•Violence risk is increased in patients with schizophrenia.•Our understanding of the nature of that link is limited.•The HCR-20v3 represents one of the best structured ways of assessing that ...risk.•The HCR-20 should be re-evaluated every 6 months.•The HCR-20v3 is most effective at identifying those at low risk of violence.
Aggression and violence are common day to day problems in psychiatric settings. However, the optimal means of assessing that risk remains unclear. In the context of that uncertainty many tools have evolved, among which the HCR-20 is one of the most globally accepted, though many questions remain about its performance, how and when it should be deployed and how it can be most effectively used. In this 12 month follow up study of 210 forensic psychiatric inpatients with a diagnosis of a schizophrenia spectrum disorder we explored these issues. We found that the performance of the HCR-20v3, especially its Total score, performed well up to 6 months after it was rated but its performance deteriorated after that. Repeating the HCR-20v3 at 6 months stabilised the risk assessment and led to improved performance in the second months over and above the first rating. The HCR-20v3 was good at identifying those subjects at low risk of violence over 6 months of follow up in a forensic inpatient setting. The real-world implications of this study are that the HCR-20v3 is an effective means of identifying patient at low risk of violence, but it should be reassessed every 6 months.
Angelman Syndrome (AS) is a rare genetic disorder that impacts 1:20,000 people. Challenging behaviour, such as severe injurious behaviour, aggression and frequent unprovoked episodes of laughter are ...a significant problem among adults with AS that adversely impacts an individual's quality of life. This study, for the first time, aims understand the characteristic of challenging behaviour, its frequency, and the factors associated with it in adults with AS. Data from participants with AS (N = 37; aged 18-46 years) registered with the Global Angelman Registry, were divided into challenging behaviour and non-challenging behaviour groups based on the presence or absence of 50% of the behaviours recorded in the registry. Descriptive statistics, chi-squared and t-test analysis were conducted to assess the impact of variables on challenging behaviour. Multiple regressions were conducted to investigate the predictors of challenging behaviour. 56% of the sample presented with challenging behaviour. Disorders of arousal, self-injury, behaviour dysregulation, repetitive behaviour, and the lack of physical therapy accounted for 59% of the variance of challenging behaviour in this population. It was found that challenging behaviour was very common in this population. A significant association was found between challenging behaviour and both sleep arousal and the lack of physical therapy. Sleep arousal and the lack of physical therapy were the key factors associated with challenging behaviour in this study. Targeted interventions are needed to decrease challenging behaviour and future research should focus on sleep interventions and increased opportunities for physical therapy.
Abstract Longitudinal research is crucial to fully assess the putative impact of the COVID‐19 pandemic on children with an intellectual disability in special school settings—ideally drawing on data ...pre‐pandemic to be able to evaluate later impact. Data on challenging behaviour and adaptive skills were collected annually for 348 students in one special school across four time points pre‐pandemic and one time point post‐pandemic. Data were analysed using multilevel models with repeated observations over the five time points. There was a decrease in aggressive and destructive behaviours and a decrease in adaptive skills at the post‐pandemic time point, after accounting for other important covariates. There was no evidence of a change in stereotyped or self‐injurious challenging behaviours. Other research using longitudinal methods is rare, but the current findings are consistent with previous research reporting on the impact of COVID‐19 on children and young people, particularly from parent reports. Future considerations for schools include adopting appropriate strategies to support learners to reintegrate back into education. Further research is needed to look at the longer‐term impact of the pandemic on challenging behaviour in children with an intellectual disability.
Individuals who have a dual diagnosis of both a psychiatric disorder and an intellectual disability (ID) are more likely to exhibit challenging behaviour than the general population. Clinicians ...globally have been encouraged to use positive approaches such as Positive Behaviour Support (PBS) when managing challenging behaviour.
To explore nurses' views, opinions and perceptions on the use of positive behaviour support, as an adjunctive therapy, in the management of challenging behaviour in adults with a dual diagnosis of a mental health disorder and an intellectual disability within a mental health setting.
A descriptive qualitative study was undertaken to identify registered nurses' experiences of using PBS in managing challenging behaviour. Data were collected from ten participants via semi-structured interviews and analysed using thematic analysis.
Two themes were constructed; 1) Being involved from the beginning and 2) Impact on adults with a dual diagnosis.
Nurses' involvement from the onset was fundamental in maximising the potential of PBS. Benefits of PBS were identified. Having a meaningful relationship with clients and a good knowledge of their behaviours was integral to the success of PBS.
Participants emphasised the importance of continuous education around PBS. Nurses should be included in the formulation of PBS plans.
•Nurses identified the need for continuous education around PBS, highlighting the potential benefits of practical workshops, where nurses could be afforded an opportunity to enhance their PBS skills.•Nurses held the belief that their inclusion in PBS formulation from the outset was imperative to help aid the success of the intervention.
•This paper focuses on the views of nurses on the use of PBS in the management of challenging behaviour, in adults with a dual diagnosis of a mental health disorder and an intellectual disability. There has been an international focus on reducing restrictive practices in the management of challenging behaviours. Consequently, there is an increased use of PBS. It is important nurses use PBS from the onset to ensure the consistent management of challenging behaviours. Having a good rapport and relationship with clients has a positive impact on PBS outcomes.
PURPOSEThis study explored experiences of the management of challenging behaviours after traumatic brain injury (TBI) in the acute hospital setting from the perspectives of family members.MATERIALS ...AND METHODSA qualitative, interpretive phenomenological approach was adopted involving semi-structured interviews with 10 family members. Interviews were transcribed and analysed using thematic analysis, with Ecological Systems Theory applied as a guiding framework to discuss findings and implications for practice.RESULTSFour primary themes were identified: 1) The hospital environment; 2) Hospital staffing; 3) Identifying and preventing triggers, and 4) Family support and information.CONCLUSIONSThis qualitative study highlights the need for further information, education, and support to families of patients with TBI in the acute setting. Further research investigating the implementation of best practice approaches for managing challenging behaviours practice in acute settings is needed to overcome the barriers of the hospital environment, inexperienced and inconsistent staffing, and difficulties identifying triggers within the acute hospital setting, experienced by families. Approaches for family involvement in behaviour management strategies, and facilitation of communication for people with TBI in the acute setting requires exploration.
Objectives: Alzheimer's disease (AD) and mild cognitive impairment (MCI) are often accompanied by neuropsychiatric symptoms (NPS; e.g. depression/apathy/irritability) causing challenges for people ...living with dementia/caregivers and predicting worse disease progression. Accurately assessing NPS is critical to research on AD/MCI. However, there are limitations to both self-reports and clinician evaluations; the field often relies on informants to assess NPS. Informants' perception of NPS are influenced by disease and caregiver factors that may lead to biased assessments. We aimed to assess the relationship between participants self-reported affective states (valence/arousal) and informant-reported NPS.
Methods: Data from a double-blinded intervention design (primarily testing neurostimulation's effect on NPS) were used to examine the relationship between participant-reported affective states and informant-reported NPS over 1 month. Forty participants (24 females) with MCI and NPS (mean age = 71.7, SD = 7) were enrolled along with informants (primarily spouses/partners) who regularly interact with participants. NPS assessment occurred weekly and at pre- and post-intervention, and participant-reported affective states were assessed at 14 timepoints.
Results: Generalized Estimating Equations showed that participant levels of arousal, but not valence, were significantly related to corresponding informant-reported NPS at weekly (arousal: B= −0.59, SE = 0.27, Wald's χ
2
= 4.61, p=.032; valence: B = 0.17, SE = 0.19, Wald's χ
2
= 0.80, p=.37) and pre-/post- (arousal: B= −4.00, SE = 1.58, Wald's χ
2
= 6.42, p=.011; valence: B= −3.34, SE = 1.80, Wald's χ
2
= 3.43, p=.06) assessments.
Conclusion: The findings indicate that informant-reported NPS may be more strongly influenced by arousal, and informants may be less attuned to valence in people living with MCI.
This pilot study aimed to evaluate the effectiveness of a staff intervention for post-primary schools using the New Authority approach to behaviour management, an approach informed by the principles ...of Non Violent Resistance (NVR). A review of the literature highlighted gaps in current approaches to behaviour management, particularly when responding to young people from backgrounds of trauma, chronic stress and socio-economic disadvantage, neurodivergent students and those with neurodevelopmental delays – those to whom behaviour management strategies are most often applied. The intervention aimed to reduce the frequency of unproductive behaviours in the classroom and increase participant self-efficacy, measured both quantitatively and qualitatively through an experimental and outcome evaluation design. Results, though preliminary, showed a reduction in the frequency of a range of aggressive and anti-social behaviours, and a smaller reduction for low-level disruptive behaviours. Results also indicated that participants displayed an increased sense of self-efficacy in management of student behaviour after the intervention. Feedback indicated moderate to high satisfaction with the intervention. Thematic analysis showed that participants valued the increased support from colleagues inherent within the intervention. The New Authority is proposed as a relationship-based response to challenging behaviour in schools that is sensitive to the brain's response to stress, the impact of trauma and disadvantage, and the impact of neurodivergence and neurodevelopmental delays.
•The New Authority approach is a proposed bridge between behaviourist and dialogue-only behaviour-management approaches.•Preliminary results showed that the intervention reduced aggressive and anti-social behaviours at post-primary level.•The intervention reduced low level disruptive behaviours to a lesser extent.•The New Authority for Schools resulted in increased staff self-efficacy when responding to challenging behaviour.•The New Authority is sensitive to the impact of trauma, social disadvantage, neurodiversity and disability.
Two clinical practice guidelines appraised as high-quality outline recommendations for the management of challenging behaviours after traumatic brain injury in hospital and inpatient rehabilitation ...settings.
High-quality guideline recommendations with the strongest supporting evidence for non-pharmacological treatment include behaviour management plans considering precipitating factors, antecedents, and reinforcing events.
High-quality guideline recommendations with the strongest supporting evidence for pharmacological management include beta blockers for aggression in traumatic brain injury.
Few guidelines provide comprehensive detail on the implementation of recommendations into clinical care which may limit adoption
Clinical practice guideline (CPG) recommendations for the management of challenging behaviours after traumatic brain injury (TBI) in hospital and inpatient rehabilitation settings are sparse. This systematic review aims to identify and appraise CPGs, and report high-quality recommendations for challenging behaviours after TBI in hospital and rehabilitation settings.
A three-step search strategy was conducted to identify CPGs that met inclusion criteria. Two reviewers independently scored the AGREE II domains. Guideline quality was assessed based on CPGs adequately addressing four out of the six AGREE II domains. Data extraction was performed with a compilation of high-quality CPG recommendations.
Seven CPGs out of 408 identified records met the inclusion criteria. Two CPGs were deemed high-quality. High-quality CPG recommendations with the strongest supporting evidence include behaviour management plans; beta-blockers for the treatment of aggression; selective serotonin reuptake inhibitors for moderate agitation; adamantanes for impaired arousal/attention in agitation; specialised, multi-disciplinary TBI behaviour management services.
This systematic review identified and appraised the quality of CPGs relating to the management of challenging behaviours after TBI in acute hospital and rehabilitation settings. Further research to rigorously evaluate TBI behaviour management programs, investigation of evidence-practice gaps, and implementation strategies for adopting CPG recommendations into practice is needed.
Background
National policy recommends intensive support teams for all areas of England for adults with intellectual disabilities who display challenging behaviour. However, to the best of our ...knowledge, there has not been a systematic evaluation of intensive support teams to date.
Objectives
Our objectives were to identify and describe the geographical distribution and characteristics of intensive support teams in England; to create a typology of intensive support teams; to investigate clinical and cost outcomes of intensive support team models and factors associated with those outcomes; and to explore professionals’, service users’ and carers’ experiences and describe the wider system context in which they operate.
Design
This was a two-phase mixed-methods study. In phase 1, a national survey examined the intensive support team models in operation in England. In phase 2, an observational study of adults with intellectual disabilities investigated the clinical effectiveness and cost-effectiveness of the two intensive support team models. Semistructured interviews with intensive support team managers and professionals, carers, and adults with intellectual disabilities explored their experiences of intensive support team care. In parallel, we examined service-level outcomes related to the function of intensive support teams.
Setting
Phase 1 included 80 intensive support teams serving 242 community intellectual disability services in England. Phase 2 included 21 intensive support teams, half of which were in the enhanced intensive support teams model and half of which were in the independent model.
Participants
In phase 1, a total of 73 intensive support team managers provided data. In phase 2, a total of 226 participants with intellectual disabilities from 21 intensive support teams (enhanced: teams,
n
= 11; participants,
n
= 115; independent: teams,
n
= 10; participants,
n
= 111) were enrolled in the study. A total of 42 stakeholders were interviewed.
Main outcome measure
The main outcome measure was the Aberrant Behaviour Checklist-Community, version 2, total score. Additional data sources were the carer and self-reported questionnaires, qualitative interviews and focus groups.
Results
Two intensive support team models were identified in England – enhanced and independent. Challenging behaviour at 9 months was reduced in both intensive support team models (β 3.08, 95% confidence interval –7.32 to 13.48;
p
= 0.561), but the observed Aberrant Behaviour Checklist-Community, version 2, score reduction appeared larger in the independent model than in the enhanced model (21% vs. 13%, respectively). No statistically significant differences were found in the secondary outcomes Psychiatric Assessment Schedule for Adults with Developmental Disabilities Clinical Interview organic condition (odds ratio 1.09, 95% confidence interval 0.39 to 3.02), affective or neurotic disorder (odds ratio 0.91, 95% confidence interval 0.32 to 2.59), or psychotic disorder score (odds ratio 1.08, 95% confidence interval 0.21 to 5.50); risk score (
β
1.12, 95% confidence interval –0.44 to 2.68); or quality of life questionnaire score (
β
–2.63, 95% confidence interval –5.65 to 0.40). Similarly, no differences were observed between models in relation to cost-effectiveness (health and social care costs mean difference £3409.95, 95% confidence interval –£9957.92 to £4039.89; societal costs mean difference –£4712.30, 95% confidence interval –£11,124.85 to £2106.36). The experiences of stakeholders did not differ between the intensive support team models, with carers and adults with intellectual disabilities valuing service accessibility, person-centred care and engagement. All stakeholders reported a range of barriers to intensive support team care. Service-level data and the operational policies from intensive support teams showed variation in organisational function and the roles of intensive support teams. The most commonly delivered intervention was positive behaviour support.
Conclusions
The study describes the operation of intensive support teams in England and identified two distinct models. We did not find advantages or disadvantages associated with clinical outcomes between models, nor did we find cost differences. On this basis, we recommend that local services decide which model best suits their circumstances.
Limitations
This was not a randomised controlled trial. It is possible that confounding factors have not been controlled for as there was no matching between intensive support teams. Last, there was no comparison with usual care.
Future work
There is need to develop model fidelity and investigate clinical effectiveness and cost-effectiveness in a randomised controlled evaluation of intensive support teams against treatment as usual.
Study registration
This study is registered as ClinicalTrials.gov NCT03586375, Integrated Research Application System (IRAS) 239820 and National Institute for Health and Care Research (NIHR) Central Portfolio Management System (CPMS) 38554.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in
Health and Social Care Delivery Research
; Vol. 10, No. 33. See the NIHR Journals Library website for further project information.
A pilot cluster randomized controlled trial was performed to evaluate the effects of a music group intervention and a leisure activities group intervention on well-being, self-esteem, social ...acceptance, challenging behaviour and three components of executive functions (inhibitory control, cognitive flexibility and visual working memory) of adults with intellectual disabilities (ID).
Twenty-nine participants living in four residential facilities for people with ID were randomized into a music or a leisure activities group intervention. Sixteen weekly sessions of one hour were performed with six to eight participants per group. Measurements were carried out at baseline, post-intervention and 11 weeks follow- up. Results were analysed with linear mixed models.
The leisure activities group intervention improved more than the music group intervention on internalizing behaviour overall and on inhibitory control at post-intervention. However, further analyses showed that this improvement was only significant in one of the two leisure activities facilities.
A leisure activities group intervention seems a promising intervention to improve internalizing behaviour and inhibitory control of younger adults with mild ID. Implications for the delivery of leisure activities group interventions and especially music group interventions are discussed.
Involvement in leisure activities of people with ID is associated with better well-being, an improvement in social skills and a reduction in emotional and behavioural problems. Active music making, as a specific form of leisure activities, seems to improve well-being, social acceptance and challenging behaviour (CB) as well. Moreover, in different (non-clinical) groups a significant effect of active music making has been found on self-esteem and executive functioning (EF). So far, little attention has been paid to the possible positive effects of active music making on adults with ID. In the current paper, a randomized controlled trial (RCT) was conducted to compare the post-intervention and follow-up measurements with baseline measurements between a music group intervention and a leisure activities group intervention on well-being, self-esteem, social acceptance, CB and EF in adults with ID. Multilevel models were used to detect possible intervention effects of 16 weekly sessions. Overall, inhibitory control and internalizing behaviour improved more amongst the participants of the leisure activities group than amongst the participants of the music group. This was mainly the case for younger participants who had mild ID. These effects are discussed and recommendations regarding the improvement of a music intervention for people with ID are presented.
•This study compared the effect between two group interventions (music and leisure activities) for adults with ID.•Participants in the leisure activities group intervention displayed significantly less internalizing behaviour.•Participants in the leisure activities group intervention showed significantly higher inhibitory control.•More research is necessary to fine-tune the appropriate duration and intensity of a music intervention.
