Modification of motivational interviewing for use with people with mild intellectual disability and challenging behaviour

Abstract

Background Motivational interviewing is a promising method to increase treatment motivation for people with mild intellectual disability and challenging behaviour. The purpose of the present study was to identify how professionals could adapt motivational interviewing techniques for use with clients.

Method We conducted semistructured qualitative interviews and focus groups with 26 clients, parents, and professionals. A general inductive approach led to the identification of multiple core themes.

Results The authors recommend several modifications to accommodate motivational interviewing for use with clients: adapt to language level, adjust to cognitive abilities, and control for social desirability of responding. In addition, certain characteristics of professionals were also found to be critical for effective motivational interviewing: trustworthiness, engagement, acceptance, empathy, and honesty.

Conclusions Concrete recommendations for the adaptation of the motivational interviewing techniques for use with people with mild intellectual disability and challenging behaviour are identified. Certain characteristics of professionals are also critical for maximising the treatment motivation of clients.     

The antecedents of loneliness in older people with an intellectual disability

IntroductionThe cognitive discrepancy approach to loneliness is often used to describe loneliness in ageing populations, but to date, it has never been used to explore loneliness in older people with an intellectual disability. An analysis is needed utilising a refined list of causes of loneliness in this population.MethodUsing data from a nationally representative dataset of people aged over 40 with an intellectual disability (N = 708), this analysis runs repeated regressions of variables grouped into conceptual blocks, organised from sociodemographic to network quality.ResultsVariables selected predicted 23% of the loneliness variance. Functional limitations, education, working in the community, transport difficulties, pain, stress caused by service change, emotional health problems and confiding were all significant predictors of loneliness.ConclusionThat for those with fewer functional limitations only transport difficulties precipitated loneliness, suggests living a more independent life protects from loneliness, in this group. Those with functional limitations and who lead a more service dependent life appear more exposed to loneliness precipitating variables.     

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.     

Chronic kidney disease in older people with intellectual disability: Results of the HA-ID study

With increasing longevity and cardiovascular events, chronic kidney disease may also become a significant problem in older people with intellectual disability (ID). We studied prevalence and associations of chronic kidney disease as part of the Healthy Ageing and Intellectual Disability (HA-ID) study, a large Dutch cross-sectional study among people with ID aged 50 years and over, using creatinine and cystatin-C measurement in plasma. Glomerular filtration rate (GFR) was calculated using the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. Equations based on creatinine (as the MDRD equation) may underestimate kidney dysfunction in people with sarcopenia, because low muscle mass leads to a low creatinine production. Therefore, also prevalence of chronic kidney disease was studied in the sarcopenic group, using different GFR equations. Prevalence of chronic kidney disease, among 635 participants, was 15.3%, which equals prevalence in the general Dutch population. In the group of participants with sarcopenia (n = 82), the CKD-EPI equation based on creatinine and cystatin-C gave a higher prevalence of chronic kidney disease than did the MDRD equation, but confidence intervals were very wide. Chronic kidney disease was associated with higher age, Down syndrome, obesity, hypercholesterolemia and hypothyroid disease.GFR should be measured in all older people with ID and polypharmacy, and in older people with ID and Down syndrome as part of the regular health checks. Moreover, if sarcopenia is present and information on GFR is required, this should not be measured based on creatinine only, but additional measures, such as cystatin-C, should be taken into account.     

Service support to people in Wales with severe intellectual disability and the most severe challenging behaviours: processes, outcomes and costs

A survey of people with severe intellectual disability and the most severe challenging behaviour in Wales identified five adults living in family homes, 17 in new specialist community housing and 19 in traditional services. With the omission of two people from the latter group and with a restricted collection of data for people living in the family home, the present study explored service input, outcome and costs across the three setting types. Process and outcome indicators for the family home group, who received little service input, were better than those for the traditional service group, although less good than those for the community house group. The specialist community home model produced significant gains over the traditional services in virtually all areas. Across the residential data set as a whole, there was no association between staff:resident ratios and severity of disability or between costs and severity of disability. This was largely true of the service types separately. There was a relationship between costs and service quality. However, this association was underpinned by gross differences between community houses and traditional settings. Costs, processes and outcomes ceased to be related when the two residential types were considered separately. Although higher costs of new community services compared to traditional services may be set against improved outcomes, high costs within the former could not be related to benefit. Outcome indicators were generally related to each other, suggesting that high quality in one sense was matched by high quality in other senses. Outcome was significantly associated with the ability of residents. Outcome indicators also tended to be related to observed staff performance, which was independent of resident ability. Therefore, outcome may be considered as dually determined by differences in resident ability and in what staff did.     

Evaluating a staff training program on the interaction between staff and people with intellectual disability and challenging behaviour: An observational study

Background: The aim of this study was to evaluate the effects of a training program focusing on improvement of emotional intelligence (EI) and support staffs’ awareness of their behaviour towards people with an intellectual disability based on interactional patterns. The support provided regarding the needs for autonomy, relatedness, and competence was observed in line with self-determination theory (SDT).

Method: A pre-test–post-test control group design (N?=?29) was used, with 17 support staff participating in the experimental group. For both groups, video recordings of interactions between staff and clients were analysed with an SDT-observation system.

Results: The results showed that a training program focusing on EI and interactional patterns positively affected the support provided by staff with regard to clients’ needs for autonomy, relatedness, and competence.

Conclusions: As most EI studies focus on insights and understanding of oneself, this study is an important first step in focusing on staff behaviour during daily interactions.     

Autonomy in relation to health among people with intellectual disability: a literature review

Background Since the 1990s, individualisation, participation, normalisation and inclusion have been the main principles of care for people with intellectual disability (ID). Autonomy has become an important issue for these people. This review of the literature tried to answer the question: how do people with ID exercise autonomy in relation to health? Method Searches in Cochrane, Medline and PsycINFO were based on the following aspects of autonomy: self‐determination, independence, self‐regulation and self‐realisation. Results Thirty‐nine of 791 articles met our criteria, including 14 on self‐determination, seven on independence, 15 on self‐regulation and three on self‐realisation. Conclusions In spite of decades of promoting autonomy, the exercise of autonomy in relation to health has so far rarely been an issue in the literature.     

The characteristics and residential situations of people with severe intellectual disability and the most severe challenging behaviour in Wales

A total population study of people in Wales with severe intellectual disability and the most severe challenging behaviour was undertaken to identify their characteristics, and the nature of their residential arrangements and service support. Forty-one participants were identified: five living in family homes, 17 in community housing, 17 in hospitals and two in hostels. The family home group had slightly higher adaptive behaviour scores than residents in community housing. Both groups had significantly higher scores than the hospital and hostel residents combined. Assessments of challenging behaviour showed the groups to be similar and to have a considerable range and extent of severely problematic behaviour. Co-occurrence of several forms of frequent severe problem behaviour was the norm and there was a marked association with social impairment. The five people living in their family homes had nominated service keyworkers, but reported professional input was low. The residential situations comprised two main service types: (1) traditional services, which were characterized by large living unit and facility size, atypical architectural design, relative isolation from the community, a greater level of buildings adaptations, low staff:resident ratios, a relatively high percentage of qualified staff, and a relative absence of systematic approaches to goal planning and structured activity; and (2) new community houses, which were characterized by small size, domestic design, location within the community, a lower level of buildings adaptations, much higher staff:resident ratios, and less emphasis on qualified staff but a greater emphasis on systematic working methods. Community settings were similar in having ‘specialist’ resident groupings based on challenging behaviour or conditions like autism in which challenging behaviours are common. A policy to provide for people with these characteristics being resettled from traditional settings in this way seems to have been established.     

Overweight and obesity in older people with intellectual disability

Overweight and obesity are major health problems associated with increased cardiovascular disease risk, which is not sufficiently studied in people with intellectual disability yet. The present study was part of the Healthy Ageing in Intellectual Disability (HA-ID) study. The aim of this study was to establish (1) the prevalence of overweight, obesity and body fat percentage in older people with intellectual disability (ID) through measurement of Body Mass Index (BMI), waist circumference, waist-to-hip ratio (WHR) and skin fold thickness, and compare this with prevalence of overweight and obesity in the general population, and (2) the association of overweight and obesity with participant and treatment characteristics (gender, age, level of ID, Down syndrome, autism, independent living, smoking, (instrumental) activities of daily living ((I)ADL), physical activity and use of atypical antipsychotic medication) using regression analyses. In this cross-sectional study 945 persons, aged 50 and over with borderline to profound ID, living in central settings, in community settings and independently were included. Overweight and obesity were highly prevalent, with more obesity (26%) than in the general Dutch older population (10%) as measured by BMI, and 46-48% obesity as measured by waist circumference and WHR respectively. Women, people with Down syndrome, higher age, less severe ID, autism, people who are able to eat independently, preparing meals and doing groceries independently, people with physical inactivity and use of atypical antipsychotics were significantly more at risk of being overweight or obese. This merits specific actions by policy makers and clinical practice to improve health outcomes.     

Measurement invariance in the assessment of people with an intellectual disability

Intellectual assessment is central to the process of diagnosing an intellectual disability and the assessment process needs to be valid and reliable. One fundamental aspect of validity is that of measurement invariance, i.e. that the assessment measures the same thing in different populations. There are reasons to believe that measurement invariance of the Wechsler scales may not hold for people with an intellectual disability. Many of the issues which may influence factorial invariance are common to all versions of the scales. The present study, therefore, explored the factorial validity of the WAIS-III as used with people with an intellectual disability. Confirmatory factor analysis was used to assess goodness of fit of the proposed four factor model using 13 and 11 subtests. None of the indices used suggested a good fit for the model, indicating a lack of factorial validity and suggesting a lack of measurement invariance of the assessment with people with an intellectual disability. Several explanations for this and implications for other intellectual assessments were discussed.     

Spiritual care for people with intellectual and developmental disability: An exploratory study

Background: A faith-based (pseudonym, Adam’s House – AH) and a non-faith-based care service (pseudonym, Greenleaves – GL) were explored to find out if and how spiritual support was provided for people with intellectual and developmental disabilities (IDDs).

Method: Six months were spent volunteering within each service and a mixed-methods approach was utilised including applied and ethnographic methods to explore and describe if and how spirituality was embedded within the two services.

Results: Themes found included community of value; homely functional care; and barriers to spiritual care. GL staff tended to provide what we termed “religious spiritual care” while AH staff administered both “religious” and “non-religious” spiritual-based support. This difference may be related to the type of training found only at AH which included spiritual dimensions.

Conclusion: Services could benefit from acknowledging the importance and significance of spiritual care training and education for effective and varied spiritual care for people with IDD who desire such support.     

Characteristics influencing attendance at a primary care health check for people with intellectual disability: An individual participant data meta-analysis

BackgroundHealth checks benefit adolescents and adults with intellectual disability, however uptake is low despite government–funded incentives.AimTo assess the characteristics of people with intellectual disability who, when offered a health check with their primary care physician at no cost, completed the health check.Methods and proceduresData from three randomised controlled trials considering health checks in people with intellectual disability living in the community were included in an individual-patient data meta-analysis. The studies used the same health check and the participant characteristics investigated (age, sex, cause of disability, level of disability and socio-economic position) were defined identically, but participants were sourced from different settings: adults living in 24-h supported accommodation, adults living in private dwellings, and school-attending adolescents.Outcomes and resultsIn total 715 participants were offered health checks. Compared to participants with Down syndrome, participants with other known causes of disability were more likely not to attend their health check (odds ratio;95%CI) = (2.5;1.4–4.7), as were participants with no known cause of disability (2.3;1.2–4.3). These associations remained significant after adjusting for potentially confounding variables.Conclusion and implicationDown syndrome was the only characteristic positively associated with health check attendance across all study settings. Future research should focus on strategies to increase health check uptake in this population.     

Melatonin decreases daytime challenging behaviour in persons with intellectual disability and chronic insomnia

Background   Persons with intellectual disability (ID) and sleep problems exhibit more daytime challenging behaviours than persons with ID without sleep problems. Several anecdotal reports suggest that melatonin is not only effective in the treatment of insomnia, but also decreases daytime challenging behaviour. However, the effect of melatonin treatment on daytime challenging behaviour in persons with ID has not been investigated in a randomised controlled trial.
Method   We investigated the effects of melatonin on challenging behaviour using data from two randomised controlled trials on the efficacy of melatonin on sleep problems in 49 persons (25 men, 24 women; mean age 18.2 years, SD = 17.1) with ID and chronic insomnia. Participants received either melatonin 5 mg (<6 years 2.5 mg) or placebo during 4 weeks. Daytime challenging behaviour was measured by the Storend Gedragsschaal voor Zwakzinnigen – Maladaptive Behaviour Scale for the Mentally Retarded (SGZ; Kraijer & Kema, 1994 ) at baseline week and the end of the fourth treatment week. Salivary dim light melatonin onset (DLMO) was measured at baseline and the last day of the fourth treatment week. Sleep logs were used to gather information on sleep parameters.
Results   Melatonin treatment significantly reduced SGZ scores, sleep latency, and number and duration of night wakes, and treatment increased total sleep time and advanced DLMO. However, after 4 weeks of treatment, change in SGZ scores did not significantly correlate with change in sleep parameters, nor with change in DLMO. Relatively strong correlations were found between change in SGZ scores, change in DLMO and number of night wakes.
Conclusions   Melatonin treatment in persons with ID and chronic insomnia decreases daytime challenging behaviour, probably by improving sleep maintenance or by improving circadian melatonin rhythmicity.     

Antipsychotic medication for challenging behaviour in people with intellectual disability: a systematic review of randomized controlled trials

A study was performed to determine the effectiveness of antipsychotic medication for people with intellectual disability (ID) and challenging behaviour. Randomized controlled trials comparing antipsychotic medication to placebo in people with ID and challenging behaviour were identified by electronic searching and hand-searching. Reviewers independently evaluated and analysed data on an intention-to-treat basis. Only three randomized controlled trials could be included in the analyses. These trials provided no evidence as to whether antipsychotic medication does or does not help adults with ID and challenging behaviour. There is limited data on this important issue and good quality research is urgently needed.     

Evaluating staff training: Taking account of interactions between staff and clients with intellectual disability and challenging behaviour

Abstract

Background Hastings (2010) has recently emphasised 3 aspects in the training of staff who serve clients with mild to moderate intellectual disability and challenging behaviour (CB): Staff attitudes, self-awareness, and clients' perspectives. This study investigates whether programs include these aspects.

Method A systematic search yielded 11 relevant articles.

Results Generally, all programs aimed to improve staff knowledge and skills. Client variables concerned frequencies and severities of CB. None of the studies included clients' perspectives or staff attitudes and self-awareness.

Conclusions The fact that staff attitudes and awareness or clients' perspectives were not among the main goals of the training studies suggests that recent views of effective treatment of CB are not yet the object of scientific study. Given the acknowledgment of these aspects, it is warranted that future research focuses upon these recent insights.