Challenging Behaviour in Intellectual Disability

Dr Shahid Zaman Consultant Psychiatrist, Cambridgeshire & Peterborough NHS Foundation Trust & Affiliated Lecturer, CIDDRG, Dept. Psychiatry, Cambridge

Challenging Behaviours

• • • • • Definition Epidemiology Behavioural phenotypes Assessment Management

Challenging Behaviour

Challenging behaviour is NOT a diagnosis

Challenging Behaviour

“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”

(Emerson, 1995)

Varieties of behaviours

• • • • • • • Aggression Self-injury Stereotypies Verbal commotion Breaking items or property Socially inappropriate Oppositional behaviour

Epidemiology

• • • • Rates vary between 5.7% to 64% Reflects the different criteria or definitions and different settings Higher rate in males than females Prevalence increases with age peaking at 15– 34 years, which is followed by a decline Prevalence is greater in people with more severe intellectual disability (esp. aggression and self injurious behaviour)

Behavioural phenotypes

• • • Genes are ultimately responsible for particular phenotypes The term encompasses many types of behaviours It includes: stereotypies, SIB, self stimulation. eating and sleep behaviours

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.

O’Brien et al., 2002

Behavioural phenotypes

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.

Behavioural phenotypes

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.

O’Brien et al., 2002

Genes & development & environment genes

environment

development

Genetic syndromes-some behavioural manifestations • • • Down’s syndrome: sociable, happy, stubborn, affectionate…but there is much variation Fragile X syndrome: social avoidance, gaze aversion; impulsive, hyperactive, distractible, wrist-biting, preserverative speech Prader-Willi syndrome: initially poor feeders, from c. 3 years upwards over-eating, temper problems, skin-picking, anxiety & psychosis

Genetic syndromes-some behavioural manifestations • • • Cornelia de Lange syndrome: SIB, autistic features Rett syndrome: females, hand stereotypies, autistic features, irregular breathing, seizures Lesch-Nyhan syndorme: compulsive SIB; motor problems-inc. choreo-athetosis, spasticity, seizures

Neuro-developmental disorders inc. ID & ASD CB Mental illness Physical health

Modified from Xenitidis et al., 2001

Biopsychosocial approach

• • • • Aetiology: genetic/biological; psychological; social (environmental) Precipitating Perpetuating Maintaining

Multidisciplinary approach

• • • • • • • • • • Patient Care managers Carers and family Nurses Psychologists SALT Psychotherapists (Art, Music) OT Psychiatrist GP

Challenging Behaviour- individual or intrinsic factors • • • CB may be contributed or explained by : By a neuropsychiatric diagnosis-depression, mania, psychotic illness, autism, neurodevelopmental syndrome associated with behavioural phenotype By a physical health problem-condition that cause pain or discomfort e.g. peptic ulcer or reflux etc., behaviours associated with seizures, adverse effects of medication,

Challenging Behaviour- common factors to consider • • • • • • Is the behaviour a means of communication?

Access / avoid - external or internal events (demands, emotions, sensory issues) A recent bereavement or loss Sensory integration Environment – under or over stimulation Single behaviour can be multifunctional

Challenging Behaviour- interpersonal and social factors • • • There may be an issue with relationship with residential associates Are there carer factors? Not liked, abused, poor understanding of person’s needs (communication style, habits, likes and dislikes) Is the place where staying unsuitable?

Assessment

• • • • • • • • • Collection of information Multidisciplinary: therapist, nurses, psychologist, carer, GP Baseline measures

Single hypothesis

Risk assessment Co-morbidity (physical, e.g. pain, psychiatric) Setting (community vs hospital) Mental Health Act

Scales

Assessment

• • • • • • What are the behaviours?

What is the possible antecedent(s)?

What are the maintaining factors? Any maladaptive learned behaviours?

What are factors that may reduce or stop the behaviours?

Communication issues?

Staff training?

pharmacotherapy-when?

• • • • • • • Try to avoid 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

PharmacologicalManagement • • • • • Treat underlying mental disorder or physical disorder 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 of self-injury Serotonergic antidepressants Sexually inappropriate behaviour - Antilibidinal drugs such as cyproterone acetate, neuroleptic drugs e.g. benperidol Aggression – lithium, benzodiazepines (paradoxical excitment), mood stabilisers

Behavioural approach

• • • 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

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 Quantitation of behaviour Hypothesis of the genesis and maintenance of the behaviour: consider biological, psychological and social factors Therapeutic intervention designed to test the hypotheses developed (single hypothesis testing) Evaluation of effectiveness of the intervention Generation and testing of alternative hypotheses