. The presence of severe ID independently predicted the presence of severe behavioural problems. Schizophrenia spectrum disorders and personality disorders independently predicted the presence of severe behavioural problems, whereas the presence of an anxiety disorder independently predicted their absence. There is an increasing evidence base of relationships between mental disorders and behavioural problems in people with ID although the pattern of these relationships remains unclear.

Health and sleep problems in Cornelia de Lange Syndrome: a case control study

BACKGROUND

Self-injury, sleep problems and health problems are commonly reported in Cornelia de Lange Syndrome (CdLS) but there are no comparisons with appropriately matched participants. The relationship between these areas and comparison to a control group is warranted.

METHOD

54 individuals with CdLS were compared with 46 participants with intellectual disability (ID) of mixed aetiology who were similar in terms of degree of ID, mobility, age and gender using informant-based measures of health problems, sleep and self-injury.

RESULTS

Participants with CdLS experienced significantly more current and lifetime health problems with eye problems and gastrointestinal disorders prominent. Although 55% of those with CdLS experienced sleep problems this prevalence was not different from the comparison group. Sleep disorder was not associated with self-injury in the CdLS group, skin problems were associated with severity of self-injury but not presence.

DISCUSSION

People with CdLS experience a range of significant health problems and have more health concerns than others with the same degree of ID. Although this has been well documented in the past, the current high prevalence of health concerns indicates the need for regular health assessment and appropriate intervention.

Atypical behaviors in children with autism and children with a history of language impairment

The frequency, course, and inter-relationships of atypical eating, sleeping, self-injurious behavior, aggression and temper tantrums in children with autism and children with a history of language impairment (HLI), was investigated using a parent interview that was created to examine these problem behaviors. The relationships between these behaviors and language, IQ, severity of autistic symptoms and depression were also assessed. Atypical eating behavior, abnormal sleep patterns, temper tantrums, and self-injurious behavior were significantly more common in the children with autism than those with HLI. Within the autism group, children who exhibited more atypical behaviors tended to have a lower nonverbal IQ, lower levels of expressive language, more severe social deficits and more repetitive behaviors. No relationship between the number of atypical behaviors and measures of cognitive or language ability was noted in the HLI group. However, having more atypical behaviors was related to increased restricted, repetitive behaviors in children with HLI. The atypical behaviors could be divided into two groups: abnormal eating and sleeping, which were independent and tended to begin early in life; and self-injury, tantrums and aggression, which began later and were inter-related. Sleep abnormalities were more common in children (groups combined) diagnosed with major depression.

Cognitive behaviour therapy and people with learning disabilities: implications for developing nursing practice

People with learning disabilities are an ageing and increasing population and have been the subject of policy initiatives by the four countries of the UK, detailing the range of supports that need to be in place for this group. The evidence base of their mental health needs is growing and with it the need to ensure the full range of psychotherapies available to the general population are made available to people with learning disabilities. Cognitive Behaviour Therapy (CBT) is now a widely accepted and effective form of psychotherapy for many mental health problems and the evidence base is growing on the effectiveness with the learning disability population; however, the model needs to be applied differently for this group to take account of their cognitive impairment and support needs. Registered Nurses in Learning Disabilities are well placed to apply this approach within their clinical practice; however, there is an absence of leadership and direction in the development of CBT for this group of clinicians. There is a need to support education and practice development to contribute to addressing the emotional needs of people with learning disabilities. Action is required to support education to prepare Registered Nurses in Learning Disabilities to practice CBT and to contribute to the ongoing development of research in this area of clinical practice.

Pharmacological management of challenging behavior of individuals with intellectual disability

In many Westernized countries, including Australia, concerns about the use of psychotropic drugs to manage the challenging behavior of individuals with intellectual disability have resulted in the development of legislative and procedural controls. Although these constraints may limit indiscriminate use, employing medication remains a common practice. This study examined information about 873 individuals (566 males, 307 females) who were the subjects of reports to the Intellectual Disability Review Panel in March 2000 concerning the use of chemical restraint. A high proportion of people with intellectual disability were reported to have received drugs for purposes of behavioral restraint. The range of drugs was extensive, although those from the antipsychotic class were the most frequently reported. Many individuals concurrently received more than one type of drug or more than one drug from the same drug class. More males than females and more older than younger individuals were administered medication. A relationship between gender and age was apparent, with younger males but older females dominating. The use of drugs to mange the behavior of people with intellectual disability may at times be warranted. However, it is important that the extent and type of drug use, as well as the characteristics of those who are medicated, be subject to ongoing scrutiny.

Risk factors for self-injurious behaviours among 222 young children with autistic disorders

The aim of this study was to identify risk factors for self-injurious behaviours (SIBs) in children with autistic disorders. The occurrence of SIB was examined in comparison with the following variables: chronological age, sex, adaptive skills, speech level, associated medical condition, degree of autism and parental social class. The subjects were 222 children aged under 7 years and all of them fulfilled the ICD-10 criteria for infantile autism. Retrospective data were collected on demographic characteristics and medical condition. Children were assessed in terms of speech, degree of autism and adaptive skills in communication, socialization and daily living skills domains. Results indicated that 50% of the children experienced SIB and 14.6% had severe SIBs. Lower chronological age, associated perinatal condition, a higher degree of autism and a higher daily living skills delay were risk factors of SIBs but parental class, sex and epilepsy were not.

Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments

OBJECTIVES

To explore whether self-injurious behavior (SIB) alters pain expression in children with severe cognitive impairments and the relation between SIB and chronic pain.

STUDY DESIGN

Caregivers of 101 nonverbal children 3 to 18 years of age (55% boys) completed the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R) retrospectively and for an observed pain episode. Caregivers of children with SIB (n = 44) completed the Behavior Problems Inventory, the Self-Injury Grid, and the Self-Injury and Self-Restraint Checklist.

RESULTS

Multivariate analysis of variance indicated that NCCPC-R scores did not differ between children with and those without SIB. However, t tests indicated that children with chronic pain (n = 13) self-injured less body surface (P =.01) and fewer body sites (P =.04) than did children without (n = 31). Multiple Correspondence Analysis generated 2 dimensions (49% variance), suggesting a distinction between two SIB forms: (1) high frequency of SIB to the head/hand and absence of chronic pain and (2) less frequent SIB near the site of pain.

CONCLUSIONS

Children with severe cognitive impairments who display SIB do not have reduced pain expression, and chronic pain may influence the frequency and location of SIB. Further research should examine the usefulness of these findings for management of SIB and pain.

Self-injurious behavior in rhesus monkeys: new insights into its etiology, physiology, and treatment

Self-injurious behavior (SIB) is a significant human health problem frequently associated with profound intellectual disabilities, genetic diseases, and psychiatric conditions. However, it also occurs in subclinical populations and appears to be on the rise in adolescents and young adults. SIB is also seen in a small percentage of nonhuman primates that injure themselves through biting. We have begun to characterize SIB in rhesus monkeys to identify some of the risk factors associated with this disorder, and to determine the parallels with the human condition. In our study population, 14% of individually housed monkeys (the vast majority of which are males) have a veterinary record for self-inflicted wounding. Wounding is rare, but self-directed biting is common. SIB can be elicited during aggressive altercations and may be associated with husbandry events. Some monkeys appear to be more vulnerable to acquiring SIB. This increased vulnerability is associated with certain social experiences in the first 2 years of life and with exposure to a larger number of moderately stressful events as compared to controls. Monkeys with SIB also have a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, indicated by a blunted cortisol response to mild stressors. Our findings suggest that SIB may be a coping strategy to reduce arousal. Biting appears to rapidly lower an escalating heart rate. The potentially reinforcing effects of SIB may account for the failure of some treatment regimens. These findings are compared to studies of SIB in humans, and concordances are identified.

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.

Being in a fragmented and isolated world: interviews with carers working with a person with a severe autistic disorder

AIM

To illuminate the meaning of being a carer for a person with a severe autistic disorder.

BACKGROUND

Carers working with people with severe autism are occasionally exposed to residents' self-injurious behaviours and violent actions and at time residents appear resistant to all forms of treatment.

DESIGN/METHOD

A qualitative case study was conducted. Six Swedish carers enrolled nurses (ENs), working on a special ward in a nursing home were interviewed about their lived experiences when caring for an individual with a severe autistic disorder. Narrative interviews were conducted and interpreted using a phenomenological-hermeneutic method inspired by Paul Ricoeur.

FINDINGS

Two themes were formulated which describe the carers' reality and their dream of an ideal. This ideal described carers' experiences of being trapped in a segmented and isolated care reality and their longing to achieve a sense of wholeness. The findings were interpreted and reflected on in the light of a framework inspired by the German philosopher Karl Jaspers in order to achieve a deeper understanding of the text.

CONCLUSIONS

In their desperation, the carers used their empirical knowledge based on scientific knowledge, which could be understood as a substitute for their vision of a consolating wholeness. This paper shows that searching for a substitute to consolation seems to be an important aspect of the meaning of being a carer for a person with a severe autistic disorder.

Mental disorder in adults with intellectual disability. 2: The rate of behaviour disorders among a community-based population aged between 16 and 64 years

Despite the difficulty of defining behaviour disorder, most previous studies have reported a high rate of behaviour disorders in people with intellectual disability (ID). The aim of the present study was to establish the overall rate and types of behaviour disorders in a population-based sample of adults with ID. The other aim was to explore the possible risk factors that are associated with the overall rate as well as different types of behaviour disorders. One hundred and one adults with ID aged between 16 and 64 years were randomly selected from a sample of 246 such adults, i.e. those who were known to the Vale of Glamorgan Social Services Department in South Wales, UK. Thirteen behaviour disorders were rated according to the Disability Assessment Schedule. Background data on subjects were also collected, and were subsequently analysed to assess the relationship between different risk factors and behaviour disorders. Sixty-one subjects (60.4%) had at least one behaviour disorder of any severity or frequency. Twenty-three per cent of subjects showed aggression, 24% self-injurious behaviour, 36% temper tantrum, 26% overactivity, 29% screaming, 38% attention-seeking behaviour, 20% objectionable habits, 18% night-time disturbance and 12% of subjects showed destructiveness. Statistically significant associations were seen between the rate of overall behaviour disorder and the use of psychotropic medication, and between family and group home residence. The rate of aggression was significantly associated with the use of psychotropic medication. The rate of self-injurious behaviour was significantly associated with the severity of ID, female gender and poor communication abilities. The rate of temper tantrum was significantly associated with the use of psychotropic medication. Twenty-four subjects showed severe or frequent aggression, destructiveness, self-injury or temper tantrum, and 11 individuals showed real challenging behaviours. Severe behaviour problems were significantly associated with female gender, severity of ID, the presence of a history of epilepsy and attendance at day activities.

Self-injurious behavior: gene-brain-behavior relationships

This paper summarizes a conference held at the National Institute of Child Health and Human Development on December 6-7, 1999, on self-injurious behavior [SIB] in developmental disabilities. Twenty-six of the top researchers in the U.S. from this field representing 13 different disciplines discussed environmental mechanisms, epidemiology, behavioral and pharmacological intervention strategies, neurochemical substrates, genetic syndromes in which SIB is a prominent behavioral phenotype, neurobiological and neurodevelopmental factors affecting SIB in humans as well as a variety of animal models of SIB. Findings over the last decade, especially new discoveries since 1995, were emphasized. SIB is a rapidly growing area of scientific interest to both basic and applied researchers. In many respects it is a model for the study of gene-brain-behavior relationships in developmental disabilities.

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.