Andrew H. Reid

Challenging Behaviour: Analysis and Intervention in People with Learning Difficulties

Eric Emerson Cambridge University Press, pounds sterling19.95, pp 233 ISBN 0 521 40665 X The term “challenging behaviour” is a product of the 1980s and of political correctness. As defined by Eric Emerson it is: “Culturally abnormal behaviour of such an intensity, frequency or duration that the physical safety of the person or others is likely to be placed in serious jeopardy, or behaviour which is likely to seriously limit the use of, or result in the person being denied access to, ordinary community facilities.” In the context …

Behavioural syndromes identified by cluster analysis in a sample of 100 severely and profoundly retarded adults

Very little is known about psychiatric disorders in severely and profoundly retarded adults. We have investigated these disorders by systematically recording and collecting data about the behaviour of 100 severely and profoundly retarded hospitalized adults and subjecting the data thus derived to cluster analysis. Eight clusters were isolated. The clinical psychiatric significance of these clusters is discussed and their relationship to cause retardation, duration of stay in hospital and visiting is considered. A diagnostic framework for psychiatric disorder in severely and profoundly retarded adults is put forward and some possible treatment approaches are suggested.

Personality disorder in mental handicap.

100 randomly selected mildly or moderately mentally retarded adults were assessed for personality disorder using the Standardized Assessment of Personality devised by Mann et al. (1981). By the terms of this instrument 56% of patients showed features of abnormal personality, and in 22% this abnormality was marked, suggesting the presence of personality disorder. Personality problems may be a more significant factor in assessing a mentally retarded persons acceptability in a community setting than has hitherto been realized.

A double-blind, placebo controlled, crossover trial of carbamazepine in overactive, severely mentally handicapped patients

A double-blind, placebo controlled, crossover trial of carbamazepine in 12 severely and profoundly mentally retarded, overactive adult patients is described. The trial lasted 7 months and those patients in whom overactivity was the dominant problem responded to some degree to carbamazepine with a reduction in overactivity. This was particularly so in patients in whom overactivity was accompanied by some elevation of mood. Patients in whom overactivity was part of a wider spectrum of multiple behaviour disorders showed a scatter of responses. There was no relationship between response to carbamazepine and the presence or absence of epilepsy. The trial identified a small group of mentally retarded patients in whom carbamazepine might be clinically useful.

Psychiatric disorder in an adult training centre and a hospital for the mentally handicapped

Seventy-five mentally handicapped adult individuals attending a training centre were compared with 75 adult patients in a mental subnormality hospital using a standardized psychiatric interview. Ten of the individuals at the training centre were rated in the pathological range for overall psychiatric disturbance compared with 23 patients in hospital. Details are presented for the various psychiatric symptoms.

Schizophrenia in Mental Retardation: Clinical Features.

Schizophrenia is a small but important aspect of the psychiatry of mental retardation. In this article the literature is reviewed and the clinical features, symptomatology, and diagnostic parameters are discussed. Data are presented about prevalence rates, degree of mental retardation, male: female distribution, and age of onset. There appears to be no specific relationship with epilepsy or chromosomal abnormalities, although paranoid syndromes are often associated with disorders of hearing and vision. Differential diagnosis is considered and treatment approaches outlined.

The effects of hypnotics on imipramine treatment

Plasma imipramine and desmethylimipramine concentrations and depression ratings were measured over a 3 week period in 3 groups of hospitalised depressed patients given standard doses of imipramine. The first group received imipramine alone, the others either amylobarbitone or nitrazepam in addition as a night sedative. The plasma antidepressant levels were consistently higher in the group receiving no hypnotic but only significantly so in the case of ‘total’ IMI in the imipramine alone group compared to the group receiving imipramine plus amylobarbitone. The inter-individual differences in plasma levels were large. There was no difference between the groups with regard to changes in depression, sleep or side-effects. From a clinical point of view, there is therefore no evidence from this study of adverse effects of these drugs given in combination nor any evidence to suggest that the dosage of imipramine given should be adjusted when administered along with either of the hypnotics studied.

Psychiatry of mental handicap: a review.

Over the last twenty years there has been a change in concepts of care for mentally retarded people. It is widely held that it is preferable for retarded people to remain in the community, either within their natural or foster family, and if this is not possible, then care within a small group, community home or hostel environment is considered preferable to care in hospital. Some advocates of community care policies maintain that all retarded people can be cared for in this way. The reality is that whereas most retarded people can be managed in the community, there is a substantial number who, by reason of physical dependency, psychiatric or behavioural disorder, require the resources and facilities of medical and nursing care in hospital. The diagnosis, clinical features, natural history and treatment of psychiatric and behavioural disorders in mentally handicapped people have therefore assumed a much greater significance, since these disorders are now frequently more important than the degree of intellectual retardation in determining whether a retarded person does or does not need to be cared for in hospital. For example, a sociable, friendly Downs syndrome patient with an IQ of around 40 may be quite acceptable within a hostel or community home, whereas a much less severely retarded patient with an IQ of around 70 and an unstable affective disorder, or an aggressive, irritable personality, may be very disruptive and wholly unacceptable in such a setting.

Diagnosis of psychiatric disorder in the severely and profoundly retarded patient.

Behaviour problems are particularly common among severely and profoundly mentally retarded patients, but there have been few attempts to introduce concepts of psychiatric diagnosis into this field. This is perhaps understandable since these behaviour problems can equally well be viewed through developmental, sociological or behavioural perspectives. Moreover, whereas there is now some consensus of opinion that our recognized psychiatric diagnostic categories of functional and organic psychoses are applicable in the field of mild and moderate mental retardation (Heaton-Ward 1977, Reid 1972), this is less so in the case of more severely retarded patients. It is nevertheless important to develop appropriate psychiatric diagnostic concepts for these patients, since there are serious limitations to treatment approaches based exclusively on developmental, sociological or behavioural perspectives, just as there are limitations to treatment approaches based exclusively on psychiatric insights. The phenomenon of stereotypic behaviour can be used to illustrate these points. Stereotypy is a very common phenomenon amongst severely subnormal patients. It can be viewed as a developmental phenomenon and akin to hand and finger regard in small babies. It can be seen as an institutional phenomenon related to boredom. It can be related to severe sensory deficits such as blindness. It can be imitative or anticipatory, pleasurable or related to excitement. It can have a communicative function. Complex and absorbing stereotypies, in a setting of social and emotional withdrawal, can be a prominent diagnostic feature in the syndrome of early childhood autism. These different perspectives each have different, although complementary, treatment implications: each can shed some -light on the problem but none are universally explanatory. For example, where stereotypic behaviour is related to boredom, clearlystructured and stimulating activity can produce marked improvement; but where intense stereotypic behaviour is part of the syndrome of early childhood autism, over-stimulation can actually serve to increase the phenomenon. Similar considerations apply in respect of self injury. Self injury

Psychiatric services for people with learning disabilities

Psychiatric disorder is more common in people with learning disabilities than in the general population. Organic, social, and educational reasons account for this increase. Nearly all adults with severe mental retardation have structural brain disease, and epilepsy is more common in this population.1 In their study in the Isle of Wight, Rutter and colleagues showed very clearly the association among neurological abnormality, epilepsy, learning disability, and psychiatric disorders.2 In addition to these organic factors, educational failure; rejection and lack of social acceptance; reduced or no job opportunities, with correspondingly diminished self esteem; difficulties in finding acceptable sexual outlets despite normal sexual drives; and the problems of dysmorphic appearance all combine to increase the liability to psychiatric disorder.3 These psychiatric disorders include schizophrenic and paranoid syndromes, although diagnosing them may be difficult.4 For example,schizophrenia cannot be reliably diagnosed in …