LEARNING DISABILITIES

Health Evidence Bulletins - Wales

Literature searches completed on: 31/12/99

4:Behavioral Disturbance

This bulletin is a supplement to, not a substitute for, professional skills and experience. Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation.

The Statements The Evidence
4.1 Background
4.1a. Behavioural disturbance is referred to under a number of different terms – behavioural disorders, behavioural problems and challenging behaviour. Challenging behaviour was coined to reflect the fact that such behaviour is not intrinsic to the individual but should be viewed as a response to environmental, social, individual and historical characteristics. Problem behaviour is interpreted as a challenge to the system rather than a manifestation of an individual symptom or characteristici,ii. i. Emerson E. Challenging Behaviour: Analysis and Intervention in People with Learning Disabilities. Cambridge: Cambridge University Press, 1995
(Type V evidence - expert opinion)
ii. Jones RSP, Eayrs C. Challenging Behaviour and Intellectual Disability: A
Psychological Perspective
. Clevedon: BILD Publications, 1993
(Type V evidence - expert opinion)
4.1b. Recent studies suggest that between 12-17% of those administratively defined as having an intellectual disability will display challenging behaviouri,ii,iii,v.
Within a district of 500,000 general population, and assuming an administrative prevalence of intellectual disability of 0.45%, around 225-340 people will show challenging behaviour at any one point in time. Approximately 40-60% of these will show more severe problems.
Physical aggression, self-injury and destructiveness towards the environment tend to be the most commonly reported specific forms of challenging behaviour. Multiple forms are typically shown, and the behaviours concerned often appear to develop in childhood and remain highly persistent over time. Certain risk factors increase the likelihood of challenging behaviours. These include male gender; age between 15-35 years; having a more severe intellectual disability; having additional secondary impairments; reduced mobility and communication skills; and certain behavioural phenotypesi,ii,iii,iv.
i. Emerson E. Working with people with challenging behaviour. In Emerson E, Hatton C, Bromley J and Caine A (eds.). Clinical Psychology in People with Intellectual Disabilities. Chichester: Wiley, 1998
(Type V evidence – expert opinion)
ii. Keirnan C, Alborz. Persistence and change in challenging and problem behaviours of young adults with intellectual disability living in the family home. Journal of Applied Research in Intellectual Disabilities 1996; 9: 181-93
(Type IV evidence - cohort and cross sectional study)

iii. Emerson E, Alborz A, Reeves D, et al. The Harc Challenging Behaviour Project Report II: the Prevalence of Challenging Behaviour. Manchester: Hester Adrian Research Centre, University of Manchester, 1997
(Type IV evidence - well controlled cross sectional studies)
iv. Borthwick-Duffy S A. Prevalence of destructive behaviours. A study of aggression, self-injury and property destruction. In Thompson, T and Gray, D B (eds.). Destructive Behaviour in Developmental Disabilities. Diagnosis and Treatment. Sage: Thousand Oaks, 1994
(Type IV evidence - case registered study of 91,000 persons with intellectual disability)
v. Jacobson JW. Problem behaviour and psychiatric impairment within a developmentally disabled population. 1: Behaviour frequency. Applied Research in Mental Retardation 1982; 3: 121-139
(Type IV evidence – observational study of a population-based sample of 32,112 people with intellectual disability of all ages and all degrees of severity of intellectual disability)

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4.1c. Classification of behavioural disturbance: One of the most enduring systems classifies aggressive behavioural problems into those which are directed towards other people (aggression to others), those which are directed towards objects in the environment (destructiveness) and self-injurious behaviour.
Non-aggressive behavioural disturbance include withdrawal, anxiety and phobic reactions. Self-injurious behaviour occurs in 14% of people with intellectual disabilityi.
i. Jacobson JW. Problem behavior and psychiatric impairment within a developmentally disabled population I: behavior frequency. Applied Research in Mental Retardation 1982; 3(2): 121-39
(Type IV evidence – review of challenging behaviour in a cohort of individuals with intellectual disability)
4.2 Assessment of Behavioural Disturbance
4.2a. Assessment with a view to treatment should be wide ranging and comprehensive. Information should include cognitive abilities, communication abilities, perceptual and motor abilities, social skills, domestic skills, self-care skills, community skills, family history, living arrangements, health and medical status.
Functional analysis appears critical to effective behavioural intervention. The products of functional analysis include: a clear topographical description of the target behaviours (including classes or sequences that occur together); the identification of events that predict the occurrence and non-occurrence of the target behaviours over the person’s day; the identification of events that maintain the behaviours (i.e. the purpose or function served by the behaviour); the development of hypotheses that link specific behaviours with specific triggers and consequences; and the collection of observational data to confirm or refute these hypotheses. Data for functional analysis may be gathered by interview, by observation and by setting up analogue assessments to test specific behaviour and environmental relationshipsi,ii.
Functional analysis enhances the success rates for behavioural interventioniii,iv,v.
Reliability and validity is likely to be improved by the use of multiple methodsvi,vii.
(Health gain notation – 2 "likely to be beneficial")
i. O’Neill RE, Horner RH, Albin RW, et al. Functional Assessment of Programme Development for Problem Behaviour. A Practical Handbook. Pacific Grove, CA: Brooks/Cole, 1997
(Type V evidence - expert opinion)
ii. Sturmey P. Functional Analysis in Clinical Psychology. London: Wiley, 1996
(Type V evidence - expert opinion)
iii. Carr EG, Horner RH, Turnbull AP, et al. A Positive Behavioural Support for People with Development Disabilities. A Research Synthesis. 1999: Washington: American Association on Mental Retardation, 1999
(Type I evidence - systematic review)
iv. Scotti JR, Evans IM, Mayer LH, Walker P. A meta analysis of intervention research with problem behaviour: treatment validity and standards of practice. American Journal on Mental Retardation 1991; 96: 233-56
(Type I evidence - systematic review)
v. Didden R, Duker PC, Korzilius H. Meta-analytic study on treatment effectiveness for problem behaviours with individual who have mental retardation. American Journal on Mental Retardation 1997; 101: 387-99
(Type I evidence - systematic review)
vi. Toogood S, Timlin K. The functional assessment of challenging behaviour. Journal of Applied Research and Intellectual Disabilities 1996; 9: 206-22
(Type IV evidence - experimental analysis of outcomes for different functional analysis methodologies)
vii. Yarbrough SC, Carr EG. Some relationships between informant assessment and functional analysis of problem behaviour. American Journal on Mental Retardation 2000; 105: 130-51
(Type IV evidence - experimental analysis of outcomes for different functional analysis methodologies)

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4.2b. ABC Analysis stands for antecedents – behaviour – consequences. Behavioural problems should always be assessed in the context of their environment. Antecedents should be assessed with a view to determining the extent to which these antecedents or stimuli control the instigation of the behaviour. There should be a topographical description of the behavioural problem including the frequency, duration and intensity of the behaviour. Finally the consequences of the behaviour should be assessed to gauge their effect on the maintenance or otherwise of the problemi,ii,iii.
Antecedent analysis considers a behaviour in relation to the setting and situation in which it occurs, the time of day, week, month or year, immediate preceding activities or events, any interactions or people who are present at the time. Antecedent analysis also considers the same variables in relation to non-occurrence or absence of the behaviour. The distinction should be made between setting events (establishing operations such as tiredness, illness, mood states etc) that act by altering the value of reinforcers thereby setting the scene for challenging behaviours to occur; and specific antecedents (such as demands made on the individual) that actually trigger the behaviours of concerni,ii,iv,v.
Consequence analysis considers the effects of a behaviour on the environment, the effects on other people, previous and current attempts to manage the behaviour and consequences which seem to increase or reduce the frequency, intensity or duration of the behaviour.
i. Kennedy CH, Mayer KA. Establishing operations and the motivation of challenging behaviour. Chapter15 In Luiselli, JK, Cameron MJ (eds.) Antecedent Control. Innovative Approaches to Behavioural Support. Baltimore: Paul H Brooks, 1998
(Type V evidence - expert opinion)
ii. Horner RH, Vaughn BJ, Day HD, Ard WR. The relationship between setting events and problem behaviour: expanding or understanding or behavioural support. Chapter 16 in Koegel L K, Koegel R L and Dunlap G (eds.). Positive Behavioural Support. Including People with Difficult Behaviour in the Community. Baltimore: Paul H Brooks, 1996
(Type IV evidence - observational study)
iii. LaVigna GW, Willis TJ, Donnellan AM. The role of positive programming in behavioural treatment. In The Treatment of Severe Behaviour Disorders. E Cipani (ed). Washington DC: American Association on Mental Retardation, 1989
(Type V evidence - opinions of respected authorities based on clinical evidence)
iv. McGill P. Establishing operations: Implications for the assessment, treatment and prevention of problem behaviour. Journal of Applied Behaviour Analysis 1999; 32: 293-418
(Type V evidence – expert opinion and review of important scientific studies)
v. Smith RG, Iwata BA. Antecedent influences on behaviour disorder. Journal of Applied Behaviour Analysis 1997; 30: 343-375
(Type V evidence – expert opinion and review of important scientific studies)

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4.2c. Observation of behavioural problems in relation to the environment is fundamental to the assessment of behavioural disturbance. The observational code should be relevant to the behaviour and environment in question, ensuring systematic objective reliable data recording. This data is crucial in developing functional analysis designed to identify controlling antecedents and consequences.
Observation will inform and guide appropriate treatment, and will also provide baseline information on the frequency, duration and intensity of the behaviour disturbance with a view to gauging the effectiveness of the intervention through re-assessment after the implementation of treatmenti,ii.
(Health gain notation – 2 "likely to be beneficial")
i. Repp AC, Roberts D, Slack D, et al. A comparison of frequency, interval and time sampling methods of data collection. Journal of Applied Behaviour Analysis 1976; 9: 501-8
(Type II evidence - randomised control trial comparison of time sampling methods)
ii. Thompson T, Felce D, Symons FJ. (eds.) Behavioural Observation. Technology and Applications in Developmental Disabilities. Baltimore: Paul H Brooks, 2000
(Type V evidence - review and expert opinion)
4.2d. Continuous recording of behaviour, its antecedents and consequences are the most valid methods of observation. This data will be comprehensive and relatively free from errors. However, since an individual may have to be observed over a lengthy period of time, continuous recording is mostly impractical because of the demands on the observersi,ii.
(Health gain notation – 2 "likely to be beneficial")
i. Repp AC, Roberts D, Slack D, et al. A comparison of frequency, interval and time sampling methods of data collection. Journal of Applied Behaviour Analysis 1976; 9: 501-8
(Type II evidence - randomised control trial comparison of time sampling methods )
ii. Thompson T, Felce D, Symons FJ. (eds.) Behavioural Observation. Technology and Applications in Developmental Disabilities. Baltimore: Paul H Brooks, 2000
(Type V evidence - review and expert opinion)
4.2e. Various observational methods have been assessed for comprehensiveness in relation to continuing recording. Methods include a record of the number of discreet events recorded, a measure of the total time spent engaged in the problem behaviour as a proportion of the total observation time, and various intervals of time sampling. This latter method allows the observer to watch the individual for a short period (for example, 10, 30 or 60 seconds) and then spend the next equivalent time interval recording whether or not the behaviour occurred and the circumstances surrounding the occurrence / non-occurrence of the behaviouri,ii. i. Repp AC, Roberts D, Slack D, et al. A comparison of frequency, interval and time sampling methods of data collection. Journal of Applied Behaviour Analysis 1976; 9: 501-8
(Type II evidence - randomised control trial comparison of time sampling methods)
ii. Thompson T, Felce D, Symons FJ. (eds.) Behavioural Observation. Technology and Applications in Developmental Disabilities. Baltimore: Paul H Brooks, 2000
(Type V evidence - review and expert opinion)

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4.2f. Functional analysis assumes behavioural problems have a function for the individual. Description of the problem should include any antecedent stimuli or setting events; consequences or reinforcement contingencies which may be maintaining the problem; description of the personal, social and environmental impact of the disturbance; an analysis of the history of the problem and motivating factorsi,ii,iii,iv,v,vi,vii,viii,ix,.
(Health gain notation – 2 "likely to be beneficial")
The most common behavioural processes are positive reinforcement. The disturbance results in social or other environmental reinforcement. The behaviour is likely to increase in frequency, duration or intensity when potential social contact is denied and reduce when this contact is available.
The second type of behavioural process is maintained by negative reinforcement (escape or avoidance). Behavioural disturbance increases where demands are placed on the individual and reduces when these demands are removed.
The third common behavioural disturbance is maintained by automatic reinforcement and appears uninfluenced by consequences. It occurs when there is little environmental stimulation and is controlled and maintained intrinsically by the automatic reinforcement provided by the behaviour.
Rating scales designed to identify these processes by considering events that affect frequency, duration or intensity of a behavioural disturbance are questionable and should not be used in the absence of additional information through interview of informants or observation.
Analogue assessments tests hypotheses by arranging artificial situations providing social reinforcement, tangible reinforcement, escape, avoidance or automatic reinforcement. Situations are individually tailored and the results can be used to identify appropriate individual treatment.
More recently studies have shown that less formal assessment including rating scales, informant interviews and some observational information can be valid and reliable ways of carrying out functional analysisxi,xii.
i. Iwata BA, Dorsey MF, Slifer KJ, et al. Towards a functional analysis of self-injury. Journal of Applied Behaviour Analysis 1994; 27: 197-209
(Type IV evidence - well controlled case study)
ii. Iwata BA, Pace GM, Dorsey MF, et al.
The functions of self-injurious behaviour: an experimental-epidemiological study. Journal of Applied Behaviour Analysis 1994; 27: 215-40
(Type IV evidence - well controlled case study)
iii. Piazza CC, Fisher, WW, Hanley GP, et al. Treatment of pica through multiple analysis of its reinforcing functions. Journal. of Applied Behaviour Analysis 1998; 31: 165-89
(Type IV evidence - well controlled case studies illustrating the importance of functional analysis in relation to pica)
iv. Demchak MA, Bossert KW. Assessing Problem Behaviours. Washington DC: American Association Mental Retardation, 1996
(Type IV evidence - systematic review covering the assessment of a range of challenging behaviours)
v. Durand VM, Crimmins DB. The Motivation Assessment Scale. Topeka KS: Monaco and Associates, 1992
(Type IV evidence - studies reporting good reliability assessing different reinforcing / maintaining conditions)
vi. Thomson S, Emerson E. Inter-observer agreement on the motivation assessment scale: another failure to replicate. Mental Handicap Research (Journal of Applied Research in Intellectual Disabilities) 1995; 8: 203-8
(Type III evidence - controlled study on inter-observer agreement which found that the motivational assessment scale may have dubious reliability and validity)
vii. Piazza CC, Hanley GP, Fisher WW. Functional analysis and treatment of cigarette pica. Journal of Applied Behaviour Analysis 1996; 29: 437-50
(Type IV evidence - well controlled case study)
viii. Lally JS, Livesey K, Kates K. Functional analysis and treatment of eye poking with response blocking. Journal of Applied Behaviour Analysis 1996; 29: 129-32
(Type IV evidence - well controlled case study)
ix. Aman AG. Assessing Psychopathology and Behaviour Problems in Persons with Mental Retardation: A Review of Available Instruments. Rockville MD: US Department of Health and Human Services, 1991
(Type IV evidence - systematic review of 52 assessments of mental illness and challenging behaviour)
x. Matson JL, Bamburg JW, Cherry KE, et al. A validity study on the questions about behavioural function (QABF) scale: predicting treatment success for self-injury, aggression and stereotypies. Research in Developmental Disabilities 1999; 20: 163-76
(Type III evidence - well designed interventional study deriving behavioural function for challenging behaviour in 398 subjects)
xi. Paclawskyj TR, Matson JL, Rush KS, Smalls Y, Vollmer TR. Questions about behavioral function (QABF): A behavioral checklist for functional assessment of aberant behavior. Research in Developmental Disabilities 2000; 21: 223-229
(Type III evidence – well designed assessment study on 57 subjects showing good reliability and internal consistency for the QABF)
xii. Yarbrough SC, Carr EG. Some relationships between informant assessment and functional analysis of problem behavior. The American Journal of Mental Retardation 2000; 105: 130-151
(Type IV evidence – well controlled study on 3 individual cases showing that informant assessment provided valid hypotheses about behavioural fuction only in situations likely to evoke challenging behaviour)

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4.2g. Functional analysis is now considered in relation to a wide range of issues including its effectiveness in relation to healthcare problems, delivery by parents and carers and behavioural classificationi. i. Cone JD. Issues and functional analysis in behavioural assessment. Behaviour Research and Therapy 1997; 35: 259-75
(Type V evidence - expert opinion, review and synthesis of important studies)
4.3 Behavioural Treatments
4.3a. Behavioural treatments derived from the fact that most behaviours are governed by their antecedents and consequences. Antecedent management includes consideration of stimulus control, setting events and establishing operations. Consequences can be environmental (increasing or decreasing behavioural disturbance) or internal to the person (automatic or intrinsic reinforcement). Behavioural treatments manipulate these relationships to improve the behavioural disturbance. Behavioural interventions appear to produce superior outcomes when compared to pharmacological interventions for challenging behaviouri.
(Health gain notation – 2 "likely to be beneficial")
Both positive and negative reinforcement increase the future frequency, duration or intensity of behaviour. In positive reinforcement, a desirable outcome (eg. food, drink, attention, activity etc.) is presented contingent upon the target behaviour; in negative reinforcement, it is the contingent removal of an undesirable outcome (pain, demands, social attention) that achieves this effect.
Conversely, punishment decreases the future frequency, duration or intensity of behaviour. Positive punishment involves the contingent presentation of an aversive stimulus (eg pain, shock, forced exercise etc.), while negative punishment involves contingent removal of preferred stimuli (eg attention, activities, general access to positive reinforcement etc.)ii,iii,iv.
i. Didden R, Duker PC, Corzilius H. Meta-analytic study on treatment effectiveness for problem behaviours with individuals who have mental retardation. American Journal on Mental Retardation 1997; 101(4): 387-99
(Type I evidence - systematic review and meta-analysis of 482 empirical studies on treatment of problem behaviours of individuals with intellectual disability)
ii. Whitacker S. The reduction of aggression in people with learning disabilities: a review of psychological methods. British Journal of Clinical Psychology 1993; 32: 1-38
(Type V evidence – expert opinion based on a review of 78 studies covering a range of interventions for the reduction of aggression)
iii. Scotti JR, Evans IM, Mayer LH, Walker P. A meta-analysis of intervention research with problem behaviour: treatment validity and standards of practice. American Journal on Mental Retardation 1991; 96: 233-56
(Type I evidence - systematic review and meta-analysis of 403 studies published from 1976-1987)
iv. Repp AC, Singh NN (eds.) Perspectives on the Use of Non-aversive and Aversive Interventions for Persons with Developmental Disabilities. Sycamore, Illinois: Sycamore, 1990
(Type V evidence – expert opinion, review and synthesis of important studies)

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Positive Behavioural Approaches
4.3b. Positive behavioural approaches aim to change challenging behaviours by focussing on environmental manipulation (thus preventing the occurrence of the behaviours) and by teaching alternative adaptive responses (for example, skills that serve the same function as the target behaviour). In contingency management terms, positive reinforcement based approaches are favoured and aversive approaches rejected for technical and ethical reasons.
Using a criterion of 90% reduction in challenging behaviour from baseline levels, positive interventions are successful approximately 52% of the time; using an 80% reduction criterion, this rate increases to 68%. Using the 80% criterion, separate success rates for antecedent/stimulus based interventions was almost 70% and for reinforcement based interventions almost 72%. Success rates are generally not influenced by whether or not those procedures are implemented alone or in combination. Success rates for studies that combine positive behavioural approaches with aversive procedures produce a success rate of almost 64% using a 90% suppression criterion. Caution is urged in interpreting the latter finding in that it is based on a small number of studies. Intervention for combinations of challenging behaviours rather than single behaviours tends to be less successful. Interventions that involve systems/organisational change appear to be slightly more successful than those that do not (55% versus 42%). Some positive behavioural interventions may produce intervention effects that are at least as rapid as more aversive proceduresi,ii.
i. Carr EG, Horner RH, Turnbull AP, et al. Positive Behavioural Support for People with Developmental Disabilities. A Research Synthesis. Washington: American Association on Mental Retardation, 1999
(Type V evidence - expert opinion and review of important studies)
ii. Carr EG, Robinson S, Taylor JC, Carlson JI. Positive Behavioural Approaches to the Treatment of Severe Behaviour Problems in Persons with Developmental Disabilities: A Review and Analysis of Reinforcement and Stimulus Based Procedures. Seattle: Association for Persons with Severe Handicaps, 1990
(Type V evidence - expert opinion and review of important studies)

 

 

 

 

 

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Functional Communication Training
4.3c. Functional communication training (FCT) assumes that behavioural disturbance, rather than being seen as an aberrant activity should be viewed as a means of communicating the needs of that individual to others. FCT is effective in helping the individual learn alternative ways of communicating needs without recourse to behavioural disturbance. FCT therefore increases adaptive communication and decreases maladaptive communicationi,ii.
(Health gain notation – 2 "likely to be beneficial")
i. Carr EG, Durand VM. Reducing behaviour problem through functional communication training. Journal of Applied Behaviour Analysis 1985; 18: 111-26
(Type IV evidence - well controlled case studies. This was one of the first papers to introduce the communication hypothesis and functional communications training)
ii. Durand VM. Functional communication training using assistive devices: recruiting natural communities of reinforcement. Journal of Applied Behaviour Analysis 1999; 32: 247-67
(Type IV evidence - well controlled case studies)
4.3d. Recent studies have found that functional communication training on its own may be of limited effectiveness without concurrent extinction of the target behaviour.
(Health gain notation – 5 "unlikely to be beneficial")

Functional communication training with extinction (not delivering a consequence for problem behaviour) resulted in 90% reductions of problem behaviour in 50% of clientsi,ii,iii,iv.
(Health gain notation – 2 "likely to be beneficial")

i. Thompson RH, Fisher WW, Piazza CC, et al. The evaluation and treatment of aggression maintained by attention and automatic reinforcement. Journal of Applied Behaviour Analysis 1998; 31: 103-16
(Type IV evidence - well controlled case studies)
Other authors have found reinforcement of functional communication enhances the effectiveness of FCT.
ii. Fisher WW, Adelinis JD, Thompson RH, et al. Functional analysis and treatment of destructive behaviour maintained by termination of "don’t" (and symmetrical "do") requests. Journal of Applied Behaviour Analysis 1998; 31: 339-56
(Type IV evidence - well controlled case studies)
iii. Carr EG, Levin L, McConnachie G, et al. Communication Based Intervention for Problem Behaviour: A Users’ Guide for Producing Positive Change. Baltimore, MD: PH Brookes, 1994
(Type V evidence - expert opinion, review of important studes and description of treatment methods)
iv. Fisher W, Piazza C, Cataldo, et al. Functional communication training with and without extinction and punishment. Journal of Applied Behaviour Analysis 1993; 26: 23-36
(Type IV evidence - well controlled case studies)

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4.3e. Functional communication training with mild punishment (e.g. time out in a room or a chair) directed at the target behaviour, resulted in 90% reduction in problem behaviour in 100% of clientsi.
(Health gain notation – 2 "likely to be beneficial")
i. Hagopian LP, Fisher WW, Sullivan MT, et al. Effectiveness of functional communication training with and without extinction and punishment: a summary of 21 in-patient cases. Journal of Applied Behaviour Analysis 1998; 31: 211-35
(Type IV evidence – a summary of data from well controlled case studies comparing functional communications training with extinction against functional communications training with mild punishment)
Extinction
4.3f. Extinction is effective in reducing behavioural disturbance. By discontinuing any previous reinforcement of a behaviour, once the reinforcement is no longer available the behavioural disturbance reduces. No distinction is made between positive, negative, intrinsic or extrinsic reinforcementi,ii,iii,iv.
A serious side effect is the occurrence of extinction bursts where individuals responds with an increased frequency of the behaviour in order to gain (the now unattainable) reinforcement. In cases of aggressive, destructive or self-injurious behaviour this will present a danger to the individual and others. Extinction should normally only be considered and used in conjunction with other methods and for non-dangerous behaviours.
(Health gain notation – 3 "trade off between beneficial and adverse effects")
i. Cooper JO, Heron TE, Heward WL. Applied behaviour analysis. Chapter 17 Extinction. New York: MacMillan, 1987
(Type V evidence - expert opinion with a review of some studies and methods)
ii. Lerman DC, Iwata BA. Developing a technology for the use of operant extinction in clinical settings: an examination of basic and applied research. Journal of Applied Behaviour Analysis 1996; 29: 345-82
(Type III evidence - systematic review of basic and applied research findings on variables that influence the direct and indirect effects of extinction. An expert evaluation of the general technology for the use of extinction)
iii. Smith RG, Russo L, Le Duyd. Distinguishing between extinction and punishment effects of response blocking: a replication. Journal of Applied Behaviour Analysis 1999; 32: 367-70
(Type IV evidence – well controlled case studies)
iv. Vollmer TR, Progar PR, Lalli JS, et al. Fixed time schedules attenuate extinction induced phenomena in the treatment of severe abhorrent behaviour. Journal of Applied Behaviour Analysis 1998; 31: 529-42
(Type IV evidence – well controlled case studies)
Aversive Consequences
4.3g. There is extensive evidence that aversive consequences will produce short-term suppression of behavioural disturbance. Punishment techniques range from mild electric shock to cold water mist in the face and time out from positive reinforcementi.
(Health gain notation – 2 "likely to be beneficial")
These techniques do not carry the same requirements for functional analysis of the variables controlling the problem behaviour. They do not fit comfortably with the systematic, analytic and educational features of the majority of research on behavioural treatment. They also pose significant ethical and legal concerns.
i. Matson JL, DiLorenzo TM. Punishment and its Alternatives: A New Perspective for Behaviour Modification. New York: Springer, 1984
(Type V evidence – expert opinion and review of important studies)

 

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4.3h. Punishment does not institute alternative adaptive responses. Punishment may also have severe side effects in eliciting aggressive behaviours and avoidance or escape behaviours and it can serve as a negative modelling procedurei,ii.
Whereas more aversive procedures may produce greater levels of suppression (i.e. zero levels of target behaviour), the overall amount of change between baseline and treatment is not related to whether aversive or non-aversive approaches are used. The suppressive effect of more intrusive interventions is improved by the addition of DRO to intervention packagesiii.
Despite their obvious effectiveness, concerns about the non-constructive nature of aversive interventions, together with their lack of social validity, has resulted in these approaches being described as "default" technologies. It has been suggested their use is only indicated when alternative positive approaches have failed or are not feasible and when the costs of not intervening are greater than the costs of using aversive proceduresiv.
i. Plummer S, Bare DM, LeBlanc JM. Functional considerations in the use of procedural time out and an effective alternative. Journal of Applied Behaviour Analysis 1977; 10: 689-706
(Type IV evidence – well controlled case study)
ii. Hagopian LP, Fisher WW, Sullivan MT, et al. Effectiveness of functional communication training with and without extinction and punishment: a summary of 21 in-patient cases. Journal of Applied Behaviour Analysis 1998; 31: 211-35
(Type IV evidence – a summary of data from well controlled case studes comparing functional communications training with extinction against functional communications training with mild punishment)
iii. Scotti JR, Evans IM, Mayer LH, Walker P. A meta-analysis of intervention research with problem behaviour: treatment validity and standards of practice. American Journal on Mental Retardation 1991; 96: 233-56
(Type I evidence - systematic review and meta-analysis of 403 studies from 1976-1987)
iv. Emerson E. Challenging Behaviour. Analysis and Intervention in People with Learning Difficulties. Cambridge: Cambridge University Press, 1985
(Type V evidence: expert opinion based on clinical evidence)

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4.3i. Time out, the loss of access to positive reinforcers to behaviour for a specific period of time, is effective in reducing future occurrences of abnormal behaviour. Time out is not simply removing an individual to a secluded setting (seclusion)i,ii.
There is a distinction between "time in" and "time out". The greater the reinforcing properties of the time in situation so will be the greater effectiveness of the time out situation. Time out may simply be ineligibility to access reinforcers for a short period of time. Time out procedures can increase the effectiveness of positive programming procedures when used in conjunction with them.
(Health gain notation – 2 "likely to be beneficial")
See also 4.4i.
i. Plummer S, Bare DM, LeBlanc JM. Functional considerations in the use of procedural time out and an effective alternative. Journal of Applied Behaviour Analysis 1977; 10: 689-706
(Type IV evidence - well controlled case study)
ii. Hagopian LP, Fisher WW, Sullivan MT, et al. Effectiveness of functional communication training with and without extinction and punishment: a summary of 21 in-patient cases. Journal of Applied Behaviour Analysis 1998; 31: 211-35
(Type IV evidence – a summary of data from well controlled case studies comparing functional communications training with extinction against functional communications training with mild punishment)
4.4 Skills teaching

4.4a. Skills’ teaching is effective in people with and without behavioural disturbance in adapting to and overcome problems in their lives. A crucial aspect of positive programming, skills’ teaching develops alternative functional behaviours that supplant behavioural problems and disturbances. Self-help skills, interpersonal skills, leisure skills, parenting skills and work skills can be developed using these methods.
A meta analysis of 73 studies found that social skills training produced improvements in a broad repertoire of social skills, had effects lasting several months and had a greater effect for developmentally disabled groups than other clientsi.
(Health gain notation – 2 "likely to be beneficial")

i. Corrigan PW. Social skills training in adults with psychiatric populations: a meta analysis. Journal of Behaviour Therapy and Experimental Psychiatry 1991; 22: 203-10
(Type I evidence - systematic review and meta-analysis of 73 studies)

 

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Behavioural Shaping, Prompting and Fading
4.4b. Shaping is effective as an adjunct to training since subjects rarely achieve an adequate level of ability on their first attempt. Any approximation towards a reasonable level of skill is accepted by the therapist who then encourages subsequent attempts at improvement. The therapist may also establish one response and gradually shape it towards the desired end responsei.
In the early stages of training it is reasonable to prompt the desired response. Physical and verbal prompts can also help clients gain the confidence to begin a sequence of abilitiesi.
An essential consideration when employing prompting is to build in the fading of prompts. It is unhelpful if the client becomes dependent on the therapists’ prompts, so the therapist should have a plan to begin fading not only therapeutic prompts, but other aspects of the therapeutic situation, so that the client is able to function independentlyi.
(Health gain notation – 2 "likely to be beneficial")
i. Lindsay WR, Michie AM. Teaching new skills. in Fraser W, Sines D, Kerr M (eds.). Hallas’ The Care of People with Intellectual Disabilities. 9th Edition. Oxford: Butterworth Heinemann, 1998
(Type V evidence - expert opinion including review of important studies)
4.4c. Behavioural Chaining: is useful once a sequence or chain of skills has been established. The therapist focus’s training at one end of the chain, the next step in the sequence is trained and linked to the previous one and so on until the whole complex ability has been learned. When training begins with the first aspect in the sequence this is called forward chaining; when it begins with the last it is backward chainingi.
(Health gain notation – 2 "likely to be beneficial")
i. Carr J, Collins S. Working Towards Independence: A Practical Guide to Teaching People with Learning Disabilities. London: Jessica Kingsley, 1992
(Type V evidence - expert opinion, practical guidance including review of some important studies)

 

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4.4d. Role-play uses important stimuli from a real setting whilst remaining under therapist control. It is effective in allowing the group or individual to practice various skills concerned before going into the real setting. Role-play can involve a whole sequence of skills or one small aspect of a behavioural sequencei,ii.
(Health gain notation – 2 "likely to be beneficial")
i. Langone J, Clees TJ, Oxford M, et al. Acquisition and generalisation of social skills by High School student with mild mental retardation. Mental Retardation 1995; 33: 186-96
(Type III evidence - well designed controlled trial)
ii. Baty FJ, Michie AM, Lindsay WR. Teaching mentally handicapped adults how to use a cafeteria. Journal of Mental Deficiency Research 1989; 33: 137-48
(Type IV evidence - case controlled study)
4.4e. Modelling allows a series of complex skills to be demonstrated without going into confusing explanations of how the skill is sequenced together. Modelling will then be combined with role-playing in an effort to help clients achieve the skill of the modeli.
(Health gain notation – 2 "likely to be beneficial")
i. Lindsay WR, Michie AM. Teaching new skills. in Fraser W, Sines D, Kerr M (eds.). Hallas’ The Care of People with Intellectual Disabilities. 9th Edition. Oxford: Butterworth Heinemann, 1998
(Type V evidence - expert opinion including review of important studies)
4.4f. Social problem solving is a useful process whereby skills for determining an effective action strategy in a given situation are taught to patients. This is in addition to teaching the actual abilities to cope in specific situations.
(Health gain notation – 2 "likely to be beneficial")
Results on the effectiveness of training social problem solving skills either on their own or as an adjunct to social skills training are equivocali.
i. Loumidis K, Hill A. Training social problem solving skills to reduce maladaptive behaviours in intellectual disability groups: the influence of individual difference factors. Journal of Applied Research in Intellectual Disabilities 1997; 10: 217-37
(Type II evidence - controlled group study involving 46 subjects in two groups. Also includes an extensive review of social problem-solving skills training)

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Comprehensive systems based on behavioural principles.

4.4g. Skills Training Systems: Group comparison studies suggest that gains produced by social skills training are consistent and effective when compared with alternative group therapies and no treatment controls. Early intervention systems directed at improvements in cognitive academic and social skills have been employed for some time in children with autism. Recent studies enlisting parents to implement procedures at home have found positive resultsi,ii,iii,iv,v,vi.
(Health gain notation – 2 "likely to be beneficial")
i. Matson J, Senatore V. A comparison of traditional psychotherapy and social skills training for improving interpersonal functioning of mentally retarded adults. Behaviour Therapy 1981; 12: 282-369
(Type III evidence - well designed controlled study comparing subjects receiving traditional psychotherapy and subjects receiving social skills training. Social skills training produced greater and more consistent improvements than psychotherapy)
ii. Fox R, McMorrow M, Schloss C. Stacking the deck: teaching social skills to retarded adults with a modified table game. Journal of Applied Behaviour Analysis 1983; 16: 157-70
(Type IV evidence - a series of cases seen in a group and employing a highly innovative and engaging approach to social skills training)
iii. Michie AM, Lindsay WR, Smith AHW, Todman J. Changes following community living skills training: a controlled study. British Journal of Clinical Psychology 1998; 37: 109-11
(Type II evidence - randomised controlled study comparing 29 subjects trained in community living skills using in vivo techniques, 13 using classroom techniques and 15 acting as a no treatment control. There was an overwhelming superiority in improvements for the skills training group)
iv. Ozomoff S, Cathcart K. Effectiveness of a home programme intervention for young children with autism. Journal of Autism and Developmental Disorders 1998; 28: 25-32
(Type III evidence - a comparison of an experimental and control group with matched subjects. Significant improvements were found in the experimental cohort)
v. Sheinkopf SJ, Siegel B. Home based behavioural treatment of young children with autism. Journal of Autism and Developmental Disorders 1998; 28: 15-23
(Type III evidence - a matched group comparison showing significant improvements in the experimental cohort)
vi. Gresham FM, MacMillan DL. Early intervention projects: can its claims be substantiated and its effects replicated? Journal of Autism and Developmental Disorders 1998; 28: 5-13
(Type V evidence - expert opinion based on a review of early intervention projects where the authors acknowledge undoubted treatment successes but recommend a healthy scepticism concerning unqualified endorsement)

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4.4h. Services for people with challenging behaviour and intellectual disability: Effective behavioural support for persons with challenging behaviour can be provided within community settings. Dependence on institutional provision can be reduced as a consequencei,ii,iii,iv.
(Health gain notation – 2 "likely to be beneficial")
i. Allen D, Felce D. Service responses to challenging behaviour. Ch. 17 in Bouras N (ed). Psychiatric and Behavioural Disorders in Developmental Disabilities and Mental Retardation. Cambridge: Cambridge University Press, 1999
(Type V evidence - expert opinion based on scientific evidence)
ii. Emerson E, McGill P, Mansell J (eds.) Severe Learning Disabilities and Challenging Behaviours: Designing High Quality Services. London: Chapman & Hall, 1994
(Type V evidence – expert opinion based on scientific evidence)
including: McGill P, Emerson E, Mansel J. Individually designed residential provision for people with seriously challenging behaviours. Chapter 6
(Type V evidence – expert opinion and review of services for 22 clients)
iii. Homer RH, Close DW, Fredericks HD et al. Supported living for people with profound disabilities and severe problem behaviours. Chapter 9 in Lehr D, Brown F (eds.) People with Disabilities who Challenge the System. Baltimore: Paul Brookes, 1996
(Type V evidence – expert opinion and review of services for 12 clients)
iv. Mansell J. Specialised group homes for persons with severe or profound mental retardation and serious problem behaviour in England. Research in Developmental Disabilities 1994; 15: 371-388
(Type III evidence – well designed interventional study in 13 people with severe or profound intellectual disability and challenging behaviour)

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4.4i. In addition to having strategies for changing behaviour, carers supporting people who display dangerous behaviour will require strategies for managing these behaviours safely and effectively. Reactive behaviour management strategies included distraction and diffusion, self-protective breakaway procedures and minimal restraint. Carers can effectively be taught a range of ethically acceptable techniques and their confidence increases as a resulti,ii.
Training may also lead to a reduction in restraint, use of emergency medication, and injuriesiii.
(Health gain notation – 2 "likely to be beneficial")
It should be noted that all restraint procedures, however mild, carry the possibility of injury and should only be considered in conjunction with comprehensive policies for use and staff training.
The use of seclusion (the supervised containment of a person in a room to protect others from significant harm) for persons with a learning disability has been questioned. Its use may not bring about short-term improvements in behaviour as intended, may cause certain behaviours to worsen and elicit the appearance of new behavioursiv.
(Health gain notation – 4 "unknown")
i. McDonnell A. Training care staff to manage challenging behaviour: an evaluation of a three day training course. British Journal of Developmental Disabilities 1997; 43: 156-62
(Type IV evidence - case controlled study)
ii. Allen D, McDonald L, Dunn C, Doyle T. Changing care staff approaches to the management of aggressive behaviour in a residential treatment unit for persons with mental retardation and challenging behaviour. Research and Developmental Disabilities 1987; 18: 101-12
(Type IV evidence - observational study)
iii. Allen D, Tynan H. Responding to aggressive behaviour: the impact of training on staff knowledge and confidence. Mental Retardation 2000; 38: 97-104
(Type II evidence - controlled group comparison plus case controlled study)
iv. Mason T. Seclusion and learning disabilities: Research and deduction. British Journal of Developmental Disabilities 1996: 42: 149-159
(Type IV evidence – survey of seclusion use over a 12 month period in a special hospital)

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4.5 Relaxation
4.5a. Abbreviated progressive relaxation (APR) and behavioural relaxation training (BRT) are effective when used in individuals with moderate, severe and profound intellectual disability. BRT works more rapidly and reliably than APR, and is an established treatment approach for individuals with anxiety, agitation, restlessness and disruptivenessi,ii,iii,iv.
Because BRT is an essentially passive technique, it does not appear to have the drawbacks inherent in APR. There is no paradoxical tensing of muscles in order to relax, and there appear to be no side effects whereby clients misconstrue the demands of training, becoming more rather than less excited. It is an effective enabling technique to allow individuals to become more accessible to their environment.
(Health gain notation – 2 "likely to be beneficial")
i. Schilling D, Poppen R. Behavioural relaxation training and assessment. Journal of Behaviour Therapy and Experimental Psychiatry 1983; 14: 99-107
(Type II evidence - randomised controlled study comparing four forms of relaxation. BRT was consistently effective across all measures)
ii. Lindsay WR, Baty FJ, Michie AM, et al. A comparison of anxiety treatments with adults who have moderate and severe mental retardation. Research on Developmental Disabilities 1989; 10: 129-40
(Type II evidence - randomised controlled trial comparing BRT and APR against a control condition. Subjects in both conditions showed significant improvements over control subjects with BRT using more rapid improvement)
iii. Lindsay WR, Morrison FM. The effects of behavioural relaxation on cognitive performance in adults with severe intellectual disabilities. Journal of Intellectual Disabilities Research 1996; 40: 285-290
(Type II evidence - randomised controlled trial. Subjects receiving BRT showed more significant improvements in cognitive functioning than control subjects on all tasks except those involving long term memory)
iv. Lindsay WR, Michie AM, Marshall I, et al. The effects of behavioural relaxation training on adults with profound multiple disabilities: a preliminary study on treatment effectiveness. British Journal of Learning Disabilities 1996; 24: 119-23
(Type IV evidence - case controlled studies)
4.5b. Cue controlled relaxation (CCR) links the effects of relaxation to a cue word. In time the subject will be able to relax to the cue word only, rather than a time consuming relaxation procedure. CCR is effective at improving concentration and attention to an occupational task when used in individuals with moderate and severe intellectual disabilityi,ii.
(Health gain notation – 2 "likely to be beneficial")
i. Wells KC, Turner SM, Bellack AS, et al. Effects of cue control relaxation on psychomotor seizures: an experimental analysis. Behaviour Research and Therapy 1978; 16: 51-3
(Type IV evidence - well designed case-study employing multiple measure across various conditions)
ii. Lindsay WR, Fee M, Michie AM, et al. The effects of cue control relaxation on adults with severe mental retardation. Research in Developmental Disabilities 1994; 15: 425-37
(Type IV evidence - well designed series of case controlled studies for the sequence of introduction on a range of variables)

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4.6 The Snoezelen environment
4.6a. The Snoezelen environment was developed in Holland to induce meditation, tranquillity and relaxation. It has been adopted in the UK for people with multiple handicap and severe or profound intellectual disability. The environment is artificial with a variety of soothing stimuli for all the senses including lights, textures, sounds and smells.
The original developers have explicitly resisted empirical assessment of the environment. Recent studies have found that, with individuals who have severe and profound intellectual disability, snoezelen is no less effective than relaxation techniques on a variety of measures. It was found to be more effective than other "alternative" or "complementary" techniques such as hand massage or physical activity. It is considerably more expensive than relaxation techniquesi,ii.
A controlled trial demonstrated a decrease in aggressive responding in anger management and control conditions with no significant differences in the conditions ii .
While some studies have noted short term positive effects, one controlled study found no generalised effect outside the immediate results of the Snoezelen environmentiii.
(Health gain notation – 4 "unknown")
i. Hulsugge J, Verheul A. Snoezelen. Another World. Chesterfield: Rompa, 1987
(Type V evidence – expert opinion)
ii. Lindsay WR, Pitcaithly D, Geelen N, et al. A comparison of the effects of four therapy procedures on concentration and responsiveness in people with profound learning disabilities. Journal of Intellectual Disability Research 1997; 41: 201-7
(Type III evidence - controlled crossover group comparison employing 8 subjects who each receive treatments involving snoezelen, aromatherapy, relaxation and physical exercise)
iii. Martin NT, Gaffan EA, Williams T. Behavioural effects of long term multi-sensory stimulation. British Journal of Clinical Psychology 1998; 37: 69-82
(Type II evidence – 27 adults with severe or profound intellectual disability were included in a randomised controlled trials employing a double cross-over design. The Snoezelen environment was compared with an ordinary environment)

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4.7 Psychotherapy

4.7a. Reports of psychoanalytically informed psychotherapies have begun to appear over the last 10 years. In general these reports do not provide outcome data but where they do, the results are generally positivei,ii.
(Health gain notation – 4 "unknown")
i. Frankish P. Meeting the emotional needs of handicapped people: a psychodynamic approach. Journal of Mental Deficiency Research 1989; 33: 407-14
(Type IV evidence - case studies of 7 intellectually disabled children and adults)
ii. Beail N. Psychoanalytic psychotherapy with men with intellectual disabilities: a preliminary outcome study. British Journal of Medical Psychology 1998; 71: 1-11
(Type IV evidence - case analysis of 25 men, 20 of whom completed treatment)
4.8 Cognitive Therapy
4.8a. There is a body of evidence, based on single case studies, demonstrating the effectiveness of cognitive therapy for people with mild intellectual disability and borderline intelligencei,ii.
These reports maintain the essential principles, components and procedures of cognitive therapy (setting an agenda, developing an awareness of the role of underlying beliefs in determining thought, establishing the relationship between thoughts, feelings of anxiety and behaviour, monitoring automatic thoughts, challenging maladaptive beliefs and developing adaptive automatic thoughts) but simplify them considerably to allow for the linguistic and intellectual deficits of clients. As yet there have been no controlled treatment trials investigating long-term outcome.
(Health gain notation – 2 "likely to be beneficial")
i. Stenfert Kroese B, Dagnan D, Loumidis K. Cognitive Behaviour Therapy for People with Learning Disabilities. London: Routledge, 1997
(Type V evidence - expert opinion and review of clinical case studies)
ii. Lindsay WR. Cognitive therapy. The Psychologist 1999; 12: 238-41
(Type V evidence - expert opinion and presentation of over 50 case studies)

 

 

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4.8b. Anger management training is an essentially cognitive therapy. The way in which an individual misconstrues a situation and their personal feelings of arousal is germane to the development of anger responses. The techniques help individuals appraise and reappraise situations for the extent to which they are in reality anger arousing, to identify their own emotions more accurately, to role-play adaptive ways of behaving in these situations and to practise them in real life i,ii,iii.
One case-controlled study demonstrated a decrease in aggressive responding in anger management and control conditions with no significant differences between the conditionsi.
A further controlled trial demonstrated significant reductions in expressed anger for subjects receiving anger management training which maintained up to one year iv.
(Health gain notation – 2 "likely to be beneficial")
i. Benson BA, Rice CJ, Miranti SV. Effects of anger management training with mentally retarded adults and group treatment. Journal of Consulting and Clinical Psychology 1986; 54: 728-9
(Type II evidence - although a controlled trial it lacks a no treatment control condition)
ii. Lawrenson H, Lindsay WR. The treatment of anger in individuals with learning disabilities. In W Fraser, D Sines and M Kerr (eds.) Hallas’ the Care of People with Intellectual Disabilities. 9th Edition. Oxford: Butterworth Heinemann, 1998
(Type V evidence - expert opinion and case studies)
iii. Black L, Cullen C, Novaco R. Anger management training in people with intellectual disabilities. In B Stenfert Kroese, D Dagnan and K Loumidis (eds.) Cognitive Behaviour Therapy for People with Learning Disabilities. London: Routledge, 1997
(Type IV evidence - case controlled study)
iv. Rose J, West C, Clifford D. Group interventions for anger in people with intellectual disabilities. Research in Developmental Disabilities 2000; 21: 171-181
(Type III evidence - an interventional study without randomisation comparing 25 individuals who completed anger management training with 19 individuals from a waiting list control. The interventions produced significant reductions in expressed anger which were maintained at 6 and 12 month follow-up)

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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk