Learning Disability Managing Challenging Behaviour

Dr Nauman Khalil Consultant Psychiatrist Learning Disability Service Cambridgeshire & Peterborough NHS Foundation Trust

‘Challenging Behaviour’

The term ‘challenging behaviour’ was introduced in North America in the 1980s Originally used to describe problematic behaviours in people with ‘mental retardation’ (learning disabilities) Challenging behaviour can, however, occur across the intellectual spectrum, being particularly prevalent in populations with psychiatric disorder

Common examples of CB

aggression self-injurious behaviour property destruction oppositional behaviour stereotyped behaviours socially inappropriate behaviour withdrawn behaviour

The term itself carries no diagnostic significance, and makes no inferences about the aetiology of the behaviour CB is a descriptive concept, which is largely socially constructed, and its meaning is subject to changes in social norms and service delivery patterns over time and across geographical areas It covers a heterogeneous group of behavioural phenomena across different groups of people; for example, oppositional behaviour in children, faecal smearing in those with a severe LD and deliberate self-harm in adults with mental illness

Previously used terms

‘behavioural disturbance’ ‘problem behaviour’ ‘maladaptive behaviour’ ‘aberrant behaviour’ ‘behavioural abnormalities’.

Definition (Emerson 1995)

“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 use of, or result in the person being denied access to, ordinary community facilities”

Psychiatric disorders and challenging behaviour

Not all people with psychiatric disorders exhibit CB CB may be unrelated to a psychiatric disorder but can also be a primary or secondary manifestation of it CB may be an essential diagnostic criterion (e.g. eating disorders, personality disorders etc.) or a secondary feature (e.g. self-injury in depression, aggression secondary to persecutory delusions in schizophrenia and wandering in dementia)

Psychiatric disorders and challenging behaviour

Xenitidis et al APT (2001),vol.7,p.110

Behavioural Phenotypes

O'Brien et al., 2002

Behavioural phenotypes are syndromes with a chromosomal or genetic aetiology, comprising both physiological and behavioural manifestations, including a distinctive social, linguistic, cognitive and motor profile. The course of the syndrome, both behaviourally and medically, is not stagnant, and the presentation of the syndrome can vary according to the level of intellectual disability and input received, and can change with increasing age.

Lesch-Nyhan syndrome - self-injurious behaviour Smith-Magenis syndrome – attention seeking

Epidemiology of CB in LD

Number of studies in LD population Studies vary widely in their findings, reporting rates between 5.7% to 64% Reflects the different criteria/definitions and different settings Generally – higher rate in LD population males > females overall prevalence increases with age – peak at 15– 34years - then declines Prevalence of CB such as aggression and self injurious behaviour (SIB) is greater in people with more severe LD

Prevalence studies

Prevalence studies

Aetiology

Almost invariably multi-factorial. Best studied using a bio-psycho-social model to examine the different influences on the development and maintenance of CB

Biological factors

Genetic Studies Syndromes / Behavioural Phenotypes associated with varying degrees of specific maladaptive behaviour Prader –Willi syndrome (compulsive over eating) Lesh –Nyhan syndrome (Self Injury)

Neurochemical Studies - Role of endogenous substances in mediating human behavioural processes Endogenous opioids - pathophysiology of SIB the intrinsically rewarding properties of endorphins released by SIB Serotonin - SIB, aggression, stereotypies, anxiety and behavioural disinhibition Testosterone - mediation of aggressive and abnormal sexual behaviour Neurochemical basis of pharmacotherapeutic interventions

Brain structure and function The relationship between frequency and severity of individual CBs to particular biological variables – not well researched Recent studies on neurobiological correlates of violent behaviour a number of brain areas in the regulation of aggression, including the amygdala hippocampal complex, prefrontal cortex reduced neuronal density and abnormal phosphate metabolism in the prefrontal lobe and amygdala –hippocampal complex

Psychosocial factors

Wide range of theoretical frameworks Psychoanalytic Sociological Learning Environmental

Psychosocial factors

Access / avoid - external or internal events (demands, emotions, sensory issues) Form of communication Abuse Bereavement Sensory integration Environment – under or over stimulation Single behaviour can be multifunctional

General Principles (Assessment & Management)

Collection of information Multidisciplinary input (Speech & Language Therapist, Occupational Therapist, Psychologist) Baseline Risk assessment Investigations – co morbidity (physical, psychiatric) Setting (community vs hospital) Mental Health Act Scales e.g. Overt Aggression Scale

Functional approach ‘the emphasis is on the purpose the behaviour serves for the individual, rather than the form of the behaviour per se’ Functional assessment – Generation of hypotheses relating to the functions of the target behaviour Functional analysis – systematic evaluation of these hypotheses A – antecedent B – behaviour C – consequence

When to consider medication Risk / harm/ distress to self/ others/ property Failure of other interventions Success of medicinal intervention before Underlying mental disorders/ anxiety/ ASD/ ADHD etc.

As an adjunct to other measures Person/ carer choice Severe consequences of the behaviour

Management (Pharmacological)

Underlying mental disorder, ADHD, epilepsy or other physical conditions

Self-injury -

of self-injury opioid antagonists naloxone and naltrexone have been used for the reduction of SIB in LD mediated by a selective blockade of endorphin receptors leading to removal of the biologically based reinforcing properties Serotonergic antidepressants

Sexually inappropriate behaviour -

such as cyproterone acetate, neuroleptic drugs e.g. benperidol Antilibidinal drugs

Aggression –

lithium, benzodiazepines (? Paradoxical excirement), mood stabilisers

Management (Psychological/Behavioural)

Changing the surroundings e.g. noise level Operant conditioning (Positive, Negative, Differential) Functional communication training

Summary (Assessment & Management)

Identification of target behaviour Quantitative measurement of target behaviour Generation of hypotheses (biological, psychological and social) about the genesis and maintenance of the behaviour Therapeutic intervention designed to test the hypotheses developed (single hypothesis testing) Evaluation of effectiveness of the intervention Generation and testing of alternative hypotheses