Ian Hall

Behavioural and cognitive-behavioural interventions for outwardly-directed aggressive behaviour in people with intellectual disabilities

BACKGROUNDnOutwardly-directed aggressive behaviour is a significant part of problem behaviours presented by people with intellectual disabilities. Prevalence rates of up to 50% have been reported in the literature, depending on the population sampled. Such behaviours often run a long-term course and are a major cause of social exclusion. This is an update of a previously published systematic review (see Hassiotis 2004; Hassiotis 2008).nnnOBJECTIVESnTo evaluate the efficacy of behavioural and cognitive-behavioural interventions on outwardly-directed aggressive behaviour in people with intellectual disabilities when compared to standard intervention or wait-list controls.nnnSEARCH METHODSnIn April 2014 we searched CENTRAL, Ovid MEDLINE, Embase, and eight other databases. We also searched two trials registers, checked reference lists, and handsearched relevant journals to identify any additional trials.nnnSELECTION CRITERIAnWe included studies if more than four participants (children or adults) were allocated by random or quasi-random methods to either intervention, standard treatment, or wait-list control groups.nnnDATA COLLECTION AND ANALYSISnTwo review authors independently identified studies and extracted and assessed the quality of the data.nnnMAIN RESULTSnWe deemed six studies (309 participants), based on adult populations with intellectual disabilities, suitable for inclusion in the current version of this review. These studies examined a range of cognitive-behavioural therapy (CBT) approaches: anger management (three studies (n = 235); one individual therapy and two group-based); relaxation (one study; n = 12), mindfulness based on meditation (one study; n = 34), problem solving and assertiveness training (one study; n = 28). We were unable to include any studies using behavioural interventions. There were no studies of children.Only one study reported moderate quality of evidence for outcomes of interest as assessed by the Grades of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We judged the evidence for the remaining studies to be of very low to low quality. Most studies were at risk of bias in two or more domains: one study did not randomly allocate participants and in two studies the process of randomisation was unclear; in one study there was no allocation concealment and in three studies this was unclear; blinding of assessors did not occur in three studies; incomplete outcome data were presented in one study and unclear in two studies; there was selective reporting in one study; and other biases were present in one study and unclear in four studies.Three of the six studies showed some benefit of the intervention on improving anger ratings. We did not conduct a meta-analysis, as we considered the studies too heterogeneous to combine (e.g. due to differences in the types of participants, sample size interventions, and outcome measures).Follow-up data for anger ratings for both the treatment and control groups were available for two studies. Only one of these studies (n = 161) had adequate long-term data (10 months), which found some benefit of treatment at follow-up (continued improvement in anger coping skills as rated by key workers; moderate-quality evidence).Two studies (n = 192) reported some evidence that the intervention reduces the number of incidents of aggression and one study (n = 28) reported evidence that the intervention improved mental health symptoms.One study investigated the effects of the intervention on quality of life and cost of health and social care utilisation. This study provided moderate-quality evidence, which suggests that compared to no treatment, behavioural or cognitive-behavioural interventions do not improve quality of life at 16 weeks (n = 129) or at 10 months follow-up (n = 140), or reduce the cost of health service utilisation (n = 133).Only one study (n = 28) assessed adaptive functioning. It reported evidence that assertiveness and problem-solving training improved adaptive behaviour.No studies reported data on adverse events.nnnAUTHORS CONCLUSIONSnThe existing evidence on the effectiveness of behavioural and cognitive-behavioural interventions on outwardly-directed aggression in children and adults with intellectual disabilities is limited. There is a paucity of methodologically sound clinical trials and a lack of long-term follow-up data. Given the impact of such behaviours on the individual and his or her support workers, effective interventions are essential. We recommend that randomised controlled trials of sufficient power are carried out using primary outcomes that include reduction in outward-directed aggressive behaviour, improvement in quality of life, and cost effectiveness.

The Autism Strategy: implications for people with autism and for service development

Purpose – The aim of this article is to critically review the Autism Strategy and to discuss its implications.Design/methodology/approach – This is a summary and critical review of the Autism Strategy and its implementation. This includes discussion of the political context, reactions to the strategy by stakeholders, economic considerations, equity, integration across health and social care and the role of diagnostic services and specialist interventions.Findings – The Autism Strategy Fulfilling and Rewarding Lives was published in 2010. It aimed to increase awareness of autism, establish clear pathways for diagnosis and needs assessment, promote independent living and access to work, and help the development of local services. It focuses on intended outcomes, is not prescriptive about how those aims are achieved, and relies on existing legislation such as the Disability Discrimination Act. The emphasis on accessing mainstream services may limit the development of appropriate specialist services, especial...

Clinical and cost effectiveness of staff training in Positive Behaviour Support (PBS) for treating challenging behaviour in adults with intellectual disability: a cluster randomised controlled trial

BackgroundMany people with intellectual disability present with challenging behaviour which often has serious consequences such as the prescription of long term medication, in-patient admissions and disruption of normal daily activities. Small scale studies of Positive Behaviour Support (PBS) delivered by paid carers suggest that it reduces challenging behaviour and costs of care and improves quality of life. This study aims to investigate whether professionals training in the delivery of PBS as part of routine practice is clinically and cost effective compared to treatment as usual in community intellectual disability services.MethodThe study is a multi-centre cluster randomised controlled trial involving community intellectual disability services in England and service users with mild to severe intellectual disability and challenging behaviour. The teams will be randomly allocated into one of two conditions, either training and support to deliver PBS or treatment as usual. We will carry out assessments of challenging behaviour, use of services, quality of life, mental health, and family and paid carer burden at six and 12xa0months. We will monitor treatment fidelity and we will interview a sample of paid and family carers, service users, staff and managers about what they think of the treatment and how best we can deliver it in routine care. The main outcome is reduction in challenging behaviour at one year after randomisation. We will also carry out a health economic evaluation to examine the costs and consequences of staff training in PBS.DiscussionThe study findings will have significant implications for the delivery of PBS in community based services with the potential for reducing inpatient admissions and out-of-area placements for adults with intellectual disability and challenging behaviour.Trial registrationThis trial is registered with Clinical Trials.gov (Ref NCT01680276).Clinical Trials Unit: PRIMENT https://www.ucl.ac.uk/priment/.

An audit of the quality of inpatient care for adults with learning disability in the UK

Objectives To audit patient hospital records to evaluate the performance of acute general and mental health services in delivering inpatient care to people with learning disability and explore the influence of organisational factors on the quality of care they deliver. Setting Nine acute general hospital Trusts and six mental health services. Participants Adults with learning disability who received inpatient hospital care between May 2013 and April 2014. Primary and secondary outcome measures Data on seven key indicators of high-quality care were collected from 176 patients. These covered physical health/monitoring, communication and meeting needs, capacity and decision-making, discharge planning and carer involvement. The impact of services having an electronic system for flagging patients with learning disability and employing a learning disability liaison nurse was assessed. Results Indicators of physical healthcare (body mass index, swallowing assessment, epilepsy risk assessment) were poorly recorded in acute general and mental health inpatient settings. Overall, only 34 (19.3%) patients received any assessment of swallowing and 12 of the 57 with epilepsy (21.1%) had an epilepsy risk assessment. For most quality indicators, there was a non-statistically significant trend for improved performance in services with a learning disability liaison nurse. The presence of an electronic flagging system showed less evidence of benefit. Conclusions Inpatient care for people with learning disability needs to be improved. The work gives tentative support to the role of a learning disability liaison nurse in acute general and mental health services, but further work is needed to confirm these benefits and to trial other interventions that might improve the quality and safety of care for this high-need group.

The place of medication for challenging behaviour: a whole system perspective

This article aims to explore the place of medication in the management of challenging behaviour in people with intellectual disability by considering it in the context of the whole system around the person and by considering the challenges of implementing best practice guidance.

Training and developing staff in general hospitals: intellectual disability liaison nurses and the RAID model

Purpose – The purpose of this paper is to address the serious problems that people with intellectual disability face in getting their healthcare needs met in general hospitals by improving the training of general hospital staff. Design/methodology/approach – Review of recent developments in models of service provision including the development of intellectual disability liaison nurses and the RAID model in liaison psychiatry. Findings – There is much scope for intellectual disability liaison nurses and liaison psychiatry services to work together in staff training in general hospitals. There is a clear strategic role for both services in convincing the management of general hospitals to implement such training using economic and quality arguments. Originality/value – The authors suggest a new model of working to improve the healthcare outcomes of people with intellectual disabilities through effective training of staff in general hospitals.

Involving people with intellectual disabilities in the assessment of healthcare professionals

Purpose – It is widely recognised that people with intellectual disabilities receive a poorer quality of healthcare than their non-disabled counterparts. Training for healthcare professionals in intellectual disability is often scant or non-existent. The purpose of this paper is to explore the usefulness of employing actors with intellectual disabilities as simulated patients in the assessment of trainee psychiatrists. Design/methodology/approach – The development of a structured clinical exam “station” designed to assess the ability of trainee psychiatrists to communicate with a simulated patient played by an actor with an intellectual disability is described. The paper also assesses the potential benefits of this kind of assessment and the experience of actors and examiners taking part in this process. Findings – The station was found to perform well in discriminating between candidates of various abilities and was well received by actors, examiners and observers. The station is now routinely used in th...

Secure inpatient services: a needs assessment

Purpose – The purpose of this paper is to complete a thorough needs assessment that would enable the development of a robust pathway of care for adults with a learning disability requiring secure care, and to assist commissioners to make informed planning decisions. Design/methodology/approach – The paper identified people with a learning disability originating from London who were in secure care, and collected data about them. The paper used reference groups to inform the analysis. Findings – The paper identified 249 people in secure services and was able to include 136 patients in the analysis. In all, 64 were in NHS provision and 72 in independent sector provision; 109 (80.1 per cent) were male and 27 (19.9 per cent) female; on average, patients were cared for 61.5 miles away from their homes; NHS patients were far closer to home; 69.1 per cent had a mild learning disability; 82.3 per cent had a history of violence; approximately one in six patients could not progress due to a lack of an appropriate wa...

Improving physical health for people taking antipsychotic medication in the Community Learning Disabilities Service

Adherence with antipsychotic monitoring guidelines is notoriously low nationally. Without active monitoring and measures to improve metabolic abnormalities, more patients may develop related morbidity and mortality. An audit highlighted antipsychotic monitoring in this learning disability service in London did not match guideline recommendations. People with intellectual disability also experience health inequalities. Psychiatrists are well placed to provide advice and assistance that is suitable for those with complex communication, behaviour, and social needs. The QI team tested ideas to increase rates of antipsychotic reviews. The focus was the follow up monitoring of all universal measures recommended by NICE 2014, collected at 2-weekly intervals. We trialled interventions in four broad categories; Intervention 1: to make monitoring more structured and planned; Intervention 2: to increase staff and patient awareness of healthy eating and exercise programs; Intervention 3: to increase the collection of diet and exercise histories from patients; Intervention 4: to improve the uptake of blood tests. The interventions created an improvement in monitoring. There are lessons in the methodology for others carrying out similar projects.

Amendments to the Mental Health Act 1983: implications for people with learning disabilities

The new Mental Health Act 2007 substantially amends the Mental Health Act 1983. In this article, some of the most important changes are highlighted, including changes to the definition of mental disorder, the new professional roles of approved mental health practitioner and responsible clinician, and the new powers for Supervised Community Treatment. The likely impact of these changes for people with learning disability and professionals working with them is discussed.