Staff‐Averse Challenging Behaviour in Older Adults with Intellectual Disabilities

Background People with intellectual disabilities are increasingly reaching older adulthood. Little is known about age‐related change in the prevalence of challenging behaviours among older adults with intellectual disabilities. Materials and method The frequency and severity of staff‐averse challenging behaviours of 132 older adults with intellectual disabilities was assessed through informant ratings on the Inventory of Client and Agency Planning at two time points 8–10 years apart. Results There was an intraindividual decline in the frequency and severity of challenging behaviour using both lenient and more restricted definitions of challenging behaviour. There was a low prevalence but high comorbidity of severe challenging behaviour. Level of mental retardation and adaptive behaviour were related to the frequency and severity of challenging behaviour. Conclusions An understanding of age‐related intraindividual change in challenging behaviour has implications for staff wellbeing and optimizing the care of older adults with intellectual disabilities.     

Talking About Real‐life Events: An Investigation Into the Ability of People with Intellectual Disabilities to Make Links Between Their Beliefs and Emotions Within Dialogue

Background This study compares how people with and without intellectual disabilities talk about events, beliefs and emotions in dialogues about real‐life, emotive events and in a structured task assessing understanding of cognitive mediation. Materials and Methods A cognitive‐emotive interview was used to assist 19 adults with intellectual disabilities and 19 adults without disabilities in generating an account of an emotive, interpersonal event. Participants also completed a cognitive mediation task and an assessment of intellectual and verbal ability. Results Between‐group analyses indicated that participants with intellectual disabilities scored significantly lower than those without disabilities on the cognitive‐emotive interview and the cognitive mediation task. Participants with intellectual disabilities generated fewer beliefs within their dialogues and were less likely to provide alternative perspectives on events. Within‐group comparisons showed no significant association between the ability to talk about events, beliefs and emotions within a dialogue and performance on a cognitive mediation task, or with Full Scale or Verbal IQ scores. Conclusions Participants with intellectual disabilities had more difficulties than those without disabilities in talking about events, beliefs and emotions. Within a therapeutic context, they are likely to require assistance to reflect on events and consider alternative interpretations, which take into account individual and environmental factors. Future therapeutic developments may benefit from placing greater emphasis on emotional understanding and the intuitive links that people make between events and emotions.     

Clinical and Research Implications of an Investigation into Theory of Mind (TOM) Task Performance in Children and Adults with Non‐specific Intellectual Disabilities

Background Theory of Mind (TOM) has rarely been studied in people with intellectual disabilities. Wherever it has been studied, differing results have been found. These may be attributed to a variety of factors (e.g. the different chronological ages of samples). The validity of relating TOM performance to social behaviour has also been questioned in this population. The aim of this study was to compare TOM scores with chronological age and social ability in an attempt to contribute to current debate. Methods Twenty children were matched individually with 20 adults, all with non‐specific intellectual disabilities. The British Picture Vocabulary Scale, Raven's Coloured Progressive Matrices and four TOM tasks were administered to the participants. Their carers were then given various sociability measures to complete. Results The children achieved significantly higher TOM scores than did the adults. TOM and social ability were significantly positively correlated for the children, but not for the adults. These results are discussed in terms of the different social experiences of adults and children with intellectual disabilities. Conclusions Longitudinal research in this area is needed to clarify the present findings. If confirmed, the suitability of some TOM tasks used may be questionable, and there are clear implications for staff and client training.     

Reactive Attachment Disorder Symptoms in Adults with Intellectual Disabilities

Background Studies with children suggest that reactive attachment disorder (RAD) is associated with pathogenic early care. Little is known about RAD in adults with intellectual disabilities, many of whom experience adversity and abuse in early life. We investigated whether RAD symptoms occur in this population, and explored whether hypothesized risk factors are associated with higher RAD symptom scores. Method Fifty adults with intellectual disabilities residing in long‐stay hospitals and their carers participated in a questionnaire survey of RAD symptoms, childhood experiences, and disabilities. Results Reactive attachment disorder symptoms were present in this sample, and symptom scores were independently associated with early childhood adversity, diminished with age, but were not associated with cognitive ability, gender, other disabilities, nor number of childhood years in institutional care. Conclusions As with children with RAD, it is possible that some maltreated adults with intellectual disabilities fail to develop stranger anxiety by the usual developmental age. Over decades, they may gradually learn.     

ABAS-II Adaptive Profiles and Correlates in Samples of Children with HFASD or LFASD

This study was conducted to extend the research on the adaptive skills of 55 high-functioning children with autism spectrum disorder (HFASD) and 55 children with ASD and co-occurring intellectual disability (LFASD), ages 6–12, using the Adaptive Behavior Assessment System, Second Edition (ABAS-II). This study examined each group’s adaptive profile, compared adaptive functioning and cognitive ability, and assessed correlates (i.e., age, IQ) of adaptive skills. Results indicated children with HFASD demonstrated cognitive strengths and adaptive deficits, while children with LFASD demonstrated adaptive strengths in the areas of social and conceptual skills, and practical skills commensurate with estimated cognitive ability. Within the HFASD sample, age significantly, negatively correlated with adaptive social ability, while IQ was not significantly correlated with adaptive behavior. Conversely, in the LFASD sample, age did not correlate with adaptive ability, although IQ was significantly related to overall adaptive ability and all domains of the ABAS-II.     

Training Social Problem-solving Skill to Reduce Maladaptive Behaviours in Intellectual Disability Groups: The Influence of Individual Difference Factors

A critical review of the literature relevant to social problem-solving skills training (SPSST) in individuals with intellectual disabilities concluded that although there is some evidence that training may be effective, the evidence is weak. It is suggested that little is known about factors which may moderate the effectiveness of training; in particular the impact of age, general intellectual ability and place of residence (community or institution). A five-stage view of the social problem-solving process is offered as a means for planning and evaluating SPSST programmes, and detailed outcome criteria are proposed for assessing the effectiveness of training. A group (n = 29) of adults with intellectual disabilities was given SPSST. Comparisons were made with an untrained control group (n = 17) matched to the trained group on age, general intelligence, adaptive and maladaptive behaviour. A statistically significant improvement was found in the trained group (p < 0.01), but not in the control group (NS), on degree of maladaptive behaviour as rated by independent judges. Improvement occurred only in trainees resident in the community but was not influenced by age or level of general intelligence. Furthermore, reductions in maladaptive behaviour were associated with improvements in some but not all social problem-solving skills.     

Cognitive Therapy Abilities in People with Learning Disabilities

Background There is a need to develop and adapt therapies for use with people with learning disabilities who have mental health problems. Aims To examine the performance of people with learning disabilities on two cognitive therapy tasks (emotion recognition and discrimination among thoughts, feelings and behaviours). We hypothesized that cognitive therapy task performance would be significantly correlated with IQ and receptive vocabulary, and that providing a visual cue would improve performance. Method Fifty‐nine people with learning disabilities were assessed on the Wechsler Abbreviated Scale of Intelligence (WASI), the British Picture Vocabulary Scale‐II (BPVS‐II), a test of emotion recognition and a task requiring participants to discriminate among thoughts, feelings and behaviours. In the discrimination task, participants were randomly assigned to a visual cue condition or a no‐cue condition. Results There was considerable variability in performance. Emotion recognition was significantly associated with receptive vocabulary, and discriminating among thoughts, feelings and behaviours was significantly associated with vocabulary and IQ. There was no effect of the cue on the discrimination task. Conclusion People with learning disabilities with higher IQs and good receptive vocabulary were more likely to be able to identify different emotions and to discriminate among thoughts, feelings and behaviours. This implies that they may more easily understand the cognitive model. Structured ways of simplifying the concepts used in cognitive therapy and methods of socialization and education in the cognitive model are required to aid participation of people with learning disabilities.     

Resident Involvement in Activity in Small Community Homes for People with Learning Disabilities

Background Determining the relative importance of variables including client characteristics, setting features, staffing and care practices on the lives of people with learning disabilities in residential care continues to be a relevant topic for research. Methods Measurements were made of the adaptive and problem behaviour of 343 adults with intellectual disabilities living in 76 residential homes and of various aspects of staffing, care practices (extent of active support) and resident engagement in meaningful activity. Ordinal and logistic regression was used to identify variables best predicting engagement and care practices. Results Only adaptive behaviour and care practices predicted resident engagement in meaningful activity; only age and adaptive behaviour predicted care practices. Conclusions Given the limited scope for changing resident adaptive behaviour, attention should be given to improve active support in residential homes in order to promote greater engagement in meaningful activity by people with learning disabilities.     

Resource Input,Service Process and Resident Activity Indicators in a Welsh National Random Sample of Staffed Housing Services for People with Intellectual Disabilities

Background The aims were to: (i) explore the association between age and size of setting and staffing per resident; and (ii) report resident and setting characteristics, and indicators of service process and resident activity for a national random sample of staffed housing provision. Methods Sixty settings were selected randomly from those accommodating six or fewer adults with intellectual disabilities in Wales. Nine settings subsequently withdrew. Information from the remaining 51 was obtained on resident ages, gender, adaptive behaviour, physical and sensory disabilities, social impairment and challenging behaviour, the number and working hours of staff, staff:resident ratios at different times of the day, working practices, resident receipt of attention and assistance from staff and resident activity. The sample of 51 residences was divided into four groups of 12, 13, 13 and 13 settings each, according to ascending average adaptive behaviour scale scores. Results Age of residence was associated with larger size of residence and fewer staff hours per resident. Higher staffing per resident was associated with smaller setting size. Staffing per resident differed across adaptive behaviour groups to a limited extent. Size and age of residence, working practices, resident receipt of attention and assistance from staff did not differ across groups but resident engagement in activity did. Considerable within‐group variation was found. Conclusions The data illustrate trends in provision over time. In addition, they give a picture of recent practice and raise questions about whether staff input, on one hand, and staff training and performance, on the other hand, are well enough matched to the different needs of residents at different points of the adaptive behaviour spectrum.     

Development of the Guernsey community participation and leisure assessment—Revised (GCPLA-R)

A sufficiently psychometrically robust measure of community and leisure participation of adults with intellectual disabilities was not in existence, despite research identifying this as an important outcome and a key contributor to quality of life. The current study aimed to update the Guernsey Community Participation and Leisure Assessment (GCPLA). Adults with intellectual disabilities, carers and experts were consulted in creating a revised pool of 46 items. These were then tested and data from 326 adults with intellectual disabilities were analysed for their component structure and psychometric properties. Principal component analysis discovered a stable set of components describing seven different clusters. This revised measure (the GCPLA-R) was demonstrated to have satisfactory reliability, and scores were related to challenging behaviour and adaptive behaviour in theoretically consistent ways and were correlated with scores on comparable measures.     

Do People with Intellectual Disabilities and Psychosis have the Cognitive Skills Required to Undertake Cognitive Behavioural Therapy?

Background Cognitive skills thought to be necessary to undertake cognitive–behavioural therapy (CBT) include the ability to recognize emotions, link events and emotions, and recognize cognitive mediation. These skills have been assessed in people with intellectual disabilities, but not in those who also have psychosis. Materials and methods Tasks assessing receptive language ability and cognitive skills including the ability to differentiate between behaviours, thoughts and feelings were administered to 50 participants who had intellectual disabilities and psychosis. Results The majority of participants were able to link events and emotions and differentiate behaviours and feelings. Participants found any task involving cognitions significantly more difficult. Performance on recognizing emotions, linking events and emotions and on some of the cognitive mediation and differentiation tasks was associated with receptive language ability. Conclusions People with intellectual disabilities and psychosis have some of the skills thought to be required to undertake cognitive behaviour therapy. Recognizing cognitions and cognitive mediation is particularly challenging. The differentiation task introduced in this study may usefully supplement existing assessments.     

Interpersonal Sources of Conflict in Young People with and without Mild to Moderate Intellectual Disabilities at Transition from Adolescence to Adulthood

Background Interpersonal conflict is a source of stress and contributes to poor mental health in people with mild to moderate intellectual disabilities. Understanding the contexts in which conflict typically occurs can better equip services to help people with such difficulties. However, existing studies into the contexts of conflict have included participants with wide‐ranging ages and may not reflect the experiences of young adults in particular. Materials and Methods Twenty‐six young adults (16–20 years) with intellectual disabilities and 20 non‐disabled young adults completed a semi‐structured interview about a recent experience of interpersonal conflict. Participants were asked to describe their beliefs and feelings about the event and their subsequent response. Results Participants with intellectual disabilities were more likely to encounter conflict with strangers or peers outside their friendship group and to describe incidents of aggression than non‐disabled participants. They were also more likely to characterize the other person globally as ‘bad’ and to perceive the other’s actions as being personally directed at them. Young women with intellectual disabilities were less likely to describe responding aggressively to incidents. Conclusions Findings suggest that young adults with intellectual disabilities are often the target of overt aggression from those outside their inner social sphere, while their non‐disabled peers are more likely to experience conflict with people close to them. Young adults with intellectual disabilities may also be more likely to feel victimized by interpersonal conflict. Implications of these findings and limitations of the study are discussed.     

Assessing Components of Empathy in Sex‐ Offenders with Intellectual Disabilities

Background Because of a lack of research investigating empathy in sex offenders with intellectual disabilities, this study explored empathy in sex offenders and non‐offenders with intellectual disabilities. Specific aims were to explore differences between these groups on measures of the components of empathy. Methods The scores of 21 sex‐offenders and 21 non‐offenders with intellectual disabilities, matched by age, gender and IQ, were compared on the Test of Emotional Perception. Results No differences were found between the two groups across the components of empathy. However, sex offenders who had received treatment performed better on tasks of emotion recognition, emotion replication and response decision than the non‐offenders. Conclusions Further research is needed to understand empathy in sex offenders with intellectual disabilities before any recommendations can be made regarding treatment programmes.     

The Leicestershire Intellectual Disability Tool: A Simple Measure to Identify Moderate to Profound Intellectual Disability

Background It is often useful to ascertain whether adults have moderate to profound intellectual disability (approximate IQ < 50; developmental age <108 months) when deciding whether to refer to specialist or mainstream services. The aim of the present study was to develop a simple measure to estimate moderate to profound intellectual disability in adults with a potential need for specialist care. Materials and Methods Three hundred and twenty‐two individuals with information on home interviews from the Leicestershire Learning Disability Register were also assessed using the Vineland Adaptive Behaviour Scales. A variety of variables concerning intelligence, adaptive functioning and dependency were used to predict developmental age (as estimated from the Vineland) using backward stepwise regression. The derived equation formed the Leicestershire Intellectual Disability (LID) tool. A cut‐off point was chosen using a receiver operator characteristic (ROC) curve to achieve 95% sensitivity in identifying moderate to profound intellectual disability. Results Seven variables from the home interviews were found to predict estimated developmental age at the 10% level (P ≤ 0.1). When the tool was used to detect adults with moderate to profound intellectual disability, the area under the ROC curve was 0.93. The chosen cut‐off point was 95% sensitive and 65% specific. The positive predictive value was 95%, the negative predictive value was 65%, and the overall diagnostic accuracy was 91%. Conclusions These preliminary findings suggest that the LID tool may help to identify adults with moderate to profound intellectual disability among those with potential need for specialist care. Further evaluation is recommended.     

The Intellectually Disabled Offender: Methodological Problems in Identification

Background Reliable evidence concerning the prevalence of intellectually disabled offenders that would inform the clinician's approach to the assessment and management of risk is in short supply. This paper aims to assist the clinician in interpreting the available evidence. Methods A literature search was conducted for all years up to January 2003. Each study was first examined for the methods employed to define and measure intellectual disability. Then, the effect of this on prevalence estimates was considered. Results A wide range of methods has been used to ascertain the presence of intellectual disability – administrative definitions, psychiatric diagnosis, educational background, self‐report and direct measurement of IQ and adaptive behaviour. Conclusions Most studies reviewed used less than adequate ascertainment methods. Reliable answers to two key questions – which offenders have intellectual disabilities and which people with intellectual disabilities offend – therefore remain elusive.     

Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities: Distinctions and challenges

Purpose

The purpose of this article is to provide the reader with insight and enhanced understanding of the health care transition planning process for adolescents and emerging adults with intellectual disabilities and developmental disabilities. There are distinctly different programmatic considerations that need to be addressed in advancing their transfer of care to adult providers and promoting their transition to adulthood. These differences are due in part to the federal and state legislative initiatives that were established in the education, rehabilitation, employment, and developmental disabilities service systems. In contrast, no comparable federal and state mandates exist in the system of health care. The legislative mandates in education, rehabilitation, and employment are presented and discussed as well as the federal legislation on rights and protections for individuals with intellectual disabilities and developmental disabilities. Consequently, health care transition (HCT) planning involves application of a framework of care that is characteristically different than the planning efforts undertaken for adolescents and emerging adults (AEA) with special health care needs (SHCN)/disabilities and for typically developing AEA. The best practice HCT recommendations are discussed in the context of this intellectual disabilities and developmental disabilities framework of care.

Conclusions

Health care transition planning for adolescents and emerging adults with intellectual disabilities and developmental disabilities involves additional and distinctly clinical and programmatic models of care.

Practice Implications

Health care transition planning guidance for adolescents and emerging adults with intellectual disabilities and developmental disabilities are provided based upon best practice recommendations.     

The Relationship Between Adaptive Behavior and Specific Toileting Problems According to the Profile on Toileting Issues (POTI)

Toileting problems in people with intellectual disabilities are common but have rarely been studied. Recently, the Profile on Toileting Issues (POTI) was developed as a standalone measure to evaluate these problems. The POTI has established psychometrics. Research on interface between toileting problems in persons with intellectual disability and adaptive functioning is lacking. Eighty adults from two developmental centers were assessed to establish relationships between these skills. Greater toileting problems were strongly associated with greater deficits in adaptive skills. The implications of these findings are discussed.     

A SURVEY OF INTELLECTUAL DISABILITIES AMONGST MEN ON REMAND IN PRISON

Men detained in a South London prison on remand were screened for intellectual disabilities (mental handicap) over a three-month period. Of 157 men screened, 33 reported having intellectual disabilities. Twenty-one of these completed the General Health Questionnaire (GHQ) and were tested for IQ (on the WAIS-R), for reading and numeracy (on the British Ability Scales). An equal number of men were selected for the control group, on a ‘next man in’ basis, and they were assessed in an identical way. None of the index men had an IQ in the intellectual disabilities (mental handicap) range but the mean Verbal IQ, mean Full Scale IQ, mean reading age and mean numeracy age were all significantly lower in the index group than in the control group. Moreover, the index group had significantly higher scores on the GHQ and often had a recent history of mental illness or psychiatric hospital admission. It is concluded that men with intellectual disabilities were not over-represented in prison but that there were a number of men close to the disability range who were psychologically very vulnerable.     

Functional Communication Training and Naltrexone Treatment of Self-Injurious Behaviour: An Experimental Case Report

The self-injurious behaviour of people with intellectual disabilities, autism, and related developmental disabilities remains one of the most difficult behaviour problems to treat clinically. Two promising approaches to effective treatment involve teaching the person communication skills that are functionally equivalent to the self-injury or administering opiate antagonist medication. Here an experimental case study, in which naltrexone was combined with functional communication training, is reported. Using a within-subject ABCDC experimental design, reductions in rate of self-injury were observed during the naltrexone alone phase as well as during combined treatment phases. The implications of conducting a functional assessment prior to behavioural and pharmacological intervention are discussed.     

Challenging behaviour and its risk factors in children and young people in a special school setting: A four wave longitudinal study

Background

Longitudinal research is needed to strengthen evidence for risk factors for challenging behaviour in children with intellectual disabilities and to understand patterns of change over time.

Methods

Data on challenging behaviour were collected for 225 students in one school over four annual time points and a range of potential risk correlates. Data were analysed using Generalised Estimating Equations.

Results

Prevalence of challenging behaviour, aggression and self-injury did not vary significantly over time. Stereotyped behaviours increased over the 4-year period. Challenging behaviour was associated with lower levels of adaptive skills and autism. Stereotyped behaviour increased with age. Self-injurious behaviour was less likely to be shown in children with profound intellectual disabilities over time.

Conclusions

These findings are consistent with previous research in terms of potential risk factors identified. Implications for schools include proactive interventions for children with intellectual disabilities at high risk; especially those with autism and poorer adaptive skills.