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Background: Low- and middle-income countries often lack the fiscal, infrastructural and human resources to conduct evidence-based research; similar constraints may also hinder the application of good clinical practice guidelines based on research findings from high-income countries. While the context of health organizations is increasingly recognized as an important consideration when such guidelines are implemented, there is a paucity of studies that have considered local contexts of resource-scarcity against recommended clinical guidelines., Methods: This paper sets out to explore the implementation of the NICE Guideline 11 on family interventions when working with persons with intellectual disability and challenging behavior by a group of psychologists employed in a government health facility in Cape Town, South Africa., Results: In the absence of evidence-based South African research, we argue that aspects of the guidelines, in particular those that informed our ethos and conceptual thinking, could be applied by clinical psychologists in a meaningful manner notwithstanding the relative scarcity of resources., Conclusion: We have argued that where guidelines such as the NICE Guidelines do not apply contextually throughout, it remains important to retain the principles behind these guidelines in local contexts. Limitations of this study exist in that the data were drawn only from the clinical experience of authors. Some of the implications for future research in resource-constrained contexts such as ours are discussed. Smaller descriptive, qualitative studies are necessary to explore the contextual limitations and resource strengths that exist in low- and middle-income settings, and these studies should be more systematic than drawing only on the clinical experience of authors, as has been done in this study.

In some neuro-developmental disorders, the combined effect of intellectual disability and atypicalities of social cognition may put individuals at increased vulnerability in their social environment. The neuro-developmental disorders Williams syndrome, characterised by 'hypersociability', and autism spectrum disorders, characterised by 'social withdrawal', are at two extremes of atypical social functioning in humans. In this article, we use Williams syndrome and autism spectrum disorders as exemplars to demonstrate how atypicalities of social cognition may contribute to social vulnerability in these populations. The lives of individuals with both these disorders are marred by an increased risk of social isolation, bullying, unsteady relationships, employment difficulties and abuse. While different behavioural interventions have been tried to improve social functioning in these populations, there has been great variability in their success. Finally, we discuss different issues regarding social independence of these individuals; including employment, safety and decision making., (© 2011 The Authors. Journal of Intellectual Disability Research © 2011 Blackwell Publishing Ltd.)

Background: There is not one case report of successful trauma treatment with the use of an evidence-based treatment method in people with substantially limited verbal capacities. This paper assessed the applicability of eye movement desensitisation and reprocessing (EMDR) in two clients with moderate ID, serious behavioural problems, and histories of negative life events., Method: The 8-phase protocol of EMDR, a first-line treatment for psychological trauma, was applied., Results: In both cases, posttraumatic stress disorder (PTSD)-like symptoms decreased in a total of only 6 and 5 sessions, respectively. Gains were maintained at 32 and 10 months' follow-up., Conclusions: EMDR seems to be an applicable psychological trauma treatment for persons with limited verbal capacities. Considering the importance of these findings, further and more rigorous research is required.

Background: The quality of behaviour support plans (BSPs) can be an important influence on the quality of the support provided to people with disability who show challenging behaviours. The Behavior Support Plan Quality Evaluation Guide II (BSP-QE II) is one tool that may be useful in assessing the quality of behaviour support plans. It has previously been used to assess BSPs to support children in schools in the USA. In this preliminary study, we examined the utility of the BSP-QE II for assessing behaviour support plans designed for adults with an intellectual disability in community support services in Australia., Method: Experienced practitioners were surveyed concerning the relevance of BSP-QE II components to the evaluation of BSPs in Australia, and an audit was conducted of randomly selected BSPs submitted as a statutory requirement to the Office of the Senior Practitioner., Results: The BSP-QE II showed evidence of acceptable construct validity and interrater reliability. There was evidence of a need for substantial improvement in the quality of BSPs, consistent with previous findings conducted using other audit tools., Conclusions: The findings support the utility of the BSP-QE II, to inform and evaluate service planning in supporting adults with intellectual disability who show challenging behaviour.

Errorless learning (EL) procedures have been shown to be effective in teaching new information and new procedures to individuals with severe memory impairment. The published studies have been based on comparatively short-term interventions delivered to individuals with relatively circumscribed impairments. In this single case study, we explore the usefulness of errorless learning procedures used for seven years with an adult with profound and complicated memory and executive function impairments associated with three distinct aetiologies. In primary functional areas targeted by the intervention, outcome was documented by behavioural descriptions and a frequency rating scale. Caregiver burden was documented with qualitative descriptors. A financial cost-benefit analysis is also provided. In the absence of change in underlying neuropsychological impairments, DI's everyday functioning in critical areas improved substantially, with corresponding reduction in supports and improved quality of life. Caregiver burden was reduced to acceptable levels and cost-benefit analysis demonstrates substantial ongoing cost savings.

Background: Aggressive challenging behaviour is common in adults with intellectual disability (ID) in long-term care facilities. The government's commitment to the closure of all facilities in England has led to concerns over how to manage this behaviour in the community. The aim of this study was to assess changes in aggressive challenging behaviour and psychotropic drug use in adults with ID following resettlement using a person-centred approach., Method: The Modified Overt Aggression Scale was administered to carers of 49 adults with ID prior to discharge from a long-stay hospital and 6 months and 1 year after community resettlement., Results: All areas of aggressive challenging behaviour reduced significantly between baseline and 6 months following resettlement (P < 0.001). This reduction remained (but did not decrease further) at 1-year follow-up., Conclusions: Further work is needed to evaluate the role of environmental setting on aggressive challenging behaviour in adults with ID.

Background: People with profound and multiple disabilities often display aberrant behaviours (such as stereotypical movements) which can inhibit learning and lead to social stigmatisation. This study was designed to help a man with multiple disabilities increase his object-contact responses and reduce hand stereotypy (in this case, hand/wrist rotation)., Method: An A-B-A-B design with a 3-month post-intervention check was employed. At baseline, a combination of microswitches (or microswitch cluster) was used to monitor the man's object-contact responses and hand stereotypy. During the intervention phases and post-intervention check, the microswitch cluster was combined with preferred stimuli for object-contact responses occurring without hand stereotypy. The stimulation lasted for 8 seconds if the man remained free from hand stereotypy for that time, but was interrupted if the stereotypy appeared., Results: The intervention showed an increase in object-contact responses occurring without hand stereotypy and a reduction in session time with hand stereotypy. These data were maintained at the 3-month post-intervention check., Conclusion: Replication of these findings with other individuals would confirm the utility of this type of intervention for increasing constructive responding and reducing stereotyped behaviours.

Aim: The aim of this study was to provide insight into the adverse effects of neurobehavioral features on the community integration of young adults who have had prior severe traumatic brain injury (TBI) with a positive long-term outcome in either functional or intellectual abilities. TBI subjects were compared with patients suffering from a health condition classified as mild intellectual disability (MID)., Methods: Twenty-five subjects with prior severe TBI, but with substantially normalized perceptual-motor and intellectual functioning, were retrospectively selected according to demographic and clinical admission criteria. The TBI subject group was compared with a selected group of 34 MID subjects. The measures used were: the Wechsler Adult Intelligence Scale-Revised (WAIS-R), Instrumental Activity of Daily Living Scale (IADLS), Community Integration Questionnaire (CIQ), and Social Behaviour Check-list (SBC). The presence/absence of dysfunctional family environment and affective close relationships were also reported., Results: Significant differences between TBI and MID subjects (with greatest scores in TBI group) refer to: WAIS-R Full Scale IQ (FSIQ, indicating an average intellectual level), CIQ-Social integration (indicating a greater level than MID group), and SBC-Defective-type behaviour (indicating a greater level of apathy than MID group)., Conclusion: Defective-type behaviour--synthesized into the term apathy' has the following features: 1) can explain the unsatisfying community integration of TBI subjects with respect to the general population; and 2) best explains the similar CIQ-home integration and CIQ-productive activities compared to subjects presenting a higher intellectual disadvantage (MID patients). The multidisciplinary approach to the complex community integration process of TBI subjects might consider the high frequency of apathy as a primarily target of the community integration management.

The role of Special Olympics in the lives of mothers of adult athletes was examined. Forty-six mothers participated in a longitudinal study, completing a parenting stress questionnaire, a measure of their child's maladaptive behavior, and a survey of athlete involvement in Special Olympics at two time periods, 42 months apart. Results confirm that involvement in Special Olympics is negatively correlated with mothers' role restriction, isolation, depression, and problems with competence and attachment. Involvement in Special Olympics fully mediated the effect of child social maladjustment on maternal role restriction and depression and partially mediated its effect on maternal problems with competence. Taken together, these findings suggest that Special Olympics can function as a formal support for mothers.

Background: Inpatient aggression in treatment facilities for persons with intellectual disability (ID) can have aversive consequences, for co-clients and staff, but also for the aggressors themselves. To manage and eventually prevent inpatient aggressive incidents, more knowledge about their types and characteristics is necessary., Method: In four facilities, totalling 150 beds, specialized in the treatment of adults with mild ID or severe challenging behaviour, aggressive incidents were registered during 20 weeks using the Staff Observation Aggression Scale-Revised. Characteristics of auto-aggressive and outwardly directed incidents and differences in their incidence in male and female clients in these facilities were compared., Results: During the observation period of 20 weeks, 639 aggressive incidents were documented. Most of these (71%) were outwardly directed, predominantly towards staff, while most of the remaining incidents were of an auto-aggressive nature. Of the 185 clients present during the observation period, 44% were involved in outwardly directed incidents (range per client 1-34), and 12% in auto-aggressive incidents (range per client 1-92). Auto-aggressive and outwardly directed incidents differed regarding source of provocation, means used during the incident, consequences of the incident and measures taken to stop the incident. The proportion of men and women involved in each type of incident was comparable, as well as the majority of the characteristics of outwardly directed incidents caused by men and women., Conclusions: Although approximately half of all clients were involved in aggressive incidents, a small minority of clients were responsible for the majority of incidents. Therefore, better management and prevention of aggressive incidents for only a small group of clients could result in a considerable overall reduction of aggressive incidents in treatment facilities. Comparability of aggressive behaviour in these facilities shown by men and women and differences in characteristics of auto-aggressive and outwardly directed incidents are discussed.

The aim of this study was to evaluate whether involvement in a 16 week exercise programme improved goal attainment in areas of behaviour, access to community-based experiences, health and physical competence. Participants were women with severe intellectual disability and associated challenging behaviour (setting A,N = 14) and male/female service users with profound physical and intellectual disabilities (setting B,N = 8). The exercise programme included active and passive exercise, walking, swimming, hydrotherapy, team games and rebound therapy. Significant gains in aggregated goal attainment were demonstrated by week 16. The reliability and validity of our goal attainment procedures were demonstrated with inter-rater reliabilities exceeding 80 percent. Changes in goal attainment were concurrent with global clinical impression scores in a series of single case studies. Continuing care settings should dedicate care staff to provide routinized, continuing exercise programmes.

Background: Changes in residential accommodation models for adults with intellectual disability (ID) over the last 20 years in Australia, the United Kingdom and the United States have involved relocation from institutions primarily into dispersed homes in the community. But an evolving alternative service style is the cluster centre., Methods: This paper reports on the relocation of a matched group of 30 pairs of adults with moderate and severe IDs and challenging behaviour who were relocated from an institution into either dispersed housing in the community or cluster centres but under the same residential service philosophy. Adaptive and maladaptive behaviour, choice-making and objective life quality were assessed prior to leaving the institution and then after 12 and 24 months of living in the new residential model., Results: Adaptive behaviour, choice-making and life quality increased for both groups and there was no change in level of maladaptive behaviour compared with levels exhibited in the institution. However, there were some significant differences between the community and cluster centre group as the community group increased some adaptive skills, choice-making and objective life quality to a greater extent than the cluster centre group., Conclusions: Both cluster centre and dispersed community living offer lifestyle and skill development advantages compared with opportunities available in large residential institutions. Dispersed community houses, however, offer increased opportunities for choice-making, acquisition of adaptive behaviours and improved life quality for long-term institutionalized adults with IDs.

Background: The purpose of this paper is to describe long-term outcomes for patients discharged over a 12-year period from a medium secure service for people with intellectual disabilities (ID)., Methods: A cohort study using case-notes analysis and a structured interview of current key informants., Results: Eleven per cent of the sample was reconvicted. Fifty-eight per cent of the sample showed offending-like behaviour that did not lead to police contact. Twenty-eight per cent of the sample was currently detained in hospital under the Mental Health Act. The presence of a personality disorder, a history of theft or burglary, and young age increased the risk of reconviction. Contact with the police was less likely in those with schizophrenia. Re-admission to hospital was associated with the presence of offending-like behaviours, rather than any specific diagnosis., Conclusion: In terms of reconviction, these results are good compared with those from general forensic services; however, behavioural problems continue for many years and are managed without recourse to the criminal justice system. There is a borderline group whose needs are poorly defined and serviced. Declaration of interests Horizon National Health Service Trust, the managing authority of the service, gave the grant for this study; the corresponding author was working in the service.

Background: The pattern of residential services for people with intellectual disability in England has changed dramatically since 1971, with many more places being made available in residential homes in the community. The aim of the present study was to assess the needs and characteristics of residents and features of all the residential homes provided by a national charity., Method: Assessments of adaptive behaviour, problem behaviour and social impairment were completed by staff who knew residents well; information about costs and staffing was provided from central records., Results: A significant proportion of residents have important care needs relating to their skills, their behaviour and their social abilities. Residents with these needs are dispersed throughout services, so that a large majority of services include one or more residents with relatively complex needs., Conclusions: Compared with services in the late 1980s, these services care for a much more disabled client group. Since individuals with high levels of particular needs are typically distributed throughout services, a very high proportion of services require staff who have relatively advanced skills. Current national plans do not adequately address this need and case management arrangements may encourage the re-creation of more institutional services., Declaration of Interest: The first author is a Trustee of the charity.

Background: Active support training was fully conducted in 38 community houses accommodating 106 adults with intellectual disabilities (ID; group 1), but not in a further 36 accommodating 82 adults with ID (group 2). The aims of the present study were to analyse whether staff became more effective in supporting resident activity after the implementation of active support, and whether there was evidence of differential responsiveness by people with differing status in relation to adaptive behaviour, psychiatric diagnosis, challenging behaviour or autism., Methods: Observations of staff:resident interaction and resident engagement in activity were taken before and after active support training. Changes in Yule's Q statistics, indicating the likelihood that resident engagement in activity followed staff giving residents verbal instruction or non-verbal assistance, were compared for the two groups. In addition, changes in similar statistics were compared for residents within group 1: (1) with Adaptive Behaviour Scale (ABS) scores above and below 180; and (2) with and without severe challenging behaviour, the triad of social impairments and mental illness., Results: Yule's Q for engagement given non-verbal assistance significantly increased post-training among group 1, but not among group 2. Similar significant increases were found among group 1 residents with ABS scores below 180 without challenging behaviour, with and without the triad of social impairments, and without mental illness, but not with an ABS score above 180, with challenging behaviour and with mental illness., Conclusion: The present analysis reinforces previous studies on the effectiveness of active support training for adults with more severe ID (i.e. with ABS scores below 180). Active support was as effective for people with the triad of social impairments as for those without it. However, the effectiveness of support offered to people with challenging behaviour or mental illness did not significantly increase.

Staff in mental retardation services identify challenging behavior as a significant source of work-related stress. However, there has been little examination of the psychological processes that may explain an association between challenging behavior and staff stress. In the present study, direct-care staff (N = 83) from five community services completed a questionnaire on their emotional reactions to aggressive behavior, the coping strategies that they employ, and their experience of burnout. Staff more frequently reported using adaptive strategies than maladaptive ones to cope with aggressive behavior. Regression analyses showed that staff disengagement and adaptive coping strategies and their emotional reactions to aggressive behavior predicted burnout scores. Implications of these results for future research and for staff mental health are discussed.

The implementation of community care in the UK has led to the requirement that services should be able to meet the needs of adults with intellectual disability (ID) and additional needs in terms of challenging behaviour. However, the extent to which people with challenging behaviour are present in the community and the extent to which community services can support them effectively still requires significant research. The present study examines the prevalence of challenging behaviour amongst adults with ID residing in three London boroughs and the issues which arise from service delivery to this client group. All service providers and general practitioners in the area were contacted and asked to identify any individuals with ID and challenging behaviour. All responses were screened, and then key staff were interviewed for information on a range of demographic factors and on the Checklist of Challenging Behaviour. The reliability of the instrument was also assessed. Four hundred and forty-eight individuals were identified from a total borough population of 670 000. There was consistency in the types of behaviour which were frequently identified across the three boroughs. There were significant levels of self-injury as well as a range of behaviours of the 'hard to engage' type. Most individuals had more then one challenging behaviour and some individuals with seriously aggressive behaviour used local community services. Twenty-five per cent of the sample lived at home with their families and 50% were in community residential services. The boroughs differed in their ability to manage those with challenging behaviour in that one borough had many more people placed out-of-borough. Significant numbers of individuals with challenging behaviour were living in the community. The range and number of behaviours suggest that staff need to be very skilled in supporting such individuals, and that effective planning and support are essential if people with challenging behaviour are to be maintained in community settings.

Functional analysis results for multiple topographies of aberrant behavior were graphed in an aggregate fashion and then separately for 48 clients. The results indicated that multiple topographies of behavior may be maintained by different contingencies. These results indicate that graphing functional analysis data in an aggregate fashion and then separately may improve the accuracy of their interpretation.

We examined the use of brief functional assessments to identify idiosyncratic variables associated with aberrant behavior maintained by positive reinforcement in the form of attention. Two participants with severe developmental disabilities and their parents were involved in the assessment and treatment evaluation process. A modified attention condition was introduced, which involved both parents interacting with a third person. Results of the assessment demonstrated that aberrant behavior occurred only in the modified attention condition for both participants. Treatment consisted of the parents delivering attention on a fixed-time schedule during this specific social context. Results indicated that the treatment reduced problem behavior. Follow-up evaluations with 1 participant indicated maintenance of treatment effects for up to 6 months.

During the last two decades, a significant amount of research has examined physical exercise with people with severe and profound developmental disabilities. The research has followed three main objectives: 1) finding strategies for allowing the people to engage in physical exercise fairly independent; 2) improving the people's physical fitness; and 3) reducing the people's deviant behavior. This paper reviews the studies related to the aforementioned objectives and comments on the main findings and on the practicality and acceptability of physical exercise.

Family interactive patterns were investigated in the relatives of 20 mentally retarded patients institutionalised in two centres in Northern Italy. Expressed emotion (EE) was used as evaluation instrument. The results show a surprisingly high rate (45%) of high EE, even in relatives of patients who did not live inside the family. High EE was positively correlated to the presence of behavioral disorders in the patients, as already shown for children with conduct disorders. Treatment implications are discussed; there is an opportunity for the implementation of a family psychoeducational approach, aimed both at managing the behavioural consequences of the disorder and at enhancing rehabilitation programmes.

The emphasis on community care means closure of the long-stay institutions for people with intellectual disability. Studies have indicated that older people with intellectual disability in particular may not be adequately cared for because of poor monitoring of their changing needs and inadequate provision of services. The use of rating instruments to monitor changes, and to predict outcome or needs in this population may help to improve care by assisting with planning and projection of service requirements. In 1991, all residents of a long-stay hospital for people with intellectual disability were assessed using the Disability Assessment Schedule (DAS). Five years later, the 1991 scores of the older residents (aged > 50 years) were reviewed and compared under three outcome groups: in-patients, discharged and deceased. Furthermore, all older people resident in the hospital in 1996 were reassessed using the DAS. Out of the 144 older clients resident in 1991, five years later, 78 were still in-patients, 38 had been discharged into the community and 28 were deceased. In 1991, the decreased group had the greatest problems with continence and symbolic behaviour, while the discharged group had the greatest problems with self-help, vision, hearing, communication, social interaction, echolalia and repetitive speech. In comparison with 1991, the 1996 DAS scores of older residents showed that there were increasing problems with vision, hearing, communication, behaviour and symbolic activities. The present study suggested that the DAS is a useful instrument for monitoring change and predicting outcome in older people with intellectual disability.

The reliability of the Spanish version of the Social Behaviour Schedule (SBS) was tested in a vocational setting on a sample of 64 subjects with learning disabilities. Test-retest assessment showed a good percentage of agreement (80%) and adequate kappa values for most SBS items. The overall percentage of agreement of inter-rater reliability was 85% and kappa values were moderate to nearly perfect for 52% of items. Inter-informant analyses produced poorer results, with an average agreement of 43% and inadequate kappa values on 42% of items. The intraclass correlation coefficient (ICC) was 0.64 for test-retest, 0.76 for inter-rater assessment and 0.94 for inter-informant assessment. The Spearman correlation coefficient was adequate on the test-retest and inter-rater analyses, but not on inter-informant analysis. This low inter-informant agreement could be attributed to environmental factors which alter the reliability of reports from different informants in community settings with high levels of normalization. In such environments, an interview with a key informant may not suffice, and both a careful review of the clinical record and a direct interview with subjects may enhance the reliability of the information attained.

We tested the factorial stability of the Reiss Screen for Maladaptive Behavior (Reiss, 1988a, The Reiss Screen for Maladaptive Behavior test manual). Reasonable fit was demonstrated in a geographically diverse sample of 448 individuals with mild, moderate, severe and profound mental retardation according to four measures of overall fit: RMSEA, ECVI, NNFI, and NFI. The results confirm Reiss' (1988a) factor solution of this widely used dual diagnosis (mental retardation and mental illness) screening instrument.

Aberrant behaviors exhibited by people with developmental disabilities have been well documented. Often, psychotropic medications, especially neuroleptics, have been used to control behaviors such as self-injury, physical aggression, property destruction, and hyperactivity. Serious side effects of these medications have occurred, resulting in litigation and regulation of their use by courts, surveyors, and accrediting bodies. Rules and regulations have been developed requiring that behaviors/symptoms necessitating that medication usage be clearly delineated, that behavior programs be developed and implemented to reduce need, and that the interdisciplinary team approach be used to monitor effectiveness of interventions. Currently, little guidance exists on how behavioral and psychopharmacological interventions should be applied or combined. This paper presents a paradigm for integrating behavior-analytic and psychopharmacological treatment interventions in the treatment of persons with developmental disabilities that meets applicable standards. Our model is consistent with the least restrictive, yet effective treatment philosophy. Implications for research and treatment are presented.

The aim was to identify changes in communication skills and behaviour disorder of 15 clients with learning difficulties 6 mo. and 1 yr. after they moved from large- to small-scale accommodations. Clients were allocated into a group of 6 with profound multiple learning difficulties, a preverbal group of 5, and a verbal group of 4. Communication skills were measured using the Preverbal Communication Schedule, and behavioural disorder was measured using the Aberrant Behaviour Checklist. Analysis showed that from the baseline to one year follow-up, there was a significant increase from baseline in social withdrawal by the clients with multiple difficulties but that there were improvements in communication skills of both preverbal and verbal clients. No control group was involved.

There is evidence that some individuals with severe intellectual impairment who are non-verbal may, out of frustration, display such inappropriate behaviour as aggression and self-injury as a means of communicating their needs to caregivers. The purpose of this study was to develop an inexpensive augmented communication device and to teach individuals with multiple impairment to use this method to communicate their needs in order to reduce their aggressive behaviours. The Dan Communication System (DanCS) symbol boards were therefore designed with computerized voice interface to help the individuals communicate to caregivers by means of audio and visual signs. A working DanCS board has been successfully developed and can now be mass produced by a manufacturer. The DanCS board is illustrated and described. A measurement device called the Goal Attainment Scale (GAS) that focused on three target behaviours; pressing of symbols, control of aggression, and social interaction with caregivers, was used to evaluate progress in the participating subjects (N = 30). Results showed that the multiply impaired individuals in the study significantly improved in all the targeted behaviours through the use of the DanCS. Details of the study are reported.

Background: Long-stay patients with learning disabilities (n = 214) were assessed in hospital and 12 and 24 months after discharge in order to examine the effects of relocation., Method: Each resident acted as his/her own control in a prospective repeated-measures design. Skills and behavioural problems were assessed by keyworkers. Self-perceived quality of life was obtained during interviews with researchers who also completed an environmental checklist of the residents' accommodation., Results: There was little or no change in people's low pre-discharge skill levels. Certain aspects of problem behaviour improved after 12 months, although socially unacceptable behaviour increased slightly. People were less depressed (P < or = 0.01) 12 months after discharge (N = 119) and were more satisfied (P < or = 0.05) with their new 'homes' (n = 108). There were few changes in the pattern of activities or the social networks of people 12 months later. Little or no further change in outcomes was reported 24 months after discharge., Conclusions: The implementation of the deinstitutionalisation policy in Northern Ireland has been limited by the predominance of residential and nursing homes and the lack of 'ordinary' accommodation. There is a need for purchasers and providers to give more attention to ways in which the principles of normalisation could be incorporated in the process of contracting and delivering services.

Behavioural models identify the actions of others as an important factor in the development and maintenance of challenging behaviours. In the present study, 109 care staff were asked about their immediate and longer-term intervention strategies for a fictitious young man's challenging behaviour. Staff descriptions of long-term interventions were largely consistent with the aims of psychological interventions. However, their immediate intervention strategies were similar to the counter-habilitative strategies identified in previous observational and self-report research. The implications of these results for models of staff behaviour, staff training, the design of behavioural programmes and future research are discussed.

Within a behavioural framework, staff responses to challenging behaviours have been identified as likely to ensure the long-term maintenance of such behaviour. However, little has been done to understand why staff behave as they do. The present paper hypothesized that staff's beliefs about the causes of challenging behaviours may be an important factor in determining staff responses to it. Beliefs about causes of three topographies of challenging behaviour (self-injury, stereotypy and aggression) were elicited from 148 experienced and 98 inexperienced institutional staff and nursing students using a questionnaire measure. Results showed that experienced participants held beliefs that were more consistent with contemporary theories of challenging behaviours than inexperienced participants. Experienced participants also distinguished between the behaviours in terms of their causes. These data were interpreted as reflecting a 'needs-based' rather than a 'functional' approach to intervention for challenging behaviours. Implications for staff training, community living and future research on staff behaviour were briefly considered.

Neuroleptics are prescribed for 23% of individuals with learning disabilities resident in Leicestershire, England. The rate of neuroleptic prescription is significantly higher in individuals resident in N.H.S. facilities (44%) than in non-N.H.S. managed community facilities (13%). Significantly higher doses of neuroleptics are prescribed to individuals resident in N.H.S. facilities. However, ratings for the level of behavioural disturbance were significantly higher in N.H.S. facilities. The decision to prescribe neuroleptics was associated with disturbed behaviour, and higher doses of neuroleptic medication prescribed were associated with more disturbed behaviour.

Background: Little is known about the natural history and evolution of behaviour symptoms and patterns in severely and profoundly mentally retarded adults. This paper reports a cohort study of 100 such adults., Method: Abnormal behaviour symptoms and patterns have been followed, using a carer rating scale and the modified Manifest Abnormality Scale of Goldberg's Clinical Interview Schedule (1970) by the same two consultant psychiatrists in 1975, 1981 and 1992., Results: Emotional withdrawal, stereotypes and eye avoidance are particularly persistent. Carer ratings of noisiness and social withdrawal, and psychiatrist ratings of suspiciousness, overactivity and hostile irritability, are also persistent but to a lesser degree. Overall ratings of psychiatric disorder are persistent and act against successful community placement., Conclusions: Abnormal behaviour patterns in severely and profoundly mentally retarded adults show only a modest degree of abatement over time. Care staff need a good understanding of clinical psychiatric and behaviour management techniques.

The characteristics of two samples of people with learning disabilities and severely challenging behaviour were examined. The experimental sample comprised subjects who had been referred to two specialist challenging behaviour services in separate counties. The comparison sample comprised subjects from the same counties who were not referred or accepted for specialist intervention. No significant differences were found between the samples in terms of age, gender, social impairment, dependency characteristics, ability levels and mental health. Significant differences between them were found in the nature and severity of aberrant behaviour presented, as assessed by their carers. The implications of these findings are discussed with regard to how the term 'severely challenging behaviour' is defined in practice.

New models of care are needed following the closure of long-stay mental handicap hospitals. Based on an evaluation of a recently established assessment and treatment service in south-east England, this paper is concerned with the costs and likely benefits of different patterns of services for people with mild learning disabilities and severely challenging behaviour. Different models of provision are compared in terms of their costs and quality of life opportunities for clients. The assessment and treatment services provided a better understanding of the care needs, and achieved a reduction in challenging behaviours. It was therefore possible to give access to care settings closer to a normal life. For approximately 25% additional expenditure, 20 out of 34 clients who received the service moved to community placements, including three who had been referred following a breakdown in the community. If community care is to be implemented as a policy for clients with learning disabilities and serious challenging behaviours, it is necessary to recognise the financial implications. Better quality of life opportunities for this client group are associated with higher costs. When seen in the dynamic context of the costs and quality of life opportunities of the subsequent care, a high cost assessment and treatment service may be a good investment. On current evidence, the additional benefits of community homes, with a closer association with the local community, and greater freedom for clients is bought only at quite a high cost.

A benefit-cost analysis was conducted to compare services in community residences versus an institution for 11 individuals with severe mental retardation and challenging behaviors who had been moved from an institution to a community setting. Effects that were not readily quantifiable in economic terms also were examined. Overall, the community-based program costs represented slight public savings over costs of the state institution. However, community living netted significant increases in variables such as resident's social networks, opportunities for integrated activities, and income.

Thirteen people with severe or profound mental retardation identified by their local service agencies as presenting the most serious problem behaviour were transferred from institutional care to specialized group homes. A multiple time-series design and direct observation were used to evaluate whether there was any change in their level of participation in meaningful activity; social interaction and problem behaviour were also observed. Participation increased significantly on transfer and included a wider range of activities. The majority of participants did not increase their major problem behaviour. The results support the view that individualised community-based placements can replace institutions for this group of clients.

The development of severely disturbed and socially accepted behavior in mentally handicapped persons with autistic or psychotic symptoms is documented before, during and after an intensive therapy program conducted in a residential institution for mentally handicapped persons. Seven single case studies were made as long term observation with a duration between 18 and 33 weeks, mostly with a multiple baseline design. One or two follow ups with at least four weeks length were conducted in six out of seven cases up to four years after the end of the intensive therapy. The main results show (1) the decrease of disturbed behavior and the increase of socially accepted behavior during the therapy program, and (2) the significant reduction of the disturbed behavior patterns taking place during the baseline phase before the beginning of the therapy in all cases but one. The results are discussed under the aspects of a possible explanation for the findings and their impact on the discussion about psychotherapy research.

This report presents a quantitative study of facilitated communication. Participants were 12 people living at an institutional autism program and 9 people who provided them with facilitated communication support. These subjects were the 12 most competent producers of facilitated communication in the program. They were shown pictures of familiar objects and asked to type the names of the objects under three conditions: (a) assisted typing with facilitators unaware of the content of the stimulus picture, (b) unassisted typing, and (c) a condition in which the participants and facilitators were each shown pictures at the same time. In this last condition the paired pictures were either the same or different, and the participant's typing was facilitated to label or describe the picture. These participants were unable to succeed in the tasks without facilitator assistance. On trials when the facilitators and participants had different pictures, the only "correct" labels were for pictures shown to the facilitators and not shown to the participants. This finding demonstrates that the facilitators were unknowingly determining what was typed.

The extent of use and effectiveness of special treatment options (in-house behavior shaping units, specialized outside referral agencies, and mobile intensive treatment teams) in dealing with behavior problems of persons with mental retardation was determined. A survey was completed by 144 institutions throughout the United States; 86% of all facilities recognized a need for special treatment options to deal with clients who had severe behavior problems. Sixty-eight percent of the institutions had presently or in the recent past used at least one of the three treatment options. Comparisons of these options in terms of perceived effectiveness, length of intervention, and type of problem addressed were reported.

Resident and staff activity was observed in two hospital-based staffed houses for adults with severe or profound mental handicap, and seriously challenging behaviours. The results indicated that: (1) staffing resources were inefficiently deployed, leading to low levels of support being provided to service users; (2) staff attention was inequitably distributed across users, individuals showing the highest levels of seriously challenging behaviours received disproportionately more staff attention; (3) users spent little of the time they were observed engaged in constructive activities. Comparisons with data collected previously on four of the users in institutional settings indicated that: (4) no overall changes occurred in either user participation in constructive activities or (5) duration of challenging behaviours; and (6) overall, more staff contact was provided in the specialized housing projects compared to previous institutional settings. The results are discussed in terms of the determinants of quality in residential provision for people with seriously challenging behaviour.

Psychiatric and behavioural disorders were found to be relatively common in a sample of 318 individuals with a mental handicap living in the community. Many of those referred for psychiatric assessment had other non-psychiatric problems. The presence of these other needs has been recognized, and had led to the emergence of a distinct group of professionals, therapists and support staff with whom psychiatrists need to liaise to devise an adequate and effective care plan. This study also highlights the need for the development of a methodology for assessing psychiatric disorders in people with a mental handicap.

Two studies investigated effects of video-assisted training on employment-related social skills of adults with severe mental retardation. In video-assisted training, participants discriminated a model's behavior on videotape and received feedback from the trainer for responses to questions about video scenes. In the first study, 3 adults in an employment program participated in video-assisted training to request their supervisor's assistance when encountering work problems. Results indicated that participants discriminated the target behavior on video but effects did not generalize to the work setting for 2 participants until they rehearsed the behavior. In the second study, 2 participants were taught to fix and report four work problems using video-assisted procedures. Results indicated that after participants rehearsed how to fix and report one or two work problems, they began to fix and report the remaining problems with video-assisted training alone.

Perceptions by staff of the classes of reinforcers and aberrant behaviors of a sample of 470 people with predominantly severe or profound mental retardation were explored. Principal components analysis of a 45-item survey suggested eight classes of reinforcers: consumable, verbal-speaker, visual-motor, social, physical-contact, passive-observer, play, and academic reinforcers. Stepwise multiple regression was used to predict five classes of maladaptive behaviors as measured by the Aberrant Behavior Checklist (irritability, lethargy, stereotypy, hyperactivity, and inappropriate speech) from the eight classes of reinforcers. Each class of psychopathology was related to a unique set of predictors. All classes of psychopathology could be predicted by staff perceptions of underresponsiveness to social reinforcers and overresponsiveness to consumable reinforcers. The findings of organized structures of reinforcers and their covariation with pathological behaviors have implications for research and intervention as well as theoretical value in defining aberrant behaviors in people with mental retardation.

This study identifies components of personal competence and community adjustment in a national sample of persons with mental retardation living in residential facilities of six or fewer residents. Factor analysis of 65 variables yielded an 8 principal component solution that accounted for approximately half the total variance in the observed variables (49%). The eight identified components of personal competence and community adjustment were labeled (1) Self Care and Functional Personal Living Skills, (2) Community Living Skills, (3) Home Living Skills, (4) Problem Behavior, (5) Community Training Goals and Objectives, (6) Recreation/Leisure Activity, (7) Family Contact/Relationships, and (8) Community Assimilation and Acceptance. The implications of reducing potentially hundreds of indicators of personal competence and community adjustment into relatively few broad internally consistent composite constructs are discussed.

To assess the efficacy of paradoxical directives, levels of challenging behaviour during 2 weeks of paradox, reprimand and extinction were compared with baseline levels in four adults with mental handicaps attending a day centre. Paradox was the most effective procedure for reducing the frequency and severity of challenging behaviour by an average of over 70% by the end of 2 weeks and up to 90% in certain subjects; extinction was least effective. Paradox was most effective with more defiant subjects, when staff rated treatment success as low, when improvement using extinction and reprimand was poorest, and in reducing aggressive behaviour. The present authors suggest the overjustification effect offers an explanation for the effects of paradox.

A descriptive evaluation is provided of a hospital-based unit for people with mental handicaps and challenging behaviours. The characteristics of clients admitted to the unit over a 15-month period are described, together with admission and discharge patterns, and treatment interventions undertaken. The progress of four clients is studied in detail via single-case studies. While reductions in levels of challenging behaviour occurred during admission, these changes were not generally maintained at follow-up. Implications for future service design are discussed.

The importance of social effectiveness in securing personal needs, and of social competence training in rehabilitation programmes for psychiatric and mentally retarded patients, have been frequently stated. The need to improve further the social effectiveness, especially communication skills, of the mentally retarded prior to discharge from hospital has been particularly stressed. However, the focus of communication training has been on linguistic and arithmetic skills, while little attention has been paid to non-verbal skills, this despite the fact that their importance in communication has been widely demonstrated. It is suggested here that improvement in basic interaction skills, including non-verbal components, will improve communication and increase the social effectiveness of the mentally retarded in the community outside the hospital. An attempt was made to improve mentally subjects' basic interaction skills by means of a social skills training group. There was significant improvement in target behaviours after training and some improvement was maintained at 8 weeks follow-up. The study suggests that such training groups might effectively the communication skills of mentally retarded subjects.