Behavioural symptoms among people with severe and profound intellectual disabilities: a 26-year follow-up study

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

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

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.

Self-injury, aggression and destruction in children with severe intellectual disability: Incidence, persistence and novel, predictive behavioural risk markers

BACKGROUND

A risk informed, early intervention strategy for self-injurious, aggressive and destructive behaviours in children with severe intellectual disability is gaining support. The aims of this study were to establish the cumulative incidence and persistence of self-injury, aggression and destruction and the relationship between these behaviours and two potentially predictive behavioural risk markers (repetitive behaviour, and impulsivity and overactivity) in children at high risk.

METHODS

In a longitudinal design self-injury, aggression and destruction were assessed by teachers of 417 children with severe intellectual disability on two occasions separated by 15-18 months.

RESULTS

Aggression, destruction and self-injury were persistent (69%, 57% and 58% respectively). Repetitive and restricted behaviours and interests (RRBI) and overactivity/impulsivity (O/I) were significantly associated with aggression (O/I OR=1.291, p<.001), destruction (RRBI OR 1.201, p=.013; O/I OR 1.278, p<.001) and/or self-injury (RRBI, OR 1.25, p=.004; O/I OR=1.117, p<.001). The relative risk of the cumulative incidence of self-injury, aggression and destruction was significantly increased by repetitive and restricted behaviours and interests (self-injury 2.66, destruction 2.16) and/or overactivity/impulsivity (aggression 2.42, destruction 2.07).

CONCLUSIONS

The results provide evidence that repetitive and restricted behaviours and interests, and overactivity/impulsivity, are risk markers for the onset of self-injury, aggression and destruction within the already high risk group of children with severe intellectual disability.

Psychological therapies for people with intellectual disabilities: comments on a matrix of evidence for interventions in challenging behaviour

BACKGROUND

Psychological therapies with a proven efficacy in the general population are being adapted for use with people who have intellectual disabilities in community settings.

METHODS

A systematic review of peer-reviewed literature published between 1980 and 2010 was carried out, to identify the evidence base for effective psychological interventions in challenging behaviour. Relevant databases were searched using applied key terms. Evidence was graded, according to the quality of the research. A best-evidence Matrix was produced to improve guidance for service providers and practitioners in the range, volume and quality of psychological interventions.

RESULTS

There is a limited amount of efficacy research that meets the most stringent standards of empirical evidence.

CONCLUSIONS

It is important to broaden the evidence base and consider the context of psychological interventions, alongside the values underpinning care and treatment.

Social inclusion and people with intellectual disability and challenging behaviour: a systematic review

BACKGROUND

Social inclusion is central to disability policies internationally. The high risk of social exclusion for people with intellectual disability is compounded for those with challenging behaviour.

METHOD

A systematic literature review examined how social inclusion of people with intellectual disability and challenging behaviour has been researched and operationalised in the empirical literature, and aimed to determine what evidence exists about the extent of social inclusion by people with intellectual disability and challenging behaviour.

RESULTS

A thematic analysis of the 14 papers identified that social inclusion has been poorly defined and measured, and that the little research that has occurred in respect of people with challenging behaviour has demonstrated their potential to be socially included.

CONCLUSIONS

Clearer conceptualisation of inclusion, and greater understanding of practices that support social inclusion and system level mechanisms, which ensure goals around inclusion gain prominence in funding and support plans, may address the neglect of this critical quality-of-life domain for people with challenging behaviour.

Behavioural and emotional problems in people with severe and profound intellectual disability

BACKGROUND

People with severe and profound levels of intellectual disability (ID) are frequently examined as a single group in research. However, these two groups may be significantly different, particularly in the area of emotional and behavioural difficulties.

METHOD

The Developmental Behaviour Checklist (DBC) was completed by parents and caregivers of 107 people with severe ID and 22 people with profound ID at four time periods across 12 years. Regression analyses were used to examine trends in sub-scale scores across time and groups.

RESULTS

Significant differences between the groups of people with severe and profound ID were found. People with profound ID had significantly lower scores across all sub-scales except Social Relating. This was usually related to fewer items being selected as present for people with profound ID, as opposed to the scores being attributable to lower item severity scores.

CONCLUSIONS

There are significant differences between groups of people with severe and profound ID in scores on the DBC, indicating differences in behavioural and emotional problems. Caution should be exercised by researchers treating these two disparate groups as a single group, and by practitioners translating such findings into practice.

Workforce development and challenging behaviour: training staff to treat, to manage or to cope?

Staff working directly with adults' challenging behaviours in learning disability services need to be very good at what they do. They also need to want to do the job. A theory-practice gap exists, however, between what is known about effective, evidence-based approaches and whether and how these are used in person-centred community services. Many frontline staff working with people with the most serious challenging behaviours do not have the skills to implement programmes to change behaviour. This discussion article reviews workforce development in the context of clinical and service guidelines and asks whether the legitimate purview of frontline staff is treating challenging behaviour, managing it or simply coping with it on a daily basis, whilst maintaining the best quality of life possible for service users.

Persistent challenging behaviour in people with an intellectual disability

PURPOSE OF REVIEW

The aim of the present review is to summarize recent research findings on the persistence of challenging behaviours in adults and children with an intellectual disability.

RECENT FINDINGS

Studies varied in their definition and measurement of persistence or change in challenging behaviours. Persistence levels tended to be high in adults and challenging behaviours were stable over time, especially in individuals with autism. Moderate to high stability levels were evident in children, although there was a tendency for decreases in mean scores for behaviour problems over time.

SUMMARY

A substantial proportion of people with an intellectual disability experience persistent and stable challenging behaviours across their lives. Our knowledge of the factors that drive these high levels of persistence remains limited.

Does visual impairment lead to additional disability in adults with intellectual disabilities?

BACKGROUND

This study addresses the question to what extent visual impairment leads to additional disability in adults with intellectual disabilities (ID).

METHOD

In a multi-centre cross-sectional study of 269 adults with mild to profound ID, social and behavioural functioning was assessed with observant-based questionnaires, prior to expert assessment of visual function. With linear regression analysis the percentage of variance, explained by levels of visual function, was calculated for the total population and per ID level.

RESULTS

A total of 107/269 participants were visually impaired or blind (WHO criteria). On top of the decrease by ID visual impairment significantly decreased daily living skills, communication & language, recognition/communication. Visual impairment did not cause more self-absorbed and withdrawn behaviour or anxiety. Peculiar looking habits correlated with visual impairment and not with ID. In the groups with moderate and severe ID this effect seems stronger than in the group with profound ID.

CONCLUSION

Although ID alone impairs daily functioning, visual impairment diminishes the daily functioning even more. Timely detection and treatment or rehabilitation of visual impairment may positively influence daily functioning, language development, initiative and persistence, social skills, communication skills and insecure movement.

Persistence of challenging behaviours in adults with intellectual disability over a period of 11 years

BACKGROUND

Challenging behaviours in people with an intellectual disability (ID) often develop early and tend to persist throughout life. This study presents data on the chronicity of challenging behaviours in adults with ID over a period of 11 years, and explores the characteristics of people with persistent serious behaviour problems.

METHOD

Support staff provided data on 58 adults living in a long-term residential facility using an interview survey schedule assessing challenging behaviours in 1992 and 2003.

RESULTS

Participants presenting with serious physical attacks, self-injury and frequent stereotypy were the most likely to persist in these behaviours over time. These behaviours were characterised by high persistence percentages and associations over time. However, the earlier presence of serious challenging behaviours did not significantly affect the likelihood of serious challenging behaviours in 2003. Individuals with persisting behaviour problems differed from those who did not present serious behaviour problems on the basis of their younger age, increased mobility, and decreased sociability and daily living skills in 1992.

CONCLUSIONS

Estimates of persistence for challenging behaviours are affected by the statistics chosen to represent stability. The apparent persistence of serious challenging behaviours highlights the need to identify the factors related to maintenance of these behaviours over time. The participant characteristics and adaptive behaviours identified in the present study were not consistently related to the persistence of challenging behaviours. Therefore, other factors, including environmental characteristics, are likely to be related to challenging behaviour persistence.

Staff training and challenging behaviour: who needs it?

Staff working directly with people who have challenging behaviour in learning disability services need to be D good at what they do. These staff are trained by their employers to manage and to treat challenging behaviours and to improve the quality of life of people in their care. While such training is generally well evaluated by care staff, there is limited evidence that training alone changes poor attitudes or improves staff performance. Training has not been linked to quality of outcomes for service users. From research on treating challenging behaviour, achieving maintenance of behavioural gains after treatment has been discontinued is the exception rather than the rule. Can the same be said for maintaining gains achieved through staff training in the area of challenging behaviour? This discussion article reviews the value of training for staff working with people with challenging behaviour.

Developmental course of psychopathology in youths with and without intellectual disabilities

BACKGROUND

We aimed to describe similarities and differences in the developmental course of psychopathology between children with and without intellectual disabilities (ID).

METHODS

Multilevel growth curve analysis was used to analyse the developmental course of psychopathology, using the Child Behavior Checklist (CBCL), in two longitudinal multiple-birth-cohort samples of 6- to 18-year-old children with ID (N = 978) and without ID (N = 2,047) using three repeated measurements across a 6-year period.

RESULTS

Children with ID showed a higher level of problem behaviours across all ages compared to children without ID. A significant difference between the samples in the developmental courses was found for Aggressive Behaviour and Attention Problems, where children with ID showed a significantly larger decrease. Gender differences in the development of psychopathology were similar in both samples, except for Social Problems where males with ID showed a larger decrease in problem behaviour across time than females with ID and males and females without ID.

CONCLUSIONS

Results indicate that children with ID continue to show a greater risk for psychopathology compared to typically developing children, although this higher risk is less pronounced at age 18 than it is at age 6 for Aggressive Behaviour. Contrary to our expectations, the developmental course of psychopathology in children with ID was quite similar from age 6 to 18 compared to children without ID. The normative developmental trajectories of psychopathology in children with ID, presented here, can serve as a yardstick against which development of childhood psychopathology can be detected as deviant.

Person Focused Training: a model for delivering positive behavioural supports to people with challenging behaviours

BACKGROUND

Person Focused Training is introduced as a model of service delivery for people with severe challenging behaviours. It is defined as training and supporting staff to conduct functional assessments and to design and implement positive behavioural support for specific individuals with challenging behaviours.

METHOD

Longitudinal outcome data are presented from 138 behaviour support plans developed by staff over a seven year period were analysed to determine reductions in frequency of challenging behaviours. Degree of behaviour change was determined across topography of behaviour, gender, age, level of disability, location of residence and role of course participant.

RESULTS

Results indicate that the implementation by staff of behaviour support plans are associated with significant improvement in 77% of cases at an average follow-up of 22 months after implementation of support plans. Only location of residence was identified as related to reduction in challenging behaviours with large residential centres being associated with lower rates of behavioural improvement.

CONCLUSIONS

It is argued that Person Focused training may represent an alternative to existing models of supporting individuals with challenging behaviours. The implications of front-line staff designing and implementing behaviour support plans for the organisation of services and the role of the clinical psychologist are considered.

Medical screening in the emergency department for psychiatric admissions: a procedural analysis

Patients who are admitted to psychiatric inpatient wards often undergo a medical screening examination in the emergency department to rule out serious or underlying medical conditions that may be better treated elsewhere. Unfortunately, prior research has been conflicting on the relative merits of various screening procedures, making it difficult to implement guidelines. A systematic review of the literature was undertaken to research the current state of knowledge in medical screening procedures. Electronic searches were conducted in PubMed, MEDLINE, and the Cochrane Library for publication years 1966-2003. No restrictions were placed on language or on quality of publications. Twelve studies were found that reported specific yields of various screening procedures. Results indicate that medical history, physical examination, review of systems, and tests for orientation have relatively high yields for detecting active medical problems in patients presenting with psychiatric complaints. Routine laboratory investigations generally have a low yield for clinically significant findings. However, these should be added selectively for four groups at higher risk of serious medical conditions, i.e., the elderly, substance users, patients with no prior psychiatric history, and patients with preexisting medical disorders and/or concurrent medical complaints.

Autism spectrum disorder: screening, diagnosis, and medical evaluation

Autism spectrum disorder (ASD) are a group of behaviorally defined neurodevelopmental disabilities with core deficits in socialization, communication, and behavior, although the presentation can be extremely variable. This article describes the core deficits in ASD, as well as the differential diagnosis and the more commonly associated comorbid disorders. The importance of early diagnosis is emphasized, and screening and assessment tools are reviewed. Finally, the role of the pediatric neurologist is discussed with regard to specific components of the evaluation, including history, physical examination, and ancillary testing.